Gastrointestinal Flashcards

Question

Answer 1

The majority of colorectal cancers are sporadic rather than familial. However, there is a 2-3 fold increased risk of colorectal cancer in people with a family history in a single first-degree relative. Familial syndromes include: * Familial adenomatous polyposis syndrome (FAP)   * 100% risk by age 40 * Hereditary non-polyposis colorectal carcinoma (HNPCC) * 80% progress to CRC **Risk factors**   * Increasing age   * Smoking * Alcohol * Processed meat: high fat, low fiber diet * Obesity * Inflammatory bowel disease   * Endocarditis and bacteraemia due to Streptococcus gallolyticus * APC mutation   * MYH-associated polyposis   * Hamartomatous polyposis syndrome

Answer 2

1. Colorectal carcinoma * Most are adenocarcinoma (colorectal mucosa) – 95% * Arise from adenomatous polyps * Mutation in oncogenes (KRAS) and tumour suppressor genes (APC, TP53) 1. Neuroendocrine tumours (carcinoid) * Neuroendocrine cell lineage * Most low grade * Appendix most common site 1. Gastrointestinal stromal tumours (GIST) * Spindle cell neoplasm * 80% CD117 (C-kit) and 10% PDGFRA (platelet derived growth factor receptor alpha) * high and low malignant potential 1. Lymphomas 1. B-cell lymphomas: Marginal zone lymphoma (MALT), diffuse large b cell lymphoma, Burkitt lymphoma 2. T-cell lymphoma: associated with malabsorption syndrome i.e. coeliac disease

Answer 3

* Blood in stool, irone deficiency anaemia * Change in bowel habits * Colicky abdominal pain due to obstruction * Tenesmus - a distressing and persistent urge to empty rectum * signs of metastasis

Answer 4

1. Digital Rectal Exam 2. Complete colonoscopy (gold standard) 3. FBC - anaemia 4. Staging CT

Answer 5

Screening for colorectal cancer and adenomatous polys is performed in asymptomatic men and women \> 50 yo _Low-risk (3 options)_ 1. Colonoscopy every 10 years if not polyps/ carcinomas detected 2. Annual Faecal Occult Blood test 3. Sigmoidoscopy every 5 years and FOBT every 3 years _High risk_ 1. _Complete colonoscopy 10 years earlier than the index patients age at diagnosis or no later than 40yo_

Answer 6

1. **Dyslipidaemia** – Abnormal lipoprotein levels (LDL \> 130 mg/dL, HDL \< 40mg/dL) .in association with an increased risk of cardiovascular disease 2. **Hyperlipidaemia** – elevated blood lipid levels (total cholesterol, LDL, triglycerides) 3. **Hypercholesterolemia** – elevated total cholesterol (\>200mg/dL) 4. **Hypertriglyceridemia** – elevated triglyceride levels (associated with increased risk of acute pancreatitis) 5. **Hypolipoproteinaemia** – elevated levels of a certain lipoprotein

Answer 7

_Acquired_ * Obesity * Diabetes mellitus * Physical inactivity * Alcoholism * Hypothyroidism * Nephrotic syndrome * Cholestatic liver disease * Cushing’s disease * Drugs: OCP, metoprolol, high dose diuretic Congenital * Hyperchylomicronemia * Familial hypercholesterolemia (mutation of LDL receptor leading to increased LDL) * Familial hypertriglyceridemia

Answer 8

1. Xanthomata 2. xanthalesmata 3. arcus senalis 4. fatty liver 5. atherosclerosis with secondary disease --\> CAD\< PAD, stroke, MI, Carotid artery stenosis

Answer 9

1. **General measures** – lifestyle modification, dietary changes (reduce saturated fat and cholesterol intake), weight management, physical activity 2. **Medical therapy** * Statins (Atorvastatin) * Inhibits HMG-CoA reductase, prevents synthesis of cholesterol in liver * Ezetimibe * Used with statins, when statins don’t work alone, decreased cholesterol absorption in small intestine * PCSK9 inhibitors (Evolocumab) * Monoclonal Ab inhibit PCSK9 from degrading LDL receptors 1. **Treatment xanthomas and xanthelasmas** – surgical

Answer 10

Primary * Rare type seen in patients who have ascites and end-stage liver disease * Continuous Ambulatory Peritoneal dialysis * Gram -ve: E.coli, Klebsiella pneumoniae * Gram +ve: Streptococcus pneumoniae, Staph aureus Secondary * Usually polymicrobial, enteric bacteria * Aerobic: E.coli, Klebsiella, Enterobacter, Streptococci, Enterococci * Anaerobic: Bacterioides, Clostridia, Eubacteria

Answer 11

_General Symptoms_ * Diffuse abdominal pain with abdominal guarding and/or rebound tenderness * Nausea, vomiting * Fever and chills * Possibly shoulder pain * Ascites in spontaneous bacterial peritonitis _Physical examination_ * Distressed patient, knees drawn up when supine, avoids movement * Abdominal pain and rigidity, rebound tenderness * Sparse peristaltic sounds

Answer 12

Lab 1. FBC 2. CRP 3. Peritoneal fluid analysis - Neurtophil count, glucose, LDH, pH, gram stain and culture 4. Serum creatinine and LFTs - underlying liver dysfunciton 5. Blood culture Imaging 1. U/S (Underlying disease - pancreatitis, appendicitis, cholangitis), peritoneal fluid 2. Abdominal X-ray - air fluid levels, free air secondary to organ perforation 3. CT abdomen and pelvis

Answer 13

Primary Peritonitis * Broad spectrum antibiotics - cefotaxime, ceftriaxone Secondary peritonitis * Fluid replacement * Drainage of asbcess * Broad spectrum antibiotics - Tazocin OR Ciprofloxacin + metronidazole

Answer 14

_Maldigestion_ 1. Chronic pancreatitis à exocrine pancreatic insufficiency à lack of enzymes à reduced hydrolysis of carbohydrates, proteins and lipids 2. GI surgery (resections) à lack of gastric acid à impaired breakdown of nutrients 3. Bile acid deficiency (cholestasis, bile acid malabsorption) à incomplete emulsification of fats 4. Medications (orlistat) à inhibits gastric and pancreatic lipase _Malabsorption_ 1. Inflammation * Crohn’s disease, Ulcerative colitis 1. Infection * Tropical sprue, giardiasis, traveller’s diarrhoea, Whipple’s disease 1. Coeliac disease 2. Lactose Intolerance (lactase deficiency) * Dietary elimination and challenge are generally diagnostic * If elimination of lactose is necessary for Tx – alternative calcium source recommended 1. HIV enteropathy 2. Cystic fibrosis 3. Irritable bowel syndrome 4. Diagnosis of exclusion

Answer 15

Vitamin A * Night blindness, retinopathy, xerophthalia Vitamin D * Osteomalacia and rickets vitamin E * Demyelination of posterior column (neuromuscular deficiency) Vitamin K * Increased bleeding tendency

Answer 16

* B1 - beriberi --\> symmetrical peripheral neuropathy, muscle wasting, confusion, cardiomyopathy * B3 - pallegra --\> Dermatitis, Dementia, Diarrhoea, Da big tongue (glossitis) * B12 - Megaloblastic anaemia

Answer 17

1. FBC * Macrocytic or microcytic anaemia * Decreased electrolytes, decreased total protein, vitamin deficiencies 1. Stool test * Analysis of faecal fat over 72 hours * Detection of pathogens 1. X-xylose absorption test – assesses the absorptive function of the upper small intestine 2. Blood tests * Vitamin B-12 * Vitamin D * Folate * Iron * Calcium * Phosphorus * Carotene * Albumin * Protein 1. Lactose Hydrogen Breath test 2. Imaging – Structural problems e.g. Crohn’s disease 3. Tissue transglutimase and Biopsy e.g. coeliac

Answer 18

malabsorption due to chronic immune-mediated reaction to dietary gluten GI symptoms * chronic diarrhoea, steatorrhoea * Flatulence, abdominal bloating * lack of appetite Extra-intestinal * Dermititis herpatiformis * fatigue, weight loss, vitamin deficiency, osteoporosis

Answer 19

1. Tissue transglutimase - first line test 2. Anti-emdomysial antibody (EMA) - harder to perform 3. FBC - low Hb and microcytic RBCs 4. Biopsy - confirmatory test showing atrophic villi

Answer 20

* Insufficient water intake (particularly in elderly and critically ill) * Increased free water loss * Renal loss * Diuretics * Hyperglycaemia * Polyuric phase of renal failure * Diabetes insipidus * Extra-renal loss * Diarrhoea * Vomiting * Burns * Increased sweating * Fever * Inflammation * Ascites

Answer 21

Symptoms * thirst * headaches, dizziness, disorientation * weakness, fatigue Signs * Sunken eyes * decreased skin turgor * dry skin and dru mucous membranes * in infants - sunken fontanelle * in children - no tears

Answer 22

1. Serum sodium - hypernatraemia 2. Increased haematocrit (hypovolaemia) 3. Decreased bicarbonate levels (lactic acidosis) 4. BUN to serum creatinine ration \> 20:1 (renal hypoperfusion in hypovolaemia) 5. Urine osmolality \<800 - renal, \> 800 - extra-renal 6. BGL - (hypo could mean decreased fluid intake, hyper could mean osmotic diuresis)

Answer 23

Patients who are hypovolemic as result of severe dehydration require immediate fluid resuscitation with crystalloids 1. Fluid resuscitation * Adults: rapid infusion of isotonic crystalloids * Children: rapid infusion of isotonic saline 1. Correction of electrolyte abnormalities * Hypernatraemia or hyponatramia once volume resuscitated

Answer 24

* Ventral Hernias * Epigastric hernia * Umbilical hernia * Incisional hernia * Spigellan hernia * Parastomal hernia * Groin hernias * Inguinal hernia * Femoral hernia * Pelvic hernias (rare) * obturator, sciatic, perineal hernias * Flank hernia * Incisional, lumbar hernia

Answer 25

\*Most are asymptomatic _Reducible hernia_ Can be pushed back with minimal pressure * Completely reducible non-tender mass on the abdominal wall (epigastric region, umbilicus, groin, etc.) * Increases on straining (coughing, lifting heavy object) * Decreases on lying down * Edges of the fascial defect are palpable * Bowel sounds may be heard _Irreducible/ incarcerated hernias_ Cannot be pushed back with pressure * Absent cough impulse * May lead to _obstructed hernia_ (features of acute bowel obstruction) * If left untreated, can lead to a _strangulated hernia_ (blood supply cut off) with ischaemia of the hernia contents * Acute pain at site of hernia * Edematous, erythematous, warm overlying skin * Possibly features of bowel obstruction

Answer 26

* Floor* – inguinal ligament * Roof* – transversalis and internal oblique * Front* – external oblique aponeurosis + internal oblique for the lateral * Back* – laterally, transversalis fascia; medially; conjoined tendon Deep ring – created by transversalis fascia Superficial ring – formed by external oblique **_Direct_** * Enters through the fascia transversalis on the posterior wall of the inguinal canal in the area known as Hasselbach’s triangle (Lateral = inferior epigastric artery, medial = rectus abdominus, inferior = inguinal ligament) * Hernia does not pass through deep ring -\> not covered by internal spermatic fascia **_Indirect_** * Indirect hernias pass through the deep inguinal ring following the path of the spermatic cord, may protrude into the superficial ring; congenital * Lateral to the inferior epigastric artery * Commonly seen in children

Answer 27

Obstruction of appendiceal lumen by: 1. Lymphoid tissue 2. Hardened faecal matter 3. Less common: foreign bodies, worm infestation, intestinal infections, tumours (carcinoid), haemolytic disease Stasis of mucus and fluid à bacterial growth and local inflammation à rising intraluminal pressure à vascular compromise à ischaemia à necrosis à perforation and peritonitis

Answer 28

_Non-specific_ * Progressive fever * Anorexia (hamburger sign) * Nausea, vomiting, * Constipation (maybe) _Abdominal pain_ * Initially dull, migratory periumbilical pain (due to visceral peritoneum irritation) * After 4-24 hours, sharp RLQ pain (due to parietal peritoneum irritation by a distended and inflamed appendix) with rebound tenderness _Signs of appendicitis_ 1. **Blumberg’s sign**; rebound tenderness caused upon suddenly ceasing deep palpation of the RLQ 2. **McBurney point tenderness**: an area one-third of the distance from the anterior superior iliac spine to the umbilicus (in the RLQ) 3. **Rovsing’s sign**; deep palpation of the LLQ causes RLQ referred pain 4. **Psoas sign**: RLQ pain with extension of the right leg against resistance 5. **Obturator sign**: RLQ pain with flexion and internal rotation of the right leg

Answer 29

1. CRP 2. FBC 3. B-hCG 4. Urinalysis - rule out UTI 5. UEC - sepsis, kidneys 6. LFTs 7. Lipase - pancreatitis 8. Imaging - U/S, CT

Answer 30

1. Bowel rest (nil by mouth), IV fluid therapy, observation 2. Analgesia 3. Antibiotics with anaerobic and gram negative cover (cefazolin and metronidazole) 4. DVT prophylaxis 5. Appendectomy * Body can still function properly without an appendix * When appendix become inflamed and swollen and can lead to perforation, want to remove before it ruptures * May lead to serious infection peritonitis or abscess * Risks: bleeding, infection, injury to nearby organs, blocked bowels * Laparoscopic incision

Answer 31

* Primary * Low dietary fibre * Lack of exercise * Dehydration * Secondary * Mechanical - bowel obstruction - colorectal carcinoma, stenosis * Medications - opioids, iron supplements, antacids * Endocrine - hypothyroidism, DM, electrolyte imbalance * Neurological - MS, diabetic neuropathy * Post-surgical ileus * GI conditions e.g. IBD

Answer 32

1. Discontinue non-essential medications causing the constipation 2. Use PO or IV rehydration with normal saline to correct dehydration and electrolytes 3. Insert a catheter in cases of urinary retention secondary to distal faecal impaction 4. _Oral laxatives_ * Stool softener (Coloxyl) [Docusate sodium] * Osmotic laxatives (Movicol) 1. _Rectal laxatives_ * Osmotic laxatives (glycerine suppository) * Stimulant laxative (bisacodyl suppository or Senna) 1. _Enemas_ * Rectal stool softener (microlax) * Sodium phosphate hypertonic enema 1. _Opioid antagonist_ – methylnaltraxone 2. _5-HT4 receptor antagonist_ – prucalopride 3. _Digital manual faecal disimpaction_

Answer 33

Frank Haematochezia * Anal fissue * haemorrhoids * Rectal cancers * Rectal varices * traums Frank mixed * Diverticulitis * Colorectal cancer * IBD * Polyps * angiodysplasia * Mesenteric ischaemia Melaena * Upper GI bleed - duodenal ulcer, oesophageal perforation * Upper GI malignancy * oesophageal varices * gastritis

Answer 34

**Crohn's** Pathology * Tranmural inflammation * Dicontinuous inflammation (skip lesions) * Can affect entire GI tract, but typically terminal ileum * commonly leads to fistulas, abscesses and stenosis * Linear ulceration Clinical * Constant pain, mainly RLQ * malnourished * Increased frequency of bowel movements or contripated * typically non-bloody watery diarrhoea **Ulcerative colitis** Pathology * Continuous inflammation * Starts from rectum and goes upwards * only mucosal and submucosal inflammation * No granulomas * Fistulas are very rare Clinical features * Bloody diarrhoea with mucus * greatly increased frequency of bowel movements * normally dont have weight loss * pain mostly before defecation or during defecation, mainly LLQ

Answer 35

**Lab tests** _Blood_ 1. Increased inflammatory markers – CRP, ESR, thrombocytes, leukocytes 2. FBC – anaemia, leukocytosis 3. ASCA – elevated _Faeces_ 1. Stool analysis to rule out gastroenteritis caused by bacteria 2. Detection of fecal calprotectin and/ or lactoferrin **Imaging** 1. Plain abdominal X-rays: bowel distention, pneumoperitoneum 2. Plain radiography with barium swallow (enteroclysis) to detect fistulas or stenosis 3. U/S – GI wall thickness caused by inflammation and oedema **Endoscopy** – confirms diagnosis * Ileocolonoscopy or Oesophagogastroduodenoscopy findings * Segmental/ discontinuous patterns (Skip lesions) * Linear ulcers * Fissures, fistulas * Transmural and erythematous inflammation

Answer 36

**_Pharmacotherapy_** **Symptoms** 1. Anti-diarrhoeal agents (Loperamide) 2. Topical corticosteroids (Triamcinolone) * For pain relief in oral lesions 1. Topical 5-Aminosalicyclic acid derivatives (5-ASA) * In the case of inflammation of the distal colon **Acute exacerbations** _Mild_ 1. Topical corticosteroids: Oral budesonide 2. 5-ASA: Sulfasalazine, metronidazole 3. Antibiotics: Metronidazole, ciprofloxacin * Indicated for fistulas, perianal abscess * Reduces intestinal bacteria, immune response and risk of infection _Moderate to severe_ 1. Systemic corticosteroids (Prednisolone) _Steroid-refractory_ 1. Immunosuppressant’s 1. TNF-alpha antibodies (infliximab, adalimumab) 2. If necessary in combination with azathioprine 3. Alsternative – methotrexate **Maintenance therapy** 1. First line: 5-ASA Alternatives: Azathioprine, methotrexate of TNF-alpha antibodies **_Surgery_** * Resect affected and non-functional intestinal loops * Indicated in failed medical therapy or severe complications e.g. abscess, perforation, toxic megacolon, obstruction, stricture

Answer 37

**Lab tests** Blood 1. FBC – anaemia, leukocytosis 2. CRP 3. Perinuclear ANCA Stool analysis * Test for bacteria to rule out other causes * Calprotectin and lactoferrin are indicators of mucosal inflmattation Imaging 1. Colonoscopy * Inflamed, reddened mucosa * Bleeding on contact with endoscope * Fibrin-covered ulcers * Adjunct imaging can include x-ray, CT, MRI, U/S

Answer 38

**_Pharmacotherapy_** **Symptoms** 1. Anti-diarrhoeal agents (Loperamide) **Acute exacerbations** _Mild_ 1. 5-ASA: Sulfasalazine, mesalamine _Moderate to severe_ 1. Systemic corticosteroids (Prednisolone) _Steroid-refractory_ 1. Immunosuppressant’s 1. TNF-alpha antibodies (infliximab, adalimumab) 2. If necessary in combination with azathioprine 3. Alsternative – methotrexate **Maintenance therapy** 1. First line: 5-ASA Alternatives: Azathioprine, methotrexate of TNF-alpha antibodies **_Surgery_** * Resect affected and non-functional intestinal loops * Indicated in failed medical therapy or severe complications e.g. abscess, perforation, toxic megacolon, obstruction, stricture

Answer 39

Disturbance of the normal colonic microflora * Alterations in bacterial degradation -\> osmotic diarrhea * Direct effect of antibiotic e.g. erythromycin stimulate intestinal motility * Infection by organisms _Clostridium difficile_ is a gram-positive rod bacillus that is commonly involved in AAD. C. difficile infection rate particularly high among hospitalized patients. The resulting damage to the intestinal flora promotes infection. The most severe C.difficile infection is pseudomembranous colitis, which may lead to ileus, sepsis, and toxic megacolon,

Answer 40

* Idiopathic * Gall stone * Ethanol * Trauma * Steroids * Mumps * Autoimmune * Scorpion bite * Hypertriglyceridaemia, hypercalcaemia * ERCP * Drugs - azathroprine, sulfonamides

Answer 41

* Constant severe epigastric pain * Classically radiating towards the back * Worse after meals and when supine * Improves on leaning forwards * Nausea and vomiting * General physical examination * Shock, tachycardia, hypotension, oliguria/anuria * Abdominal examination * Abdominal tenderness, distention, guarding * Ileus with reduced bowel sounds and tympany on percussion * Ascites * Skin changes (rare) * Cullen’s sign – periumbilical ecchymosis and discoloration * Grey-turner’s sign – flank ecchymosis and discoloration * Fox’s sign – ecchymosis over inguinal ligament

Answer 42

Diagnosis of acute pancreatitis requires 2 of the following 3 features: 1. Abdominal pain consistent with acute pancreatitis (acute onset, persistent, severe epigastric pain often radiating to the back) 2. Serum lipase/ amylase at least 3 times greater than upper limit of normal 3. Characteristic findings on U/S, CT or MRI

Answer 43

_Lab tests_ 1. serum pancreatic enzymes (normal enzymes don’t rule out pancreatitis) * lipase if \>= 3 times upper reference range * amylase * note that the enzyme levels are not directly proportional to severity or prognosis 1. Haematocrit * Should be conducted at presentation and 12 and 24 hours after admission * Hct indicates third space fluid loss and inadequate fluid resuscitation * ¯ Hct indicates the rarer acute haemorrhagic pancreatitis 1. WBC count – leukocytosis indicates severe pancreatitis 2. Blood urea nitrogen * Rising blood urea nitrogen levels \> 48 hours of resuscitation indicates persistent third spacing of fluid and is a predictor of [severe pancreatitis](https://www.amboss.com/us/library#xid=SS0y_2&anker=Zddf844840f5720312501dda501be5e3a). 1. CRP and prolactin levels * [Procalcitonin](https://www.amboss.com/us/library#xid=xm0E3g&anker=Zeeaeba2c795feb36e7fbf2b4a2197d1b) levels help determine if a rise in [CRP](https://www.amboss.com/us/library#xid=j50_Pg&anker=Z2ebcd0ab92f8f1e3847364e735669ff5) is due to [necrosis](https://www.amboss.com/us/library#xid=VP0GdT&anker=Z28b2cd3d009fe208ee54280c99b41b38) caused by bacterial pancreatitis, as [procalcitonin](https://www.amboss.com/us/library#xid=xm0E3g&anker=Zeeaeba2c795feb36e7fbf2b4a2197d1b) typically indicates bacterial infection, whereas [CRP](https://www.amboss.com/us/library#xid=j50_Pg&anker=Z2ebcd0ab92f8f1e3847364e735669ff5) may be elevated in either sterile or bacterial pancreatitis. 1. LFTs * ALT (\> 150 U/L) indicates pancreatitis caused by biliary disorders (in 85% of cases) and a more fulminant disease course. * ALP, bilirubin à gallstone 1. Serum calcium levels * Hypercalcemia may cause pancreatitis, then in turn cause hypocalcaemia 1. Serum triglyceride levels 2. Electrolytes (K, Ca) 3. Renal function tests I_maging_ 1. U/S – most useful initial test 2. CT scan – not routine, only when diagnosis is in doubt 3. MRCP - Magnetic resonance cholangiopancreatography (noninvasive but less sensitive than ERCP) 4. ERCP – Endoscopic retrograde cholangiopancreatography – may worsen pancreatitis but can extract stone 5. X-ray

Answer 44

_General_ 1. Fluid resuscitation 2. Analgesia – IV opioids 3. Bowel rest _Drug therapy_ 1. Analgesics – fentanyl or hydromorphone 2. Antibiotics – only used if evidence of infected necrosis (Tazocin) _Surgery_ 1. Biliary pancreatitis * Urgent ERCP and sphincterotomy in patients with evidence of choledocholithiasis or cholangitis * Cholecystectomy followed – in all patients with biliary pancreatitis

Answer 45

Epigastric abdominal pain * Pain radiates to the back, is relieved on bending forwards and exacerbated after eating * Pain is initially episodic and becomes persistent as the disease progresses * Often associated with nausea and vomiting Features of pancreatic insufficiency * Late manifestation (after 90%) of the pancreatic parenchyma is destroyed * Steatorrhoea (exocrine hormone deficiency) * Cramping abdominal pain, bloating, diarrhea, weight loss * May cause fat-soluble vitamin deficiency * Malabsorption and weight loss * Pancreatic diabetes

Answer 46

_General measures_ 1. Abstinence from alcohol and nicotine 2. Small regular meals low in fat 3. Pancreatic enzyme replacement with meals 4. Parenteral administration of fat-soluble vitamins (A,D,E,K) 5. Endocrine insufficiency - insulin administration _Pain management_ 1. Analgesics: NSAIDs, opioid for severe pain (fentanyl, morphine), low dose tricyclic antidepressants (amitriptyline) 2. Intractible pain 1. Celiac ganglion block (offers temporary relief) 2. Endoscopic papillotomy \_ductal dilation and stent placement + remove stone 3. Extracorporeal show wave lithotripsy _Surgery_ If pancreatic cancer is suspected or in those with intractable pain 1. Pancreaticojejunostomy 2. Resection of affected pancreas (distal pancreatomy, Whipple’s procedure) 3. Thoracoscopic bilateral splanchiectomy (destroys sensory nerves)

Answer 47

Metabolic syndrome describes a constellation of medical conditions which increase the risk for several health problems: * primarily CVD disease * T2DM * Fatty liver (Non-alcoholic steatohepatitis à increased risk of liver cirrhosis and hepatocellular carcinoma) Presence of \>= 3 of the following conditions: 1. Insulin resistance (fasting glucose \> 5.6mmol/L) 2. Hypertension (\>= 130/85 mmHg) 3. Dyslipidaemia * Elevated triglycerides: (\>= 1.8 mmol/L) * Low HDL (\<1.0mmol/L in men and \< 1.3 mmol/L in women) 1. Abdominal obesity (waist cirfumference \>=102cm in men, \>= 88cm in women)

Answer 48

* Helicobacter Pylori * Long term use of NSAIDs * Zollinger-Ellison Syndrome

Answer 49

* Abdominal pain * Epigastric tenderness * Upper GI bleeding * Pain after eating * Nocturnal pain/ worse lying down

Answer 50

* Serology IgG (Blood test) * Urea Breath Test - fasting * Faeces Antigen * Urease Test (endoscopy and biopsy) * Culture main lab (endoscopy and biopsy) * Histology (endoscopy and biopsy) List increases in complexity and cost

Answer 51

* PPI (esomeprazole 20mg) * Amoxicillin * Metronidazole/ Clindamycin (If ulcer caused by NSAIDs - stop NSAIDs and use PPI)

Answer 52

* Gastric adenocarcinoma * MALT lymphoma

Answer 53

**Ischaemic colitis** – Hypo perfusion of the large bowel, which is mostly transient and self-limiting, but can also lead to severe acute ischaemia with bowel infarction **Acute mesenteric ischaemia** – acute inadequate blood flow to the small intestine that can result in bowel infarction **Chronic mesenteric ischemia** – constant or episodic hyoperfusion of the small intestine, usually due to atherosclerosis **_Acute ischaemia_** 1. Acute arterial embolism (AF, MI, Valvular heart disease, endocarditis) 2. Arterial thrombosis (atherosclerosis, arteritis, aortic aneurysm, dissection) 3. Non-occlusive mesenteric ischaemia (low cardiac output, hypotension, vasopressive drugs , cocaine) 4. Venous thrombosis (infection, malignancies, Oestrogen therapy, hypercoagulability disorders) **_Chronic Ischaemia_** 1. iAtherosclerosis * Risk factors: HTN, smoking, DM, high cholesterol

Answer 54

* [Superior mesenteric artery](https://www.amboss.com/us/library#xid=R60lkS&anker=Zbd73768ac25cd57aae7b69c63c8adf99) ([SMA](https://www.amboss.com/us/library#xid=R60lkS&anker=Zbd73768ac25cd57aae7b69c63c8adf99)): supplies the distal duodenum, jejunum, ileum, and the right colon from the cecum to the splenic flexure * [Inferior mesenteric artery](https://www.amboss.com/us/library#xid=R60lkS&anker=Z2bdecfdcdd5e68e76c1be04f570a2fb9) ([IMA](https://www.amboss.com/us/library#xid=R60lkS&anker=Z2bdecfdcdd5e68e76c1be04f570a2fb9)): supplies the left colon from the splenic flexure to the rectum The **splenic flexure** and the rectosigmoid junction are at high risk for [colonic ischemia](https://www.amboss.com/us/library#xid=cS0aA2&anker=Za5a3e828cf2d10df3a9693a9fc3b2c34) because they are “**watershed areas**”.

Answer 55

* Hyperactive phase (80% of patients don’t progress past this phase) * Sudden onset of crampy abdominal pain (usually LLQ) * Bloody, loose stools * Paralytic phase * Pain more diffuse * Bowel sounds absent * Bloating * Bloody stools cease * Stock phase * Acute abdomen with abdominal guarding and rebound tenderness * Signs of septic shock \*Classic case – bloody diarrhea and severe abdominal pain after abdominal aortic aneurysm repair

Answer 56

Lab tests Severe ischaemic colitis 1. lactate (increases in hypoperfusion and decreased aerobic metabolism) LDH, creatinine kinase 2. leukocytosis 3. metabolic acidosis Imaging 1. Colonoscopy 2. CT scan

Answer 57

_Mild-moderate_ * Supportive care (IV fluids, bowel rest) * Antiplatelet drugs * Reduce risk of atherosclerosis _Severe_ Surgical intervention – laparotomy or bowel resection

Answer 58

hemodynamic instability will be defined as global or regional perfusion that is not adequate to support normal organ function Signs and symptoms 1. Hypotension 2. Abnormal HR 3. SOB 4. Cold extremities, peripheral cyanosis 5. Decreased urine output 6. Alternative consciousness 7. Chest pain

Answer 59

**_Mechanical Bowel Obstruction_** _Small bowel obstruction_ * Adhesions (post-operative, prior abdominal surgery) * Incarcerated hernia * Malignant tumours or metastases * Strictures (Crohn’s Disease, congenital, radiation, enteritis) * Foreign body * Superior mesenteric artery syndrome (SMA passes in close proximity anterior to the third segment of the duodenum à duodenum compressed between SMA and aorta) * In children – pyloric stenosis, congenital intestinal atresia, intussusception _Large bowel obstruction_ * Malignant tumours * Strictures (diverticulitis, IBD, congenital) * Volvulus * Adhesions (post-operative, prior abdominal surgery) * Infective mass (TB, appendiceal mucocele) * Fecal impaction **_Paralytic ileus_** * Intra-abdominal surgery or trauma (e.g. laparotomy, retroperitoneal haemorrhage) * Endocrine (DM, hypothyroidism, porphyria, uraemia) * Electrolyte disturbances (hypokalaemia) * Neurosurgical procedures e.g. spinal surgery * Vascular (mesenteric infarct) * Inflammation of intra-abdominal organs (appendicitis, cholecystitis) and peritonitis * Medication (anticholinergics, opioids, antidepressants

Answer 60

* Nausea and vomiting * Dehydration, possible fever * Constipation with abdominal distention * Abdominal pain and discomfort – vague or periumbilical cramping, colicky pain * Persistent, focal pain usually implies bowel necrosis * Sudden acute pain, followed by temporary pain relief indicates bowel perforation _Auscultation_ 1. Mechanical bowel obstruction - increased high pitched, tinkling bowel sounds 2. Paralytic ileus - absent bowel sounds

Answer 61

_Imaging_ 1. Abdominal X-ray * SBO/ LBO: dilated loops of small or large bowel, air-fluid levels proximal to the obstruction, distal bowel collapse, minimal gas in colon * LBO: air-fluid levels in the colon, bowel distention before obstruction * Paralytic ileus: uniform distribution of gas in the small bowel, colon and rectum * Bowel perforation: free air in abdomen 1. CT abdomen with IV and oral contract 2. Abdominal U/S 3. Barium or gastrografin enema _Lab tests_ 1. FBC – leukocytosis (indicates ischaemia or necrosis) 2. Blood gas analysis (metabolic alkalosis due to severe vomiting, metabolic acidosis if ischaemia or sepsis) 3. Inflammatory markers - in paralytic ileus 4. Coagulation profile – pathological in sepsis

Answer 62

**Mechanical Obstruction** Conservative (partial obstruction, no signs of ischaemia, or necrosis or clinical deterioration * Fluid resuscitation, electrolyte correction * Nasogastric tube * Bowel rest * Antibiotics (suspected bowel perforation, prophylaxis for surgery) Surgical * Surgical bowel decompression (removal of adhesions, bowel resection, stenting for tumours, herniotomy) **Paralytic ileus** * Conservative treatment * Specific to underlying condition e.g. reducing postoperative opioid use * Possible surgical management

Answer 63

1. **_Hepatocellular adenoma (rare)_** * Young women on oral contraception or anabolic steroid use * Complications – rupture or progression to HCC 1. **_Hepatic Haemangioma_** * Composed of endothelium-lined blood-filled sinuses. More common in women between 30-50 years. 1. **_Bile duct adenoma_**

Answer 64

1. Metastatic 2. Hepatocellular carcinoma 3. cholangiocarcinoma 4. hepatoblastoma

Answer 65

Epidemiology * Highest incidence in asia * Higher incidence in countries with high HBV and HCV Aetiology * HBV, HCV * Food contamination by alfatoxins * Hemochromatosis Investigations * Core needly biopsy

Answer 66

* fatty liver (steatosis) * alcoholic hepatitis (inflammation and necrosis) * alcoholic liver cirrhosis

Answer 67

* Abdominal pain * Hepatomegaly * Ascites * Weight gain/ loss * Malnutrition and wasting * Anorexia * Fatigue * Splenomegaly * Jaundice * Palmar erythema * Asterixis * Hematemesis and melena

Answer 68

1. LFTs – elevated AST and ALT, normal or elevated ALP 2. GGT increased in ETOH 3. Serum ferritin - increased 4. Elevated bilirubin 5. FBC – macrocytic anemia, leukocytosis, thrombocytopenia 6. Urea – decreased due to muscle wasting 7. Electrolyte disturbances 8. U/S – mild hepatomegaly

Answer 69

* Alcohol abstinence * Weight reduction * Nutritional supplement * Immunizations * 2^nd line liver transplant

Answer 70

Heptatitis for \< 6 months * Viral * Hep A, E, (majority) and B, C, D   * In immunosuppressed/ transplant – CMV, EBV, HSV   * Other infections – toxoplasma, Q fever, Leptospirosis, Brucellosis   * Alcohol   * Drugs – paracetamol   * Toxins – mushrooms, carbon tetrachloride   * Ischaemia (double blood supply so hard)   * Pregnancy   * Autoimmune conditions   * Metabolic – Wilson’s disease  

Answer 71

* Viral–Hep B,C, D * Alcohol * Drugs – methotrexate, amiodarone, isoniazid * Autoimmune hepatitis (AIH)   * Biliary * Primary biliary cirrhosis (PBC)   * Primary sclerosing cholangitis (PSC)   * biliary obstruction (gallstone, stricture) * Metabolic * Alpha-1-antitrypsin deficiency   * Hereditary haemochromatosis   * Wilson’s disease   * NAFLD (Non-alcoholic fatty liver disease)  

Answer 72

* HBsAg and resulting HBsAb * HBcAg (not present in blood), resulting ABcAb in blood * HBeAg and resulting HBeAb

Answer 73

Aim of treatment is to suppress HBV to improve diagnosis. * HBeAg seroconversion to HBeAb antibody * Reduce HBV DNA below detectable elvels * Settling of liver inflammation (raised ALT) 1. Nucleosides and Nucleotides analogue – e.g. (Lamivudine, Tenofovir, Entacavir) OR 2. Interferon – blocks viral mRNA synthesis, many side effects Also stop ETOH consumption and caution with sexual contacts.

Answer 74

Hep A - faecal-oral Hep B and C * Parenteral (blood exposure) – IDVU, tattoos, transfusion * Vertically – 3-5% risk from HCV RNA +ve mothers * Sexual – very low risk, higher with anal intercourse * Developing countries – medical practices

Answer 75

1. HCV antibody * Indicate infection at some point, takes 7-8 weeks to seroconvert 1. PCR (HCV RNA) * Defines active infection, becomes positive within 1-2 weeks * Used to monitor treatment success (Sustained viralogical response = PCR –ve 3/12 after Tx) * Persistence past 6/12 indicates chronic infection 1. ALT

Answer 76

* 12 weeks of oral medication with a 90% SVR success rate Sofosbuvir (polymerase inhibitor) + Ledipasivir (asembly inhibitor) combination

Answer 77

Defective RNA virus. Can only be effective if there is also HBsAg present. Diagnose using serology - IgM and IgG Nil Vaccine

Answer 78

Vaccine for A and B Chronic are B,C D

Answer 79

1. LFTs (LFTs do not correspond to the degree of hepatocellular damage) * AST and ALT increase with hepatocellular damage * Albumin * GGT increased in ETOH 1. Serum bilirubin * Raised à jaundice 1. Serum albumin * Reduced and associated with ascites 1. Coagulation profile * Prothrombin time – prolonged as liver produces coagulation factors I, II, V, VII, VIII, IX, X, XI, XIII, protein C&S 1. Platelet count - reduced due to portal HTN with hypersplenism 2. FBC * Portal hypertension – splenic enlargement – thrombocytopenia * Liver disease affects EPO leves * MCV à alcoholic anaemia * WCC decreased due to hypersplenism 1. Viral serology * Hep B and C 1. Urea * Hepatic encephalopathy 1. VBGs + ABGs * Metabolic acidosis 1. Creatinine * Hepato-renal syndrome 1. Glucose * Elevated at liver stores glucose 1. Abdominal MRI – Increased caudate lobe, smaller islands of regenerating nodules à alcoholic cirrhosis Liver biopsy - diagnostic for Liver cirrhosis

Answer 80

* Encephalopathy * Coagulopathy * Hepatorenal syndrome and renal failure * Metabolic derrangements (hyponatraemia, hypoglycaemia, hypokalaemia, metabolic alkalosis) * SIRS * ascites * gastro-oesophageal varices * spontaneous bacterial peritonitis * hypogonadism and feminisation

Answer 81

* Deterioration of liver function * Infections – spontaneous bacterial peritonitis * Gastrointestinal bleeding * Constipation * Portal vein thrombosis * Hypovolaemia/ electrolyte disturbances * Renal failure * Excessive protein consumption

Answer 82

Hepatic encephalopathy encompasses a severe spectrum of neuropsychiatric abnormalities in patients with severe liver dysfunction. Caused by elevated blood ammonia levels Disturbances of consciousness, ranging from mild confusion to coma Multiple neurological and psychiatric disturbances: * Asterixis * Fetor hepaticus * Fatigue, lethargy, apathy * Memory loss * Impaired sleeping patterns * Irritability * Disorientated, socially aberrant behaviour * Slurred speech * Muscle rigidity

Answer 83

Deterioration of kidney function in patients with advanced liver disease. The condition is cause by renal vasoconstriction resulting in hypoperfusion of the kidneys. **Diagnostic criteria** 1. Cirrhosis with ascites 2. Serum creatinine \> 1.5mg/dL 3. No improvement of serum creatinine after at least 2 days with diuretic withdrawal and volume expansion with albumin 4. Absence of shock 5. No current or recent treatment with nephrotoxic drug 6. Absence of parenchymal kidney disease Protein excretion \< 500mg/d, microhaematuria (\>50 RBC per high power field) Treatment 1. General – improve liver function if possible (stop alcohol consumption) 2. Pharmacotherapy: combination of midodrine, octreotide, and albumin 3. Surgical – placement of transjugular intrahepatic portosystemic shunt or liver transplant

Answer 84

1. _Mechanical filter_ – acts as a sieve to remove particular matter 1. Portal hypertension due to increasing obstruction of blood flow through liver 2. abdominal swelling (ascites, splenomegaly, irregular hepatomegaly, portosystemic shunts (bypass liver to systemic), varices (caput medusa), hepatorenal syndrome 3. haematemesis, malena and oesophageal varices bleeding 1. _Detoxification_ – removes toxins and metabolites from blood and either breaks them down or excretes them in the bile 1. Nitrogen - encephalopathy – mental confusion, asterixis, fetor hepaticus 2. Bile (hyperbilrubinaemia) – jaundice, itch 3. Oestrogen – gynecomastia, hypogonadism, spider naevi 1. _Digestion_ – metabolises nutrients, produces bile which aids in digestion of fats in gut 1. Decreased bile excretion - diarrhoea, steatorrhoea, malabsorption of fat soluble vitamins 2. Decreased metabolism – LOA, LOW 1. _Protein manufacture_ 1. Decreased albumin production – ascites, peripheral oedema 2. Decreased clotting factor production – coagulopathy and bruising

Answer 85

Cirrhosis is a diffuse pathological process, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules, separated by a fibrous septum. It can arise from a variety of causes and is the final stage of any chronic liver disease. It leads to portal hypertension, liver insufficiency, and hepatic failure, in general, it is considered to be irreversible in its advanced stages.

Answer 86

Chronic constipation and increasing weakness of CT due to age --\> protrusion of herniated intestinal mucosa and submucosa through gaps in the muscular layer of the intestinal wall **_Symptoms_** * Mostly asymptomatic * Most common cause of **lower GI bleeding** in adults * Can present with abdominal pain in patients with chronic constipation

Answer 87

Stool gets lodged in diverticula à obstruction of intestinal lumen à increased intraluminal pressure and erosion of diverticula wall à inflammation Symptoms: * Low grade fever * Sigmoid colon most commonly affected - LLQ pain * Possible tender, palpable mass * Change in bowel habits (50% constipation, 25-35% diarrhea) * Nausea and vomiting; caused by bowel obstruction or ileus * urinary urgency and frequency (15%) * acute abdomen --\> perforation +/- peritonitis

Answer 88

**_Lab tests_** _Blood tests_ * Leukocytosis * decreased Hb (bleeding) * CRP _Stool test_ – rule out pathogens in diarrhea **_Imaging_** * 1^st line à Abdominal CT with oral and IV contrast * Abdominal U/S **_Colonoscopy_** * Not indicated during an acute episode à increased risk of perforation and exacerbating diverticulitis * Performed once inflammation has subsided (6 weeks) to assess extent of diverticulitis and rule out malignancy

Answer 89

_Conservative management_ * IV fluids and bowel rest * broad spectrum antibiotics e.g. tazocin * Analgesia - moephine, paracetamol _Surgical management_ If complicated with say an abscess * CT-guided percutenous abscess drain If complicated by peritonitis, sepsis, intestinal obstruction * resection of affected segment If reccurent disease unresponsive to antibiotics, patient can have elective * resection of affected segment

Answer 90

Colonic polyps are abnormal colonic mucosal overgrowths. Subtypes based on histology: Low malignant potential * Hamartomatous polyps (Increased risk of malignancies) * Juvenile polyposis syndrome * Peutz-Jeghers syndrome * Cowden syndrome * Inflammatory polyps (Seen in Ulcerative colitis) * Mucosal polyps * Submucosal polyps Moderate malignant potential * Serrated polyps * Hyperplastic polyps (minimal risk of mal) * Sessile serrated polyps (risk of mal 5%) * Traditional serrated adenome (risk 5%) High malignangt potential * tubular adenoma (\<5% mal risk) * Tubulovillous (20% mal) * Villous adenoma (50% risk)

Answer 91

* Mutation of tumour suppressor gene APC (Autosomal Dominant) * \<1% of colorectal cancers, but lifetime risk of colorectal cancer is 100% at age 45 * Diagnosis: \> 100 polyps in the entire Gi tract, particularly colon * Screening beginning at 10yo * Tx – prophylactic proctocolectomy + ileoanal anastomosis at time of diagnosis

Answer 92

Hypertrophic pyloric stenosis – the most common cause of gastric outlet obstruction in infants – is characterised by hypertrophy and hyperplasia of the pyloric sphincter in the first months of life. Symptoms * frequent regurtitation * olive-shape palpable in epigastrum * peristaltic wave in epigastrum * hungry vomiters Investigating * U/S Tx * IV rehydration, correct electrolytes * Frequent small meals, elevate head * Surgery - pyloromyotomy

Answer 93

Metaplasia – change from the specified squamous epithelium of the tubular oesophagus to specialized intestinal type glandular mucosa with mucin secreting goblet cells symptoms * Heartburn, cough, reflux symptoms complications * adenocarcinoma * squamous cell carcinoma Treatment * PPI and surveillance

Answer 94

Achalasia is a failure of the lower oesophageal sphincter to relax that is caused by the degeneration of inhibitory neurons within the oesophageal wall. Clinical features: * Dysphagia to solids and liquids * Regurgitation * Retrosternal pain and cramps * Weight loss Investigations 1. Endoscopy – to rule out pseudoachalasia (usually normal) 2. Barium oesophagram 3. Oesophageal manometry (confirmatory test) * Lack of peristalsis in the lower two thirds of oesophagus * Incomplete or absent relaxation of LES * No evidence of mechanical obstruction 1. CXR * Widened mediastinum * Air-fluid level on lateral view * Possible absence of gastric air bubble Treatment Surgery * Pneumatic dilation – endoscope-guided graded dilation of the LEW that tears the surrounding muscle fibres with the help of a balloon * LES myotomy (heller myotomy)

Answer 95

Pancreatic adenocarcinoma (pancreatic duct carcinoma) * Precursor lesions include: * MCN and IPMN * Pancreatic intraepithelial neoplasm dysplasia of pancreatic duct * Aetiology * Old age * Smoking * Diabetes * Precursor lesion * FHx * Chronic pancreatitis * Molecular carcinogens * K-ras, G-nas, P53, SMAD4, HER2 * Poor prognosis, direct infiltration Acinar cell carcinoma

Answer 96

* Belt-shaped epigastric pain which radiate to the back * Jaundice * Courvoiseier sign: enlarged gallbladder and painless jaundice * Pale stools, dark urine, and pruritis * Weight loss, nausea, weakness, poor apetite * Diarrhea (possible steatorrhea secondary to exocrine pancreatic insufficiency) * Superficial thrombophlebitis * Thrombosis * Impaired glucose tolerance (rare)

Answer 97

_Lab tests_ * Tumour markers – CEA, CA 19-9 * Lipase _Imaging_ * First test: usually contrast-enhanced abdominal CT or U/S * Endoscopic retrograde cholangiopancreatography

Answer 98

1. Gastrointestinal stromal tumours (associated with KIT mutation) 2. MALT (mucosal asssociated lymphoid tissue) [related to H. pylori] 3. Neuroendocrine (carcinoid) 4. Hereditary Diffuse Gastric Carcinoma

Answer 99

_Sliding Hernia_ * Most common type   * Part of the stomach is pulled up above the diaphragm forming a cell shaped dilated  segment   * This is due to congenitally short oesophagus   * Or due to a secondary defect like scaring of the oesophagus following chronic injury   _Rolling Hernia (Paraoesophageal hernia)_   * Portion of the cardiac end of the stomach pushes through the diaphragm rolling up alongside the oesophagus   * This is usually small and the lower end of the oesophagus is normally placed   * Less than 10% of hernias are this type  

Answer 100

* Epigastric/ substernal pain * Early satiety * Retching * Symptoms of GORD can occur Saint’s triad: cholelithiasis, diverticulosis, hiatal hernia

Answer 101

Investigations * barium swallow * endoscopy * CXR treatment * surgery * PPI * lifestyle mod

Answer 102

Congenital defect in which the upper oesophagus is not connected to the lower oesophagus, ending blindly instead. It is caused by the abnormal development of the tracheoesophageal septum. Oesophageal atresia with a fistula connected distally to the trachea is the most common kind of oesophageal malformation. It prevents immediately after birth with cyanotic attacks, foaming at the mouth and coughing and prevents any attempts to pass a feeding tube into the stomach. Prenatal * Polyhydramnios - increased risk of premature birth Postnatal * Oesophageal atresia à pooling of secretions à excessive mouth secretions/ foaming at mouth * Transoesophageal fistula --\> If the fistula is connected to the proximal oesophageal segment: aspiration and subsequent aspiration pneumonia * Coughing spells * Rales * Cyanotic attacks ---\> if the fistula is connected to the distal oesophageal segment - gastric distention

Answer 103

Congenital ananglionic megacolon, is an inherited disorder primarily affecting newborns. The conditions is characterised by an aganglionic colon segment, usually the rectosigmoid region, which fails to relax leading to functional intestinal obstruction. **Early presentation** * Delayed passage of meconium * Distal intestinal obstruction: abdominal distention and bilious vomiting * Tight anal sphincter with explosive release of stools and air upon removal of the finger * Failure to thrive/ poor feeding * Palpation of faeces via the abdominal wall **Late presentation** * Chronic constipation with possible inability to pass gas

Answer 104

Oedematous malnutrition affecting children, characterised by bilateral pitting oedema in the absence of another medical cause of oedema, generally occurring while receiving a monotonous cereal-based diet. Marasamic kwashiorkor is the presence of severe wasting in addition to oedema.

Gastrointestinal Flashcards

(133 cards)