DPD: Amir Sam Gastro Cases

Question 1

What are the causes of hepatomegaly? (3C’s + I)

Answer 1

Cancer (primary or secondary deposits)
Cirrhosis (early on)
Cardiac (congestive HF + constrictive pericarditis)
Infiltration (fatty, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases)

Question 2

What are the 5 broad causes of liver disease?

Answer 2

Alcohol
AI
Drugs
Viral
Biliary disease

Question 3

List 4 broad causes of splenomegaly

Answer 3

HTN (portal hypertension)
Haematological
Infection e.g. TB
Inflammation e.g. sarcoid

Question 4

What 2 natures of pain occur in the abdomen?

Answer 4

Colicky: Obstruction
Constant: Inflammation

Question 5

List 5 organs/ conditions causing epigastric pain

Answer 5

Stomach: Peptic ulcer, GORD
Pancreas: Acute pancreatitis
Heart: MI
Aorta: Ruptured AAA
Liver/ gall bladder: cholecystitis, hepatitis

Question 6

What symptom characterises acute pancreatitis? What investigation would you perform? What would you expect to see?

Answer 6

Pain

Bloods- high amylase

Question 7

List 4 characteristics of chronic pancreatitis. What would you expect to see in the bloods? What investigation is suggestive?

Answer 7

Pain 
Weight loss
Loss of exocrine function
Loss of endocrine function
Normal amylase in blood
Stool sample: Low faecal elastase

Question 8

List 5 organs/ conditions causing RUQ pain

Answer 8

Gall bladder: cholecystitis, cholangitis, gallstones
Liver: hepatitis, abscess
Lungs: basal pneumonia 
Appendix: appendicitis
Kidney: Pyelonephritis

Question 9

List 2 systems and causative conditions causing RIF pain

Answer 9

GI: Appendicitis, mesenteric adenitis, IBD, malignancy

O+G: Ovarian cyst rupture, twist, bleed. Ectopic pregnancy

Question 10

List 2 organs/ conditions causing suprapubic pain

Answer 10

Cystitis

Urinary retention

Question 11

List 2 systems and causative conditions causing LIF pain

Answer 11

GI: Diverticulitis, IBD, malignancy

O+G: Ovarian cyst rupture, twist, bleed. Ectopic pregnancy

Question 12

List 4 causes of diffuse abdominal pain

Answer 12

Obstruction
Infection: Peritonitis, gastroenteritis
Inflammation: IBD
Ischaemia: mesenteric ischaemia

Question 13

List 5 medical causes of diffuse abdominal pain

Answer 13

DKA
Addisons
Hypercalcaemia
Porphyria
Lead poisoning

Question 14

What symptoms/ signs/ figures are consistent with spontaneous bacterial peritonitis?

Answer 14

Generalised abdominal pain
Ascites
WCC > 250 cell/mm3

Question 15

What are the 5 causes of abdominal distension?

Answer 15

Fat
Flatus 
Faeces
Fetus 
Fluid

Question 16

How do you assess for the presence of fluid in abdominal distension? Features of what else may be present?

Answer 16

Percuss for shifting dullness

Liver disease

Question 17

What causes flatus? What is a risk factor for this? What symptoms may accompany flatus? How may you detect it?

Answer 17

Obstruction
Previous surgery (risk of adhesions)
N+V
Not opened bowel
Tinkling, high pitched BS on auscultation

Question 18

What are the 2 types of fluid found in ascites? What causes the presence of each?

Answer 18

Transudate: Less protein. (Failures- liver, heart, kidney)
Exudate: More protein (Malignancy, infection, Budd-Chiari syndrome)

Question 19

Name 2 causes of pre-hepatic jaundice

Answer 19

Haemolysis

Gilberts syndrome

Question 20

Name a broad cause of hepatocellular jaundice. How is the conjugated BR excreted?

Answer 20

Hepatitis (Alcohol, AI, Viruses, Drugs)

Conjugated BR leaks out of hepatocytes + is excreted as dark urine

Question 21

List 3 causes of post-hepatic jaundice. Describe the urine and stool.

Answer 21

Gallstones in CBD
Stricture
Ca of head of pancreas
Dark urine 
Pale stool (low stercobilinogen)

Question 22

Which cause of jaundice results in pale stool? How may you differentiate between the causes?

Answer 22

Obstructive/ post-hepatic
Pancreatic cancer= painless
Gallstones= painfull

Question 23

What is trousseau’s sign of malignancy?

Answer 23

Thrombophlebitis (inflammation of a vein due to a clot)

Question 24

Which liver enzymes are most markedly raised in hepatic and obstructive jaundice?

Answer 24

Hepatic: AST + ALT
Obstructive: ALP + GGT

Question 25

List 5 main causative organisms of infective colitis presenting with bloody diarrhoea. Think CHESS

Answer 25

``` Campylobacter Haemorrhagic E.coli Entamoeba histolytica Salmonella Shigella ```

Question 26

Excluding infection what is the more likely cause of bloody diarrhoea in the young and old? In the young, what other features may suggest this?

Answer 26

Young: Inflammatory colitis (IBD)- episcleritis, erythema nodosum Old: Ischaemic colitis, malignancy, diverticulitis

Question 27

List 5 steps in management of an acute GI bleed

Answer 27

``` ABC IV access Fluids G+S, X-match blood OGD ```

Question 28

What 2 drugs are important to administer in a variceal bleed?

Answer 28

``` Abx Terlipressin (constricts splanchnic vessels) ```

Question 29

What investigations are necessary in acute abdomen presentations?

Answer 29

``` FBC U+Es LFTs CRP Clotting G+S, X match blood Erect CXR CT ```

Question 30

Describe 6 management principles/ administrations in acute abdomen presentations

Answer 30

``` NBM IV fluids Analgesic Anti-emetics Antibiotics Monitor vitals + UO ```

Question 31

What investigations will you perform in a patient presenting with jaundice?

Answer 31

``` Bloods: FBC, LFTs, CRP Abdominal USS (post-fast) ```

Question 32

What investigations will you perform in a patient presenting with dysphagia and weight loss?

Answer 32

OGD + Biopsy

Question 33

What investigations will you perform in a patient presenting with PR bleeding and weight loss?

Answer 33

Colonoscopy

Question 34

List 5 features involved in managing ascites

Answer 34

Diuretics (spironolactone +/- furosemide) Dietary Na+ restriction Fluid restriction in patients with hyponatraemia Monitor daily weight Therapeutic paracentesis (with IV albumin)

Question 35

How is the albumin gradient calculated?

Answer 35

Serum albumiin - Ascites albumin

Question 36

In which conditions does the albumin gradient rise >11g/L? Why?

Answer 36

Cirrhosis: causes portal HTN + make less albumin HF: back flow of blood obstructs liver venous outflow Increased pressure forces fluid out of the vessels into peritoneal cavity but leaves albumin in vessels

Question 37

In which conditions does the albumin gradient drop <11g/L? Why?

Answer 37

Infection (TB), Inflammation, Malignancy: High albumin in ascitic fluid Nephrotic syndrome: Serum albumin is low as losing in urine

Question 38

What will you prescribe for encephalopathy? Why?

Answer 38

``` Lactulose (reduces gut transit time, reducing time to make ammonia) Phosphate enemas (increases bowel movement) ```

Question 39

Other than laxatives, what else is involved in management of encephalopathy?

Answer 39

Avoid sedation Treat infections Exclude GI bleed (would act as large protein meal)

Question 40

Describe 2 features of wound infection post-op

Answer 40

Erythematous | Discharge

Question 41

Describe 3 features of anastomotic leak post-op

Answer 41

Diffuse abdo. tenderness Guarding, rigidity Hypotensive, tachycardic

Question 42

Describe 4 features of a pelvic abscess post-appendectomy

Answer 42

Pain Fever Sweats Mucus diarrhoea

Question 43

Describe a perianal abscess? How is it treated?

Answer 43

Tender, red swelling | Incision + drainage

Question 44

Give 2 symptoms/ signs of an anal fissure. How is it treated?

Answer 44

Rectal pain on defecation Stool coated with blood Increase fluid + fibre GTN cream

Question 45

Describe 3 features of IBS presentation

Answer 45

Recurrent abdo. pain, bloating Improves with defecation Change in frequency/ form of stool

Question 46

How is IBS treated?

Answer 46

Diet + lifestyle modification Abdo pain: anti-spasmodics Constipation: laxatives Diarrhoea: antidiarrhoeals