GI Flashcards
(176 cards)
1
Q
Define intestinal obstruction
A
Blockage of the lumen of the gut
Arrest of onward propulsion of intestinal contents
2
Q
Name 3 broad types of causes of intestinal obstruction
A
- Intraluminal obstruction = something in the bowel
- Intramural obstruction = something in the wall of the bowel
- Extraluminal obstruction = something outside of the bowel
3
Q
Give 3 causes of intraluminal obstruction of the intestine
A
- Tumour
- Diaphragm disease
- Meconium ileus
- Gallstone ileus
4
Q
What is diaphragm disease?
A
Mucosa/submucosa fold due to fibroid diaphragm leaving a pinhole lumen
5
Q
What is thought to cause diaphragm disease?
A
NSAIDs
6
Q
Give 3 causes of intramural obstruction of the intestine
A
- Inflammatory disease = Chron’s, Diverticular disease
- Tumours
- Neural = Hirschsprung’s disease
7
Q
Describe how Crohn’s disease can cause intestinal obstruction
A
Crohn’s disease –> fibrosis –> contraction –> obstruction
8
Q
Describe how diverticular disease can cause intestinal obstruction
A
Out pouching of mucosa –> faeces trapped –> inflammation in bowel wall –> contraction –> obstruction
9
Q
What is Hirschsprung’s disease?
A
A congenital condition where there is a lack of nerves in the bowel –> no ganglion cells –> no contraction –> distal obstruction and gross dilation of the bowel
10
Q
Give 3 causes of extraluminal obstruction of the intestine
A
- Adhesions
- Volvulus
- Peritoneal tumour
11
Q
What are adhesions?
A
Fibrous bands stick 2 bits of bowel together so bowel is pulled and distorted
12
Q
What causes adhesions?
A
Often formed after abdominal surgery (pelvic, gynaecologist, colorectal)
13
Q
What is volvulus?
A
Bowel twisting around each other cuts off blood supply/ lumen
Risk of ischaemia, necrosis and perforation
14
Q
Which areas of the bowel are most likely to be affected by volvulus?
A
Occurs in areas of bowel that have mesentery
Often in the sigmoid colon
15
Q
Give 4 common causes of small bowel obstruction in adults
A
- Adhesions
- Hernias
- Crohn’s disease
- Malignancy
16
Q
Give 3 common causes of small bowel obstruction in children
A
- Appendicitis
- Volvulus
- Intussusception
17
Q
What is intussusception?
A
One part of the intestine telescopes into another section of the intestine
Caused by force in-balances
18
Q
Give 5 symptoms of small bowel obstruction
A
- Nausea and anorexia
- Early feculent vomit
- Diffuse colicky pain
- Late constipation
- Distention
- Tenderness
19
Q
Does abdominal distension occur more distal or proximal to an intestinal obstruction?
A
More distal = greater distension
20
Q
Give 4 signs of small bowel obstruction
A
- Vital signs - increased HR, hypotension, raised temp
- Tendernes and swelling
- Resonance
- Bowel sounds
21
Q
What investigations might you do in someone who you suspect to gave a small bowel obstruction?
A
- Take a good history - ask about previous surgery
- FBC, U+E, lactate
- X ray
- CT, USS, MRI
22
Q
What is the management/treatment for small bowel obstruction?
A
- Fluid resuscitation
- Bowel decompression
- Analgesia and antiemetics
- Antibiotics
- Surgery - laparotomy, bypass segment, resection
23
Q
Which is more common, small or large bowel obstruction?
A
Small bowel obstruction = 60-75% of intestinal obstruction
24
Q
What can untreated intestinal obstruction lead to?
A
- Ishcaemia
- Necrosis
- Perforation
25
Give 2 common causes of large bowel obstruction
1. Colorectal malignancy
| 2. Volvulus
26
Where is the usual site of perforation in large bowel obstruction if the ileocaecal valve is competent?
Caecum
27
How long does acute prevention of large bowel obstruction last?
Average of 5 day of symptoms = abdominal pain and obstipation
28
Give 5 symptoms of large bowel obstruction
1. Bloating
2. Late vomiting
3. Colicky pain
4. Distension
5. Blood in stool
6. Volvulus = sudden, pain, localised tenderness and distension
29
What investigations might you do in someone who you suspect to gave a large bowel obstruction?
1. Digital rectal examination
2. Sigmoidoscopy
3. Plain X ray
4. CT scan
30
Describe the management for a large bowel obstruction
1. IV fluid replacement - replace loss and correct electrolyte imbalance
2. Bowel decompression
3. Surgery
31
Define hernia
Abnormal protrusion of an organ into a body cavity it doesn't normally belong
32
What are the risks of hernia's if left untreated?
Become strangulated
33
Give 2 symptoms of hernias
1. Pain
| 2. Palpable lump
34
Describe the progression from normal epithelium to colorectal cancer
Normal epithelia --> adenoma --> colorectal adenocarcinoma --> metastatic colorectal adenocarcinoma
35
Define adenocarcinoma
A malignant tumour of glandular epithelium
36
What is familial adenomatous polyposis?
Autosomal dominant condition where you develop thousands of polyps in your teens
37
Describe the pathophysiology of familial adenomatous polyposis
Mutation in APC protein --> beta catenin not broken down --> beta catenin upregulates epithelium proliferation genes --> adenomas form
38
Describe the pathophysiology of HNPCC
Loss of both DNA repair genes --> cellular genetic damage
39
What are the implications of having HNPCC?
1. Risk of further cancers
| 2. Can't use DNA damaging chemo
40
What are precursors to colorectal cancer?
Polyploid adenomas
41
Describe the epidemiology of colorectal cancer
Normally adenocarcinoma
Incidence peaks around 60-70 years
Males > females
42
Give 5 risk factors for colorectal cancer
1. Increasing age
2. Family history
3. Western diet
4. Alcohol
5. Smoking
43
Give 3 reasons why bowel cancer survival has increased over recent years
1. Introduction of the bowel cancer screening programme
2. Colonoscopic techniques
3. Improvements in treatment options
44
What can affect the clinical presentation of a colorectal cancer?
How close the cancer is to the rectum
45
Give 2 signs of a left sided/sigmoid colorectal cancer
1. Altered bowel habit
2. PR bleeding
3. Colicky pain
46
Give 3 signs of a right sided colorectal cancer
1. Iron deficiency anaemia
2. Right iliac fossa mass
3. Weight loss
47
Give 4 signs of colorectal cancer
1. Abdominal mass
2. Perforation
3. Haemorrhage
4. Fistulae
48
What investigations might you do in someone who you suspect might have colorectal cancer?
Colonoscopy = gold standard, biopsy and removal of small polyps
Tumour markers are good for monitoring progress
CT/MRI for staging
49
How can adenoma formation be prevented?
NSAIDs
50
What screening programme is used to identify bowel cancer?
Faecal occult blood (FOB) screening
For over 65s
+ve result = biopsy
51
What is the treatment for adenoma?
Endoscopic resection
52
What is the treatment for colorectal adenocarcinoma?
Surgical resection
53
What is the treatment for metastatic colorectal adenocarcinoma?
Chemotherapy and palliative
54
Explain resection coding
```
R0 = tumour completely excised locally
R1 = microscopic involvement of margin by tumour
R2 = macroscopic involvement of margin by tumour
```
55
Explain Dukes staging and prognosis
```
A = limited to muscularis mucosae = 95% 5-year survival
B = extension through muscularis mucosae (not lymph) = 75% 5-year survival
C = involvement of regional lymph nodes = 35% 5-year survival
D = distant metastases = 25% 5-year survival
```
56
What does T refer to in the staging of cancer?
T = refers to primary tumour and suffixed by number that denotes tumour size
57
What does N refer to in the staging of cancer?
N = refers to lymph node status and is suffixed by numbers that denotes number of lymph nodes or group of lymph nodes containing metastases
58
What does M refer to in the staging of cancer?
M = refers to anatomical extent of distant metastases
59
What does the T mean for colorectal cancer staging?
```
T1 = invades submucosa
T2 = Muscularis propria
T3 = Bowel wall
T4 = Peritoneum
```
60
What does the N mean for colorectal cancer staging?
```
N1 = spread to lymph nodes
N2 = spread to lymph nodes above the diaphragm
```
61
What does the M mean for colorectal cancer staging?
M1 = surrounding structure involvement (liver)
62
Name 5 things that can break down the mucin layer in the stomach and cause gastritis
1. Mucosal ischameia
2. H. pylori
3. Aspirin, NSAIDs
4. Increased acid (stress)
5. Bile reflux
6. Alcohol
63
Give 3 symptoms of gastritis
1. Epigastric pain
2. Nausea and vomiting
3. Indigestion
4. Haematemesis
64
What investigations are done with someone you suspect has gastritis?
```
Endoscopy (erythema)
Biopsy (histology change)
Blood tests (inflammation)
```
65
Describe the treatment for gastritis
1. Decrease alcohol and smoking
2. Antacid (magnesium carbonate)
3. PPI (omeprazole)
4. H2 receptor antagonist (ranitidine)
5. Enteric coated aspirin
66
How do you treat H. pylori?
Triple therapy:
Normal --> amoxicillin, omeprazole and clarithromycin/metronidazole
Penicillin resistance --> clarithromycin, omeprazole and metronidazole
67
Give 4 causes of peptic ulcers
1. NSAIDs
2. Mucosal ischaemia
3. Increased acid production (stress)
4. Bile reflux
5. Alcohol
6. H. pylori
68
How does mucosal ischaemia cause ulcer formation?
Lack of blood flow to cells --> no mucin production = no mucosal protection --> ulcer formation
69
How does increased acid production (stress) cause ulcer formation?
Mucosa overwhelmed --> corrosion --> ulcer formation
70
How does NSAIDs cause ulcer formation?
Reduced prostaglandin synthesis due to salicylic acid release --> cell death --> no mucin production = no mucosal protection --> ulcer formation
71
How does bile reflux cause ulcer formation?
Mucosal cell damages --> no mucin production = no mucosal protection --> ulcer formation
72
How does H. pylori cause ulcer formation?
Increased stomach acid production
Acute inflammatory reaction (neutrophils)
Urease production --> ammonia --> mucosal layer damage
73
Give 3 symptoms of peptic ulcers
1. Epigastric pain
2. Bleeding
3. Perforation
4. Heartburn
74
What investigations might you do in someone who you suspect to have peptic ulcers?
1. H. pylori test = urease breath test and faecal antigen test
2. Gastroscopy
3. Barium meal
75
How can you treat peptic ulcers?
1. Stop NSAIDs
2. PPI (omeprazole)
3. H. pylori eradication (triple therapy)
4. Surgery
76
Name 2 complications of peptic ulcers
Haemorrhage due to erosin to artery
| Peritonitis due to erosion through wall
77
Give 5 broad causes of malabsorption
1. Defective intraluminal digestion
2. Insufficient absorptive area
3. Lack of digestive enzymes
4. Defective epithelial transport
5. Lymphatic obstruction
78
Malabsorption: what can cause defective intraluminal digestion?
1. Pancreatic insufficiency due to pancreatitis/CF - lack of digestive enzymes
2. Defective bile secretion due to biliary obstruction or ileal resection
3. Bacterial overgrowth
79
Malabsorption: what can cause insufficient absorptive area?
1. Coeliac disease
2. Crohn's disease
3. Extensive surface parasitisation
4. Small intestinal resection or bypass
80
Malabsorption: give an example of when there is a lack of digestive enzymes
Lactose intolerance - disaccharide enzyme deficiency
81
Malabsorption: what can cause lymphatic obstruction?
1. Lymphoma
| 2. TB
82
Describe the distribution of inflammation seen in Crohn's disease
Patchy (skip lesions), granulomatous, transmural inflammation
83
Describe the distribution of inflammation seen in Ulcerative colitis
Continuous inflammation affecting only the mucosa
84
What part of the bowel is commonly affected by Crohn's disease?
Can affect anywhere from the mouth to anus
85
What part of the bowel is commonly affected by Ulcerative colitis?
Spreads proximally from the rectum but only affects the colon
86
State one histological feature that will be seen in ulcerative colitis
1. Crypt abscess
| 2. Increase in plasma cells in the lamina propria
87
What damage does Crohn's disease do to the GI tract?
Deep ulcers and fissures --> cobblestone look
Goblet cells
Less crypt abscesses
88
In Crohn's or UC is smoking a protective factor?
Ulcerative colitis
89
Name 3 causes of IBD
1. Genetic
2. Stress/depression
3. Inappropriate immune response
90
Give 4 signs and symptoms of Ulcerative colitis
1. Episodic/chronic diarrhoea +/- blood/ mucus
2. Abdominal pain
3. Systemic - fever, malaise, anorexia, weight loss
4. Clubbing
5. Erythema nodosum
6. Ankylosing spondylitis
91
Give 4 signs and symptoms of Crohn's disease
1. Diarrhoea
2. Abdominal pain
3. Systemic - weight loss, fatigue, fever, malaise
4. Bowel ulceration
5. Anal fistulae/stricture
6. Clubbing
7. Skin/joint/eye problems
92
What investigations might you do in someone with IBD?
1. Bloods - FBC, ESR, CRP
2. Faecal calprotectin - shows inflammation but is not specific for IBD
3. Flexible sigmoidoscopy
4. Colonoscopy
93
What is the treatment for Crohn's disease?
Smoking cessation
Corticosteroids
Surgical resection
94
What is the treatment for Ulcerative colitis?
Smoking protects
Aminosalicylates
Prednisolone
Surgical resection
95
Give 5 complications of Ulcerative colitis
1. Colon --> blood loss, colorectal cancer, toxic dilatation
2. Arthritis
3. Iritis, episcleritis
4. Fatty liver and primary sclerosing cholangitis
5. Erythema nodosum
96
Give 5 complications of Crohn's
1. Malabsorption
2. Obstruction --> toxic dilatation
3. Fistula/abscess formation
4. Anal skin tag/fissures/fistula
5. Neoplasia
6. Amyloidosis
97
Describe the pathophysiology of Coeliac disease
1. Gliadin from gluten deaminated by tissue transglutaminase --> increases immunogenicity
2. Gliadin recognised by HLA-DQ2 receptor on APC --> inflammatory response
3. Plasma cells produce anti-gliadin and tissue transglutaminase --> T cell/cytokine activated
4. Villous atrophy and crypt hyperplasia --> malabsorption
98
When does Coeliac disease usually present?
2 peaks - infancy and 5th decade
99
Give 5 symptoms of Coeliac disease
1. Diarrhoea and steatorrhoea
2. Weight loss
3. Irritable bowel
4. Iron deficiency anaemia
5. Osteoporosis
6. Fatigue
100
What investigations might you do in someone who you suspect to have coeliac disease?
Serology - tissue tansglutaminase and anti-gliadin antibodies
Endoscopy - duodenal biopsy post 6 weeks gluten diet
101
What 3 histological features are needed in order to make a diagnosis of coeliac disease?
1. Raised intraepithelial lymphocytes
2. Crypt hyperplasia
3. Villous atrophy
102
What part of the bowel is mostly affected in coeliac disease?
Duodenum
103
How do you treat coeliac disease?
Lifelong gluten free diet
| DEXA scan for osteoporosis risk
104
Give 3 complications of Coeliac disease
1. Osteoporosis
2. Anaemia
3. Increased risk of GI tumours
105
What cells normally line the oesophagus?
Stratified squamous non-keratinising cells
106
What is Barrett's oesophagus?
When squamous cells undergo metaplastic changes and become columnar cells (glandular too)
107
What can cause Barrett's oesophagus?
1. GORD
| 2. Obesity
108
Give a potential consequence of Barrett's oesophagus
Adenocarcinoma
109
Describe how Barrett's oesophagus can lead to oesophageal adenocarcinoma
1. GORD damages normal oesophageal squamous cells
2. Glandular columnar epithelial cells replace squamous cells (metaplasia)
3. Continuing reflux leads to dysplastic oesophageal glandular epithelium
4. Continuing reflux leads to neoplastic oesophageal glandular epithelium - adenocarcinoma
110
Give 3 causes of squamous cell carcinoma
1. Smoking
2. Alcohol
3. Poor diet
111
Name 2 types of Oesophageal cancer
1. Adenocarcinoma - distal 1/3rd of oesophagus
| 2. Squamous cell carcinoma - proximal 2/3rds of oesophagus
112
What can cause oesophageal adenocarcinoma?
Barrett's oesophagus
113
Give 5 symptoms of oesophageal carcinoma
1. Dysphagia
2. Weight loss
3. Heartburn
4. Haematemesis
5. Anorexia
6. Pain
114
What investigations might be done on someone you suspect has oesophageal cancer?
Endoscopy and biopsy
Barium swallow
CT/MRI for staging
115
How can you treat oesophageal cancer?
Surgical resection
Chemotherapy
Palliative care
116
Give 3 causes of gastric cancer
1. Smoked foods
2. Pickles
3. H. pylori infection
4. Pernicious anaemia
5. Gastritis
117
Describe how gastric cancer can develop from normal gastric mucosa
Smoked/pickled food diet leads to intestinal metaplasia of normal gastric mucosa
Several genetic changes lead to dysplasia and then eventually intra-mucosal and invasive carcinoma
118
Give 3 symptoms and signs of gastric cancer
1. Weight loss
2. Anaemia (pernicious)
3. Vomiting
4. Dyspepsia and dysphasia
5. Epigastric mass
6. Hepatomegaly
7. Enlarged supraclavicular nodes
119
What investigations might you do in someone who you suspect has gastric cancer?
1. Endoscopy
2. CT
3. Laparoscopy
120
What is the advantage of doing a laparoscopy in someone with gastric cancer?
It can detect metastatic disease that may not be detected on USS/endoscopy
121
What is the treatment for proximal gastric cancers that have no spread?
3 cycles of chemo and a full gastrectomy
| Lymph node removal too
122
What is the treatment for distal gastric cancers that have no spread?
3 cycles of chemo and partial gastrectomy if tumour is causing stenosis or bleeding
Lymph node removal
123
What vitamin supplement will a patient need following gastrectomy?
They will be deficiency in intrinsic factor so will need vitamin B12 supplements to prevent pernicious anaemia
124
Give 3 causes of appendicitis
1. Faecolith
2. Lymphoid hyperplasia
3. Filarial worms
125
Describe the pathophysiology of appendicitis
Lumen of appendix is obstructed --> invasion of gut organism into appendix wall --> inflammation
126
Give 4 symptoms of appendicitis
1. Right sided pain located at McBurneys point
2. Anorexia
3. Nausea and vomiting
4. Constipation
5. Tenderness with guarding and rebound
6. Tachycardia
127
What investigations might be done in a patient you suspect has appendicitis?
Blood tests = raised WCC, CRP, ESR
USS
CT - gold standard
128
What is the treatment for appendicitis?
Appendicectomy
| IV antibiotics pre-op
129
Give 2 complications of appendicitis
1. Ruptured appendix --> peritonitis
2. Appendix mass
3. Appendix abscess
130
Who is most likely to be affected by diverticular disease?
Older patients and those with low fibre diets
131
Describe the pathophysiology of diverticulitis
Out-pouching of bowel mucosa --> faeces can get trapped here and obstruct the diverticula --> abscess and inflammation --> diverticulitis
132
What part of the bowel is most likely to be affected by diverticulitis?
The descending colon
133
What is acute diverticulitis?
A sudden attack of swelling in the diverticula
| Can be due to surgical causes
134
Describe the signs of acute diverticulitis
Pain in left iliac fossa region
Fever
Tachycardia
135
Give 3 causes of Gastro-oesophageal reflux disease (GORD)
1. Hiatus hernia
2. Abdominal obesity
3. Gastric acid hyper section
4. Slow gastric emptying
5. Smoking
6. Obesity
7. Alcohol
8. Drugs - CCBs, nitrates, antimuscarinic
136
Describe the pathophysiology of GORD
Lower oesophageal sphincter dysfunction --> reflux of gastric contents --> oesophagitis
137
Name 3 oesophageal symptoms of GORD
1. Heartburn
2. Bleching
3. Food/acid and water brash
4. Odynophagia
5. Dysphagia
138
Name 3 extra oesophageal symptoms of GORD
1. Nocturnal asthma
2. Chronic cough
3. Laryngitis
4. Sinusitis
139
What investigations are done for someone you suspect has GORD?
Diagnosis can be made without investigations
Endoscopy
Barium swallow
140
What is the treatment of GORD?
1. Lifestyle changes - weight loss, smoking cessation, small regular meals, avoid hot drinks, alcohol, citrus fruits
2. PPI
3. H2 receptor antagonist
4. Antacids - magnesium trisillicate
5. Surgery - Nissen fundoplication (laparoscopically increase resting LOS pressure)
141
What is the criteria for dyspepsia?
>1 of the following:
- Postprandial fullness
- Early satiation
- Epigastric pain/burning
142
Give 5 causes of dyspepsia
1. Excess acid
2. Prolonged NSAIDs
3. Large volume meals
4. Obesity
5. Smoking/alcohol
6. Pregnancy
143
Give 5 red flag symptoms that you might detect when taking a history from someone with dyspepsia
1. Unexplained weight loss
2. Anaemia
3. Dysphagia
4. Upper abdominal mass
5. Persistant vomiting
144
What investigations might you do in someone with dyspepsia?
1. Endoscopy
2. Gastroscopy
3. Barium swallow
4. Capsule endoscopy
145
What is the management for dyspepsia if the red flag criteria has been met?
1. Suspend NSAID use and review medication
2. Endoscopy
3. Refer malignancy to specialist
146
What is the management for dyspepsia without red flag symptoms?
1. Review medication
2. Lifestyle advice - lose weight, stop smoking, cut down on alcohol, diet modification
3. PPI for 1 month
4. Test and treat H/ pylori infection
147
Give an example of a functional bone disorder
IBS
148
Describe the mil-factorial pathophysiology of IBS
The following factors can all contribute to IBS:
- Psychological morbidity - trauma in early life
- Abnormal gut motility
- Genetics
- Altered gut signalling (visceral hypersensitivity)
149
Give 3 symptoms of IBS
1. Abdominal pain
2. Bloating
3. Change in bowel habit
4. Mucus
5. Fatigue
6. Backache
150
Give an example of a differential diagnosis for IBS
1. Coeliac disease
2. Lactose intolerance
3. Bile acid malabsorption
4. IBD
5. Colorectal cancer
151
What investigations might you do in someone who you suspect has IBS?
Rule out differentials
1. Bloods - FBC, U+E, LFT
2. CRP
3. Coeliac serology
4. Colonoscopy
152
Describe the non pharmacological treatment of IBS
Education
Resistance
Dietary modification - reduce caffeine, plenty of fluids, increase fibre intake
153
Describe the pharmacological treatment of IBS
1. Antispasmoidics for bloating - mebeverine
2. Laxatives for constipation
3. Anti-motility agent for diarrhoea - loperamide
4. Tricyclic antidepressants
154
Which of the following is FLASE regarding colorectal cancer?
a. Bowel cancer screening is offered to people aged 65 or over
b. The majority of cancers occur in the proximal colon
c. FAP and HNPCC are 2 inherited causes of colon cancer
d. Proximal cancers usually have a worse prognosis
e. Patients with PSC and UC have an increased risk of developing colon cancer
b. The majority of cancers occur in the proximal colon
155
A 50-year-old man presents with dysphagia. Which one of the following suggest a benign nature of his disease?
a. Weight loss
b. Dysphagia to solids initially then both solids and liquids
c. Dysphagia to solids and liquids occurring form the start
d. Anaemia
e. Recent onset of symptoms
c. Dysphagia to solids and liquids occurring form the start
156
A 19-year-old girl presents with abdominal pain and loose stool. Which of the features suggest that she has irritable bowel syndrome?
a. Anaemia
b. Nocturnal diarrhoea
c. Weight loss
d. Blood in stool
e. Abdominal pain relieved by defecation
e. Abdominal pain relieved by defecation
157
Which statement is true regarding H. pylori?
a. It is a gram-positive bacterium
b. HP prevalence is similar in developing and developed countries
c. 15% of patients with a duodenal ulcer are infected with H. pylori
d. PPIs should be stopped 1 week before a H. pylori stool antigen test
e. It is associated with an increased risk of gastric cancer
e. It is associated with an increased risk of gastric cancer
158
A 56-year-old man presents with abdominal distension and shortness of breath. Examination revealed fever of 38C, a tense distended abdomen with shifting dullness. He also has dullness to percussion in the right lung base. Several spider naevi are seen on his chest. Which is the most important test in the management of this patient?
a. CXR
b. USS abdomen
c. Echocardiogram
d. Ascitic tap
d. Ascitic tap
159
Which of the following features best distinguishes Ulcerative colitis from Crohn’s disease?
a. Ileal involvement
b. Continuous colonic involvement
c. Non-caseating granuloma
d. Transmural inflammation
e. Perianal disease
b. Continuous colonic involvement
160
A 68-year-old lady presents with abdominal pain and distention. She last opened her bowels 5 days ago. She has a poor appetite and has lost some weight recently. Her PMH includes an abdominal hysterectomy and diverticulosis. She drinks 20 units of alcohol a week and smokes 5 a day. Examination reveals a distended abdomen with tympanic percussion throughout. There is a small left groin lump with a cough impulse. Which one of the following is NOT likely to be the cause of her abdominal pain and distention?
a. Colon cancer
b. Adhesions
c. Ascites
d. Diverticulitis
e. Strangled hernia
c. Ascites
161
A patient drinks 4 pints (567ml = 1 pint) of beer (4%) a day, and 2 standard (175ml) glasses of red wine (13%) on Saturday and Sunday additionally. How many units of alcohol is he drinking per week?
a. 73 units
b. 62 units
c. 94 units
d. 57 units
e. 49 units
a. 73 units
| Alcohol unit = strength of the drink (%ABV) x amount of liquids in mls / 1000
162
A 71-year-old man was admitted to hospital with pneumonia after he returned from a cruise holiday in the Mediterranean Sea. He was treated with a week of augmentin (co-amoxiclav) for his pneumonia. On day 7 of his admission, he started having diarrhoea 10 times a day without any blood. He feels unwell and dehydrated. He had a flexible sigmoidoscopy which showed this. What is the likely organism responsible for his diarrhoea?
a. Norovirus
b. Escherichia coli
c. Giardia lamblia
d. Clostridium difficile
e. Salmonella enteritidis
d. Clostridium difficile
163
A 52-year-old lady presents with fatigue and itching. She noticed pale stool and dark urine. She suffers from hypercholesterolaemia and rheumatoid arthritis. She takes simvastatin and cocodamol. Examination revealed jaundice, xanthelasma, spider naevi, and hepatomegaly. Her bloods showed Bili 150, ALP 988, ALT 80, positive AMA and a raised IgM. What is the most likely diagnosis?
a. Simvastatin induced liver injury
b. Primary biliary cirrhosis
c. Gallstones
d. Autoimmune hepatitis
e. Primary sclerosing cholangitis
b. Primary biliary cirrhosis
164
A 16-year-old girl is admitted with vomiting and abdominal pain. She reports taking 20 paracetamol tablets after her boyfriend split up with her. Which one of the following test results would you NOT expect to see?
a. A metabolic acidosis
b. A prolonged prothrombin time
c. A raised creatinine
d. Hyperglycaemia
e. ALT 1000
d. Hyperglycaemia
165
A 68-year-old unkempt and malnourished homeless man was brought to the hospital with haematemesis. Endoscopy found bleeding varices. Subsequent USS showed a coarse shrunken liver. On day 2 admission he was found to be ataxic, confused with nystagmus. What is the most likely cause of his neurological presentation?
a. Alcohol toxicity
b. Alcohol withdrawal
c. Delirium tremens
d. Wernicke’s encephalopathy
e. Korsakoff syndrome
d. Wernicke’s encephalopathy
166
A 23-year-old man was brought in at 2am with RIF pain and was diagnosed with acute appendicitis. He was stable and was scheduled for appendicectomy in the morning. During the ward round, he acutely deteriorated. He was immediately brought to theatre for a perforated appendix. What clinical signs would you NOT expect to see?
a. Fever
b. Bowel sounds
c. Tachycardia
d. Rebound tenderness
e. Guarding
b. Bowel sounds
167
Which antibody is associated with coeliac disease?
a. Anti-ds-DNA
b. Anti-phospholipid
c. ANCA
d. Alpha gliadin
e. Rheumatoid factor
What are the other antibodies associated with?
d. Alpha gliadin = coeliac
a. Anti-ds-DNA = SLE
b. Anti-phospholipid = Anti phospholipid syndrome
c. ANCA = small vessel vasculitis
d. Alpha gliadin = coeliac
e. Rheumatoid factor = RA
168
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Jenny’s been non-stop to the loo and has recently been diagnosed with IBS using the Rome III criteria. She’s tried out a low FODMAP diet, but her diarrhoea won’t budge. Which of the following drug sis the most appropriate pharmacological intervention for this patient?
a. Ferrous sulphate
b. Loperamide
c. Methotrexate
d. Metronidazole
e. Omeprazole
What are the other types of medication?
```
b. Loperamide = anti-diarrhoeal, anti-motilitic
a. Ferrous sulphate = iron supplement
b. Loperamide = anti-diarrhoeal, anti-motilitic
c. Methotrexate = DMARDs
d. Metronidazole = Antibiotic
e. Omeprazole = PPI
169
A 34-year-old South African patient presents to A&E with severe pain in his left iliac abdominal region. He describes hat the pain has come on suddenly and since its onset he has not been able to pass stool. He has had no previous abdominal surgery, is a non-smoker and his tissue transglutamase results are negative. What is the most likely diagnosis?
a. Coeliac
b. Colorectal cancer
c. Large bowel obstruction – volvulus
d. Small bowel obstruction – adhesion
e. Strangulation hernia
c. Large bowel obstruction – volvulus
170
Which if the following is not a feature of Crohns disease?
a. Mouth ulcers
b. Mucosal inflammation
c. Granulomatous skip lesion
d. Raised CRP levels
e. Smoking decreased the risk of the disease
e. Smoking decreased the risk of the disease
Protective in UC
171
Which indicates IBD not IBS?
a. Smelly stool
b. DXA scan revealing decreased bone mineral density
c. Nocturnal diarrhoea
d. Abdominal cramps
e. Feeling fatigued
c. Nocturnal diarrhoea
172
Which 2 of the following statements about ascending cholangitis are false?
a. Caused by bacterial infection of biliary tree
b. Patients experience epigastric pain
c. Patients present with temperature
d. Patients present with yellowing of the sin and sclera
e. Murphy’s sign is negative
b. Patients experience epigastric pain
| e. Murphy’s sign is negative
173
What is the cystic artery a branch of?
a. Coeliac trunk
b. Gastroduodenal artery
c. Last gastroepiploic artery
d. Right hepatic artery
e. Splenic artery
d. Right hepatic artery
174
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Which from of hepatitis is a DNA virus?
a. Hep A
b. Hep B
c. Hep C
d. Hep D
e. Hep E
How is each spread?
```
b. Hep B
a. Hep A = faceo-oral
b. Hep B = blood/bodily fluids
c. Hep C = blood/bodily fluids
d. Hep D = blood/bodily fluids
e. Hep E faeco-oral
175
Haemochromatosis is a metabolic liver disease caused by uncontrolled intestinal absorption of which ion?
a. Ca2+
b. Cu2+
c. Fe2+
d. Li+
e. K+
c. Fe2+
176
H. pylori eradication = PPI and 2 antibiotics. Which antibiotics?
a. Amoxicillin and clarithromycin
b. Doxycycline and metronidazole
c. Ethambutol and trimethoprim
d. Lithium and clarithromycin
e. Rifampicin and amoxicillin
a. Amoxicillin and clarithromycin
