CPC 7 haematemesis and melaena

Question 1

Causes of upper GI bleeding by anatomical areas.

Answer 1

Oesophagus
Stomach
Duodenum

Question 2

Causes of bleeding in the oesophagus

Answer 2

Oesophagitis
Mallory-Weiss tear
Varices

Question 3

What causes varices?

Answer 3

Portal hypertension

Question 4

What are the classes of causes of portal hypertension?

Answer 4

Pre-hepatic, intra-hepatic and post-hepatic.

Question 5

Pre-hepatic causes of portal hypertension

Answer 5

Portal vein thrombosis

Question 6

Intra-hepatic causes of portal hypertension

Answer 6

Cirrhosis
Schistosomiasis
Sarcoidosis
Congenital hepatic fibrosis.

Question 7

Definition of liver cirrhosis

Answer 7

A diffuse process characterized by fibrosis and conversion of normal architecture into structurally abnormal nodules.

Question 8

Causes of liver cirrhosis

Answer 8

	Alcoholic
	Viral
	Autoimmune (5%)
	Metabolic
	NAFLD

Question 9

Post-hepatic causes of portal hypertension

Answer 9

o Venous outflow obstruction
o Budd-Chiari syndrome
o Veno-occlusive disease.

Question 10

Complication of portal hypertension.

Answer 10

As well as varices,
o	Splenomegaly
o	Ascites
o	Spontaneous bacterial peritonitis
o	Encephalopathy.

Question 11

Treatment for portal hypertension leading to oesophageal varices and haematemesis.

Answer 11

A transjugular intrahepatic portosystemic shunt, which connects the portal vein to a branch of the abdominal aorta, providing a bypass of the liver.

Question 12

Where do varices occur in portal hypertension.

Answer 12

Usually O-G junction also retroperitoneal, rectal and caput medusae.

Question 13

Gastric causes of upper GI bleeding.

Answer 13

Peptic ulcer
Gastritis
PHG (portal hypertensive gastropathy). 
Malignancy
Vascular ectasia.

Question 14

Risk factors for peptic ulcers

Answer 14

Easy to remember - 4. 
•	H. pylori
•	Smoking
•	Drugs – including NSAIDs, aspirin, cocain and corticosteroids. 
•	Stress

Also 5 more:
•	COPD
•	Alcoholic cirrhosis
•	Endocrine cell hyperplasia
•	Zollinger-Ellison Syndrome (PUD of stomach, duodenum and jejunum)
•	Viral infection.

Question 15

Ways to diagnose H pylori infection. Direct and indirect, invasive and non-invasive.

Answer 15

• Direct, invasive – Histology, culture
• Direct, non-invasive - Faecal antigen
• Indirect, invasive – CLO test
• Indirect, non-invasive – Urea breath test, serology

Question 16

What is gastropathy?

Answer 16

Gastropathy is mucosal injury to the stomach without significant inflammation, commonly secondary to endogenous or exogenous irritants.

Question 17

Symptoms of gastropathy

Answer 17

• None
• Pain
• Nausea and vomiting
• Acute GI bleed
• Acute gastric ulcer
• Massive haematemesis.

Question 18

Causes of gastropathy

Answer 18

• H. pylori is common cause. Also autoimmune gastritis, commonly causes diffuse atrophic gastritis.

Question 19

Common risk factors of gastropathy.

Answer 19

Involves NSAIDs, alcohol, smoking, chemotherapy, bile reflux uraemia and etc. Occurs in 25% of those taking aspirin for rheumatoid arthritis.

Question 20

Gastric cancer - epidemiology

Answer 20

• More common in Japan. 90% are adenocarcinoma. Others include malt lymphoma, neuro-endocrine tumours and GI stromal tumours.

Question 21

Risk factors for gastric cancer

Answer 21

Genetic factors, being in lower socioeconomic groups, H. pylori, diet, smoking, chronic gastritis.

Question 22

Genetic factors predisposing to gastric adenocarcinomas

Answer 22

o Lynch syndrome
o Hereditary diffuse gastric cancer (defect in e-cadherin)
o Familial adenomatous polyposis.

Question 23

Growth patterns of gastric adenocarcinomas.

Answer 23

Intestinal type

Diffuse type

Question 24

Epidemiology of intestinal type of gastric adenocarcinoma.

Answer 24

Predominates in at risk areas, presentation usually around 55, male:female = 2:1

Question 25

Pathology of intestinal type of gastric adenocarcinoma.

Answer 25

 Has precursor lesions, mostly exophytic, ulcerated or excavated.  Haematological spread to liver, lungs and nodes, esp Virchow’s node.

Question 26

Epidemiology of diffuse type of gastric adenocarcinoma.

Answer 26

 Uniform geographical distribution, equal numbers of males and females.

Question 27

Pathology of diffuse type of gastric adenocarcinoma.

Answer 27

 No precursor lesions. Flat, linitus plastica |  transperitoneal spread (Krukenberg tumour).

Question 28

Symptoms of gastric adenocarcinoma

Answer 28

Vague, generally similar to gastritis.

Question 29

Prognosis of gastric adenocarcinoma.

Answer 29

Survival sharply declines with advancement of cancer, even after metastasis.

Question 30

Causes of haematemesis and melaena presentations:

Answer 30

More than 20%: peptic ulcers, oesophagitis, gastritis. More than 10%: duodenitis, varices. Less than 10%: PHG, malignancy, Mallory-Weiss tear, vascular ectasia.

Question 31

Intrinsic clotting cascade pathway

Answer 31

XII, XI, IX, X (VIII), prothrombin (V), Thrombin, fibrinogen.

Question 32

Extrinsic clotting cascade pathway

Answer 32

Injury, tissue factor, VIIa + TF, X, thrombin, fibrinogen.

Question 33

APTT

Answer 33

involves the intrinsic pathway and time taken to clot

Question 34

PT

Answer 34

involves the extrinsic pathway and time taken to clot.

Question 35

Definition of portal hypertension

Answer 35

Sustained increase in portal venous pressure, caused by obstruction to blood flow somewhere in the portal circuit with complications arising from increased pressure and dilatation of the venous bed behind the obstruction

Question 36

Clinical features of multiple endocrine neoplasia type 1

Answer 36

parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia pituitary (70%) pancreas (50%, e.g. Insulinoma, gastrinoma) also: adrenal and thyroid

Question 37

Zollinger-Ellison syndrome

Answer 37

Characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome.

Question 38

Features of Zollinger-Ellison syndrome

Answer 38

multiple gastroduodenal ulcers diarrhoea malabsorption