Gastroenterology

Question 1

Definition of Crohn’s Disease

Answer 1

IBD which affects entire GIT mouth to anus, transmural inflammation

Question 2

Risk factors for Crohn’s

Answer 2

GxE 
Genetic predisposition 
Family history
Smoking
Western lifestyle

Question 3

Signs & Symptoms of Crohn’s

Potential differentials

Answer 3

Diarrhoea +/- mucus
Weight loss
FTT
Fatigue
Maliase
Crampy abdo pain
Skin manifestations: pyoderma grangrenosum, erythema nodosum
Complications e.g. bowel obstruction

Differentials: IBS, IBD e.g. UC, gastroenteritis, C diff infection, malignancy, coeliac, acute appendicitis

Question 4

Investigations into potential IBD

Answer 4

• Bloods:
		○ FBC; anaemia (Hb), infection (WCC)
		○ U&Es
		○ LFTS; low albumin
		○ CRP/ESR; inflammation
		○ Fe studies; anaemia, B12 & folate; nutritional status

	• Stool:
		○ Culture; r/o infective process
		○ Calprotectin
	• Colonoscopy 
		○ Biopsies to confirm Crohn's vs UC
		○ R/O malignancy
Surveillance as well for CrCa risk

Question 5

Management of Crohn’s

Answer 5

Management: - aim to induce & maintain remission
Medical
• Steroids - used in acute exacerbations +/- 5-ASA analogues to reduce inflammation
• 5-ASA e.g. sulfasalazine, mesalazine - reduce relapses, anti-inflammatory agents
• Immunosuppressives e.g. azathioprine, methotrexate - reduce relapses, steroid sparing agents
• Anti-TNF agents e.g. infliximab - very affective in achieving & maintaining remission, usually reserved for refractory cases

Surgical
• Local resection of disease
• Stoma formation
• Treatment of complications

Question 6

Complications of Crohn’s

Answer 6

GI complications
	• Haemorrhage e.g. PR bleeding 
	• Bowel strictures
	• Bowel obstructions
	• Fistula formation
	• Malabsorption
Colorectal carcinoma

Other complications
• Kidney stones
• Gallstones
Uveitis

Question 7

Pathology of Ulcerative Colitis

‘‘CLOSE UP’’

Answer 7

Continuous submucosal inflammation of large intestine

Continuous inflammation
Limited to colon & rectum
Only submuscoal 
Smoking - protective
Excrete blood/mucus
Use aminosalicytes
Primary sclerosing cholangitits

Question 8

Risk factors for UC

Answer 8

Genetic predispositon

Ex-/non-smokers

Question 9

S&S of UC

Answer 9

Diarrhoea
Constipation - when rectum becomes inflamed
Mucus
PR bleeding
Weight loss
Fever 
Skin manifestations

Question 10

Management of UC

Answer 10

Medical - induce & maintain remission
• Mesalazine (topical anti-inflammatory) +/- steroids in acute flare ups
• Thiopurines (azathioprine and mercaptopurine): work through purine synthesis inhibition in lymphocytes leading to immunosuppression.
○ Must check TPMT enzyme activity before use.
○ Homozygous mutations in TPMT can lead to dangerous bone marrow suppression.
○ Major side-effects include pancreatitis and hepatotoxicity.
• Biologics: infliximab/adalimumab
○ tumour necrosis factor alpha inhibitors

Surgical
Panproctocolectomy; technically curative

Question 11

Complications of UC

Answer 11

• Hemorrhage
	• Toxic megacolon
	• Colorectal carcinoma
	• Fatty liver
Primary sclerosing cholangitis

Question 12

Pathology of colorectal carcinoma

Answer 12

Mostly adenocarcinoma
Tend to arise from adenoma-carcinoma sequence - due to damage & repair cycles
Common mutations inc APC - Kras - p53

Question 13

Risk factors/aetiology - colorectal carcinoma

Answer 13

Environmental factors - diet, red meat, alcohol
Chronic inflammation or IBD
Hereditary syndromes - Lynch (MLH1 & MSH2), FAP (APC)

Question 14

Signs & Symptoms of Colorectal carcinoma (L vs R)

Answer 14

Left sided & rectum; CIBH, rectal bleeding, blood/mucus, tenesmus

Right sided (later presentation); IDA, signs of anaemia, weight loss, lower abdominal pain (rarer)

Question 15

2WW Criteria for CrCa

Answer 15

Aged 40 or over with unexplained weight loss AND abdominal pain

Aged 50 or over with unexplained rectal bleeding

Aged 60 or over with IDA or CIBH

Any +ve FIT tests

Question 16

Investigations into CrCa

Answer 16

Examination - PR & abdominal

Bloods - FBC (anaemia), Fe studies (anaemia), LFTs, CEA

Stool - culture, calprotectin, FIT or FOB test

Imaging - sigmoid/colonoscopy + biopsies, CT/MRI for staging

Question 17

Treatment for CrCA

Answer 17

Surgery - resection, stoma formation +/- chemotherapy

Palliative options inc stenting/bypass

Question 18

Complications of CrCa

Answer 18

Bowel Obstruction

Perforations

Question 19

Pathology of oesophageal ca

Answer 19

Upper - squamous cell, arises from mutational damage/repair cycles
Lower - adenocarcinoma, due to GORD/Barrett’s oesophagus

Question 20

Risk factors for oesophageal ca

Answer 20

SCC - diet, smoking, HPV-16, HPV-18, alcohol

Aden - GORD, Barrett’s, reflux, obesity, ZE syndrome

Question 21

S&S of oesophageal ca - potential differentials

Answer 21

• Progressive dysphagia
  
  • Weight loss
  • Cachexia
  • Fever
  • Anaemia
  • Retrosternal pain
  • Hoarse voice

Differentials: any condition which may cause/contribute to dysphagia e.g. strictures, achalasia, myasthenia gravis

Question 22

Investigation - Oesophageal Ca

Answer 22

OGD + biopsy
CXR
Barium swallow
CT/PET for staging

Question 23

2WW Criteria for Oesophageal Ca

Answer 23

Any patient with dysphasia

Any patient >55yrs with w/l + upper abdominal pain/reflux/dyspepsia

Question 24

Treatment options for oesophageal ca

Answer 24

surgery - oesophagectomy
chemo
RT
palliative options - stenting

Question 25

Definition of lower GI bleeds

Answer 25

bleeding distal to ligament of Treitz (suspensory ligament of the duodenum)

Question 26

Causes of lower GI bleeds

Answer 26

Anatomical - anal fissures, fistulas, haemorrhoids, diverticulosis Inflammation - IBD (UC, CD), infection Vascular - ischaemic colitis, angiodysplasia Neoplasia - colorectal carcinoma, polyps Other - upper GI bleeds, trauma

Question 27

Investigations for lower GI bleeding

Answer 27

History + PR examination Bedside - obs, ECG, blood glucose, lying/standing BP Bloods - FBC, U&Es, LFTs, Clotting, X-match Stool - culture, calprotectin Imaging - erect CXR, CTAP, colonoscopy/OGD

Question 28

Management of lower GI bleeds

Answer 28

Initial A to E assessment & quantify state of shock • Minor bleeds – conservative management • Major – colonoscopy & treat lesion, interventional radiology options Oakland Scoring - predicts readmission https://www.mdcalc.com/oakland-score-safe-discharge-lower-gi-bleed

Question 29

Oakland score - parameters & what's it used for

Answer 29

Use in patients presenting with lower GI bleed (urgent, emergent, or primary care setting) to help determine if outpatient management is feasible. Age, sex, previous GI bleed, HR, BP, Hb, DRE examination

Question 30

Definition of UGIB & common sources

Answer 30

Bleeding proximal to ligament of Treitz | Oesophagus, stomach, duodenum

Question 31

Causes of UGIB

Answer 31

Oesophagus - varices, oesophagitis, MW tear, malignancy Stomach - varices, gastric ulcer, MW tear, malignancy Duodenum - peptic ulcer, duodenitis, diverticulum, aortoduodenal fistula

Question 32

Risk factors for UGIB

Answer 32

``` Medication - NSAIDs, Steroids, anticoagulants Advancing age Alcoholism/excess CLD CKD PUD/prev PUD Prev h.pylori infection ```

Question 33

Investigations for UGIB

Answer 33

Bedside - observations, BP, BM's, ECG, monitor UO Bloods - FBC, U&Es, LFTs, clotting, ABG/VBG, G&S, X-match Imaging - erect CXR, endoscopy

Question 34

Management of UGIB

Answer 34

Initial resuscitation & A to E - consider blood products Non-variceal - PPI, adrenaline + clips/thermal coag Variceal; terilpressin, prophylactic abx, adrenaline + bands/TIPs

Question 35

Scoring system for UGIB

Answer 35

Blatchford - primary assessment, - when to scope 0-2 – low risk >2 – admit Rockall - post endoscopy, ABCDE (age, BP & HR, co-morbidity, diagnosis, endoscopic findings) Re-bleeding risk

Question 36

Pathophysiology of Coeliac Disease

Answer 36

Autoimmune reaction to prolamin peptides in gluten, barley & rye Immunological response leads to mucosal damage & villous atrophy in small intestine Leads to malabsorption

Question 37

S&S of Coeliac Disease

Answer 37

V varied, can be asymptomatic ``` Diarrhoea Bloating Steatorrhoea Abdo pain Weight loss FTT Primary amenorrhea Fatigue Malaise ```

Question 38

Investigations for Coeliac Disease

Answer 38

Examination - signs of anaemia, malnutrition, dermatitis herpetiformis Bloods - FBC, Fe studies, B12, folate, Ca, Anti-TTG & anti EMA Stool - culture, ?calprotectin Endoscopy - visualisation & biopsy

Question 39

Management of Coeliac Disease

Answer 39

Gluten free diet Education & dietary support Vit & mineral supplements if needed

Question 40

Pathophysiology of pancreatitis

Answer 40

Pancreatitis is caused by the abnormal release and activation of enzymes, which cause autodigestion of pancreatic tissue

Question 41

Aetiology of pancreatitis - I GET SMASHED

Answer 41

``` Idiopathic GALLSTONES - women & older patients ETHANOL - men & younger patients Trauma Steroids Mumps/EBV/CMV Autoimmune Scorpions Hyperlipidemia ERCP, emboli Drugs e.g. furosemide, thiazide diuretics, azathioprine ```

Question 42

S&S of Pancreatitis

Answer 42

Can be quite vague Abdominal/epigastric pain - radiating to back, relieved by leaning forwards, worse on movement, a/w nausea & vomiting Anorexia/LOA Steatorrhoea Abdominal tenderness/distension Cullen's (umbilical) & Turner's (flank) signs - haemorrhagic

Question 43

Investigations into pancreatitis

Answer 43

Bloods - FBC (WCC), U&Es (urea), LFTs (LDH, AST, albumin), Amylase, Lipase, ABG Imaging - CXR (r/o GI perf), USS (gallstones & biliary dilatation), CT/MRI (assess for complications)

Question 44

Glasgow Score - Pancreatitis

Answer 44

Severity Score; 0-1 mild, 2 moderate, 3 or more severe ''PANCREAS'' ``` paO2 <8 age >55 neutrophils >15 calcium <2 renal function, urea >16 enzymes (LDH, AST) albumin <32 sugar >10 ```

Question 45

Management of Pancreatitis

Answer 45

``` Resuscitation & A-E assessment IV fluids Analgesia NBM & NG tube ERCP & cholecystectomy - gallstones (if needed) ```

Question 46

Complications of Pancreatitis

Answer 46

* Chronic pancreatitis * Malnutrition * QOL * Pseudocysts * Necrosis

Question 47

Pathophysiology of Cirrhosis

Answer 47

Chronic damage to liver leading to loss of hepatocytes Hepatocytes replaced by fibrosis & nodules Leads to portal HTN & liver failure

Question 48

Aetiology of Cirrhosis

Answer 48

``` Alcoholism NAFLD Viral hepatitis - B&C Autoimmune hepatitis Hereditary - haemochromatosis, Wilson's Vascular - Budd Chiari syndrome Drugs - MTX, amiodarone ```

Question 49

S&S of Cirrhosis

Answer 49

Early non-specific signs - anorexia, weight loss, fatigue, weakness, nausea Loss of synthetic function - easy bruising, abdominal swelling, ankle oedema Loss of detoxification - altered sleep, jaundice, personality changes, amenorrhea PR bleeding/melena Haematemesis

Question 50

Signs of examination of chronic liver disease

Answer 50

''ABCDE'' - ascites & asterixis, bruises, clubbing, dupuytren's contracture, erythema (palmar) jaundice spider navei caput medusa organomegaly - liver/spleen

Question 51

Investigations for cirrhosis

Answer 51

Bloods - FBC (Hb, MCV, Plts), LFTs, Clotting, AI/serology screen, albumin, AFP Ascitic tap - micro, C&S, biochem, cytology Liver USS+ biopsy - gold std Endoscopy?

Question 52

Child Pugh Score - Cirrhosis

Answer 52

Severity & prognosis 5 markers (3x max each) Albumin, Ascites, Bilirubin, INR/PT, HE

Question 53

Management of Cirrhosis

Answer 53

Treat/reverse cause Prevent further damage - alcohol, diet, avoid hepatotoxic drugs Dietary support - high protein, low na diet Monitor & treat complications

Question 54

Potential complications of Cirrhosis

Answer 54

Ascites - drain, diuretics HE - laxatives UGIB - ?TIPS SBP - abs & prophylaxis

Question 55

Definition & causes of acute liver failure

Answer 55

Acute dysfunction w/o underlying liver disease Causes: trauma, drug OD (paracetamol), alcohol excess, infection (Hep A/B/E), pregnancy related, Budd-Chiari syndrome

Question 56

Definition of autoimmune hepatitis

Answer 56

Chronic relapsing hepatitis with an unknown aetiology, characterised by the presence of autoimmune features, hyperglobulinaemia and autoantibodies

Question 57

Pathogenesis & Aetiology of Autoimmune hepatitis

Answer 57

Commonly affects women of all ages (type 1) & younger women/girls (type 2) Thought to be genetic predisposition & environmental trigger (e.g. drugs, infection) Auto-immune reaction causes chronic inflammation & damage, can lead to cirrhosis & failure Type 1 (Classic): anti-nuclear antibodies (ANA), anti-smooth muscle antibodies (SMA), anti-actin antibodies, anti-liver soluble antigen Type 2: anti-LKM (liver kidney microsomes), antibodies to liver cytosol antigen

Question 58

'Ways' in which AIH can present

Answer 58

• Asymptomatic (25%) - persistently elevated LFTs • Acute hepatitis (40%) - fever, RUQ pain, anorexia, hepatomegaly, N&V, diarrhoea, jaundice • Chronic liver disease/cirrhosis Acute liver failure (rare) - jaundice, confusion, coagulopathy

Question 59

Investigations for AIH

Answer 59

``` Routine bloods • FBC - low Hb, Plts & WCC may be low in hypersplenism • U&Es • LFTs - deranged, AST/ALT esp in acute • Clotting Non invasive liver screen • Auto-antibodies; ANA, anti-SMA, anti-LKM • Immunoglobulins Imaging • USS etc to r/o other causes • Not diagnostic Biopsy ```

Question 60

Management of AIH

Answer 60

Immunosuppression - mainstay of management • Steroids i.e. prednisolone • Azathioprine Follow up & monitoring - remission = normal AST/ALT

Question 61

Cholelithiasis vs Choledocholithiasis vs Cholecystitis

Answer 61

Cholelithiasis: refers to gallstones - solid deposits that develop in the gallbladder. Choledocholithiasis: refers to gallstones within the biliary tree. Cholecystitis - inflammation of gallbladder, commonly caused by gallstones

Question 62

Types of gallstones & risk factors for developing them

Answer 62

Mixed, cholesterol or pigment ``` Female Age Diet - high fat Medication - high oestrogen Obesity Family hx/genetics Crohn's Haemolytic disorders ```

Question 63

Causes of cholecystitis

Answer 63

Gallstones (calculous) | Non-calculous cholescystitis (significant systemic upset or following major surgery)

Question 64

S&S of Gallstones

Answer 64

Asymptomatic | but can present with biliary colic (intermittent severe RUQ pain) or cholecystitis

Question 65

S&S of cholecystitis

Answer 65

``` RUQ/epigastric severe pain, tenderness & guarding N&V Pyrexia Tachycardia can become hypotensive ``` Murphy's sign - catching breath

Question 66

Investigations for cholecystitis

Answer 66

Bedside - observations, BM, urine dip, preg test Bloods - FBC, cultures, U&Es, CRP, LFT, amylase Imaging - USS

Question 67

Management of Cholecysitis

Answer 67

Medical - abx, fluids, analgesia Surgical - cholecystectomy, ERCP or MRCP if CBD stones present

Question 68

Management of Gallstones

Answer 68

Conservative - fluids, anti-emetics, analgesia Lifestyle advice - dietary, weight loss Monitor & treat complications

Question 69

Definition & risk factors for cholangiocarcinoma

Answer 69

Cancer arising from bile ducts (can be intra or extrahepatic) RFs: primary sclerosing cholangitis (UC pts), liver flukes (parasitic infections)

Question 70

Clinical features of cholangiocarcinoma

Answer 70

``` Obstructive jaundice - pale stool, dark urine, generalised itching W/L RUQ pain Palpable GB Hepatomegaly ```

Question 71

Investigation & Dx of Cholangiocarcinoma

Answer 71

Bloods - liver & jaundice screen, LFTs, bilirubin, albumin, serology, Ca19-9 Imaging (Dx) - CT or MRI + biopsy, ct staging MRCP/ERCP can aid in dx or management

Question 72

Treatment of cholangiocarcinoma

Answer 72

Surgery - can be curative in early stages, combined with chemo/RT Palliative options in majority of cases e.g. stents, bypass obstruction, sx control with chemo/RT

Question 73

Definition of Primary Sclerosing Cholangitis (PSC)

Answer 73

An autoimmune mediated disease characterised by cholestasis, bile duct strictures & hepatic fibrosis Primary: refers to PSC. Absence of another identifiable cause. Secondary: refers to any condition causing bile duct damage and biliary obstruction.

Question 74

Pathology of PSC

Answer 74

Autoimmune 'attacks' causing progressive inflammation & hepatic fibrosis as well as destruction of intra & extrahepatic ducts. This leads to reduction in flow of bile (cholestasis), narrowing of bile ducts (stricturing) and cirrhosis of liver

Question 75

Aetiology of PSC

Answer 75

Genetic predisposition x environmental trigger | Strong a/w IBD especially UC

Question 76

Clinical features of PSC

Answer 76

Can remain asymptomatic especially in early stages, can be incidental finding or symptoms tend to develop from cholestasis • Incidental finding - persistently raised ALP • Intermittent jaundice, itching, fatigue, RUQ pain • Hepatomegaly, splenomegaly & stigmata of CLD Can also present with cholangitis (Charcot's Triad) • Fever • RUQ pain Jaundice

Question 77

Diagnosis of PSC

Answer 77

PSC is characterised by a ‘cholestatic’ pattern on LFTs and absence of autoantibodies. MRCP - gold std, visualise biliary strictures & dilatation

Question 78

Treatment options of PSC

Answer 78

Medical - aimed at managing complications • Cholangitis - IV abx & fluids • Bone disease - at increased risk of osteoporosis & osteopenia, Vit D supplements • Itching - cholestyramine ERCP - balloon dilatation & stents • Help to manage disease Liver transplant • Only option which alters survival, recurrence is a risk

Question 79

Complications of PSC

Answer 79

``` Cholangiocarcinoma • COD in majority of patients with PSC • Low threshold for imaging if suspected Colorectal carcinoma • Due to a/w IBD, annual colonoscopies Hepatic malignancy Due to cirrhosis, 6mths USS +/- AFP ```

Question 80

Definition & pathophysiology of hepatocellular carcinoma

Answer 80

Primary malignancy of hepatocytes Damage & repair cycles promoting mutations

Question 81

Risk factors/aetiology of HCC

Answer 81

Chronic liver disease - alcoholic liver disease, NAFLD, cirrhosis, hepatitis, AIH Metabolic liver disease - haemochromatosis Alfatoxins

Question 82

Clinical presentation of HCC

Answer 82

``` Stigmata of chronic liver disease on examination Weight loss Fatigue Maliase Weakness LOA Ascites/abdominal distension Jaundice ```

Question 83

Investigations for HCC

Answer 83

Bloods - full liver screen e.g. FBC, U&Es, LFTs, AI, serology, AFP Imaging - CT or MRI +/- biopsy, CT staging

Question 84

Treatment options for HCC

Answer 84

``` Surgical resection Local therapy e.g. ablation Transplant Chemo e.g. multikinase inhibitors (e.g. Sorafenib) RT or brachytherapy ```

Question 85

Definition of gastric carcinoma

Answer 85

Malignancy of stomach - adenocarcinoma (90%)

Question 86

Risk factors for gastric cancer

Answer 86

``` Smoking Alcohol Diet Obesity Atrophic gastritis H. pylori infection ```

Question 87

S&S of gastric cancer

Answer 87

Constitutional symptoms: fevers, anorexia, lethargy, weight loss Dysphagia: if involvement of gastric cardia Indigestion Dyspepsia Nausea/vomiting Haematemesis/melaena Post-prandial fullness

Question 88

Examination - suspected gastric cancer

Answer 88

Usually absent unless late presentation with distant spread ``` Pallor Cachexia Lymphadenopathy Virchow node: left supraclavicular node Metastatic lesions Hepatomegaly Sister Mary Joseph nodule: periumbilical metastasis ```

Question 89

2WW Criteria - gastric cancer

Answer 89

• Upper abdominal mass consistent with gastric cancer, OR • Dysphagia, OR • > 55 years with weight loss and one of the following: ○ Upper abdominal pain ○ Reflux o Dyspepsia

Question 90

Dx of gastric cancer

Answer 90

* OGD +/- biopsy * CT/MRI staging * Bone scan - mets * USS for lymph nodes

Question 91

Management of gastric cancer

Answer 91

``` Medical • Chemo & radiotherapy - 5FU • Targeted monoclonal abs - HER2 Surgical Gastrectomy - full or partial ```

Question 92

Pancreatitis cancer - most common type

Answer 92

Ductal adenocarcinoma (85%)

Question 93

Risk factors for pancreatic cancer

Answer 93

Age, smoking, alcohol, chronic pancreatitis, diabetes, hereditary syndromes (BRCA, FAMMM), genetics

Question 94

Clinical presentation of pancreatic cancer

Answer 94

Later presentation Jaundice, abdo pain & unexplained weight loss diarrhoea, steatorrhoea, dark urine, new onset diabetes, signs of metastasis

Question 95

2WW criteria for pancreatic cancer

Answer 95

New onset jaundice >40yrs >60yrs w/ unexplained weight loss +: diarrhoea, constipation, back pain, abdominal pain, nausea, vomiting or new onset diabetes

Question 96

Investigations for pancreatic cancer

Answer 96

Bloods: FBC, U&Es, LFTs, clotting, Ca19-9. CEA Imaging: USS, CT/MRI pancreas, CT-TAP, PET staging, ERCP Biopsy

Question 97

Treatment of pancreatic cancer

Answer 97

Medical - chemo (pal), pain control, nutritional support | surgical - <20% suitable, Whipple's (possibly) for HOP tumours with no vascular involvement or mets

Question 98

Definition of primary biliary cirrhosis | Typical patient?

Answer 98

Chronic inflammatory liver disease involving progressive destruction of intrahepatic bile ducts, leading to cholestasis and ultimately cirrhosis Typical patient - female (9:1), around 50yrs old, may have a family hx

Question 99

Pathophysiology of PBC

Answer 99

Autoimmune attack of small intrahepatic bile ducts. Damage & destruction of these ducts causes obstruction of the outflow of bile (cholestasis). This leads to a backpressure into the liver which causes irritation leading to fibrosis, cirrhosis & liver failure. Bile acids, bilirubin & cholesterol are no longer being excreted through bile ducts into intestines & so they build up in the blood - cause itching, jaundice, increased risk of CVD.

Question 100

Aetiology & Risk factors for PBC

Answer 100

unknown exact cause, most likely GxE Possible environmental triggers Infection, pollutants, bacteria Female sex Middle aged Other AI conditions e.g. thyroid, coeliac Rheumatoid conditions e.g. systemic sclerosis, Sjogren's & RA

Question 101

Clinical features of PBC

Answer 101

``` Can be incidental finding on blood tests - persistently raised ALP & cholesterol Fatigue Pruritis GI disturbances Abdominal pain Jaundice Pale stools Xanthoma/xanthelasma Signs of CLD - ABCDE ```

Question 102

Investigations for PBC

Answer 102

Bloods • FBC • U&Es • LFTS - raised ALP & GGT, bilirubin (can be normal or raised in later stages) • Clotting - prolonged PTT • Autoantibodies - anti-mitochondrial antibodies (most specific to PBC) & anti-nuclear antibodies • ESR - raised • Immunoglobulins - IgM raised Imaging • USS - excludes extrahepatic biliary obstruction e.g. gallstones, strictures • Liver biopsy - diagnostic & used in staging

Question 103

Management of PBCMedical

Answer 103

* Ursodeoxycholic acid - reduced intestinal absorption of cholesterol * Colestyramine - bile acid sequestrate, can help with pruritis * Immunosuppression is considered in some patients Surgical • Liver transplant - in end stage liver disease Monitor & treat complications

Question 104

Aetiology of Bowel Obstruction

Answer 104

Mechanical: small (adhesions, hernia, malignancy, intussuspection), large (colorectal cancer, volvulus, diverticular strictures) Non-mechanical: pan-intestinal (paralytic ileus), colonic (acute colonic psuedo-obstruction)

Question 105

Clinical features of bowel obstruction

Answer 105

Abdominal pain, distension, vomiting & obstipation Anorexia Small bowel diarrhoea Complete constipation Abdominal tenderness/peritonism Rebound Abdominal distension Abdominal mass

Question 106

Investigations - bowel obstruction

Answer 106

Bedside - observations, ECG, fluid balance, catheter, PR examination, pregnancy test Bloods - VBG/ABG (lactate), FBC (WCC), U&Es (electrolytes, dehydration), LFTs, clotting, CRP (high), amylase, group & save Imaging - erect CXR (free air), abdominal XR (dilated bowel loops), CTAP

Question 107

Bowel dilation limits on X-ray

Answer 107

Small - >3cm Large - >6cm Caecum - >9cm

Question 108

Management of Bowel Obstruction

Answer 108

Conservative/supportive - NBM, Drip & Suck, analgesia, anti-emetics, abx if needed, correction of electrolytes Endoscopic - decompression, stenting Surgery - resection, laparotomy/laparoscopy

Question 109

Pathophysiology behind appendicitis & aetiology

Answer 109

Obstruction of lumen of appendix Stasis & bacterial overgrowth, increase in intraluminal pressure, venous congestion & ultimately arterial compromise leading to necrosis Aetiology - faecoliths, lymphoid hyperplasia, carcinoid tumours, fibrous strictures

Question 110

Clinical Features - Appendicitis

Answer 110

Colicky abdominal pain migrated to RIF & becomes constant Symptoms: Abdominal pain, RIF pain, nausea, anorexia, constipation Signs: RIF tenderness, percussion tenderness, localised guarding, tachycardia & pyrexia Rovsing's Sign - palpation in LIF causes pain in RIF

Question 111

Investigations - Appendicitis

Answer 111

Bedside - examination, observations, urine dip & pregnancy test Bloods - FBC, U&Es, LFTs, clotting, amylase, CRP, group & save Imaging - USS (+ pelvic to r/o gynae) & CT can confirm dx in older patients

Question 112

Management of appendicitis

Answer 112

Conservative - for acute uncomplicated appendicitis (antibiotics - co amoxiclav) Surgical - laparoscopic appendectomy/open if needed, pre-op co-amox & post op 7days abx if pus or perforation

Question 113

Definition & Pathophysiology of Acute/Ascending Cholangitis

Answer 113

Acute infection & inflammation of biliary tree | Usually occurs due to bacterial overgrowth after obstruction of biliary tree

Question 114

Aetiology - Acute Cholangitis

Answer 114

``` • Choledolithasis - stones in biliary tree • Benign Strictures • Chronic pancreatitis • Iatrogenic injury (e.g. during cholecystectomy) • Radio / chemo-therapy • Idiopathic • Malignant Strictures • Pancreatic cancer • Gallbladder cancer Cholangiocarcinoma ```

Question 115

Clinical Presentation - Acute Cholangitis

Answer 115

• Charcot's Triad - RUQ pain, jaundice & fever | Nausea & vomiting

Question 116

Investigations - Acute Cholangitis

Answer 116

Bedside • Observations • ECG • Urine dip & cultures • Pregnancy test - in female patients of child bearing age Bloods • FBC - WCC • U&Es - dehydration • CRP - inflammation • LFTs • Amylase Imaging • USS - useful in checking presence of stones • CT - good visualisation of the biliary tree, evaluate for abnormal lesions/tumours or where other dx MRCP - offers excellent visualisation of the biliary tree. Often used where CT/USS are inconclusive.

Question 117

Management of acute cholangitis

Answer 117

Antibiotics Fluids Analgesia Biliary Drainage - ERCP/Percutaneous transhepatic cholangiography

Question 118

Definitions of diverticulosis, diverticular disease & diverticulitis

Answer 118

Diverticulosis - presence of diverticula (outpouching of colonic mucosa & submucosa through muscular wall of large bowel) Diverticular disease - diverticulosis a/w complications e.g. haemorrhage Diverticulitis - acute inflammation & infection of diverticula

Question 119

Risk factors for diverticulitis

Answer 119

``` Diet - red meat, low fibre Smoking Obesity Family history Medications - NSAIDs increase risk of perforation ```

Question 120

Clinical presentation of diverticulitis

Answer 120

``` Abdominal pain, fever & tenderness in LIF Anorexia Nausea Guarding Tachycardia ```

Question 121

Investigations - Diverticulitis

Answer 121

CT abdomen pelvis is imaging modality of choice for diagnosis of diverticulitis • Bedside: observations, urine dip & pregnancy test • Bloods: FBC, U&Es, LFTs, CRP, amylase, clotting, G&S • Imaging: CT abdo pelvis w/ contrast ideally

Question 122

Management - Diverticulitis

Answer 122

Very dependent on severity & this can range significantly • Consider inpatient vs outpatient management ○ Outpatient - fit & healthy, younger patients w/ mild disease ○ Inpatient - older, more frail patients w/ more severe disease • Antibiotics; Co-amoxiclav or ciprofloxacin (if penicillin allergic) ○ OP - 7 day course ○ IP - IV abx regime • Analgesia; paracetamol ○ Avoid NSAIDs & opioids due to increase risk of perforation • Follow-up ○ Patients managed in the community should be reassessed at 48 hours and given appropriate safety-net advice. ○ Outpatient colorectal follow-up and colonoscopy (if appropriate) should be arranged.

Question 123

Complications - Diverticulitis

Answer 123

Bowel strictures Fistula Diverticular Bleed

Question 124

Types & Aetiology - Jaundice

Answer 124

TYPES & CAUSES 1) Pre-hepatic; increased hemolysis, livers ability to conjugate is overwhelmed  hemolytic anaemia, Gilbert’s syndrome 2) Hepatic; dysfunction of liver, mixed picture  HCC, cirrhosis, iatrogenic, drugs, AIH 3) Post-hepatic; obstruction  intramural (gallstones), mural (cholangiocarcinoma), extramural (abdominal masses

Question 125

Jaundice - INTERPRETATING LFTs & URINE

Answer 125

``` Pre-hepatic = normal LFTs, increased urobilinogen (urine), no bilirubin in urine Hepatic = all round bad LFTs, mixed picture on bilirubin in urine Post-hepatic = classic cholestatic LFTs (increased GGT, ALP), bilirubin+++ urine (dark), no sterco (pale stools) ```

Question 126

'Types' - Ascites

Answer 126

Transudate (little/no protein) Exudate (protein) SAAG; >1.1 = transudate Transudate fluid - ultrafiltration of plasma due to raised portal pressure Exudate tends to be leakage of whole contents of plasma due to inflammatory causes (normal portal pressure)

Question 127

Causes of Ascites

Answer 127

``` Transudate: Cirrhosis Congestive cardiac failure Acute liver failure (trauma, OD) Liver metastasis HVT or PVT ``` ``` Exudate: Infection – bacterial, fungal, TB Malignancy Pancreatitis Nephrotic Syndrome Bowel Obstruction ```