GI

Question 1

Who does inflammatory bowel disease effect the most?

Answer 1

White + young adults

Question 2

What is the cause of IBD + the associations?

Answer 2

Idiopathic but suggested associations with: Genetics (Crohn’s), the environment (smoking), and immune response (increased response to bacteria/Ag in both UC + CD)

Question 3

What is the effect of smoking on the chance of getting IBD?

Answer 3

Increased risk in Crohn’s and decreased risk in UC

Question 4

What is the cancer risk in IBD?

Answer 4

Increased (+ a bigger increase in UC compared to Crohn’s)

Question 5

Describe the distribution of UC lesions in the GI system compared to CD (Crohn’s)?

Answer 5

UC: continuous from rectum (but only affects the large intestine)
CD: patchy distribution (mouth to anus)

Question 6

What layers of the GI system are affected in UC compared to Crohn’s?

Answer 6

UC: Mucosa
CD: All layers (mucosa –> muscularis propria + adventitia)

Question 7

What is the macroscopic intestinal of UC compared to Crohn’s?

Answer 7

UC: inflamed colon w/ polyps

Crohn’s: cobblestone appearance

Question 8

What is the microscopic appearance of UC compared to Crohn’s?

Answer 8

UC: ulcers, no granuloma, crypt abscesses, depleted goblet cells
CD: Granuloma (non-caseating), goblet cells

Question 9

What is the big symptom in Crohn’s?

Answer 9

Weight loss + diarrhoea

Question 10

What is the big symptom in UC?

Answer 10

Bloody diarrhoea w/ mucus

Question 11

Give 4 symptoms of UC

Answer 11

Malaise/lethargy, proctitis, diarrhoea, lower abdo pain

Question 12

Give 3 symptoms of Crohn’s

Answer 12

Diarrhoea, WEIGHT LOSS, pain on defacation

Question 13

What MSK conditions are Crohn’s and UC linked to?

Answer 13

HLA B27 +ve seronegative spondyloarthropathies

Question 14

Give 3 signs of UC

Answer 14

Mouth ulcers, rectal bleeding, signs of malnutrition

Question 15

Give 3 signs of Crohn’s

Answer 15

Perianal disease (anal tags, haemorrhoids…), signs of malnutrition, mouth ulcers

Question 16

What are some examples of extraintestinal manifestations of IBD

Answer 16

Erythema nodosum, clubbing, uveitis, IBD ARTHRITIS, ankylosing spondylitis (seronegative spondyloarthropathy), anaemia

Question 17

What are the general Ix’s you would carry out for a patient presenting with IBD? What will the tests show?

Answer 17

Blood cultures + stool sample (exclude infective cause of diarrhoea), bloods (anaemia, ^ inflammatory markers, ^WCC)

Question 18

What is the gold standard Ix for UC?

Answer 18

Colonoscopy

Question 19

What might you do to Ix Crohn’s?

Answer 19

barium swallow small bowel imaging

Question 20

What would you do to diagnose UC?

Answer 20

Colonoscopy + rectal biopsy

Question 21

What would you do to diagnose Crohn’s?

Answer 21

Sigmoidoscopy + rectal biopsy

Question 22

What area of the GI tract does Crohn’s favour?

Answer 22

Terminal ileum

Question 23

What disease is erythema nodosum a classical feature in?

Answer 23

Sarcoidosis (red lesions on shins)

Question 24

What is the 1st line of the treatment for UC and Crohn’s?

Answer 24

Induce and maintain remission

Question 25

What is the general conservative management for UC?

Answer 25

treat anaemia + diarrhoea (codeine phosphate or loperamide)

Question 26

What is the 1st line Rx to induce remission for UC?

Answer 26

1st: corticosteroid (prednisolone) or 5-ASA (sulfasalazine)

Question 27

What is the 2nd line Rx to induce remission for UC?

Answer 27

Use BOTH corticosteroid + 5-ASA

Question 28

Whatis the 3rd line Rx to induce remission for UC?

Answer 28

Admit the pt

Question 29

How do you maintain remission in UC?

Answer 29

5-ASA (sulfasalazine)

Question 30

What is the 2nd line curative treatment for UC? What is this based on?

Answer 30

Surgery (colectomy w/ iliostomy). Based on the idea that there is a clear distinction in healthy and pathological bowel

Question 31

What is the conservative management for Crohn's?

Answer 31

SMOKING CESSATION, Rx anaemia + diarrhoea

Question 32

How do you induce remission for Crohn's?

Answer 32

Corticosteroid + anti-TNFalpha

Question 33

Give an example of anti-TNF treatment?

Answer 33

Infliximab, adalimumab, etanercept (TNF receptor)

Question 34

How would you maintain remission in Crohn's?

Answer 34

5-ASA (sulfasalazine)

Question 35

What does 5-ASA stand for?

Answer 35

5-aminosalicylic Acid

Question 36

What are SEs of 5-ASA?

Answer 36

GI upset (abdominal pain, nausea, cramping...etc)

Question 37

Give an example of an anti-emetic. How does it work?

Answer 37

Ondasetron. A serotonin 5-ht3 receptor antagonist

Question 38

Who is commonly affected by Coeliac disease?

Answer 38

White, IRISH, N. Europe

Question 39

What is Coeliac disease?

Answer 39

A gluten sensitive enteropathy - an autoimmune disease

Question 40

What contains gluten?

Answer 40

Wheat, barley and rye

Question 41

What is the toxic protein in gluten?

Answer 41

Gliadin

Question 42

What diseases give you increased risk of getting coeliac?

Answer 42

T1DM, thyroid diseases, atopy

Question 43

Describe the pathology of coeliac disease

Answer 43

Gliadin crosses damaged intestinal epithelium --> MHC binds to gliadin and presents it on HLA DQ2 or DQ8 to a Th cell --> Th cell releases inflammatory cytokines

Question 44

What do the inflammatory cytokines Th cells release in response to binding to an APC presenting gliadin?

Answer 44

Villous atrophy, crypt hyperplasia, B cell activation, increased expression of HLA DQ8/DQ2 on intestinal epithelium

Question 45

What antibodies to activated B cells produce?

Answer 45

IgA tTG (tissue transglutaminase), EMA (anti-endomysial antibody), IgA + IgG to gliadin

Question 46

In terms of symptoms/signs, what effects does villous atrophy have?

Answer 46

Malabsorption (weight loss), anaemia (reduced Fe + B12 absorption), diarrhoea (reduced water absorption), steatorrhoea (reduced fat absorption)

Question 47

What are the symptoms of anaemia

Answer 47

Fatigue, lethargy, malaise...etc

Question 48

What are some other symptoms of Coeliac disease?

Answer 48

Infertility, abdominal pain, bloating

Question 49

What is a unique sign found in Coeliac disease?

Answer 49

Dermatitis herpetiformis

Question 50

What other sign can be found in Coeliac disease?

Answer 50

Distension, weight loss..etc

Question 51

What are the two risks associated with Coeliac disease?

Answer 51

Increased risk of cancer (particularly lymphoma), osteoporosis

Question 52

What Ix's might you carry out in someone with Coeliac disease?

Answer 52

Serology, 4 or more duodenal biopsies, DEXA scan

Question 53

What are you looking for in serology to Ix Coeliac disease?

Answer 53

tTG, EMA, IgG/IgA to gliadin

Question 54

How many duodenal biopsies do you need to diagnose Coeliac disease and how long must a person keep gluten in their diet for?

Answer 54

4 or more + 6weeks

Question 55

What does a duodenal biopsy demonstrate in coeliac disease?

Answer 55

Villous atrophy, crypt hyperplasia, ^ intraepithelial lymphocytes

Question 56

What is the classic presentation of a Mallory Weiss tear?

Answer 56

A history of persistent vomiting + retching before haematemesis

Question 57

What must you do before doing an oesophageal endoscopy?

Answer 57

Stop NSAIDs + give PPI (omeprazole)

Question 58

What do peptic ulcers encompass?

Answer 58

Gastric and duodenal ulcers

Question 59

When do those with duodenal ulcers get epigastric pain?

Answer 59

At night and when hungry (relieved by eating)

Question 60

How would you eradicate H. pylori?

Answer 60

Triple therapy: omeprazole, amoxicillin + metronidazole

Question 61

How would you treat peptic ulcer not caused by H. pylori?

Answer 61

Stop NSAIDs (use COX-2 inhibitors instead), PPI (omeprazole), treat complications

Question 62

What are the complications of a peptic ulcer?

Answer 62

Perforation (causing peritonitis), gastric outlet obstruction (fibrosis/scarring), haemorrhage

Question 63

What positions are direct and indirect inguinal hernias to the inferior epigastric artery?

Answer 63

Direct: medial Indirect: lateral