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Question 1

Alcoholic ketoacidosis

Answer 1

• non-diabetic euglycaemic form of ketoacidosis
• It occurs in people who regularly drink large amounts of alcohol

Question 2

Alcoholic ketoacidosis : Pathophysiology

Answer 2

1. Often alcoholics will not eat regularly and may vomit food that they do eat, leading to episodes of starvation.
2. Once the person becomes malnourished, after an alcohol binge the body can start to break down body fat, producing ketones.
3. Hence the patient develops a ketoacidosis.

Question 3

Alcoholic ketoacidosis : Clinical presentation

Answer 3

Ittypically presents with a pattern of:
* Metabolic acidosis
* Elevated anion gap
* Elevated serum ketone levels
* Normal or low glucose concentration

Question 4

Alcoholic ketoacidosis :Management

Answer 4

The most appropriate treatment is aninfusion of saline & thiamine.

Thiamine is required to avoid Wernicke encephalopathy or Korsakoff psychosis

Question 5

Variceal bleed : When is platelet transfusion indicated?

Answer 5

Active bleeding platelet count of ;
< 50 x 10*9/litre

Question 6

Variceal bleed : When is FFP tranfusion indicated?

Answer 6

• Fibrinogen <1g/litre
• PT OR APTT of >1.5x

Question 7

Haemochromatosis : Definition

Answer 7

autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation

Question 7

Variceal bleed : When is Prothrombin complex concentrate tranfusion indicated?

Answer 7

• prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Question 7

Haemochromatosis : Investigations

Answer 7

1. transferrin saturationis considered the most useful marker
2. ferritin should also be measured but is not usually abnormal in the early stages of iron accumulation
   3.testing family members
   
   • genetic testing for HFE mutation

• transferrin saturation > 55% in men or > 50% in women
• raised ferritin (e.g. > 500 ug/l) and iron
• low TIBC

Question 8

Haemochromatosis : Management

Answer 8

• venesectionis the first-line treatment
  
  • monitoring adequacy of venesection:transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l
• desferrioxaminemay be used second-line

Question 9

Wilson’s disease

Answer 9

1. autosomal recessivedisorder characterised by excessive copper deposition in the tissues.
2. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion.

Question 10

Wilson’s disease : Incidence

Answer 10

The onset of symptoms is usually between 10 - 25 years.

Question 11

Wilson’s disease : Clinical features

Answer 11

Featuresresult from excessive copper deposition in the tissues, especially the brain, liver and cornea:
* liver: hepatitis, cirrhosis
* neurological:
* basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
* speech, behavioural andpsychiatric problemsare often the first manifestations
* also:asterixis,chorea,dementia, parkinsonism
* Kayser-Fleischer rings
* green-brown rings in the periphery of the iris
* due to copper accumulation in Descemet membrane
* present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement

Question 12

Wilson’s disease : Investigations

Answer 12

• slit lamp examination for Kayser-Fleischer rings
• reduced serum caeruloplasmin
• reduced total serum copper(counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
  
  • free (non-ceruloplasmin-bound) serum copper is increased
• increased 24hr urinary copper excretion
• the diagnosis is confirmed by genetic analysis of the ATP7B gene

Question 13

Wilson’s disease : Management

Answer 13

Management
* penicillamine(chelates copper) has been the traditional first-line treatment

Question 14

Gatroenteritis : Traveller’s Diarrhea

Answer 14

Atleast 3 loose to watery stools in 24 hours
most common cause is Escherichia coli.

• Common amongst travellers
• Watery stools
• Abdominal cramps and nausea

Question 15

Food poisoning : Shigella

Answer 15

Bloody diarrhoea
Vomiting and abdominal pain

Question 16

Food poisoning : Campylobacter

Answer 16

• A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
• May mimic appendicitis
• Complications include Guillain-Barre syndrome

Question 17

Food poisoning : Bacillus cereus

Answer 17

Bacillus cereus: from reheated rice.
* vomiting within 6 hours, stereotypically due to rice
* diarrhoeal illness occurring after 6 hours

Question 18

Viral Gatroenteritis : Pathogens

Answer 18

The most common causative organism in
* adults is norovirus
* children it is rotavirus.

Question 19

Viral Gatroenteritis : Definition

Answer 19

Viral gastroenteritis is an acute inflammation of the lining of the stomach and small intestine, resulting from viral infection.

Viral gastroenteritis is a clinical diagnosis which presents with a self-limiting episode of diarrhoea, nausea and vomiting lasting <14 days

Question 20

Colorectal ca : Carinoid tumor

Answer 20

1. Carcinoid tumors originate from neural crest
2. Common sides : Appendix and ileus
3. Produce 5HT resulting in
   * Pulmonary stenosis and HF
4. Ix : Urinary 5HIAA level
5. Mx : Ocreotide, somatostanin analogue

Question 21

Colorectal ca : Carinoid syndrome

Answer 21

Features
flushing (often the earliest symptom)
diarrhoea
bronchospasm
hypotension
right heart valvular stenosis (left heart can be affected in bronchial carcinoid)

Question 22

Liver tumors

Answer 22

1. Haemangioma - most common, no treatment or biopsy requires
2. Adenoma : assoc with Oral contraceptive pill

Angiosarcoma and Hapatocellular carcinoma are both malignant

Question 23

Crohn’s disease : Complications

Answer 23

1. Colovesical fistula - abnormal connection between colon and urinary bladder
2. CT used to identify gas within bladder
3. Cystoscopy - identified fistula tracr

Question 24

Mx of hepatocellula carcinoa

Answer 24

Hepatocellular carcinoma is a malignant liver tumor associated with viral hepatitis
and cirrhosis. It is relatively rare in the UK compared to other parts of the world

early disease: surgical resection

The Milan criteria are used to select which patients would be suitable for liver
transplantation;
these are: 1 nodule <5cm or 2-3 nodules <3cm.

Transcatheter arterial chemoembolisation can be used for unresectable tumours or whilst waiting
for a liver transplant.

HCC does not tend to respond well to conventional chemotherapy and this is usually used as a palliative option.

Question 25

Haitus hernia

Answer 25

Most patients with a sliding hiatal hernia are over forty years of age, and women are affected four times more often than men.

Clinical features
- Reflux esophagitis due to incompetence of the cardiac sphincter
- Heartburn after meals, made worse by stooping or lying down
- Dysphagia, in part caused by reflux, but also due to inefficient peristalsis resulting
from movement of the hernia upwards as the esophagus contracts
- Regurgitation of food at night, leading to aspiration pneumonia
- Saint’s triad - a sliding hiatus hernia associated with gallstones, diverticular
disease, and nausea / vomiting may be seen in children but is not common among adults.

Investigation
* Barium meal

Question 26

Oesophagitis classification

Answer 26

The Los Angeles classification for esophagitis assigns patients to grades A to D,
according to the degree of mucosal breakage in the distal esophagus. There is no
“E’ grade.
Grade A - Mucosal breaks < or = 5mm
Grade B - Mucosal breaks > 5mm
Grade C - Breaks extending between the tops of 2 mucosal folds but <75%
circumference
Grade D - Circumferential breaks > or = 75%
For grades A and B the mucosal breaks do not extend between the tops of the two
mucosal folds which they do in Grades C and D.

Question 27

Vitamin Deficiency

Answer 27