GI Flashcards Preview

Question Bank MRCS A. > GI > Flashcards

Flashcards in GI Deck (61):
1

Upper gastrointestinal haemorrhage
A Acute erosive gastritis
B Aorto-enteric fistula
C Duodenal lymphoma
D Gastric leiomyoma
E Mallory-Weiss tear
F Oesophageal varices
G Oesophagitis
H Peptic ulcer
For each case below, choose the single most appropriate diagnosis from the given list of options.
Each option may be used once, more than once, or not at all.
A 47-year-old man known to abuse alcohol presents to the Emergency department with a profuse haematemesis. He is found on examination to be jaundiced, mildly confused, with ascites and a liver flap. His serum albumin is markedly low.

A 21-year-old student is brought into the Emergency department with severe vomiting and diarrhoea. He has just returned from a holiday in Sri Lanka and is dehydrated. He continues to vomit and then complains of severe retrosternal pain and has a haematemesis.

A warden in a block of flats is called to see a 62-year-old with a massive haematemesis. He has a midline laparotomy scar from an aortic aneurysm repair and is vomiting large quantities of fresh blood.

A 70-year-old man is taken to theatre with a massive upper gastrointestinal (GI) bleed. At laparotomy he is found to have a large mass in the gastric body which is rubbery in nature and is bleeding profusely.

A 42-year-old man who was previously fit and well presents with a sudden onset of haematemesis. He has noticed melaena stool during the day and is on no medication.

The alcohol abuse and profuse haematemesis are suggestive of varices. Plus, this patient has evidence of portal hypertension.

Typical history of recurrent vomiting, then blood.

The midline laparotomy and massive haematemesis after AAA repair are highly suggestive of aorto-enteric fistula.

A possibility is peptic ulceration/stress ulcer but, in the circumstances, the examiner is probably seeking the former answer.

The rubbery large mass suggests leiomyoma. These are prone to haemorrhage.

This patient has been previously fit and well and taking no medication. Of the options offered it seems most likely that this is due to an acute peptic ulceration.

Patients with severe upper GI haemorrhage require resuscitation with respect to their airway, breathing, and circulation. A history should be gained contemporaneously. The underlying cause should then be treated.

Bleeding ulcers are injected with adrenalin or underrun; varices may be injected or banded.

2

Swallowing problems
A Achalasia of the oesophagus
B Candidal oesophagitis
C Carcinoma of the oesophagus
D Diffuse oesophageal spasm
E Globus syndrome
F Herpes simplex oesophagitis
G Motor neurone disease
H Peptic oesophageal stricture
I Pharyngeal pouch
J Systemic sclerosis
Each of the following patients presents with dysphagia.
For each one, select the most likely diagnosis from the list of options.
Each option may be used once, more than once, or not at all
A 25-year-old man on cytotoxic therapy for a haematological malignancy complains of severe retrosternal pain and dysphagia for both liquids and solids, which began five days ago.

On three occasions a 65-year-old man has developed dysphagia after eating one mouthful of steak. Each time, vomiting has relieved this, and he has then been able to complete his meal. He has a left sided neck lump.

A 70-year-old man complains of choking, nasal regurgitation and coughing during meals. His wife has noticed a change in his voice and he has a spastic gait.

A 50-year-old man presents with a six week history of progressive dysphagia for solids. Endoscopic examination five years earlier showed oesophagitis and Barrett's oesophagus.

For the past two years a 50-year-old woman has had dysphagia for solid and liquids with painless regurgitation of food after meals.

Candidal oesophagitis
Oesophageal candidiasis presents with odynophagia or pain on swallowing. Those at risk are the elderly, very young and the immunosuppressed.

Pharyngeal pouch is due to mucosal herniation of the inferior constrictor. There may be halitosis, regurgitation of food and a usually a left sided neck lump. Diagnosis is by barium swallow and treatment is surgical.

Twenty five per cent of motor neurone disease presents with bulbar palsy.

Barrett's oesophagus is a risk factor for carcinoma of the oesophagus. Clinical features include dysphagia, weight loss, hoarseness and cough. Investigations include barium swallow, oesophagoscopy with biopsies and brushings.

Achalasia is due to failure of oesophageal peristalsis and loss of relaxation of the lower oesophageal sphincter due to loss of ganglia from Auerbach's plexus. Clinical features include dysphagia for both solids and liquids at the outset, chest pain and regurgitation of old food. Diagnosis is by barium swallow and treatment is by balloon dilatation and cardiomyotomy.

3

Intestinal obstruction
A Adhesions
B Carcinoma caecum
C Carcinoma rectum
D Carcinoma sigmoid
E Gallstone ileus
F Intussusception
G Pseudo-obstruction
H Sigmoid volvulus
I Strangulated femoral hernia
J Strangulated inguinal hernia
For each of the patients below, select the most likely diagnosis from the listed options:
An 80-year-old man presents with a four day history of abdominal distension and pain. He is vomiting faeculent fluid. He has not been feeling well for three months and has lost 2 stone in weight. Clinical examination reveals visible peristalsis in the mid abdomen, distension and a mass in the right iliac fossa.

A 68-year-old lady presents with colicky abdominal pain and vomiting. Examination shows she is dehydrated, with abdominal distension and a lower midline scar from a perforated appendix. Plain abdominal film shows multiple distended small bowel loops and the presence of air in the biliary tree.

A 60-year-old man undergoes emergency lumbar disc decompression. Post operatively he is immobile. He becomes increasingly constipated and develops a distended abdomen. Rectal examination shows some hard stool but no other abnormality. A plain abdominal film show a grossly distended colon down to the pelvic brim.

A 78-year-old man presents with a three day history of vomiting faeculent fluid. He has a grossly distended abdomen and a palpable mass in the right groin. The mass is firm, slightly tender and lies below and lateral to the pubic tubercle.

An 88-year-old lady with dementia is referred by her GP because she seems to be in pain and unwell. She has a long history of constipation. On examination she has a grossly distended tympanitic abdomen which is non-tender. The plain abdominal x ray shows a large distended loop of colon.

This history of abdominal distension, pain and faeculent vomiting suggests small bowel obstruction. Examination reveals abdominal distension with visible peristalsis suggestive of small bowel obstruction.

The most likely diagnosis in someone of age 80, with a history of malaise and weight loss is caecal carcinoma.

Small bowel obstruction is suggested by the history. This could be due to adhesions from previous abdominal surgery but the abdominal x ray shows air in the biliary tree. This implies the presence of a choledochal fistula which is due to a gallstone eroding into the duodenum and causing small bowel obstruction when it lodges in the ileum.

Immobilised patients often develop an ileus, particularly after orthopaedic surgery. This is usually painless and may be associated with decreased potassium levels. The abdominal x ray shows grossly distended colon with no cut-off to imply obstruction.

This patient has symptoms of small bowel obstruction. There is a mass in the right groin, which in a man is usually due to irreducible inguinal hernia, but men can also get femoral hernias and this is implied by the fact that swelling is below and lateral to the pubic tubercle.

This is an elderly patient with dementia who often suffers with chronic constipation. In view of the dementia she is not able to give a good history but is just unwell with malaise and is obviously in some discomfort.

The presence of a very distended tympanitic abdomen is usually indicative of sigmoid volvulus and this is compatible with the abdominal x ray appearance.

4

Gastrointestinal Symptoms
A Angiodysplasia
B Duodenal ulcer
C Caecal carcinoma
D Crohn's disease
E Mallory-Weiss tear
F Oesophageal varices
G Rectal carcinoma
H Sigmoid carcinoma
I Sigmoid diverticular disease
For each of the patients below, select the most likely diagnosis from the listed options:
A 56-year-old man presents with anaemia and weight loss. Examination reveals a mass in the right iliac fossa and hepatomegaly.

A 50-year-old alcoholic presents with melaena. On examination the patient is drowsy and hypotensive. Examination of the abdomen shows splenomegaly.

A 58-year-old man is admitted with acute onset of left iliac fossa pain. Recently he has noticed he has had some vague abdominal pain and felt more constipated. On examination he is pyrexial, pale and has localised peritonism in the left iliac fossa. His abdomen is distended. Investigations show a Hb of 7 g/dL (hypochromic, microcytic), WCC of 18 ×109/L.

A 77-year-old man presents with his fourth episode of acute rectal bleeding. The blood is a mixture of fresh blood and clots. On this occasion the bleeding has been severe enough to require a 4 unit blood transfusion. A barium enema is undertaken and is normal.

This patient has presented with anaemia which suggests chronic blood loss. The most likely diagnosis is that of a caecal carcinoma which is therefore associated with a mass in the right iliac fossa and weight loss. Hepatomegaly suggests metastatic disease.

An alcoholic person with haematemesis and melaena could have a duodenal ulcer or gastritis or oesophageal varices. The presence of splenomegaly however, suggests that he probably has portal hypertension and oesophageal varices are a possibility. Drowsiness implies hepatic encephalopathy precipitated by the bleeding.

Sigmoid carcinoma
The history suggests a perforated sigmoid carcinoma. The anaemia is due to chronic blood loss from the sigmoid carcinoma. This has also caused a recent change of bowel habit with increase in constipation. The presence of pyrexia and localised peritonism in the left iliac fossa suggests the presence of inflammation. The diagnosis could be diverticulitis (rather than diverticular disease) but a localised perforation of the obstructed carcinoma would be more in keeping with the iron deficiency anaemia.

Angiodysplasia
The differential diagnosis is diverticular disease or angiodysplasia. Both can produce a significant gastrointestinal blood loss which is painless. In contrast a sigmoid carcinoma would not usually bleed enough to require a transfusion but would be associated with chronic blood loss causing anaemia. Angiodysplasia is only diagnosed by colonoscopy. Diverticulae would be seen on a barium enema.

5

Pelvic inflammatory disease

Pelvic inflammatory disease
Pelvic inflammatory disease is associated with a malodorous, green or yellow discharge. It may be associated with STDs such as Chlamydia but may occur in a sexually inactive female.

6

Chronic IBD

The most likely answer in this case is chronic inflammatory bowel disease given the weight loss, abdominal pain and diarrhoea. Addison's disease would present insidiously, and typically without bowel symptoms.

7

duodenal ulcer

This patient's symptoms are typical of a duodenal ulcer. He has increased weight because of drinking milk and eating to relieve his epigastric pain. Although the signs and symptoms are the same for duodenal and gastric ulcers, the ratio respectively is 4:1 thus more likely to be a DU.

8

pyloric stenosis

This gentleman has a long history of peptic ulceration which has been left untreated. It has therefore healed with scarring to cause pyloric stenosis. He is dehydrated because of vomiting. The succussion splash suggests it. The classical biochemical abnormality is hypochloraemic alkalosis.

9

oesophageal adenocarcinoma

This gentleman has a history of reflux that has been self treated with antacids. This does put him at risk of developing a benign oesophageal stricture secondary to his oesophagitis. He is also at increased risk of oesophageal carcinoma particularly in a Barrett's oesophagus which is related to reflux. The presence however of an iron deficiency anaemia and cachexia is more compatible with oesophageal adenocarcinoma. This is also related to the fact that he has progressive dysphagia and weight loss whereas with a benign oesophageal stricture the dysphagia may not be so progressive.

10

Oesophageal cancer Investigations:

Endoscopic ultrasonography. This patient has an oesophageal carcinoma. It could be staged by doing a CT scan which will look for liver metastases but a more accurate way of assessing whether or not it has spread to the local structures including thoracic aorta is by use of an endoscopic ultrasound.

11

Pancreatic cancer Investigations:

The history is suggestive of pancreatic carcinoma. An ultrasound has shown dilated common bowel duct. The possible diagnosis is carcinoma of the head of the pancreas. A CT scan would be the best way of staging this and would show the evidence of liver metastases and whether or not the pancreatic carcinoma involves the superior mesenteric vessels.

12

Gallstone Investigations:

The history is suggestive of gallstones and the most appropriate test to make this diagnosis is an abdominal ultrasound.

13

Dysphagia Investigations:

The history is suggestive of a pharyngeal pouch. It is not appropriate to do an endoscopy because of a risk of perforation. A barium meal looks at the stomach and duodenum and not the oesophagus. A barium swallow is therefore the most appropriate investigtion which will assess the function and anatomy of the oesophagus.

14

Stomach cancer Investigations:

Laparoscopy
This gentleman has carcinoma of the stomach. A CT scan has shown no evidence of liver metastases and an endoscopy shows a localised lesion in the antrum of the stomach. A CT scan suggests operability but a CT is not appropriate for diagnosing peritoneal metastases as they may not be evident on a CT. A laparoscopy is therefore, the appropriate way forward.

15

Reye's syndrome

Reye's syndrome is an acute disease of the liver often associated with a viral infection or salicylate toxicity. Laboratory findings include abnormal liver and muscle enzymes. Treatment is supportive.

16

Galactosaemia

Galactosaemia is a result of galactose-1-phosphate uridyl transferase. It accumulates in kidneys, liver and brain and clinical manifestations include jaundice, hepatomegaly, hypoglycaemia, vomiting, seizures and poor weight gain. Diagnosis is made by identifying urinary galactose. Treatment is dietary adjustment.

17

sentinel loop in pancreatitis

Acute onset of upper abdominal pain would suggest acute pancreatitis. The diagnosis will be confirmed by a markedly elevated serum amylase. The loop of small bowel seen on the plain film is due to an ileus of the duodenum and is known as the sentinel loop.

18

Gallstone ileus

Gallstone ileus is the most likely cause, as she is mobile and living independently. If air is seen in the biliary tree on plain abdominal x ray this is usually indicative of gallstone ileus. Ten percent of gallstones are radio-opaque and will be seen within the lumen of the small bowel.

19

sentinel loop in pancreatitis

Acute onset of upper abdominal pain would suggest acute pancreatitis. The diagnosis will be confirmed by a markedly elevated serum amylase. The loop of small bowel seen on the plain film is due to an ileus of the duodenum and is known as the sentinel loop.

20

A 72-year-old man presents to the Emergency Department with acute onset of abdominal pain. Examination reveals peritonitis. Following resuscitation a laparotomy was performed.
At surgery faecal peritonitis secondary to a perforated caecal tumour was found. A right hemicolectomy was performed. The proximal end of the bowel was exteriorised.

The operation of choice is a right hemicolectomy, thus removing the tumour. If there is no evidence of perforation then a primary anastomosis would be performed. However, there is a much higher risk of anastomotic breakdown in a contaminated field. Therefore an end ileostomy is formed. A mucus fistula is also required, to allow mucus to drain from the remaining colon.

21

A 79-year-old woman was admitted with a closed loop colonic obstruction. She suffers from mild angina but is otherwise well. An unprepared gastrografin enema revealed an obstructing lesion in the mid-sigmoid colon. At laparotomy the proximal colon was found to be healthy. A resection was performed.

Hartmann's procedure
Carcinoma is the commonest of large bowel obstructions. The operation of choice for an obstructing sigmoid tumour is a Hartmann's procedure. The tumour is removed (sigmoid colectomy) and a colostomy formed. (Sometimes there may be enough distal sigmoid to bring out as a mucous fistula rather than do a Hartmann's procedure. This would be easier to close subsequently.)

Primary anastomosis should usually be avoided, as there is a higher risk of anastomotic leak in patients presenting with obstruction.

22

Nissen fundoplication

Nissen fundoplication; antireflux surgery is indicated for cases of failed medical therapy. In a Nissen's the gastric fundus is mobilised and loosely wrapped around the oesophagus, which contains a large bore nasogastric tube to prevent the wrap from being sutured too tight. The wrap functions as a 'flutter valve' reducing transient lower oesophageal sphincter relaxation and increases the angle of oesophageal insertion.

23

Ivor lewis procedure

An Ivor-Lewis procedure involves a right thoracotomy and laparotomy and is best employed for mid and lower third tumours of the oesophagus. The advantage of this procedure is the excellent exposure and ease of anastomosis. However, the patient requires a thoracotomy with its associated morbidity. A direct, open approach is likely to be adopted in this patient as the tumour is locally advanced and nodes should be excised.

24

Intussusception

Intussusception in children can occur between 3 months and 6 years of age, but it is more common in the first three years.

Colicky abdominal pain, straining and lethargy are clinical features. Bloody mucus and vomiting occur late when the bowel becomes strangulated and ischaemic.

The condition involves the telescoping of one segment of the bowel into an adjacent segment.

Most cases are idiopathic however in a minority of cases there is a 'mechanical leading segment' which predisposes to the abnormality, for example, polyposis, Peutz-Jeghers syndrome.

Pneumatic or hydrostatic reduction is therapeutic in most cases which present within 24 hours. Pneumatic reduction appears to have a higher success rate.

25

Which one of the the listed courses of action is the most useful in assessing the role of surgery in the following patient?
A 29-year-old male presents with severe gastro-oesophageal reflux.

Laparoscopic fundoplication is the treatment of choice for patients with GORD refractory to, or intolerant of, proton pump inhibitor therapy.

An oesophageal pH study will establish physiological response to PPI treatment.

The patient should have had an endoscopy at least six months prior to surgery to exclude any unsuspected pathology - Barrett's oesophagus or adenocarcinoma.

An oesophageal transit study is indicated to rule out a primary motor disorder (for example, achalasia, scleroderma) when suspected and to rule out aperistalsis, which may result in post-operative dysphagia after some forms of fundoplication.

26

Necrotising enterocolitis

Necrotising enterocolitis is more common in premature infants. Mesenteric ischaemia causes bacterial invasion of the mucosa leading to sepsis.

Terminal ileum, caecum and the distal colon are commonly affected. The abdomen is distended and tense, and the infant passes blood and mucus per rectum. x Ray of the abdomen shows distended loops of intestine and gas bubbles may be seen in the bowel wall.

27

Hirschsprung's disease

Hirschsprung's disease is an absence of ganglion cells in the neural plexus of the intestinal wall. It is more common in boys than girls. The delayed passage of meconium together with distension of abdomen is the usual clinical presentation.

A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels, and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.

28

EBV

The young patient with abdominal pain, cervical lymphadenopathy and jaundice with hepatosplenomegaly suggests EBV infection rather than hepatitis A.

29

dysphagia

Dysphagia is defined as difficulty in swallowing in contrast to odynophagia which refers to painful deglutition.

Dysphagia could be due to intraluminal, mural (including muscular disorders) extrinsic or functional causes.

The symptom may be described by some as sticking sensation. The site is usually well localised especially in the upper two thirds of the oesophagus due to its innervation pattern (somatic as opposed to visceral).

Retrosternal burning is most characteristic of GERD. It may be aggravated by food and drinks.

The fact that this is associated with stickiness of food in this elderly woman probably suggests that she has a stricture probably benign as she is otherwise well.

The 70-year-old man clearly has a malignant stricture or Ca oesophagus. Difficulty in initiation of swallowing is usually a pharyngeal problem in view of his age and of the choices provided he is most likely to suffer from Ca pharynx.

Globus hystericus (syndrome) mainly affects people between 30 to 60. The predominant symptom is a feeling of lump and is not a true dysphagia. It is most pronounced for dry swallow (swallowing own saliva) than when eating or drinking.

The 22-year-old probably has achalasia as her main problem is difficulty in swallowing liquids. In achalasia there is most often difficulty in swallowing liquids as they are not as heavy as solids to open the lower oesophageal sphincter but as the disease progresses the patients experience some difficulty swallowing solids as well.

30

Solitary painful ulcer

Differential diagnoses of solitary painful ulcer in the rectum at 60 years are

Cancer
Solitary rectal ulcer syndrome (otherwise known as ulcerative proctocolitis)
Rarely infections like amoebiasis, or bilharziosis.
The best response amongst those given here is ulcerative proctocolitis.

31

Ranson Criteria

There are a number of criteria used in the Ranson's scoring system which reflect prognosis associated with acute pancreatitis.

Ranson's criteria on admission that signify a worse prognosis include:

Age more than 55 years
White cell count more than 16,000
Lactate dehydrogenase more than 600 U/L
Aspartate aminotransferase more than 120 U/l
Glucose more than 10 mmol/L.

32

Macrocytic anaemia

Anaemia and macrocytosis are suggestive of B12 deficiency. This patient's symptoms could be due to inflammatory bowel disease which may reduce B12 absorption from the terminal ileum.

Other causes of macrocytic anaemias include

Folate deficiency
Liver disease
Excessive alcohol consumption
Myelodysplasia
Hypothyroidism.

33

PBC

Primary biliary cirrhosis (PBC) is a chronic and progressive cholestatic disease of the liver. The etiology is unknown, although it is presumed to be autoimmune in nature. The major pathology of this disease is a destruction of the small-to-medium bile ducts, which leads to progressive cholestasis and often end-stage liver disease.

For asymptomatic patients with antimitochondrial antibody (AMA)-positive findings, a normal biochemical liver profile, and histologic features that are compatible with PBC, the progression of the disease is relatively slow; however, the patient life expectancy is not identical to that of the general population. Of these patients, 40-67% develop symptomatic disease in approximately five to seven years.

Once they develop symptoms (mainly cholestasis) and remain untreated, the median patient survival duration ranges from 5.5-12 years. Generally, the median survival duration from the time of diagnosis is 7.5 years for patients who are symptomatic and 16 years for patients who are asymptomatic. Women comprise 75-90% of patients with PBC.

34

Reye's syndrome

Adult OTC cold remedies often contain aspirin and the diagnosis here is Reye's syndrome. Reye's syndrome is a severe, non-inflammatory, progressive encephalitic illness of children that is often accompanied by fatty infiltration of the liver. Studies in children have shown that using aspirin or salicylate-containing medications to treat viral illnesses increases the risk of developing Reye's syndrome. Although it does occur in adults, it is rarely recognised after 19 years of age. Children of both sexes and all races can affected.

35

This enzyme is present in the liver cell cytosol, brain and myocardium. A rise may occur in hepatitis and myocardial infarction.



Answer correctCorrect
ALP is raised in cholestasis and may be elevated in bone disease, which is why bone isoenzyme may be requested to differentiate the source of the elevation.

The correct answer is Aspartate aminotransferase (AST)
AST is not a specific hepatic enzyme like ALT, so may be raised in a range of other pathologies, for example, MI, pulmonary embolism.

36

This is a microsomal enzyme. Its activity can be induced by phenytoin.

γ-GT is a microsomal enzyme, usually raised in association with alcohol excess/cirrhosis/hepatic metastatic disease and may be raised in phenytoin therapy.

37

This enzyme is present in the canalicular and sinusoidal membranes of the liver, as well as bone, intestine and placenta and there is a large range of isoenzymes.

ALP is raised in cholestasis and may be elevated in bone disease, which is why bone isoenzyme may be requested to differentiate the source of the elevation.

38

Somatisation disorder in acute abdominal pain

Somatisation in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis. Somatisation often occurs in response to psychosocial stress and generally persists even after the acute stressor has resolved, resulting in the child and family believing that the correct medical diagnosis has not yet been found. In this case, the death of the mother may be the precipitating factor. All the following criteria are required for a diagnosis - four different pain sites (for example, head, abdomen, back, joints, extremities, chest, rectum) or functions (for example, menstruation, sexual intercourse, urination), two gastrointestinal symptoms other than pain (for example, nausea, bloating, vomiting not caused by diarrhoea, or intolerance of several different foods), one sexual or reproductive symptom other than pain and one pseudoneurological symptom (for example, impaired balance, paralysis, aphonia, urinary retention).

39

Abdominal migraine

Abdominal migraine is also known as cyclical vomiting syndrome, and is most frequent in adolescents. Patients have violent and sometimes prolonged episodes of vomiting. Attacks may be precipitated by stress, intercurrent infections, or menses. Almost 78% have prodromal symptoms including nausea, headache, fever, emotional withdrawal, lethargy, sleep pattern changes, and crying.

40

Haemorrhoids

Haemorrhoids are the commonest cause of painless rectal bleeding in young patients. In women, the incidence increases following pregnancy and delivery which causes increased pressure in the venous system of the ano-rectal region. Haemorrhoids are broadly divided into internal and external haemorrhoids. The patients present with painless bleeding per rectum and the presence/protrusion of a mass from the anal passage. In most instances, the patient will be able to push the hemorrhoids back into the anal canal.

41

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic suppurative disease of the apocrine sweat glands characterised by recurrent ulcers, abscesses, sinuses and, occasionally, fistulas. It commonly affects the axilla, inguinal region, perineal region and the buttocks. Chronic, longstanding hidradenitis suppurativa leads to subcutaneous fibrosis, scarring and contractures. The management of this condition usually involves excision of all the affected area. The area could either be left to heal by secondary intention or covered with a skin-graft or local flap. It is not closed primary.

42

Investigation diverticular disease

In patients with a history suggestive of diverticular disease, flexible sigmoidoscopy is the first line of investigation. If patients are presenting with diverticulitis then flexible sigmoidoscopy is done once the acute symptoms have subsided.

43

Investigation colonic tumours

The clinical presentation of patients with colonic malignancy depends on the site of the tumour.

Right-sided colonic carcinoma commonly presents with anaemia, tiredness, malaise and loss of weight, while the left sided colonic carcinoma presents with change in the bowel habits, bleeding per rectum, tenesmus (mainly rectal carcinoma) and intestinal obstruction.

Tumours of the rectum may sometimes be palpable on digital rectal examination. The growth could either be palpated as a polyp or a nodule or a nodulo-ulcerative growth.

Rigid sigmoidoscopy can be used in the outpatient clinic to detect a growth in the rectum or in the distal part of sigmoid colon since it can visualise the colon up to 25 cms from the anal verge. If a tumour or a polyp is detected by rigid sigmoidoscopy examination, then further investigations may be undertaken to visualise more proximal aspects of the colon. These investigations include:

Flexible sigmoidoscopy which is useful in inspecting the colon up to the splenic flexure, about 60 cms from the anal verge
Colonoscopy can visualise the colon up to the caecum thus inspecting for multiple polyps as in familial adenomatous polyposis.
Barium enema can visualise the colon up to the caecum. Small lesions can be missed. This is performed far less often these days.
A biopsy of the lesion can be obtained during endoscopic examination.

Contrast CT scans are quick and almost instantly available.

44

CT scan in mesenteric infarction

The classical presentation of mesenteric infarction is severe peri-umbilical or central abdominal pain that is disproportionate to the clinical findings. In the later stages, plain abdominal x- ray may reveal a 'thumb-print' pattern in the colon which is caused due to interstitial oedema with haemorrhage in the affected segment.

While mesenteric angiography may appear to be the ideal investigation it is not generally available out of hours. It may also confirm the clinical diagnosis of ischaemia and further help identify the emboli or thrombi, localise vascular obstructions, and characterise the collateral circulation. However, after 24 hours and with signs on the plain x-ray, thrombolysis is not likely to be beneficial and could delay essential surgery (assuming intervention is appropriate).

45

Small bowel follow through in Crohns

Although this disease can affect the whole of the gastrointestinal (GI) tract from the mouth to the anus, the intestine, particularly the terminal ileum, is the most commonly affected GI segment.

Patients may present with symptoms of terminal ileitis such as right iliac fossa, diarrhoea and pyrexia. The stools may be mixed with blood and/or mucus.

In addition to blood investigations, a barium meal with small bowel follow-through is the most appropriate initial investigation in the management of Crohn's disease. Other small bowel pathology may come to light if this diagnosis is wrong.

46

Erect CXR in perforation

The classical signs and symptoms of a perforated peptic/duodenal ulcer include

sudden onset of upper abdominal pain
vomiting
tachycardia
varying degrees of shock.
The signs may change when the peritonitis becomes established.

Perforation of a peptic/duodenal ulcer is common in patients who are on long term non-steroidal drugs and/or aspirin.

An erect chest x ray would be the most appropriate investigation in this patient. Air is seen under the diaphragm in almost 90% of cases

47

Intussusception in paeds

Intussusception is caused due to invagination of a segment of bowel (usually small bowel) into the lumen of the more distal bowel (usually the colon). It is a common cause of intestinal obstruction in children. Intussusception should be suspected in a child with an abdominal mass (characteristically sausage-shaped), abdominal distension, vomiting and passing blood and mucus per rectum (red-currant jelly stools).

48

Meconium ileus

Meconium ileus affects 1 in 15 000 newborns and is the cause of about 10-35% of all neonatal intestinal obstructions. This condition is caused due to a distal small bowel obstruction secondary to abnormal bulky and viscid meconium. This abnormal meconium is due to deficient intestinal secretions and nearly 90% of these infants will have cystic fibrosis. Meconium ileus usually presents within the first few days of life with gross abdominal distension, bilious vomiting and failure to pass meconium. The rectum is characteristically empty. Abdominal x ray shows distended coils of bowel. Fluid levels are scarce as the meconium is viscid.

49

Hirschsprung's disease

Hirschsprung's disease affects 1:5000 children and is an important cause of intestinal obstruction in the newborn. The affected infant fails to pass meconium and presents with abdominal distension and vomiting. Barium enema reveals a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend. In some instances, this condition is not diagnosed in early life and patients may present in their adult life with chronic constipation or subtotal large bowel obstruction.

50

Features of Crohns disease

Crohn's disease is an idiopathic, chronic, transmural inflammatory disorder of the bowel that can affect any part of the gastrointestinal tract from the mouth to the anal canal. Most cases, however, involve the small bowel particularly the terminal ileum.

The disease is associated with:

Ulcers
Abscesses
Sinuses
Fistulae in the anal/perianal region.
The patient may present with:

Abdominal pain
Intermittent fevers
Secondary anaemia
Loss of appetite
Loss of weight
Diarrhoea
The passage of blood and/or mucus per rectum.
Chronic Crohn's disease is associated with stricture in the bowels, sinus and fistula formation.

51

Ectopic pregnancy

Ectopic pregnancy occurs in less than 1% of pregnancies. The early signs of ectopic pregnancy include:

Missed periods
Minor spotting at the time of the missed periods
Vaginal bleeding.
There may be other associated signs of pregnancy such as:

Mastalgia
Morning sickness
Increased urinary frequency.
In ruptured ectopic pregnancy the abdominal pain is initially crampy, but subsequently becomes more continuous and generalised over the lower abdomen.

Severe pain is caused by the tubal rupture and is also due to discharge of a large quantity of blood into the peritoneal cavity. The degree of shock depends on the amount of blood loss.

52

Pseudo-obstruction

This woman appears to have pseudo-obstruction related to hypothyroidism as suggested by the slowness and hypothermia.

Other causes of pseudo-obstruction include:

Hypokalaemia
Diabetes
Uraemia, and
Hypocalcaemia, etc.


53

Achalasia

The swallow demonstrates the classic picture of a dilated oesophagus above a narrow-necked oesophago-gastric junction (bird-beak deformity).

The diagnosis should be confirmed by manometry prior to embarking on treatment, as this would show absence of peristaltic waves, together with a high resting lower oesophageal sphincter pressure and impaired lower oesophageal sphincter relaxation.

54

Anal fissure

The history of perianal pain exacerbated by defecation and associated with fresh bleding is typical of a fissure.

Visualisation of the fissure is often not possible as rectal examination is frequently too painful.

Most fissures are identified in the midline posteriorly and in the acute phase GTN cream is useful bringing symptomatic relief in 2/3 of cases.



55

Hypergastrinaemia

Hypergastrinaemia is usually associated with Zollinger-Ellison syndrome (type I G-cell tumour, type II hyperplasia), where in addition to recurrent ulceration there is intermittent watery diarrhoea caused by increased motility and increased secretion production. It is due to a NET tumour of the pancreas.

Neither selective serotonin reuptake inhibitors (SSRIs) nor tricyclic antidepressants (TCAs) are known to cause recurrent peptic ulceration

56

Subtotal gastrectomy complications

A sub-total gastrectomy for a gastric tumour will involve a gastro-jejunostomy. The standard reconstruction is a simple retrocolic, loop gastro-jejunostomy to the remaining stomach (Polya gastrectomy). There is, obviously, no pylorus so bile can reflux into the much smaller stomach and there may be bilious vomiting. Severe bile reflux may require revision of the gastro-jejunostomy to a roux-en-y formation. Here the proximal jejunum (and bile) is disconnected from the loop gastro-jejunostomy and reattached at least 30 cm distally. Peristalsis should then direct the bile distally rather than back into the stomach.

Constipation is not a recognised specific complication of gastrectomy but diarrhoea can occur as a result of large volumes of osmotically active foods entering the duodenum, or if there is impaired motility due to division of the vagus.

A macrocytic anaemia may be B 12 related, due to lack of intrinsic factor or as a result of an iron deficiency, as the post gastrectomy stomach does not convert iron from Fe3+ to Fe2+ and so it cannot be absorbed from the terminal ileum.

Another important and relatively common complication is 'dumping syndrome'. This is characterised by faintness, sweating, abdominal pain and tachycardia. It is caused by a transient hypovolaemia following the passage of large volumes of osmotically active food into the duodenum, or by impaired glucose control as a result of large carbohydrate loads entering the small bowel.

57

Gilbert's syndrome.

Gilbert's syndrome. This is a congenital unconjugated hyperbilirubinaemia due to a defect in glucuronosyl transferase activity and affects 2-5% of the population. Patients are usually well, but notice the appearance of jaundice after a relatively minor illness.

The elevated reticulocyte count of 20% (normal less than 1%) also suggests a pre-hepatic cause for the jaundice. Biliary atresia presents in infancy and hepatoblastoma usually presents as a mass without deranged liver function tests (LFTs).

In the case of common duct stones a pattern of deranged LFTs would be expected and pain is common.

Viral hepatitis would be expected to exhibit a transaminitis.

58

Sclerosing cholangitis

Sclerosing cholangitis has a male:female ratio of 2:1 and may present with weight loss, fatigue, pruritus and right upper quadrant discomfort, although the majority are asymptomatic and are diagnosed after investigation of elevated alkaline phosphatase.



59

A 79-year-old lady with a poor cardiac history and mild renal impairment is admitted with haematemesis and melaena. A duodenal ulcer is found at endoscopy and is actively bleeding. The ulcer was injected with adrenaline, but 12 hours later she was noted to have rebelled with further passage of fresh melaena.

Embolisation of gastroduodenal artery

This woman has active bleeding that has not responded to injection therapy. Her age and co-morbidities suggest she would not recover well from surgery. If available, the most appropriate treatment would be selective arteriography and embolisation of the gastro-duodenal artery. If this too fails then the only option left would be under-running of the bleeding vessel in the base of the ulcer and PPI treatment.

60

A fit 59-year-old man with a benign (on biopsy) gastric ulcer on the greater curvature of the stomach presents with melaena. He has completed an eight week course of omeprazole. He has required a transfusion of 6 units of blood and repeat endoscopy shows signs of an active bleed.

Partial gastrectomy


This man also has active bleeding despite medical therapy, and requires a partial gastrectomy. One must be certain as to the aetiology of a non-healing chronic gastric ulcer. Superficial biopsies of an ulcerated gastric tumour can miss the malignant tissue.

61

An 85-year-old man with peritonitis is found at laparotomy to have a perforated gastric ulcer high on the lesser curve. His past medical history includes COPD and angina.

Excision of ulcer

This gentleman with a perforation and other co-morbidity requires excision of the ulcer and suture of normal stomach wall. Patch repairs are not suitable for the stomach.