GASTRO Flashcards

Question

How will your differentials change in males compared to females?

Answer 1

Boys with abdominal pain may have torsion of the testis. In women, consider gynaecological causes, e.g. ruptured ovarian cyst, pelvic inflammatory disease, endometriosis or an ectopic pregnancy.

Answer 2

Inflammation usually produces constant pain exacerbated by movement or coughing. Colicky pain arises from hollow structures, e.g. small or large bowel obstruction, or the uterus during labour. It lasts for a short period of time (seconds or minutes), eases off and then returns.

Answer 3

* Pain radiating from the right hypochondrium to the shoulder or interscapular region may reflect diaphragmatic irritation, e.g. in acute cholecystitis. * Pain radiating from the loin to the groin and genitalia is typical of renal colic. * Central upper abdominal pain radiating through to the back, partially relieved by sitting forward, is common in pancreatitis. * Central abdominal pain, which later shifts into the right iliac fossa, occurs in acute appendicitis. * The combination of severe back and abdominal pain may indicate a ruptured or dissecting abdominal aortic aneurysm.

Answer 4

late feature of distal small-bowel or colonic obstruction

Answer 5

Ascites is an accumulation of fluid in the peritoneal cavity.

Answer 6

Exudates from the peritoneal membrane have a higher protein content than transudates and indicate inflammatory or malignant disease

Answer 7

* Idiopathic aphthous ulceration (most common) * Gastrointestinal disease: –Inflammatory bowel disease –Coeliac disease •Infection: –Viral – herpes simplex virus (HSV), human immunodeficiency virus (HIV), Coxsackie –Fungal – candidiasis –Bacterial – syphilis, tuberculosis •Systemic disease: –Reactive arthritis (see p. 686) –Behçet syndrome –Systemic lupus erythematosus •Trauma: –e.g. Dentures •Neoplasia: –e.g. Squamous cell carcinoma •Drugs: –In erythema multiforme major, toxic epidermal necrolysis –Chemotherapy, antimalarials •Skin disease: –Pemphigoid –Pemphigus –Lichen planus

Answer 8

Human papillomavirus 16

Answer 9

leucoplakia (single adherent white patch), lichen planus, submucous fibrosis and erythroplakia (a red patch)

Answer 10

Treatment is by surgical excision, which may require extensive neck dissection to remove involved lymph nodes and/or radiotherapy. Ablative treatment with photodynamic therapy is being pioneered for early lesions.

Answer 11

Malignant tumours of the mouth account for 1% of all malignant tumours in the UK. The majority develop on the floor of the mouth or lateral borders of the tongue.

Answer 12

Persistent white patches can be due to leucoplakia, which is associated with alcohol and (particularly) smoking; it is pre-malignant. A biopsy should always be taken;

Answer 13

histology shows alteration in the keratinization and dysplasia of the epithelium

Answer 14

Glossitis is a red, smooth, sore tongue associated with vitamin B12, folate, iron, riboflavin and nicotinic acid deficiency. It is also seen in infections due to Candida.

Answer 15

•Dry mouth (xerostomia): –Sjögren syndrome –Drugs (e.g. antimuscarinic, anti-parkinsonian, lithium, tricyclics, monoamine oxidase inhibitors (MAOIs)) –Radiotherapy –Psychogenic –Dehydration •Acute sialadenitis: –Viral (e.g. mumps) –Bacterial (e.g. Staphylococcus, Streptococcus) •Salivary duct obstruction: –Calculus •Sarcoidosis (see pp. 1118–1120) •Neoplasms (3% of all tumours worldwide): –Pleomorphic adenoma (15% become malignant and can cause VII lower motor neurone signs)

Answer 16

The oesophagus is lined by stratified squamous epithelium, which extends distally to the squamocolumnar junction where the oesophagus joins the stomach, recognized endoscopically by a zigzag (‘Z’) line, just above the most proximal gastric folds.

Answer 17

Vitamin B12 deficiency is caused by the malabsorption of vitamin B12. The commonest cause is pernicious anaemia. There is atrophic gastritis leading to a failure in the production of intrinsic factor. This is an autoimmune condition and is associated with other autoimmune diseases, such as thyroid disease and vitiligo.

Answer 18

gastric carcinoma

Answer 19

High dietary content of phosphates and phytate (in chapatti flour) can inhibit iron absorption by forming insoluble complexes.

Answer 20

pregnancy and iron-deficiency anaemia

Answer 21

* The submucosal plexus or Meissner plexus on the outer edge of the submucosa adjacent to the circular muscle layer * The myenteric plexus or Auerbach plexus lying between the circular and the longitudinal muscle layers.

Answer 22

↑ Enzyme secretion | ↑ Contraction

Answer 23

G cells, antrum of stomach Parietal cells in the body of the stomach ↑ Acid secretion Enterochromaffin-like cells ↑ Histamine secretion Gastrointestinal mucosa ↑ Growth

Answer 24

Dry mouth Disease of the salivary glands may lead to impaired secretion of saliva, giving rise to xerostomia (dry mouth).

Answer 25

Sjögren syndrome is an autoimmune condition in which saliva-secreting cells are destroyed. There may be associated parotid gland enlargement, with ensuing dry mouth. Dry eyes, skin and vagina are also clinical features. This condition can occur in association with other systemic autoimmune diseases (e.g. rheumatoid arthritis, thyroid disease, etc.). Difficulty with swallowing because of the lack of lubrication and mouth ulcers and oral infections may be a manifestation of systemic disease.

Answer 26

‘Water brash’ is a symptom in which there is a sudden inflow of saliva into the mouth, but without the stimulation of food. This is sometimes associated with peptic ulceration and inflammatory bowel disease.

Answer 27

Cyclizine-50mg/8h PO/IV/IM-GI causes | Cinnarizine 30mg/8h PO Vestibular disorders

Answer 28

Metoclopramide 10mg/8h PO/IV/IM GI causes; also prokinetic Domperidone 60mg/12h PR; 20mg/6h PO Also prokinetic Prochlorperazine 12.5mg IM; 5mg/8h PO Vestibular/GI causes Haloperidol 1.5mg/12h PO Chemical causes, eg opioids

Answer 29

Ondansetron 4mg/8h IV slowly | Doses can be much higher for, eg, emetogenic chemotherapy

Answer 30

Alarm symptoms: Anaemia (iron deficiency); Loss of weight; Anorexia; Recent onset/progressive symptoms; Melaena/haematemesis; Swallowing difficulty.

Answer 31

* Dysphagia: discomfort experienced as obstruction when swallowing solids or fluids * Odynophagia: pain when swallowing * Heartburn: retrosternal pain experienced as a burning sensation that may spread to the neck and across the chest, often worse in the supine position or when bending over * Reflux: when food or liquid regurgitates into the mouth without any rise in intra-abdominal pressure (as in vomiting).

Answer 32

H. pylori (90%); drugs (NSAIDS; steroids; SSRI)

Answer 33

increased Gastric acid secretion; increased gastric emptying (decreased duodenal pH); blood group O; smoking. The role of stress is debated.

Answer 34

Epigastric pain typically before meals or at night, relieved by eating or drinking milk. 50% are asymptomatic; others experience recurrent episodes. Sx: epigastric tenderness

Answer 35

Upper GI endoscopy (stop PPI 2wks before). Test for H. pylori. Measure gastrin concentrations when off PPIS if Zollinger–Ellison syndrome (p730) is suspected.

Answer 36

Non-ulcer dyspepsia; duodenal Crohn’s; TB; lym- phoma; pancreatic cancer

Answer 37

occur mainly in the elderly, on the lesser curve. Ulcers else- where are more often malignant.

Answer 38

H.pylori (~80%); smoking; NSAIDS; reflux of duodenal contents; delayed gastric emptying; stress, eg neurosurgery or burns (Cushing’s or Curling’s ulcers).

Answer 39

Asymptomatic or epigastric pain (related to meals ± relieved by antacids) ± weight loss

Answer 40

Upper endoscopy to ex- clude malignancy (stop PPI >2wks before, see FLOWCHART); multiple biopsies from ulcer rim and base (histology, H. pylori ) and brushings (cytology). Repeat endoscopy (eg if perforation or bleeding) to check healing (biopsy if suspicious of gastric ca).

Answer 41

Lifestyle: Purge stress by creating opportunities for people to move from disease into health through dialogue and reflection on their lives—eg would he/she see benefit in reduction in alcohol and tobacco use? Both will help. Avoid any aggravating foods. H. pylori eradication: Triple therapy is 80–85% effective at eradication. Drugs to reduce acid If symptoms persist, re-endoscope, recheck for H. pylori, and reconsider differential diagnoses (eg gallstones). Surgery: p626.

Answer 42

PPIS are effective, eg lansoprazole 30mg/24h PO for 4 (DU) or 8 (GU) wks. H2 blockers have a place (ranitidine 300mg each night PO for 8wks). Drug-induced ulcers: Stop drug if possible. PPIS may be best for treating and preventing GI ulcers and bleeding in patients on NSAID or antiplatelet drugs. Misoprostol is an alternative with different SE

Answer 43

Bleeding, perforation, malignancy, gastric outflow reduced .

Answer 44

Sliding hiatus hernia (80%) is where the gastro-oesophageal junction slides up into the chest. Acid reflux often happens as the lower oesophageal sphincter becomes less competent in many cases. Rolling hiatus hernia (20%) is where the gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus. As the gastro-oesophageal junction remains intact, gross acid reflux is uncommon.

Answer 45

Common: 30% of patients >50yrs, especially obese women. 50% have symptomatic gastro-oesophageal reflux.

Answer 46

leads to large losses of secreted acids from the body. | may result in metabolic alkalosis.

Answer 47

excessive loss of fluid (and hence NaHCO3) in faeces. | may result in metabolic acidosis.

Answer 48

1). Secretory diarrhoea Increased active secretion, or an inhibition of absorption. No structural damage, e.g. cholera. 2). Osmotic diarrhoea Loss of water due to a heavy osmotic load, e.g. in maldigestion (e.g. Coeliac disease), where the nutrients remain in lumen, in turn pulling water into the lumen. 3).Motility-related diarrhoea Abnormally high GI motility, decreasing time available for absorption of nutrients and water. Can occur in diabetic neuropathy. 4). Inflammatory diarrhoea Damage to the mucosal lining or brush border leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Caused by bacterial infections, viral infections, parasitic infections or autoimmune problems e.g. inflammatory bowel disease.

Answer 49

Maintenance of fluid/electrolyte balance (especially Na+ and K+). Anti-infective agents. Anti-diarrhoeal agents.

Answer 50

Work (is he a chef?—don’t work until an infective cause is ruled out) Acute or chronic? If acute (<2wks) suspect gastroenteritis—any risk factors? HIV; achlorhydria, eg PA, p328, or on acid suppressants, eg PPI? Travel? Diet change? Contact with D&V? Any fever/pain? Chronic diarrhoea alternating with constipation suggests irritable bowel (p276). Weight loss, nocturnal diarrhoea and anaemia mandate close follow-up (UC/Crohn’setc?).

Answer 51

``` Campylobacter, Shigella/Salmonella (p426), E. coli, amoebiasis (p436), UC, Crohn’s, colorectal cancer (p618), colonic polyps, pseudomembranous colitis, ischaemic colitis (p622). Fresh PR bleeding! ```

Answer 52

occurs in IBS(p276), colorectal cancer, and polyps

Answer 53

suggests IBD, diverticulitis, or a fistula/abscess. White cells are microscopically absent in amoebiasis, cholera, E. coli and viruses.

Answer 54

* Gastroenteritis * Parasites/protozoa * IBS (p276) * Colorectal cancer * Crohn’s; UC; coeliac

Answer 55

* Microscopic colitis * Chronic pancreatitis * Bile salt malabsorption • Laxative abuse * Lactose intolerance * Ileal/gastric resection * Overflow diarrhoea * Diverticular disease * Bacterial overgrowth * C. difficile (BOX)

Answer 56

* Thyrotoxicosis * Autonomic neuropathy • Addison’s disease * Ischaemic colitis * Tropical sprue •Pellagra • Gastrinoma * VIPoma • Carcinoid•Amyloid

Answer 57

• Antibiotics3 • PPI • Propranolol • NSAIDS • Cytotoxics • Digoxin • Laxatives Alcohol

Answer 58

Dehydration—dry mucous membranes, reduced skin turgor capillary refill >2s; shock (!think of cholera) Any fever, weight loss, clubbing, anaemia, oral ulcers , rashes or abdominal mass or scars? Any goitre/hyperthyroid signs? Do rectal exam for masses (eg rectal cancer) or impacted faeces (if you don’t put your finger in, you’ll put your foot in it by missing this diagnosis that never responds to codeine!)

Answer 59

• Blood FBC: reduced MCV/Fe deficiency, eg coeliac or colon ca; MCV increased if alcohol abuse or reduced B12 absorption, eg in coeliac or Crohn’s; eosinophilia if parasites. Raised ESR/CRP: Infection, Crohn’s/UC, cancer. U&E: Low K+≈severeD&V. Raised TSH:Thyrotoxicosis. Coeliac serology. • Stool MC&S: Bacterial pathogens, ova cysts, parasites C. diff toxin. Faecal fat excretion or 13C-hiolein (highly labelled triolein) breath test (nicer and reliable) if symptoms of chronic pancreatitis, malabsorption, or steatorrhoea

Answer 60

* Rigid sigmoidoscopy With biopsy of normal and abnormal looking mucosa: ~15% of patients with Crohn’s disease have macroscopically normal mucosa. * Colonoscopy/barium enema (malignancy? colitis?) !Avoid in acute episode. If normal, consider small bowel radiology (eg Crohn’s) ± ERCP (chronic pancreatitis).

Answer 61

Ask about frequency, nature, and consistency of stools. Is there blood or mucus in/on the stools? Is there diarrhoea alternating with constipation (eg IBS, p276)? Has there been recent change in bowel habit? Any pain?Ask about diet and drugs.

Answer 62

It is more common in middle-aged men and is premalignant for adenocarcinoma of the oesophagus, requiring careful surveillance with repeated endoscopy and intensive medical therapy. High-grade cases may need mucosal ablation or surgery

Answer 63

Prolonged vomiting or aspiration of gastric juice can lead to hypo(check this) chloraemic, hypokalaemic, metabolic alkalosis. Excessive loss of alkaline intestinal fluid leads to metabolic acidosis. Death may result unless intravenous infusions of NaCl, dextrose and K+ are given. This is particularly important in hyperemesis gravidarum – prolonged vomiting in pregnancy.

Answer 64

Reflux pain: burning, worse on bending, stooping or lying down •Seldom radiates to the arms •Worse with hot drinks or alcohol •Relieved by antacids ``` Cardiac ischaemic pain •Gripping or crushing •Radiates to neck or left arm •Worse with exercise •Accompanied by dyspnoea ```

Answer 65

(?None in young, mildly affected patients.) Indications for investigation: age >40yrs; change in bowel habit; associated symptoms (weight loss, PR mucus or blood, tenesmus). Blood: FBC, ESR, U&E, Ca2+, TFT. Sigmoidoscopy and biopsy of abnormal mucosa. Barium enema/colonoscopy if suspected colorectal malignancy. Transit studies; anorectal physiology; biopsy for Hirschprung’s etc are occasionally needed.

Answer 66

Often reassurance, drinking more, and diet/exercise advice is all that is needed. Treat causes . A high-fibre diet is often advised, but may cause bloating without helping constipation

Answer 67

INCREASE faecal mass, so stimulating peristalsis. They must be taken with plenty of fluid and may take a few days to act.

Answer 68

difficulty in swallowing; GI obstruction; colonic atony; faecal impaction

Answer 69

Bran powder 3.5g 2–3 times/d with food (may hinder absorption of dietary trace elements if taken with every meal). Ispaghula husk, eg 1 Fybogel® 3.5g sachet after a meal, mixed in water and swal- lowed promptly (or else it becomes an unpleasant sludge). Methylcellulose, eg Celevac® 3–6 500mg tablets/12h with ≥300mL water. S terculia, eg Normacol® granules, 10mL sprinkled on food daily.

GASTRO Flashcards

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