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Flashcards in Gastro Deck (259):
1

A 35 year old woman complains of a cough for many months and is found to have TB. She is HIV positive and complains of painful swallowing. What is the likely cause? And why?

Oesophageal candidiasis
Immunocompromised patient
Causes odynophagia, dysphagia and substernal chest pain

2

What is a mallory Weiss tear? How do diagnose it?

Occur at gastro-oesophageal junction
Can be caused by repeated vomiting following alcohol consumption
Bleeding usually stops spontaneously within 2 days
Endoscopy needed for diagnosis

3

How does acute pancreatitis present?

Severe upper abdominal pain, can transmit to back and left shoulder blade
Eating or drinking might make it worse, particularly fatty foods
Nausea and vomiting
Diarrhoea
Fever

4

What is angiodysplasia?

Vascular lesion of GI tract, swollen fragile blood vessels which can result in blood loss from GI tract

5

What is an acute abdomen?

Condition of severe abdominal pain, usually requiring hospitalisation +/- emergency surgery
Caused by acute disease of or injury to the abdominal organs
History usually

6

What different pathological processes could be underlying an acute abdomen?

Inflammation
Infection
Distension
Perforation
Ischaemia
Neoplasm

7

What would be on your differential list for a patient with acute abdominal pain in the right hypochondrium?

Gall bladder: gallstones
Stomach: peptic ulcer, gastritis
Hepatic flexure colon: cancer
Lung: pneumonia

8

What would be on your differential list for a patient presenting with acute abdominal pain in their epigastric region?

Gall bladder: gallstones
Stomach: peptic ulcer, gastritis
Transverse colon: cancer
Pancreas: pancreatitis
Heart: MI

9

What would be on your differential list for a patient with acute abdominal pain in the left hypochondrium?

Spleen: rupture
Pancreas: pancreatitis
Stomach: peptic ulcer
Splenic flexure colon: cancer
Lung: pneumonia

10

What would be on your differential list for a patient with acute abdominal pain in the right lumbar region?

Ascending colon: cancer
Kidney: stone, hydronephrosis, UTI

11

What would be on your differential list for a patient with acute abdominal pain in the left lumbar region?

Descending colon: cancer
Kidney: stone, hydronephrosis, UTI

12

What would be on your differential list for a patient with acute abdominal pain in the umbilical region?

Small bowel: obstruction/ischaemia
Aorta: leaking AAA

13

What would be on your differential list for a patient with acute abdominal pain in the right iliac fossa?

Appendix: Appendicitis
Caecum: tumour, volvulus, closed loop obstruction
Terminal ileum: crohns, mekels
Ovaries/fallopian tube:ectopic, cyst, PID
Ureter: renal colic

14

What would be on your differential list for a patient with acute abdominal pain in the hypogastric region?

Uterus: fibroid, cancer
Bladder: UTI, stone
Sigmoid colon: diverticulitis

15

What would be on your differential list for a patient with acute abdominal pain in the left iliac fossa?

Sigmoid colon: diverticulitis, colitis, cancer
Ovaries/fallopian tube: ectopic, cyst, PID
Ureter: renal colic

16

What intestinal problems could cause an acute abdomen?

Acute appendicitis, mesenteric adenitis, Mekel’s diverticulitis, perforated peptic ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated hernia

17

What is mesenteric adenitis?

Abdominal lymphadenopathy which causes abdominal pain
Usually in children

18

What are potential hepatobiliary causes of an acute abdomen?

Biliary colic, cholecystitis, cholangitis, pancreatitis

19

What is cholecystitis?

Inflammation of gall bladder commonly due to blockage of the cystic duct with gallstones (Cholelithiasis) which causes a build up of bile and therefore increased pressure in the gallbladder

20

What is cholangitis?

Infection of the common bile duct commonly caused by infection secondary to a gallstone or tumour

21

What can be vascular causes for an acute abdomen?

Ruptured AAA, mesenteric ischaemia, ischaemic colitis

22

What are potential urological causes for an acute abdomen?

Renal colic, UTI, testicular torsion, urinary retention

23

What are potential gynaecological causes for an acute abdomen?

Ectopic pregnancy, ovarian cyst (rupture/haemorrhage/torsion), salpingitis, Mittelschmerz (ovulation pain)

24

What might be some medical causes for an acute abdomen?

Pneumonia, MI, DKA

25

What can cause right iliac fossa pain?

APPENDICITIS acronym
Appendix/ abscess
Pelvic inflammation
Period pain
Ectopic/ endometriosis
Neoplasm
Diverticulitis
Intussusseption (inversion of one portion of intestine within another)
Chrohn’s/ Cyst
IBD
Torsion
IBS
Stones

26

What can cause left iliac fossa pain?

SUPERCLOTS acronym
Sigmoid diverticular disease
Ureteric colic
Pelvic inflammation/ period pain
Ectopic/ endometriosis
Rectal abscess/haematoma
Colon cancer
Left lower pneumonia
Ovarian cyst
Torsion
Stones

27

What are important questions in a history for an acute abdomen?

Site and duration
Onset – sudden vs gradual
Character – colicky, sharp, dull, burning
Radiation – e.g. Into back or shoulder
Associated symptoms
Timing – constant, coming and going
Exacerbating and relieveing factors
Severity
Have you had a similar pain previously?
What do you think could be causing the pain?

28

What associated symptoms would you want to ask about in an acute abdomen history?

GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/melaena, dyspeptic symptoms, vomiting
Urine: dysuria, heamaturia, urgency/frequency
Gynae: normal cycle, LMP, dysmenorrhoea/menorrhagia, discharge
Others: fever, appetite, weight loss, distention

29

What is Rovsing’s sign?

Sign of appendicitis: palpation of left lower quadrant of persons abdomen increases pain felt in the right lower quadrant

30

A 55 year old male undergoes an endoscopy after being referred by his GP with recurrent indigestion. Endoscopy reveals a small duodenal ulcer and H. pylori is demonstrated to be present. How would you treat this patient?

Omeprazole, metronidazole and clarithromycin: triple therapy for a week. Continue PPI after this

31

What is Cullen's sign?

Superficial oedema and bruising in subcutaneous fat around umbilicus
Takes 24-48 hours to appear and can predict acute pancreatitis

32

What is grey turners sign?

Bruising of the flanks - sign of retroperitoneal haemorrhage

33

What resuscitation management might be required for an acute abdomen?

Secure airway
Oxygen
Fluid Balance: IVF, catheter, bloods, Xmatch
Analgesia
IV Antibiotics
Thromboprophylaxis

34

Describe the pathophysiology of Crohn's disease

Has skip lesions between patches of inflammation
Can affect anywhere between mouth and anus
Has a particular predominance for terminal ilium
Intramural inflammation with lymphocyte infiltration
Inflammation spreads through layers of bowel including up to the serosa
May be granulomas present

35

What is bacterial overgrowth syndrome?

Occurs in patients who have had reconstructive bowel surgery, particularly on ileo caecal valve
Involves a change in the small bowel intestinal flora to more colonic, with increased numbers of organisms
Symptoms: diarrhoea, flatulence, abdominal distension and pain

36

What is cryptosporidiosis?

Protozoan infection pathogenic in immunocompromised disease
Can causes severe colitis in patients with AIDS

37

What is whipples disease?

Rare infection caused by tropheryma whipplei, bacteria which predominantly colonises the duodenum but can cause systemic upset
Main symptom: malabsorption

38

What is the duke classification for colorectal carcinoma?

Duel stage A: confined to mucosa
Stage B1: involves muscularis propria
Stage B2: invades beyond muscularis propria, but doesn't invade local or regional lymph nodes
Stage C1: regional lymph nodes
Stage C2: apical lymph node
Stage D: distant metastases

39

A 72 year old man presents with acute severe abdominal pain. He has a history of ischaemic heart disease for which he takes nitrates, atenolol and amlodipine
On examination his pulse is 115 and irregularly irregular, a blood pressure of 104/72 and a temperature of 37.4. Examination of the abdomen reveals diffusely tender abdomen with absent bowel sounds. What is the likely diagnosis?

Mesenteric ischaemia - absent bowel sounds, AF and presence of vascular disease

40

Name 3 genetic causes for liver cirrhosis

Alpha 1 anti trypsin deficiency
Wilson's disease
Haemochromatosis

41

What is the frames brief advice tool?

Feedback: on patient's risk for alcohol problems
Responsibility: highlight that individual is responsible for change
Advice: advise reduction or give explicit direction to change
Menu: provide a variety of options for change
Empathy: emphasise a warm, reflective and understanding approach
Self-efficacy: encourage optimism about changing behaviour

42

What is toxic mega colon?

Rare but important complication in UC
Hallmarks are systemically compromised patient, abdominal radiograph showing colon dilation over 6cm

43

What are management options for toxic mega colon?

Conservative: fluid resuscitation, IV antibiotics, hydrocortisone, cyclosporine
Surgical: colectomy required if evidence of perforation, increased toxicity or persistent dilation

44

A 56 year old man is brought into a&e by the police. He was arrested for being drunk and disorderly. He complained of feeling unwell and vomited on route to the hospital. He is a known alcoholic with liver disease. What is the most appropriate immediate management?

Thiamine and vitamin B to prevent alcohol induced brain damage - wernickes Korsakoff's syndrome

45

What is bupropion?

Atypical antidepressant used as a smoking cessation drug to reduce cravings but can also be used to reduce withdrawal symptoms in alcoholism

46

What are some surgical causes of abdominal pain?

Obstruction
Perforation
Peptic ulcer disease
Malignancy
Biliary colic
Cholecystitis
Pancreatitis
Ruptured AAA
Renal colic
Diverticulitis

47

What are some medical causes of abdominal pain?

Diabetic ketoacidosis
GORD
Hepatitis
Colitis

48

What is courvoisiers law?

Palpable gallbladder in the presence of jaundice is unlikely to be due to gallstones

49

What are ALARM symptoms for oesophageal cancer?

Persistent dyspepsia in those over 55
Unintentional weight loss
Unexplained iron deficiency anaemia
GI bleeding
Odynophagia
Dysphagia
Persistent vomiting
Epigastric mass

50

What are the components of the Glasgow prognostic score for acute pancreatitis?

PANCREAS
PaO2 55
Neutrophils, WCC >15
Calcium 16
Enzymes, LDH >600, AST >200
Albumin 10

51

A 55 year old alcoholic presents with haematemesis. His pulse is 120, bp 108/70. He has numerous spider naevi over his chest. His abdomen is distended with ascites. What would you request next for this patient?

Urgent Endoscopy
Bleeding oesophageal varices top of differential list

52

What is charcots triad for ascending cholangitis?

Colicky right upper quadrant pain
Jaundice
Swinging fevers

53

A 44 year old female presents with 3 month history of fatigue, and malaise. IgG is raised. LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?

Autoimmune hepatitis

54

72 year old male discharged from hospital after suffering an MI. After discharge he presents with muscle aches and pains. His LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?

Drug induced hepatitis - statins

55

An 18 year old female presents with a sore throat. LFTs show isolated raised bilirubin. What is the likely diagnosis?

Gilbert's syndrome

56

A man has eaten some undercooked meat at a bbq and you suspect he has gastroenteritis caused by E. coli or v cholerae. What is the pathological mechanism causing diarrhoea in this man?

Endotoxins stimulating secretion of electrolytes into the intestinal lumen by activating and increasing cAMP. This increases the amounts of Na, K and bicarbonate in the apical side of the lumen which then draws water across

57

Why do patients with pancreatic insufficiency get diarrhoea?

Nutrients not broken down properly so biologically active in lumen exerting osmotic effects and increasing water content in large bowel

58

What is diarrhoea?

200ml of water per daily excrement

59

How is hepatitis b most frequently acquired worldwide?

Vertical transmission in the perinatal period

60

Describe the different types of hepatitis infections

A and E: always acute
B: chronic if in neonate, acute in adult
C: chronic only
D: only ever present if b is present

61

Which part of the intestine will contain a meckels diverticulum?

Ileum, two feet from ileocolic junction

62

What is a gallstone ileus?

Small bowel obstruction
Stones enter GI system via cholecystoduodenal fistula and migrate distally until they exit rectum or become lodged in the narrowest part of intestine - terminal ileum

63

What is a pilonidal sinus? How do you treat them?

Caused by ingrowing hairs
Painful redness and swelling at base of coccyx
People who are prone to them can be successfully treated by waxing the affected area. They often present as abscesses due to infection

64

A 35 year old man complains of sharp pains in anal region during defecation. There are small patches of blood on the tissue. What is the likely diagnosis?

Anal fissure

65

A 52 year old man presents with 3 month history of increasing discomfort in perineal region. He complains of throbbing and swelling and is struggling to sit down. What is the likely diagnosis?

Perianal abscess

66

How would a perianal haematoma present?

Tenderness in perianal region
Lump
Pea sized
Bluish in colour
Painful
No history of weight loss or other red flag symptoms

67

What are classic symptoms of rectal cancer?

Fresh blood
Mucus
Tenesmus
Diarrhoea

68

What is biliary colic?

RUQ pain in absence of raised white cell count, normal LFTs and fever

69

What is the embryological origin of the digestive tract?

Endoderm

70

A patient has presented with signs and symptoms of hepatitis A. What red flag signs will you look out for that will make you consider emergency admission to hospital?

Severe illness: collapse, severe pain
Vomiting
Dehydrated
Signs of hepatic decompensation: consciousness level, bleeding tendency

71

What is the commonest reason for hospital admission in hepatitis A?

Supportive therapy: IV fluids

72

Is statutory notification of hepatitis A diagnosis required?

Yes, notifiable disease. Communicate to Local protection unit (public health department)

73

What advice should you give to a patient on preventing hepatitis A transmission?

Emphasis on hygiene measures, frequent and thorough hand washing

74

What is the typical duration of illness with hepatitis A?

2-10 weeks

75

What dietary advice should be given to a patient with hepatitis A?

High carb, low fat and protein
Avoid alcohol
Avoid medications metabolised in the liver

76

What is the transmission route of hepatitis A?

Faecal-oral route
Consuming contaminated food and water or coming into contact with food through compromised personal hygiene and poor sanitation associated with developing countries

77

Give some complications of a cholecystectomy

Biliary leak from cystic duct or gall bladder bed
Injury to bile duct leading to stricture and secondary biliary liver injury

78

List some complications of gallstones

Acute cholecystitis
Acute cholangitis
Gallstone related pancreatitis
Biliary enteric fistula
Gallstone ileus
Bowel obstruction

79

What LFT abnormality would you expect to see in a patient with a fatty liver?

Twofold elevation of AST and ALT
Mild elevation of ALP and gGT

80

What is the rule of 2s for a meckels diverticulum?

2% population
2 feet from ileocolic junction
2 inches long

81

What is a major side effect of clindamycin?

C diff - pseudomembranous colitis

82

What is the blood supply to the liver?

Dual circulation
Portal: blood from intestines via superior and inferior mesenteric and splenic veins
Systemic: hepatic vein and artery

83

What are the functions of the liver?

Metabolism
Bile production
Detoxification
Excretion - bilirubin, drugs
Plasma protein synthesis - albumin, clotting factors
Storage - glycogen, vitamins, minerals

84

What carbohydrate metabolism occurs in the liver?

Glucose enters hepatocyte (insulin dependent) and is converted to glycogen
Gluconeogenesis occurs to produce glucose

85

What lipid metabolism occurs in the liver?

Triglyceride oxidation
Converts excess carbohydrate and protein into fatty acids and triglycerides which are exported and stored in adipose tissue
Synthesis of cholesterol, HDL and apolipoproteins

86

What protein metabolism occurs in the liver?

Catabolism - amino acid breakdown by transamination and deamination. ALT/AST
NH3 converted to urea

87

What protein metabolism abnormalities would exist in liver disease?

Blood urea nitrogen low due to decrease amino acid breakdown
Hyperammonemia - potentially fatal

88

What plasma proteins are made by the liver?

Albumin
Globulins
Fibrinogen and clotting factors

89

How is bilirubin modified and excreted?

Bilirubin formed from breakdown of haem
Bilirubin and albumin transported to liver
Conjugated to bilirubin glucuronide in the liver
Secreted in bile
Converted to urobilinogen by gut bacteria
80% excreted (converted to stercobilin)
20% reabsorbed and excreted in urine

90

What drug metabolism occurs in the liver?

First pass metabolism
Phase 1: oxidation, reduction, hydrolysis by cytochrome p450
Phase 2: glucuronidation, sulfation, acetylation
Enzymes like gamma GT

91

What components of the immune system are synthesised by the liver?

Acute phase proteins - CRP
Complement components

92

What do decreased albumin levels indicate?

Poor liver function: decreased production
Poor kidney function: increased loss

93

What bleeding/clotting tests are measures of liver function?

Prothrombin time and INR
Partial thromboplastin time
Individual factor deficiencies

94

Why do alkaline phosphatase levels rise in liver damage? What else could cause a rise?

Increased release from damaged hepatocytes
High levels with blocked ducts
Bone disease

95

What causes a rise in gamma GT?

If rise alongside ALP - liver disease/ bile duct obstruction
Persistently increased in chronic alcoholics

96

What causes ALT and AST to rise?

Acute liver injury
ALT usually increased more than AST except in alcoholic hepatitis where AST > ALT

97

What different measures of bilirubin are there? And what do these show?

Total: conjugated plus unconjugated
Unconjugated > conjugated: haemolysis, cirrhosis, Gilbert's
Conjugated > unconjugated: decreased elimination - viral hepatitis, drugs, alcoholic liver disease, blockage of bile ducts

98

What type of bilirubin abnormalities might newborns have?

Unconjugated bilirubinaemia - increased haemolysis
Conjugated bilirubinaemia - biliary atresia, neonatal hepatitis

99

What is kernicterus?

Bilirubin encephalopathy
Blood brain barrier not developed in newborns

100

What are different patterns of liver injury?

Hepatocyte degeneration: Hepatocyte ballooning, Feathery degeneration, Steatosis - macro/micro vesicular, Accumulation of iron or copper
Necrosis: centrolobular, mid zonal, periportal
Inflammation: portal, lobular, interface
Fibrosis: portal fibrous expansion, bridging fibrosis, nodule formation

101

What can cause hepatic failure?

Hepatocyte necrosis: drugs, HAV, HBV
Progression of chronic liver disease - cirrhosis
Encephalopathy - raised blood ammonia levels

102

Describe the changes that occur in cirrhosis

Entire liver architecture disrupted
Portal/portal and portal/central bridging fibrosis
Nodules of proliferating hepatocytes surrounded by fibrosis
Vascular relationships lost - abnormal communication resulting in portal and arterial blood bypassing hepatocytes

103

What can lead to portal hypertension?

Cirrhosis: increased resistance to portal blood flow
Pre hepatic: portal vein thrombosis
Post hepatic: constrictive pericarditis, budd-Chiari

104

What types of neoplasia can occur in the liver?

Benign adenoma
Hepatocellular carcinoma
Cholangiocarcinoma
Mets

105

What GI presentations can cause vomiting?

Gastroenteritis
Appendicitis
Pyloric stenosis
Stenosing gastric cancer
Intestinal obstruction

106

What GI presentations can cause dysphagia?

Gastro-oesophageal Reflux Disease
Benign oesophageal stricture
Oesophageal cancer
Pharyngeal pouch
Pharyngeal cancer

107

What GI causes can lead to acute abdominal pain?

Perforated Peptic Ulcer
Appendicitis
Gastroenteritis
Obstruction
Diverticular disease
IBD
Ischaemia
Pancreaticobiliary

108

What GI causes can lead to chronic abdominal pain?

Irritable Bowel Syndrome
Chronic peptic ulcer
GORD
Gastritis
Gastric Cancer
IBD

109

What GI presentations can cause haematemesis?

Peptic Ulcer
Acute Gastritis
Mallory-Weiss Tear
Oesophageal cancer
Gastric Cancer
Oesophageal varices
GORD

110

What are Peyers patches in the small intestine?

Organised lymphoid nodules mainly in ileum
Preventing growth of pathogenic bacteria in intestines

111

Describe the morphology of oral ulcers

Surface Slough
Granulation Tissue
Fibrosis

112

List some causes of oral ulceration

Simple Apthous
Trauma (physical, heat, chemical, radiation)
Infections (viral, bacterial)
Drugs (cytotoxics, NSAIDS, bisphosphonates)
Bullous Disease
Allergic
Crohn’s Disease
Malignancy

113

What are risk factors for oral cancer?

Smoking/smokeless tobacco
Spirits
Older
Male
co-morbidities

114

What factors might be present in a younger patient with oral cancer?

HPV related (especially HPV16)
Over-express p16, inactivate p53 and Rb

115

What can h pylori cause as a carcinogen?

Chronic Gastritis
Increases risk of Adenocarcinoma and Gastric MALT Lymphoma

116

What problems will be present in a patient with autoimmune chronic gastritis?

Antibodies to parietal cells, intrinsic factor
Reduced pepsinogen 1 secretion
Endocrine cell hyperplasia
B12 deficiency
Defective acid secretion

117

What are some causes of chronic gastritis?

Autoimmune
Chemical: drugs (NSAIDs), alcohol
H pylori

118

What virulence factors do h pylori possess?

Flagella (motile in mucus)
Urease (urea to ammonia, lower pH)
Adhesins
Cytotoxin associated gene A

119

How does h pylori lead to gastric lymphoma?

H. pylori induces polyclonal B cell proliferation

120

Name some causes of constipation

Low-fibre diets
IBS
Hirschsprungs
Autonomic neuropathy
Parkinsons
colon tumours

121

Name some causes of chronic diarrhoea

IBD
IBS
coeliac
pancreatic insufficiency
colon tumours
carcinoid syndrome

122

Name some causes of nausea and vomiting

Bowel obstruction
Gastroenteritis
Head injury
Raised ICP
Migraine

123

What are some causes of localised abdominal distension?

Organomegaly
Bladder obstruction
Hernia
Inflammatory mass
Tumours

124

Give some differentials for rectal bleeding

Blood mixed with stool – colon carcinoma
Blood streaks on stool – rectal carcinoma
Blood after defecation – haemorrhoids
Blood mixed with mucus – colitis
Bleeding – diverticular disease
Bleeding and pain – anal fissure/carcinoma
Melena – upper GI bleed

125

Describe the appearance of the bowel in crohns

Transmural inflammation: serosal fat wrapping, granulomas and lymphoid aggregates
Deep, fissuring ulcers
Stenosis and fistula formation

126

Describe the inflammation present in IBD

Increased inflammatory cells in lamina propria
Gland architectural distortion
Metaplasia – paneth cell/ pyloric
Cryptitis and crypt abscesses
Goblet cell depletion
Deep fissuring ulcers in CD / Superficial ulcers in UC
Transmural inflammation with lymphoid aggregates in CD
Granulomas in CD
Normal areas in between inflamed areas in CD

127

What different types of polyps can be present in the bowel?

Inflammatory polyps
Hyperplastic polyps (no neoplastic potential)
Hamartomatous polyps – Juvenile, Peutz-Jeghers
Sesile Serrated polyps
Adenomas – tubular, tubulo-villous, villous, Dysplasia - low vs high grade

128

What is peutz jeghers syndrome?

Autosomal dominant disorder characterised by development of hamartomatous polyps in GI tract and hyperpigmented macules on lips and oral mucosa

129

What cells do GIST tumours arise from?

Interstitial cells of Cajal – Gut pacemaker

130

What tumours of the appendix can occur?

Mucocele
Low- grade Appendiceal Mucinous Neoplasm (LAMN)
Goblet cell carcinoid
Adenocarcinoma

131

Which histocompatibility complex is associated with coeliac disease?

HLA B8

132

What food types contain gluten which triggers coeliac?

Wheat
Rye
Barley

133

What pathological changes are present in coeliac disease?

Subtotal or total villous atrophy
Crypt hyperplasia

134

What may cause splenomegaly?

Blood oncological conditions: leukaemia, lymphoma
Cirrhosis: portal hypertension
Infections: malaria, glandular fever
Haemolytic anaemia

135

What does whipples disease present with?

Diarrhoea
Abdominal pain
Lymphadenopathy
Fever
Weight loss
Arthritis

136

What are some causes of hepatomegaly?

Congestive cardiac failure
Alcoholic liver disease
Chronic bronchitis
Diabetes Mellitus
Liver mets
Leukaemia
Hepatitis
Haemochromatosis

137

What are some causes of intestinal pseudo obstruction?

Hypothyroidism
Hypokalaemia
Diabetes
Uraemia
Hypocalcaemia

138

Give some GI causes of vomiting

Gastroenteritis
Appendicitis
Pyloric stenosis
Stenosing gastric cancer
Intestinal obstruction

139

Name some GI causes of dysphagia

GORD
Benign oesophageal stricture
Oesophageal cancer
Pharyngeal pouch
Pharyngeal cancer

140

Name some GI causes of acute abdominal pain

Perforated peptic ulcer
Appendicitis
Gastroenteritis
Obstruction
Diverticular disease
IBD
Ischaemia
Pancreaticobiliary

141

Name some GI causes of chronic abdominal pain

IBS
Chronic peptic ulcer
GORD
Gastritis
Gastric cancer
IBD

142

Name some GI causes of haematemesis

Peptic ulcer
Acute gastritis
Mallory Weiss tear
Oesophageal cancer
Gastric cancer
Oesophageal varices
GORD

143

What is an ulcer?

Local defect in the surface of an organ produced by the shedding of inflamed necrotic tissue

144

What is the morphology of an ulcer?

Surface Slough
Granulation tissue
Fibrosis

145

Define lower GI bleed

Bleeding distal to ligament of treitz

146

What commonly causes lower GI bleeds in children and adolescents?

Meckels diverticulum
Polyps
IBD
Intussusception

147

What commonly causes lower GI bleeds in adults?

Diverticular disease
Angiodysplasia
Neoplasm
Ischaemic colitis

148

What causes bleeding in diverticular disease?

Rupture of vasa recta

149

What are the most common regions for angiodysplasia?

Caecum and ascending colon

150

How can angiodysplasia be identified on colonoscopy?

Distinct red mucosal patches consisting of capillaries

151

How does a lower GI bleed due to IBD tend to present?

Bloody diarrhoea

152

What typically causes ischaemic colitis?

Hypoperfusion
Vasospasm
Occlusion

153

How does a patient with ischaemic colitis typically present?

Abdominal pain accompanied with bloody diarrhoea

154

What is the average age at which a patient with FAP will develop colon cancer?

39 years

155

What resuscitation steps might you take for a patient with a severe lower GI bleed?

Large bore IVs
Aggressive volume replacement
Cross match and transfuse as needed
Coagulation studies
Admission to a close monitoring unit

156

What investigations can you do to localise the source of a lower GI bleed?

Proctoscopy: anal outlet bleeding, proctitis, cancer
Flexible sigmoidoscopy: anus and rectum
Colonoscopy
Radio nucleotide imaging
Angiography
NGT lavage - rule out upper GI bleed

157

What are advantages and disadvantages of a colonoscopy?

High diagnostic yield
85% lesions identified
Assess colon and ileum
Low complication rate
Therapeutic
Diminished visualisation with profuse bleeding
Requires bowel prep

158

What are advantages and disadvantages of radionucleotide imaging for GI bleeds?

Sensitivity
Can be repeated in 24 hours
Low complication rate
Not a good localising study
Precursor to angiogram

159

What are advantages and disadvantages of mesenteric angiography?

Sensitivity
Diagnostic and therapeutic
Selective embolisation
Invasive study

160

What are potential complications of mesenteric angiography?

Pseudoaneurysm
Bowel infarction
MI due to vasopressin

161

What are advantages and disadvantages of CT angiography for GI bleeds?

Accessible
Quick
Sensitive
Anatomic detail
No bowel prep needed
Not therapeutic

162

What surgery is performed if the site of a GI bleed is identified vs if it isn't identified?

Identified: segmental resection with anastamosis
Not identified: total colectomy and end ileostomy

163

What proportion of polypectomys will result in post procedure bleeding?

6%

164

How do you treat post polypectomy bleeding?

Endoscopic injection therapy
Electro coagulation
Endoscopic clipping

165

What are most common causes of small intestine bleeding?

Angiodysplasia
Small bowel diverticula
Meckels diverticulum
Neoplasia
Crohn's disease
Aorto enteric fistula

166

What are common organisms which can cause infective colitis?

Campylobacter jejuni
E. coli
Shigella
C diff
Amoebiasis
Cryptosporidium
Giardia

167

What is acute phase treatment for UC?

Enemas in distal disease
Steroids +/- Azathioprine in disease extending proximally

168

What is the management for toxic megacolon?

Initially: IV steroids +/- cyclosporine with careful monitoring of clinical indices, FBC and CRP
If things deteriorate or fail to improve within 48 hours then surgical intervention

169

When is caecal volvulus more common?

Pregnancy
Distal colonic obstruction

170

How do you manage a caecal volvulus?

Laparotomy if fit, derotation, fixation/resection
If bowel looks non viable then hemicolectomy

171

A 51 year old man is referred to open access endoscopy unit with Hx of new onset dyspepsia and iron deficiency anaemia. He undergoes endoscopy at which there is diffuse thickening of the gastric mucosa with occasional superficial erosions. What is the likely pathology?

Gastric lymphoma
T cell Hodgkin's lymphoma related to h pylori infection
Symptoms mimic gastritis/peptic ulceration

172

What are risk factors for developing a gastric ulcer?

H pylori
Smoking
Chronic liver disease
Chronic renal failure
Hyperparathyroidism
Drugs: aspirin, steroids, NSAIDs)

173

What are risk factors for gastric carcinoma?

Diet: high salt, high starch, pickled and smoked food)
Cigarette smoking
Blood group A
Alcohol
Premalignant conditions: pernicious anaemia, menetriers disease, adenomatous polyposis, juvenile polyps, previous gastric resection)

174

What is the treatment for gastric carcinoma?

D2 gastrectomy with pre op chemo: epirubicin, cisplatin and 5-fluorouracil

175

A 34 year old man is admitted with suspected perforated acute appendicitis and undergoes an emergency laparotomy. On the ward 2 hours after, he is noted to have irregular tachycardia of 120bpm. His BP is 120/70 and he is pyrexial at 38.5. What is the likely problem?

Atrial fibrillation related to infection

176

When is anastomotic leak a particular problem in colorectal surgery?

Low anterior resection

177

What are signs and symptoms of thiamine deficiency?

Muscle tenderness, weakness, reduced reflexes
Confusion, memory impairment
Impaired wound healing
Poor balance, falls
Constipation
Reduced appetite
Fatigue

178

List some possible causes for a dupuytrens contracture

Epilepsy
Diabetes Mellitus
Alcoholic liver disease
Smoking
Trauma
Heavy manual labour

179

What is the mutated gene defect in hereditary non polyposis colonic carcinoma?

Mismatch repair genes important for DNA surveillance

180

What is the typical presentation for a patient with HNPCC?

Colon cancer at age 40
Females with endometrial and ovarian carcinoma

181

What is von Hippel Lindau disease?

Autosomal dominant condition associated with presence of phaeochromocytomas, CNS haemangiomas and hypernephromas
Due to absence of tumour suppressor gene vHL

182

What is peutz jeghers syndrome?

Autosomal dominant condition associated with mucocutaneous pigmentation and multiple GI hamartomas

183

Name some drugs which associated with acute pancreatitis

Steroids
Oestrogens
Thiazides
Valproate
Azathioprine
Alcohol
Chemo: cisplatin/vinca alkaloids

184

A 68 year old female with difficulty swallowing. She has not lost any weight, she has a history of rheumatic fever as a child and on examination she is in atrial fibrillation. What is the likely cause of her dysphagia?

Left atrial dilatation

185

A 60 year old has longstanding history of GORD. He complains of difficulty in swallowing but has not lost any weight. What is the likely cause of his dysphagia?

Benign stricture of the oesophagus

186

A 67 year old male with a history of ischaemic heart disease and stroke presents with a few months progressive difficulty swallowing and weight loss of one stone. To begin with it affected solids more than liquids but he is now having difficulty with liquids as well. What is the likely cause of his dysphagia?

Carcinoma of the oesophagus

187

A 35 year old male has longstanding difficulty swallowing. He has difficulty with both liquids and solids. He has not lost any weight. An endoscopy shows a dilated oesophagus with food debris in it. What is the likely cause of his dysphagia?

Achalasia of the cardia

188

What are risk factors for dupuytrens contracture?

Male sex
Age over 40
Family history
Diabetes mellitus
High alcohol intake
Smoking
Trauma
Anticonvulsant medication

189

Give some causes for portal hypertension

Pre hepatic: portal vein thrombosis, splenic vein thrombosis, tumoral compression
Hepatic: cirrhosis, hepatitis, alcoholic hepatitis, primary biliary cirrhosis, Wilson's disease, haemochromatosis
Post Hepatic: thrombosis of IVC, right HF, constrictive pericarditis, severe tricuspid regurgitation, budd chiari syndrome, arterial portal venous fistula

190

What can be some causes of poor nutrition?

Poverty
Isolation – eating alone
Sarcopenia
Physical ill health
Mental ill health
Dementia

191

What is malnutrition?

State of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome

192

What are some potential consequences of malnutrition in secondary care?

Increased Complications
Increased Sepsis
Increased length of stay
Increased Readmission Rate

193

What are potential consequences of malnutrition in primary care?

Increased Hosp Admissions
Increased Dependency
Increased GP visits
Increased Treatment Costs

194

Which types of patients are at risk of malnutrition?

Elderly (especially if institutionalised)
Chronic ill-health e.g. diabetes, renal, COPD, neuro
Cancer
Deprivation / poverty
GI disorders / post GI surgery
Alcoholics
Drug Dependency
Poor Dentition/oral care
Dysphagia
Patients with Altered Nutritional Requirements: Critical care, Sepsis, Cancer, Trauma, Surgery, Renal Failure, Liver Disease, GI and pancreatic disorders, COPD, Pregnancy

195

What screening tool is used to identify patients at risk of malnutrition?

MUST: malnutrition universal screening tool

196

What are the components of the MUST screening tool?

BMI: very underweight less than 18.5, underweight 18.5 - 19.9
Weight loss score: >10%, 5-10%
Acute disease effect score

197

What tests can be done to look for h pylori? What special instructions should be given before?

Urea breath test: 2 weeks before, stop taking abx, bismuth and PPI
Blood test: antibodies to h pylori, can remain positive for years
Stool test: diagnose infection and confirm cure after treatment
Biopsy: usually done opportunistically during endoscopy

198

What are aspects of a nutritional assessment?

Weight
Height
BMI
Percentage weight loss
Anthropometrics (MUAC, TSF, Grip Strength, MAMC)
Biochemistry
Assessment of current intake
Subjective global assessment
Hydration
?Bowels and nausea
?Swallowing difficulties/oral health
Re-feeding syndrome

199

What are some risk factors for hiatus hernia?

Obesity
Increased intra abdominal pressure
Previous hiatal operation

200

What is the appropriate management for a patient who scores 0 on their must assessment?

Repeat screening weekly
If patient obese, consider outpatient referral to dietician

201

What is the appropriate management for a patient who scores 1 on their must assessment?

Observe and record food and drink intake
Highlight risk at nursing handover and medical rounds
Offer milky drinks and snacks
Encourage high calorie meal choices
Repeat screening weekly

202

What would be classed as clinically significant weight loss?

Unintentional weight loss greater than 10% in past 3-6 months

203

What is the appropriate management for a patient who scores 2+ on their must assessment?

Inform medical team
Refer to dietician
Observe and record food and drink intake
Highlight risk at nursing handover and medical rounds
Offer milky drinks and snacks
Encourage high calorie meal choices
Repeat screening weekly

204

What measurements can be taken to assess someone's nutritional status?

% weight loss
MUAC: mid upper arm circumference
Hand grip strength
TSF: triceps skin fold

205

What are some causes of low albumin?

Sepsis
Acute/chronic inflammatory conditions
Cirrhosis
Nephrotic syndrome
Malabsorption
Malnutrition

206

What are some benefits of adequate nutrition support?

Increased immune function
Enhanced wound healing
Improved ventilation and respiratory reserve
Mobility
Better psychological status
Decreased length of stay
Decreased infectious complications
Decreased morbidity and mortality

207

What is a potential complication of chronic liver disease for which you may need to do an ascitic tap?

Spontaneous bacterial peritonitis

208

What type of diet should be advised in advanced chronic liver disease and why?

Low protein
Protein breakdown in bowel results in ammonia production which is implicated in precipitation of hepatic encephalopathy

209

What are different types of nutritional support?

Whole food by mouth
Nasogastric tube
Nasoduodenal tube
Nasojejunal tube
Gastrostomy tube
Jejunostomy tube
Total parenteral nutrition
Peripheral parenteral nutrition

210

What oral nutritional support can be provided?

High energy/protein diet
Little and often
Food fortification
Build up soups/shakes

211

What are indications for enteral nutrition?

Nil by mouth - dysphagia
Sedated - low GCS
Unable to meet nutritional requirements orally - poor appetite, drowsy, high requirements due to disease
Strictures
Pre op nutrition support
Oncology

212

What are problems with enteral nutrition?

Tube removal
Loose stools
Vomiting and nausea
Aspiration

213

What does nice guidance say about enteral feeding and dementia?

Artificial feeding should not be used in people with severe dementia for whom dysphagia or disinclination to eat is a manifestation of disease severity

214

Why is parenteral nutrition used?

Intestinal failure - post op ileus, bowel obstruction, short bowel syndrome, fistulas

215

What is refeeding syndrome?

Potentially life threatening complication in severely malnourished patients
Fluid and electrolyte shifts, metabolic complications

216

Who is particularly at risk of refeeding syndrome?

Chronic alcoholics
Chronic malnutrition
Anorexia nervosa
Prolonged fasting
Patients unfed for >5 days with evidence of stress and depletion
Chronic antacid users
Chronic diuretic users
Oncology patients on chemotherapy
Malabsorption

217

What factors are levels of risk of refeeding syndrome based on?

BMI
Unintentional weight loss
Length of time with little/no nutrition
Electrolyte levels prior to initiation of feeding

218

What electrolyte disturbances occur in refeeding syndrome?

Hypokalaemia
Hypomagnesaemia
Hypophosphataemia
Thiamine deficiency
Salt and water retention

219

What are potential complications of refeeding syndrome?

Cardiac failure
Cardiac arrest
Pulmonary oedema
Arrhythmias
Respiratory depression
Liver dysfunction
Polyuria
Bowel disturbance
Weakness
Confusion
Lethargy
Seizures
Tremors
Death

220

When refeeding a patient, what precautions should be taken to avoid refeeding syndrome?

Introduce feed slowly
Vitamins prescribed to support metabolism: forceval, ketovite tablets, pabrinex, vit B co strong
Daily monitoring and replacement of electrolytes

221

What conditions can lead to malabsorption?

Coeliac disease
Pancreatitis
Surgical resection of ileum
Crohn's
Lactase deficiency

222

What are symptoms of malabsorption?

Weight loss
Abdominal distension
Diarrhoea
Steatorrhoea
Pernicious anaemia
Hypochromic anaemia

223

What tests can be done for coeliac disease?

Endomysial antibody
IgG antigliadin antibody
Jejunal biopsy
Anti TTG (tissue transglutaminase)

224

What tests can be done for chronic pancreatitis?

Function: faecal elastase
Form: cross-sectional imaging (CT)

225

What are the Rome III criteria for diagnosing irritable bowel syndrome?

Recurrent abdominal pain or discomfort at least 3 days a month in past 3 months
Associated with two or more of following: improvement with defecation, onset associated with a change in frequency of
stool, onset associated with a change in appearance of stool

226

What investigations can be done for irritable bowel syndrome?

Bloods: B12, folate, iron, tTG, thyroid function
Stool: Faecal calprotectin
Colonsocopy

227

What stool volumes mean diarrhoea?

Stool volume >200mls/day
Stool weight >200g/day

228

What is the treatment for pseudomembranous colitis?

Metronidazole

229

Describe the colonic inflammation in ulcerative colitis

Superficial
Continuous
Always present in the rectum
Limited to the colon

230

What features would make you suspect an acute severe colitis?

Stools >6/day
Temp >37.8
Pulse >90
Hb 30mm/hr
Truelove-Witts criteria

231

What investigations would you do for acute severe colitis?

Bloods
Stool culture, blood culture
Stool for c.difficile toxin
Abdominal x-ray
Sigmoidoscopy and biopsy

232

What would you do to manage acute severe colitis?

Admission
Fluid resuscitation
Steroids: IV 5 days
Antibiotics
If not getting better: Ciclosporin, Inflixamab, Colofixamab, Surgery

233

What is the most common cause of upper GI haemorrhage?

Peptic ulcer disease

234

List two risk factors for peptic ulcer formation

H. pylori
Drugs
Smoking

235

What are the symptoms of dyspepsia?

Epigastric pain
Heartburn
Reflux

236

How do you manage dyspepsia?

Alarm signs or >55yrs: Upper GI endoscopy
Lifestyle
Antacids
PPI
If no improvement: H. pylori test

237

How do we test for H. Pylori?

Carbon-13 urea breath test or a stool antigen test

238

What treatment regimen is used to eradicate H pylori?

PPI, amoxicillin and either clarithromycin or metronidazole

239

What are the alarms symptoms for dyspepsia?

Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena / haematemesis
Swallowing difficulty

240

What is the management for a mallory Weiss tear?

Most bleeds are minor and discharge is usual within 24 hours
OGD if necessary: Clip, Adrenaline

241

A 27 year old presents with a 3 day Hx Melaena and has vomited a cup full of blood this morning. On examination pulse 105, BP 104/68, T 37.0, RR 14, Sats 98%, Pale conjunctive, Chest clear. HS normal. Abdomen soft. Mild epigastric tenderness. PR – black tarry stools. No fresh blood. What is the immediate management?

ABCDE approach
Consider need for 02
Large bore cannulas to each ACF
Blood for FBC, Xmatch, U+E, clotting, LFT
Start iv fluid replacement: Crystalloids, Blood, Consider clotting products
Calculate Blatchford score
Further management dependent upon likely cause/severity of bleeding

242

A 42 year old unemployed man presents with a one hour history of vomiting fresh blood. He has a background history of excess alcohol usage. What is the likely diagnosis?

Ruptured oesophageal varices

243

How do you manage ruptured oesophageal varices?

Initially manage as per all GI haemorrhage
Terlipressin
Prophylactic antibiotics
If endoscopy fails SB (Sengstaken–Blakemore) tube temporary salvage
Consider TIPSS (Transjugular intrahepatic portosystemic shunt)

244

What is the appropriate follow up after a ruptured oesophageal varices event?

Repeat endoscopy initially after 3 months, then after 6 more months then yearly
Management of liver disease
Consider beta-blockade (prophylaxis)

245

What bowel signs and symptoms require urgent referral for suspected bowel cancer?

Bleeding and:
Abdominal pain
Change in bowel habit
Weight loss
Iron-deficiency anaemia
Rectal / abdominal mass
Faecal occult blood

246

What is the management for diverticulitis?

Mild attacks managed at home with oral fluids and antibiotics
If more severe: NBM, IV fluid, Antibiotics, USS/CT to detect abscesses, CT-guided drainage of abscesses

247

How does haemorrhoidal disease typically present?

Painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass

248

What is the difference between internal and external haemorrhoids?

Internal haemorrhoids proximal to dentate line in anal canal
Eternal haemorrhoids distal to dentate

249

What are treatment options for haemorrhoids?

Increase dietary fibre, rubber band ligation, infrared photocoagulation, sclerotherapy, surgical haemorrhoidectomy

250

What are potential complications of haemorrhoids?

Recurrence or worsening of symptoms, excessive bleeding and non-reducible prolapse

251

What are some causes of colitis?

Infective inc. psueomembranous
IBD
Ischaemic
Radiation
Necrotizing enterocolitis in newborns

252

List some associated symptoms of IBD

Eyes: episcleritis, uveitis
Kidneys: stones, hydronephrosis, fistulae, UTI
Skin: erythema nodosum, pyoderma gangrenosum
Mouth: stomatitis, apthous ulcers
Liver: steatosis
Biliary tract: gallstones, sclerosis cholangitis
Joints: spondylitis, Sacroiliitis, peripheral arthritis
Circulation: phlebitis

253

How does angiodysplasia present?

Chronic, painless intermittent rectal bleeding
May be long periods of time between bleeds

254

What can be seen on colonoscopy in a patient with angiodysplasia?

Abnormal epithelium
Small lesions with irregular edges and a draining vein

255

What is the management for angiodysplasia?

Supportive care
Angiography with embolisation
Colonoscopy with: Cautery, Clips, Adrenaline, R colon is thin walled so risk of perforation

256

Why does Crohn's increase risk of gallstones?

Decreased bile salt content due to terminal ileum resection/disease involvement so higher concentration of cholesterol in bile

257

Why can cholangitis lead to a prolonged prothrombin time?

Gallstone obstructs pancreas
This leads to reduced fat soluble vitamin uptake so reduced vit K and therefore increased PT

258

Why do you not give morphine to a patient with acute pancreatitis?

Causes sphincter of oddi to contract so may make it worse

259

What investigations would you do for suspected diverticulitis?

FBC
ESR
CRP
CT colon
Don't do colonoscopy during acute attack due to risk of perforation