- progressively worsening swallowing over several years - troubled by regurgiation of undigested food and halitosis(bad breath) - suffers fits of coughing on lying flat

achalasia - leads to regurg of undigested foods and halitosis - tends to present in middle aged women

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severe epigastric pain that radiates to back- after having a few too many drinks the night before

-next step in management after taken serum amylase

acute pancreatitis

fluid resuscitation as many patietns with acute pancreatitis develop systemic inflammatory response syndrome (SIRS) which can lead to multiple organ dysfunction (MODS)

Supportive measures such as fluid resuscitation and oxygen supplementation are the mainstay of the treatment for acute pancreatitis

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cullens sign is

bruising around the umbillicus from acute pancreatitis or an ectopic pregnancy

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mcburneys sign is

pain over mcburneys point seen in acute appendicitis

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troisers sign is

presence of virchows node in the left supraclavicular fossa and is a marker for gastric cancer

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Hearburn (retrosternal discomfort after eating and on lying down), acid taste in mouth (acid brash), excessive salivation (waterbrash), difficulty swallowing and nocturnal asthma

Reflux oesophagitis (GORD)

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Is gord associated with tight clothes

yes

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progressively worsening swallowing over several years
troubled by regurgiation of undigested food and halitosis(bad breath)
suffers fits of coughing on lying flat

achalasia

leads to regurg of undigested foods and halitosis
tends to present in middle aged women

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CXR- wide mediastinum and shadow behind the heart, with a fluid level

achalasia

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furthere confirmation of achalasia after xray

barium swallow or oesophagoduodenoscopy

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treatment of mild and severe achalasia

mild- nitates and anticholinergic medications

severe- surgical (Heller’s operation)

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loss of the myenteric plexus and failure of relaxation of the lower circular muscles

achalasia

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food sticking in back of throat
pale, spoon shaped nails, smooth tongue and angular cheilitis

Plummer vinson syndrome

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Endoscopy or barium meal shows friable web across the anterior oesophageal lumen

-caused by hyperplasia and hyperkeratosis of the oesophageal mucosa

plummer vinson syndrome

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is plummer vinson syndrome pre malignant and should be biopsied

yes

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plummer vinson syndrome consists of

iron deficiency anaemia, glossitis, angular cheilitis, dysphagia

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difficulty swallowing, first mouthful easy to swallw and then increasingly difficulty and neck swelling

Pharyngeal pouch

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enlargement of the left atrium, double cardiac silhouette, straightening of the left border of the heart and horizontal left bronchus

left atrial hypertrophy

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mitral stenosis associated with

large left atrium

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Budd chairi syndrome classicaly presents with

abdo pain, ascites and hepatomegaly

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obstruction of IVC causes

venous collaterals in the back with upward direction flow and bipedal oedema

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-hypopigmented patches on skin, weight loss, loose stools, oligomenorrhoea(infrequent menstrual periods), finger swelling, fine tremor, resting tachycardia, warm peripheries

Thyrotoxicosis

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soft tissue swelling on fingers that resembles clubbing, bulging eyes, raised waxy lesions on shins

(classical triad)

graves disease

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16y/o boy with malaise, weight loss, polydipsia(abnormal thirst)

-raised blood glucose

Type 1 diabetes

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evidence of liver function test that drinking excessive amounts:

macrocytic anaemia, low urea and sodium levels, deranged LFTs and elevated INR

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AST:ALT ratio greater than 2 suggests

alcoholic hepatitis -wise to prescribe vitamin supplements particularly thiamine

what do these suggest: ascites, hepatomegaly, multiple pulmonary metastases

malignancy

weight loss, anorexia, swellin gof abdo, pleural effusion, hepatomegaly, multiple opacities throughout lung fields 51y/o women

ovarian cancer

is suspect ovarian cancer what invesigations:

CA-125 blood test and pelvic ultrasound to calculate risk of malignancy. (RMI) Ct scan of abdomen and pelvis will allow for staging - If RMI and CT suggest ovarian cancer, diagnosis can be confirmed by histology from tissue obtained during laparotomy

most common primary liver tumour

hepatocellular carcinoma

in 60% of patients raised alpha fetoprotein in

Hepatocellular carcinoma

Ultrasound- focal lesions(filling defects) and may show involvement of the portal vein

hepatocellular carcinoma

examination may reveal hepatomegaly or right hypochondrial mass

hepatocellular carcinoma

penicillamine (treatment for wilsons disease) is associated with

membranous nephropathy

diffuse proliferative glomerulonephritis is associated with

SLE

barium study of -- shows birds peak on lower oesophagus while manometry reveals abnormally high oesophageal sphincter tone that fails to relax on swallowing

oesophgeal achalasia

reduced secretion of - is linked to the development of achalasia

nitric oxide

patient is most likely prescribed an opiate like codeine phosphate to manage pain from osteoarthritic knee joint. Opiates like codeine phosphate cause well known to cause

constipation

what should be co presrcibed when prescribe an opiate (deal with pain)

laxative such as senna

raised bilirubin and ALP suggests may have

cholecystitis or cholangitis

what would confirm if its a biliary problem

ultrasound scan

is suspect pneumonia by lung consolidation but have raised bilirubin and ALP, do --- to rule out biliary problem

ultrasound scan

-symptomatic anaemia (PALE), chronic diarrhoea, had glossitis with decreased vitamin b12 level and increased folate

suggestive of Small Intestine Bacterial overgrowth - definitive treatment =antibiotics!

effective antibiotics in SIBO

metronidazole, ciprofloxacin, co-amoxiclav, rifaximin

--- results from ingestion of seafood

Ciguatera toxicity treatment -conservative

describe geographic tongue

recurrent episodes of tongue soreness by spicey/ acidic foods depapillation of tongue affects 2-3% of population often asymptomatic no association with oral cancer

most common oral malignancy

squamous cell carcinoma

ulcer on lateral border of tongue/ floor of mouth - had for months, is a smoker

squamous cell carcinoma

pruritic rash affecting wrists and shins and oral soreness. white striae and ulceration

lichen planus- stress is a risk factor - affects skin and mucous memebranes skin- red papules that may have white on them oral- painless white streaks or painful ulcers and erosions

iron deficiency initially presents with

angular stomatatitis and smooth, red sore and depapillated tongue

corticoteriod use associated with oral candiasis (\_\_)

thrush

treatment for oral candiasis

mild- topical miconazole gel severe- oral fluconazole -rinsing mouth after using inhaler should help prevent this in future

high urine 5. hydroxyindoleacetic acid content diagnosis of

carcinoid syndrome

carcinoid syndrome relates to carcinoid tumour that releases

serotonin

symptoms of carcinoid syndrome

flushing, diarrhoea, bronchospasm- can develop right sided heart failure

young man, gait was unsteady, could not see, low comprehension, seemed drunk but not had any alcohol, pooed alot that smelt low calcium and phosphate levels

Vitamin D deficiency - ataxia, steatorrhoea, cognitive decline, visual problems

if got vitamin D deficiency give dose of vitamin

E ???

vitamine B deficiency most commonly occurs in

malnourished patietns with a significatn alcohol history

patient had progressive forgetfullness, has hepatomegaly and ascites adn now has cirrhosis . what test would suspect diagnossi

low serum ceurolplasmin or low serum copper, urinary copper over last 24hrs raised liver biopsy is confirmatory as suffering from wilsons disease progressing to cirrhosis

treatment of wilsons disease now causing cirrhosis

Penicillamine

AST:ALT ratio is often measured to distinguish between

alcoholic and viral hepatitis

---- is greater than AST in viral hepatitis whereas in alcoholic hepatitis ___ is greater than ALT

ALT AST

alpha 1 antitrypsin leads to

panacinar emphysema in the lungs and periodic acid schiff (PAS)- positive globules in the liver - can increase risk of hepatocellualar carcinoma

alpha fetoprotein is a marker for

hepatocellular carcinoma

anti smooth muslce antibodies are indicative of

autoimmune hepatitis

signs of iron overload( haemochromatosis)

arthralgia and erectile dysfunction

intervention if got villous atrophy

gluten free diet- coeliac!

ive got coeliac disease and not avoiding gluten then may gt

persistance of rsh, diarrhoea, and may increase risk of small bowel lymphoma

budd chairi syndrome triad

abdo pain, tender hepatomegaly, ascites

once blood test reveal hep c positive what test next?

Hep C genotype - guides length and type of treatment

treatment of hyperkalaemia

calcium gluconate should be given immediately - to reduce risk of arrythmias - does not iteself reduce potassium insulin and dexrtrose corrects potassium levels

in achalasia what tests can exclude carcinoma

oesophagoscopy and CT scan

treatment of achalasia

dialtion of the sphincter either using Botox or balloon dilatation. if this fails, surgical management is an option

barium swallow --- gives a picute of stenosis

oesophageal webs

corkscrew

oesophageal spasm

sign that peritonitis is not localised

absent bowel sounds

board like abdomen suggest

generalised peritonitis

erythema nodosun is extra manifestation of crohns or uc but not palmar erythema!

barrets oesophagus associated with --malignancy

oesophageal

achalasia is particulary associated with

squamous cell carcinoma

intermittent bloating and diarrhoea in young patient w everything else normal

irritable bowel syndrome

stool shows- trophozoites and cysts - symptoms- diarrhoea, offensive bowel gas, steatorrhoea, abdo cramps and bloating

Giardiasis

giardiasis treated with

metronidazole

mimics coeliac (villous atrophy) and occurs after travellers of south east asia and caribean.

tropical sprue

what leads to catastrophic haematemesis

oesophageal varices! not mallory weiss tear-prolonged vomitting causing bright red haematemesis

prescence of caput medusae suggests

portal hypertension

treatment for NAFLD

no current medications but weight loss is the mainstay treatment

mildly raised ALP and aminotransferases. obesity and type 2 diabetes. Does not drink alcohol. Hepatomegaly.

NAFLD

azathioprine is used in

autoimmune hepatitis

before starting azithiprine, what should be testes for

Thiopurine methyltransferase (TPMT) acitivty

severe itching, mild jaundice

primary biliary cholangitis!!!

psc is different to pbs

psc is more common in men and anti mitocchondrial antibody is negative and p-anca is positive

ANA, anti smooth muscle antibody, LKM are elevated in

autoimmune hepatitis

common presentation of coeliac disease

vague abdo pain, bloating, diarrhoea, delayed puberty, anaemia if frquently present

first line invstigation for coeliac disease

serological blood tests

definitive diagnosis of coeliac disease

distal duodenal biopsy showing partial or complete villous atrophy, crypt hypertrophy,

crohns differ from coeliac

crohns have bloody diarrhoea but with MUCUS, more severe abdo pain and more acutely unwell

crypts abscess is typical for

crohns or uc --terminal ileum involement, apthous stomatits , non caseating granulomata, stricturing of bowel wall

crohns

absence of bilirubin inn the uterine

gilberts syndrome

diagnosis of tropical sprue

small intestinal biopsy

been in india and has diarrhoea and had diarrhoeain india what test

small intestinal biopsy - determine between giardia or tropical sprue

risk factors for ascending cholangitis

biliary stent and ERCP

asecding cholangitis is most often caused by gram negative rods such as

e.coli, klebsiella and enterobacter

rigors can be caused by

ascending cholangitis

triad of gastrinoma

recurrent peptic ulcer disease, watery diarrhoea and weight loss

--is useful in treatment of gastrinoma

octreotide

first line diuretic in treatment of ascites secondary to liver cirrhosis

spironolactone

average recommended calorie intake for men

2500 and 2000 for women

one unit of alcohol is equivalent to

10ml of alcohol

one pint of beer at 5% is how may units

how often should colonscopies be done in patietns with UC thats well controlled

every 5 years

what is associated with coeliac disease

iron deficineciy

small intestine villous atrophy upon exposure to gliadin( in wheat and grain)

coeliac disease

abdominal aortic aneurysm is diagnosed when abdominal aorta has diameter greater than

3cm

management if asymptomatic with multiple gallstones

nothing

symptomatic gallstone disease presents with

colicky right upper quadrant pain that is typically worse after eating fatty foods

tenderness over mcburneys point

appendicitis

mcburneys point is the landmark for -- in most people

appendix

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