GI AND LIVER Flashcards

Question

what are the risk factors for the Mallory-weiss/Boerhaave syndrome?

Answer 1

- Significant alcohol use. - History of food poisoning, gastroenteritis, gallstones, cholecystitis etc. - Chronic cough e.g. bronchiectasis, COPD, lung cancer. - Hiatus hernia.

Answer 2

- Haematemesis following second episode of vomiting, it may have a ‘coffee-ground’ appearance or bright-red bloody haematemesis. - Dizziness and postural hypotension. - Severe retrosternal pain (Boerhaave syndrome).

Answer 3

- oesophagogastroduodenoscopy | - Red longitudinal defect.

Answer 4

water double contrast enema (Gastrografin) to localise the lesion.

Answer 5

-Early recognition and surgical management within 12 hours of rupture

Answer 6

inflamed lymph glands in the abdomen

Answer 7

- abdominal pain - following a sore throat or cold - fever and generally unwell - nausea and diarrhoea

Answer 8

- clinically | - by excluding other causes of abdominal pain

Answer 9

- Productive cough. - Shortness of breath on exertion. - Wheezing. - Chest hyperinflation. - Jaundice. - Asterixis.

Answer 10

- Measure plasma AAT level: < 20 mmol/L. - Perform pulmonary function testing: Reduced FEV1, FVC and FEV/FVC; Increased TLC. - Perform CXR: Large lung volumes and emphysema.

Answer 11

- lifestyle advice such as smoking cessation. - hepatitis A and B vaccination. - For pulmonary manifestations: Offer bronchodilators, inhaled steroids and antibiotics. - For hepatic manifestations: Offer diuretics for ascites, endoscopy to detect and manage varices, and liver transplantation in decompensated cirrhosis.

Answer 12

first few months of life

Answer 13

- Paroxysmal, inconsolable crying or screaming - accompanied by drawing up of the knees - passage of excessive flatus - takes place several times a day, particularly in the evening.

Answer 14

- Anorexia - Vomiting and nausea - Fever - Abdominal pain, initially central and colicky (appendicular midgut colic), but then localising to the right iliac fossa (from localised peritoneal inflammation)

Answer 15

- low-grade fever - Abdominal pain aggravated by movement - Persistent tenderness with guarding in the right iliac fossa (McBurney’s point). - Rovsing’s sign – palpation of the left lower quadrant increases pain in the right lower quadrant - Psoas sign – passive extension of the right thigh with the person in the left lateral position elicits pain in the RLQ, suggestive of a retrocaecal appendix

Answer 16

- neutrophil dominant leucocytosis | - Elevated CRP

Answer 17

- supportive therapy - NBM, IV fluids and analgesia - Laparoscopic appendicectomy - postoperative antibiotics (e.g. amoxicillin + metronidazole) for complicated appendicitis where there is suspected perforation.

Answer 18

-invagination of proximal bowel into a distal segment.

Answer 19

- Paroxysmal, severe colicky pain - pallor - May refuse feeds - may vomit, which may become bile-stained depending on the site of the intussusception - sausage shaped mass palpable in the abdomen - passage of redcurrant jelly stool - abdominal distention - shock

Answer 20

target sign

Answer 21

- Perform fluid resuscitation with 0.9% NaCl. - Give clindamycin and gentamicin if sepsis is suspected. - Perform pneumatic reduction (air insufflation) as first line management in patients who are clinically stable. - Perform surgical reduction if pneumatic reduction fails.

Answer 22

a twist in the bowel that occludes its lumen.

Answer 23

- Absolute constipation. - Crampy abdominal pain. - Bilious vomiting (caecal volvulus) - If ischaemia is present: - --Severe acute abdominal pain. - --Tachycardia. - --Tachypnoea. - --Acidosis. - --Guarding and rebound tenderness.

Answer 24

- Inverted U shaped loop in sigmoid volvulus | - Coffee bean share in caecal volvulus.

Answer 25

- Bird-beak sign in sigmoid volvulus | - Corkscrew sign in caecal volvulus.

Answer 26

- Perform therapeutic flexible sigmoidoscopy with insertion of a rectal tube if there is no peritonitis or mucosal gangrene. - Perform surgical resection if there is peritonitis or mucosal gangrene.

Answer 27

- Perform surgical resection as first line. - Offer supportive care including nasogastric tube, IV fluid resuscitation and prophylactic antibiotics. - If ischaemia is not present, gram positive cover is required e.g. cefazolin. - If ischaemia is present, gram negative cover is required e.g. cefoxitin.

Answer 28

blind-ended outpouching of the ileum on the antimesenteric border approximately 60 cm from the ileocaecal valve

Answer 29

- Haematochezia | - intractable constipation

Answer 30

- Order a technetium-99m pertechnetate scan: Ectopic focus. | - Perform surgical exploration of the abdomen: Identify Meckel’s diverticulum.

Answer 31

- Perform a laparoscopic resection. - Give urgent blood transfusion if bleeding. - Remove any adhesive bands if obstruction. - Perform small bowel segmental resection and give cefotaxime and metronidazole if perforation and peritonitis.

Answer 32

- Crohn’s disease. - Diabetes mellitus. - Diet high in triglycerides, refined carbohydrates, and low in fibre. - Female gender. - Hispanic and Native-American ethnicity. - Increasing age. - Octreotide, a somatostatin analogue, due to impaired gallbladder motility. - GLP-1 analogies. - Ceftriaxone, due to precipitation of bile. - Non-alcoholic fatty liver disease. - Obesity.

Answer 33

-Severe epigastric and RUQ pain - lasting several hours - associated with nausea and vomiting.

Answer 34

- gallstones in gallbladder | - stones in the bile duct

Answer 35

- Trauma. - Burns. - Immobility. - Starvation. - Sepsis. - Acute renal failure. - Diabetes mellitus. - Vascular disease. - Total parenteral nutrition. - Narcotic analgesics.

Answer 36

- Sudden-onset, constant, severe pain in the upper right quadrant. - Referred pain in the shoulder or intrascapular region. - Tenderness in the upper right quadrant, with or without Murphy’s sign. - Nausea and vomiting. - Fever.

Answer 37

- Raised aminotransferases | - raised ALP.

Answer 38

- Distended gallbladder | - Gallstones.

Answer 39

MRCP and ERCP

Answer 40

- Provide fluid resuscitation, analgesia and antibiotics to all patients. - Refer for laparoscopic cholecystectomy preferably within a week of onset. - Refer for percutaneous cholecystectomy to manage gallbladder empyema for patients unfit for general anaesthesia and surgery, and who do not improve after fluid resuscitation, analgesia, and antibiotics.

Answer 41

- Above the age of 50. - History of cholelithiasis. - History of primary or secondary sclerosing cholangitis. - Surgical, endoscopic or radiological intervention of bile ducts.

Answer 42

- Charcot’s triad: Fever, jaundice, right upper quadrant pain. - Reynold’s pentad: Charcot’s triad, in addition to hypotension and confusion, which are indicative or sepsis.

Answer 43

- Raised ALT - raised ALP - hyperbilirubinaemia.

Answer 44

- A: Systemic inflammation: - --Fever (>38 degrees celsius) and or shaking chills. - --Laboratory data: Raised WCC. - B: Cholestasis: - --Jaundice. - --Laboratory data: Abnormal LFTs. - C: Imaging: - --Biliary dilation. - --Evidence of aetiology: Stones.

Answer 45

- Give intravenous antibiotics: - --Initially give piperacillin with tazobactam. - --Give metronidazole with ciprofloxacin as an alternative for patients with a penicillin allergy. - Perform biliary decompression: - --Perform ERCP with sphincterectomy, as first-line therapy. - --Perform percutaneous trans-hepatic cholangiography (PTC) for patients who are poor ERCP candidates. - --Perform laparoscopic choledochotomy with T tube - --Perform endoscopic lithotripsy for stones that are large or difficult to remove. -Offer opioid analgesia (morphine, pethidine, fentanyl).

Answer 46

- Chronic alcohol use - Poor nutritional status - Female sex - Age >40 years - Pregnancy - Chronic hepatitis B - Narcotics e.g. paracetamol - Hepatotoxic medication

Answer 47

- jaundice - hepatomegaly - abdominal pain with RUQ tenderness - malaise - encephalopathy - drowsiness, confusion, coma - hypotension - hypoglycaemia - cerebral oedema

Answer 48

- Hyperbilirubinaemia - Prolonged PT > 30 seconds - Elevated INR > 1.5.

Answer 49

- Admit to ICU if blood paracetamol concentration is greater than > 700 mg/L, associated with coma and elevated lactate level. - Administer activated charcoal if the patient presents within 1 hour of ingestion. -Additionally, administer intravenous acetylcysteine (140 mg/kg orally) within 8 hours for paracetamol toxicity. o

Answer 50

- There is uncertainty about the time of overdose, but it is potentially toxic - The overdose was staggered over a time period longer than an hour - The plasma-paracetamol level is over the treatment line on the treatment graph - The overdose was taken 8-36 hours before presenting

Answer 51

-If anaphylactoid reaction to acetylcysteine occurs, stop the infusion, give nebulised salbutamol, then re-commence infusion at a lower rate.

Answer 52

- often no symptoms or signs. - Vague abdominal symptoms of nausea, vomiting and diarrhoea are due to the more general effects of alcohol on the gastrointestinal tract. - Hepatomegaly, sometimes huge, can occur together with other features of chronic liver disease.

Answer 53

- Right upper quadrant pain. - Hepatomegaly. - Jaundice. - Ascites

Answer 54

- Ascites. - Varices. - Hepatic encephalopathy. - Hepatocellular carcinoma.

Answer 55

- Raised AST and ALT - AST:ALT > 2 - Elevated GGT.

Answer 56

- Recommend alcohol abstinence, weight reduction and smoking cessation. - Recommend bed rest with a diet high in protein and vitamin supplements. - Recommend the influenza and pneumococcal vaccine. - Offer prednisolone to patients with alcoholic hepatitis with a Maddrey’s Discriminant Function score of 32 or more. - Offer furosemide and spironolactone for patients with less severe ascites. - Consider liver transplantation in patients with end-stage disease.

Answer 57

- Antinuclear antibody (ANA) - smooth muscle antibody (SMA) - soluble liver antibody (SLA) positive.

Answer 58

-Anti-liver/kidney microsomal-1 (ALKM1).

Answer 59

- Fatigue. - Anorexia. - Abdominal discomfort. - Hepatomegaly. - Jaundice. - Pruritus. - Arthralgia. - Nausea. Fever.

Answer 60

- Raised AST and ALT - Mild elevation of ALP and GGT - Raised bilirubin - Low serum albumin.

Answer 61

- Raised aminotransferase levels greater than 10-fold the upper list. - Raised gamma-globulin level at least twice the upper limit of normal. - Bridging necrosis on liver histology.

Answer 62

- prednisolone and azathioprine - ursodeoxycholic acid in addition to initial management for patients with autoimmune hepatitis - primary biliary cholangitis overlap syndrome. - liver transplant

Answer 63

- Right upper quadrant pain. - Tender hepatomegaly. - Ascites - Splenomegaly due to underlying myeloproliferative disease. - Leg oedema due to obstruction of the inferior vena cava. - Jaundice and hepatic encephalopathy with acute liver failure

Answer 64

- Thrombosis | - stenosis.

Answer 65

- Perform thrombolysis for symptomatic patients presenting within 72 hours. - Offer anticoagulation (enoxaparin or dalteparin) if the patient presents after 72 hours. - Perform hepatic angioplasty as the second line treatment. - Perform surgical shunting as the third line treatment. - Perform liver transplant as the fourth line treatment, or as an emergency procedure in patients with fulminant disease.

Answer 66

the liver can still function effectively, and there are no or few clinical symptoms.

Answer 67

the liver is damaged to the point that it cannot function adequately and overt clinical complications.

Answer 68

- Alcohol misuse. - Hepatitis B and C (unprotected sex and intravenous drug use). - Obesity. - Autoimmune disease (autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis). - Genetic conditions (haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency).

Answer 69

- Presence of stigmata of chronic liver disease - Spider naevi. - Palmar erythema. - Leukonychia

Answer 70

- Haematemesis | - Melaena.

Answer 71

- Abdominal swelling. - Mild generalised abdominal pain. - Deterioration suggests spontaneous bacterial peritonitis.

Answer 72

- Fetor hepaticus (sweet smell to breath). - Asterixis. - Decreased mental function. - Coma.

Answer 73

- Raised AST and ALT - Raised GGT - Prolonged PT (most sensitive and specific finding for liver cirrhosis).

Answer 74

- Initially give spironolactone. - Offer large volume paracentesis for symptomatic tense ascites or when diuretic therapy is insufficient to control accumulation of fluid. - Offer intravenous cefotaxime and human albumin solution for spontaneous bacterial peritonitis.

Answer 75

- Offer a beta blocker for prophylaxis for variceal haemorrhage. - Offer terlipressin with suspected oesophageal variceal haemorrhage. - Perform endoscopic band ligation if bleeding does not stop following terlipressin. - Consider transjugular intrahepatic portosystemic shunt (TIPSS) if bleeding is not controlled by band ligation.

Answer 76

liver transplant

Answer 77

- Family history of coeliac disease. - Type 1 diabetes. - Autoimmune thyroid disease. - Gluten exposure. - Down’s syndrome.

Answer 78

- Diarrhoea. - Bloating. - Abdominal discomfort. - Anaemia. - Fatigue. - Weight loss. - Failure to thrive. - Depression and anxiety. - Peripheral neuropathy. - wasted buttocks

Answer 79

- Elevated titre of IgA-tissue Transglutaminase | - Elevated titre of IgG endomysial antibodies.

Answer 80

- endoscopy | - subtotal villous atrophy and crypt hyperplasia

Answer 81

- Advise long-term adherence to a gluten free diet. The usual cause for failure to respond to the diet is poor compliance. - Offer supplementation (iron, folic acid, calcium, vitamin D) if needed. - Offer pneumococcal vaccinations once every 5 years due to hyposplenism

Answer 82

- Rehydrate and correct electrolyte abnormalities. | - Offer a short course of glucocorticoid therapy (budesonide).

Answer 83

uncommon blistering subepidermal eruption of the skin associated with a gluten-sensitive enteropathy

Answer 84

- diarrhoea - anorexia - abdominal distension - weight loss.

Answer 85

- Acute infective causes of diarrhoea must be excluded, particularly Giardia - Malabsorption should be demonstrated, particularly of fat and B12. - The jejunal mucosa is abnormal, showing some villous atrophy (partial villous atrophy).

Answer 86

- folic acid - tetracycline - Severely ill patients require resuscitation with fluids and electrolytes for dehydration, and nutritional deficiencies should be corrected. - Vitamin B12 (1000 μg) is also given to all acute cases.

Answer 87

- diarrhoea and steatorrhoea - b12 deficiency - high folate

Answer 88

-hydrogen breath test

Answer 89

- correct underlying lesion | - rotating courses of antibiotics, such as metronidazole, a tetracycline or ciprofloxacin.

Answer 90

- coeliac disease | - Crohn's

Answer 91

- coeliac disease | - IPSID

Answer 92

-segmental resection

Answer 93

- if there is no evidence of lymphoma, antibiotics, e.g. tetracycline, should be tried initially. - In the presence of lymphoma, combination chemotherapy is used

Answer 94

- surgery | - radiotherapy with chemotherapy

Answer 95

enterochromaffin cells in the small intestine

Answer 96

- Diarrhoea. - Flushing. - Palpitations. - Abdominal cramps. - Telangiectasia. - Peripheral oedema. - Elevated JVP. - Cardiac murmurs. - Hepatomegaly. - Wheeze

Answer 97

- Measure serum chromogranin A: Elevated. - Measure urinary 5-hydroxyindoleacetic acid: Elevated. - Perform an CT scan of the chest, abdomen and pelvis: Location of primary tumour and liver metastases.

Answer 98

- Perform surgical resection of localised disease with no evidence or lymph node involvement or distant metastases. - Give a somatostatin analogue (octreotide or lanreotide) which controls symptoms of flushing, diarrhoea, and wheeze.

Answer 99

- Increasing age. - A diet high in animal fat and red meat. - Obesity. - Smoking. - Hereditary non-polyposis colorectal cancer (HNPCC) (Lynch syndrome) - Familial adenomatous polyposis (FAP) - Peutz-Jeghers syndrome - IBD

Answer 100

- Rectal bleeding. - Looser and more frequent stools. - Tenesmus. - Symptoms of anaemia. - Rectal mass on DRE, and occasionally, a palpable abdominal mass on examination. - Weight loss and anorexia are associated with advanced disease.

Answer 101

- Perform a FBC: Anaemia suggestive of right sided colorectal cancer. - Measure LFTs: May be abnormal in liver metastases. - Measure U&Es: May be abnormal in renal metastases or diarrhoea.

Answer 102

- Aged 40 and over with unexplained weight loss and abdominal pain. - Aged over 50 with unexplained rectal bleeding. - Over 60 with iron deficiency anaemia or change in bowel habit.

Answer 103

colonoscopy with biopsy

Answer 104

serum carcinoembryonic antigen (CEA)

Answer 105

- surgery - chemotherapy - lifestyle advice (smoking cessation and reduced intake of red meat)

Answer 106

- Family history of Crohn’s disease. - Smoking. - Infectious gastroenteritis. - Appendicectomy. - Drugs such as NSAIDs.

Answer 107

- Unexplained and persistent diarrhoea (frequent loose stools for more than 4 - 6 weeks), including nocturnal diarrhoea. - Abdominal pain or discomfort. - Perianal pain or tenderness. - Non-specific symptoms such as fatigue, malaise, anorexia, fever.

Answer 108

- Pallor. - Clubbing. - Aphthous mouth ulcers. - Abdominal tenderness or mass, for example in the right lower quadrant. - Signs of malnutrition and malabsorption such as weight loss, faltering growth or delayed puberty.

Answer 109

- Pauci-articular or polyarticular arthritis. - Erythema nodosum usually on the anterior tibial area or extensor surfaces of the arms or legs. - Uveitis and episcleritis, both of which produce a red eye, but the formed is painful and is associated with blurred vision, photophobia, headache - Metabolic bone disorders such as osteoporosis, osteopenia, osteomalacia. - sacroiliitis causing buttock pain, or spondylitis causing back pain. - Pyoderma gangrenosum. - Psoriasis - Hepatobiliary conditions such as primary sclerosing cholangitis.

Answer 110

- Recurrent urinary tract infections, passing gas or faeces through the urine or vagina. - Perianal discharge of mucus or pus. - Partial bowel obstruction presents as abdominal colicky pain and distension. - Complete bowel obstruction presents as severe abdominal pain, vomiting, no flatus, complete constipation.

Answer 111

- anaemia, either microcytic or normocytic - raised ESR and CRP - hypoalbuminaemia in severe disease - pANCA negative

Answer 112

-Faecal calprotectin and lactoferrin are raised in active colonic disease

Answer 113

- skip lesions - cobblestone appearance - deep ulcers and fissures

Answer 114

- transmural inflammation | - non-caseating granulomas

Answer 115

- nutritional therapy in children - corticosteroids - aminosalicylate

Answer 116

- thiopurine - methotrexate - TNFa inhibitor (infliximab or adalimumab) if no response to conventional therapy

Answer 117

- Offer colorectal surgery in patients with complicated perianal or internal fistulas or fistulas that fail to respond to optimal medical treatment. - Offer a thiopurine to maintain remission. - Offer 3-months post operative metronidazole to control infection.

Answer 118

- Family history. - No appendicectomy. - Drugs such as NSAIDs. - Not smoking.

Answer 119

- Bloody diarrhoea persisting for more than 6 weeks. - Rectal bleeding. - Faecal urgency and or incontinence. - Nocturnal defecation. - Tenesmus (persistent, painful urge to pass stool even when rectum is empty). - Abdominal pain, particularly in the left lower quadrant. - Pre-defecation pain that is relieved on passage of stool. - Non-specific symptoms such as fatigue, malaise, anorexia, or fever. - Weight loss, faltering growth, or delayed puberty

Answer 120

- Pallor - Clubbing. - Abdominal distension, tenderness or mass, for example in the left lower quadrant. - Signs of malnutrition or malabsorption.

Answer 121

- iron deficiency anaemia - raised WCC - raised platelets - Raised ESR and CRP - hypoalbuminaemia - positive pANCA

Answer 122

- superficial inflammation that is continuous - the mucosa looks reddened, inflamed and bleeds easily (friability). - In severe disease there is extensive ulceration with the adjacent mucosa appearing as inflammatory (pseudo) polyps. - In ulcerative colitis, the mucosa shows a chronic inflammatory cell infiltrate in the lamina propria. - Crypt abscesses and goblet cell depletion are also seen.

Answer 123

- a topical aminosalicylate - oral aminosalicylate - corticosteroids - ciclosporin

Answer 124

- thiopurine - methotrexate intravenous TNF-alpha inhibitor (infliximab or adalimumab)

Answer 125

- Genetic factors. - Increasing age. - Low-fibre diet. - Smoking. - Obesity. - Drugs such as NSAIDs.

Answer 126

- Intermittent abdominal pain in the left lower quadrant, which may be triggered by eating and relieved by the passage of stool or flatus. - Constipation, diarrhoea or occasional large rectal bleeds. - Bloating and passage of mucus rectally. - Tenderness in the left lower quadrant.

Answer 127

colonoscopy

Answer 128

-Arrange urgent admission if the patient has significant rectal bleeding and is haemodynamically unstable (a pulse greater than 150 bpm, and a systolic blood pressure lower than 90 mmHg). - Offer lifestyle advice to patients who do not need admission: - --Recommend a healthy balanced diet contains whole grains, fruits, and vegetables. - --Recommend drinking an adequate fluid intake with a high-fibre diet. - Consider prescribing a bulk-forming laxative (Ispaghula husk) if a high fibre diet is insufficient, or if symptoms of constipation or diarrhoea persist. - Offer paracetamol for pain relief. Advise the patient to avoid NSAIDs and opiate analgesia.

Answer 129

- Constant abdominal pain, usually severe and starting in the hypogastrium before localising in the left lower quadrant. - Fever. - Change in bowel habit. - Significant rectal bleeding. - Nausea, vomiting, dysuria, urinary frequency. - Tenderness in the left lower quadrant.

Answer 130

-Abscess formation suggested by abdominal mass on examination. -Perforation and peritonitis suggested by abdominal rigidity, guarding, and rebound tenderness. - Sepsis suggested by skin discolouration, raised or lowered temperature, rigors, change in conscious level, confusion, rapid pulse, reduced urination. - Fistula formation: Faecaluria, pneumaturia. - Intestinal obstruction suggested by colicky abdominal pain, vomiting, inability to pass flatus, abdominal distension.

Answer 131

- Offer paracetamol for pain relief. - Advise the patient to avoid NSAIDs and opiate analgesia. - Offer co-amoxiclav for patients who are systemically unwell, but do not meet the criteria for suspected complicated acute diverticulitis.

Answer 132

- Arrange urgent hospital admission if there is suspected acute diverticulitis: - --Offer intravenous antibiotics (co-amoxiclav or metronidazole + cefuroxime), fluid replacement, and analgesia. - Consider percutaneous drainage of an abscess that is greater than 3 cm. - Offer laparoscopic lavage or Hartmann’s procedure (sigmoid colectomy with formation of an end colostomy) for patients with faecal peritonitis or who fail to respond to antibiotic therapy.

Answer 133

- Family history of eosinophilic oesophagitis. - Male sex. - Atopic disease (asthma, atopic dermatitis, allergic rhinitis / sinusitis, food allergies). - Children and young adults. - White ancestry.

Answer 134

- Dysphagia. - Food avoidance and modification behaviours. - Regurgitation. - Heartburn. - Oesophageal pain. - Nausea and vomiting. - Failure to thrive.

Answer 135

- OGD | - Oesophageal biopsy

Answer 136

- Offer a corticosteroid (budesonide or fluticasone) for 8 weeks. - Offer dietary elimination therapy for 6 weeks. - Offer endoscopic oesophageal dilation (wire-guided bougie) in patients with severe oesophageal narrowing. - Emerging therapy includes mepolizumab, a monoclonal antibody against IL-5.

Answer 137

- alcohol | - tobacco

Answer 138

- barrett's oesophagus | - hiatus hernia

Answer 139

- Progressive dysphagia for solids (meat and bread) and then liquids within weeks. - Odynophagia. - Weight loss. - Anorexia. - Lymphadenopathy.

Answer 140

-OGD with biopsy

Answer 141

-endoscopic resection.

Answer 142

- oesophagectomy | - chemoradiotherapy

Answer 143

Perform oesophagectomy with preoperative chemoradiotherapy

Answer 144

Offer chemoradiotherapy (cisplatin, fluorouracil and radiotherapy) and offer endoscopic ablation and stenting for symptom relief

Answer 145

- Pernicious anaemia. - H.pylori. - N-nitroso compounds. - Smoking. - Family history. - Male sex. - Age 50 to 70 years.

Answer 146

- Epigastric pain. - Weight loss. - Vomiting. - Dysphagia.

Answer 147

- Anaemia from occult blood loss. - Virchow’s node. - Sister Mary Joseph’s nodule. - Acanthosis nigricans. - Dermatomyositis. - Thrombophlebitis.

Answer 148

- Perform surgical resection and perioperative chemotherapy (epirubicin + cisplatin + fluorouracil) in patients with early localised disease in a surgical candidate. - Offer chemoradiotherapy (fluorouracil + radiotherapy) in patients with early localised disease who are not surgical candidates. - For advanced and metastatic disease: - --Offer chemotherapy (ECF). - --Offer palliative gastrectomy.

Answer 149

- Cigarette smoking is the most important risk factor. - Type II diabetes mellitus. - Chronic pancreatitis. - Family history: Hereditary pancreatitis, Peutz-Jeghers syndrome, Lynch syndrome. - Increasing age. - Male gender.

Answer 150

- Obstructive jaundice. - Characteristic stretch marks secondary to cholestasis. - Painless palpable gall-bladder. - Epigastric mass is a sign of advanced disease.

Answer 151

- Dull abdominal pain that radiates through the back, that is partially relieved by sitting forward. - Anorexia. - Weight loss. - Thromboembolic phenomena. - Polyarthritis. - Skin nodules.

Answer 152

- transabdominal ultrasound showing dilated bile ducts and pancreatic mass - CT scan - FDG-PET and ERCP if ambiguous CT - CA19-9 biomarker

Answer 153

- Pancreaticoduodenectomy (Whipple procedure). - Preoperative endoscopic stent insertion. - Neoadjuvant chemotherapy (5-fluorouracil).

Answer 154

- Endoscopic stent insertion - Offer gemcitabine based combination chemotherapy or FOLFIRINOX. - Opioid analgesia or percutaneous neurolytic coeliac plexus block for pain relief.

Answer 155

- Stress and anxiety. - Smoking and alcohol. - Trigger foods, such as coffee and alcohol. - Obesity, pregnancy, hiatus hernia. - Family history. - Drugs such as alpha blockers, anticholinergics, benzodiazepines, NSAIDs. - Children with cerebral palsy or other neurodevelopmental disorders - Preterm infants, particularly with coexistent bronchopulmonary dysplasia

Answer 156

- Heartburn, which is aggravated by bending over or lying down, worsened after food, hot drinks, alcohol, and relieved by antacids. - Acid regurgitation mainly after meals. - Dysphagia is uncommon. - Posseting and poor feeding in children

Answer 157

- Lose weight if the patient is overweight or obese. - Avoid trigger foods and eat smaller meals. - Stop smoking and reduce alcohol consumption. - Sleep with the head of the bed raised (bricks under head of bed if practical). - Relaxation strategies for stress and anxiety. - Stopping drugs that may exacerbate symptoms.

Answer 158

- thickening agents (carobel) - acid suppression (gaviscon or PPI) - Nissen fundoplication with complications

Answer 159

- Recurrent peptic ulcer disease. - Diarrhoea. - Epigastric abdominal pain. - Gastro-oesophageal reflux disease. - Steatorrhoea.

Answer 160

- Measure fasting serum gastrin: Elevated. - Perform a secretin infusion test: Increase in fasting serum gastrin. - Measure serum calcium: Raised suggest MEN1 syndrome. - Consider a GI endoscopy: Prominent gastric folds.

Answer 161

- Offer a proton pump inhibitor (omeprazole 60 mg) to control gastric acid hypersecretion. - Offer surgery for localised disease if the primary site is causing symptoms. - Offer a somatostatin analogue (octreotide) and everolimus for liver metastases to limit tumour growth and symptoms. - Offer chemoradiotherapy for extrahepatic metastatic disease.

Answer 162

- Middle age. - Male gender (the reduced incidence in women is probably explained by physiological blood loss and a smaller dietary intake of iron). - White ancestry. - Family history. - Supplemental iron.

Answer 163

- Fatigue, weakness, lethargy. - Arthralgia. - Impotence and loss of libido. - Arrhythmia and heart failure (uncommon). - Bronze skin pigmentation due to excess melanin deposition. - Hepatomegaly.

Answer 164

- Raised ferritin - raised serum transferrin - reduced total iron binding capacity

Answer 165

- Perform venesection 500 mL twice weekly for 2 years. - Offer iron chelation therapy with desferrioxamine for patients who cannot tolerate venesection. - Patients should avoid iron and vitamin C containing supplements.

Answer 166

- Delay of passage of meconium. - Vomiting which can be bilious. - Abdominal distension. - Constipation. - Explosive passage of liquid and foul stools. - Fever and failure to thrive associated with enterocolitis.

Answer 167

- Perform an AXR initially: Air-fluid levels present and dilated colon. - Perform a contrast enema which is the most useful diagnostic test: Contracted distal bowel and dilated proximal bowel. - Perform a rectal biopsy which allows for definitive diagnosis: Absence of ganglion cells.

Answer 168

- Perform bowel irrigation as the initial treatment prior to surgery. It allows evacuation of gas and liquid stool through the tube. - Perform a pull through procedure surgery (Swenson procedure) within the first week of life for segmental disease. - Administer intravenous metronidazole for enterocolitis. - Perform a total colectomy and ileostomy for total colon aganglionosis.

Answer 169

- Decreased bowel sounds. - Nausea and vomiting. - Abdominal distension. - Constipation.

Answer 170

- GI surgery - electrolyte imbalances - release of inflammatory agents - dysregulation of sympathetic and parasympathetic input to GI tract - analgesia and anaesthesia

Answer 171

- Patient should be nil by mouth. - Administer intravenous hydration with normal saline. - Reduce opioid analgesia.

Answer 172

hypertrophy of the pyloric muscle

Answer 173

- 2 and 7 weeks of age - males - first born - family history on maternal side

Answer 174

- projectile, non-bilious vomiting - Hunger after vomiting until dehydration leads to loss of interest in feeding - Weight loss if presentation is delayed. - Tachycardia - Dry mucous membranes - Palpable pylorus - A hypochloraemic metabolic alkalosis with a low plasma sodium and potassium occurs as a result of vomiting stomach contents.

Answer 175

-Ultrasound examination is helpful if the diagnosis is in doubt, showing pyloric muscle thickness >4mm

Answer 176

- The initial priority is to correct any fluid and electrolyte disturbance with intravenous fluids (0.45% saline and 5% dextrose with potassium supplements). - pyloromyotomy

Answer 177

- Psychosocial factors include stress, anxiety, depression. - Genetic factors. - Gastroenteritis. - Inflammatory bowel disease. - Dietary factors such as alcohol, caffeine, spicy and fatty foods. - Antibiotics.

Answer 178

- Abdominal pain. - Bloating. - Change in bowel habits. - Lethargy. - Nausea. - Back pain. - Bladder symptoms such as nocturia.

Answer 179

- Recurrent abdominal pain, at least 1 day per week in the last 3 months: - Relieved by defecation. - Associated with a change in frequency of stool. - Associated with a change in appearance of stool.

Answer 180

- Provide advice and reassurance. - Encourage stress management such as exercise or yoga. - Advise the patient to maintain a healthy, balanced diet: - Low FODMAP diet (low fermentable carbohydrate diet, avoiding fruits, artificial sweeteners, and some green vegetables). - Reduce intake of fibre if diarrhoea. - Fibre supplements or foods high in fibre if constipation. - Reducing caffeine, alcohol, spicy and fatty foods. - Adequate fluid intake. - Consider probiotics for a minimum of four weeks. - Offer loperamide for diarrhoea.

Answer 181

- Offer a bulk forming laxative (ispaghula husk). | - Offer linaclotide if constipation persists for over 12 months or if laxatives are poorly tolerated

Answer 182

- Offer an antispasmodic agent (mebeverine hydrochloride). - Consider amitriptyline if abdominal pain persists. - Consider an SSRI (citalopram) if the patient is constipated, as TCAs can cause constipation, or where a TCA is ineffective, contra-indicated or not tolerated

Answer 183

- Travelling to countries where the virus is highly endemic. - Men who have sex with men, and people with risky sexual behaviours. - People with clotting factor disorders. - Intravenous drug use. - People at occupational risk such as laboratory workers, and sewage workers.

Answer 184

- Flu-like symptoms, including fatigue, malaise, joint and muscle pain, low-grade fever. - Gastrointestinal symptoms, such as nausea, vomiting, anorexia, right upper quadrant discomfort. - Accompanying headache, cough, sore throat, or urticaria

Answer 185

- Pruritus. - Fatigue, anorexia, nausea, vomiting. - Hepatomegaly, splenomegaly, lymphadenopathy.

Answer 186

- Malaise. - Anorexia - Muscle weakness. - Hepatic tenderness.

Answer 187

- Elevated ALT and AST (usually between 500 and 10,000 IU/L). - Low ALT in fulminant hepatitis - Elevated bilirubin - Prolonged PT.

Answer 188

- Positive HAV-IgM | - positive HAV-IgG

Answer 189

- Negative HAV-IgM | - positive HAV-IgG

Answer 190

- Positive HAV-IgM | - negative HAV-IgG

Answer 191

- People travelling to high-risk areas. - People with chronic liver disease. - People receiving plasma-derived clotting factors to treat haemophilia. - IV drug users. - Men who have sex with men with multiple sexual partners. - People at occupational risk.

Answer 192

- Advise paracetamol or ibuprofen for pain relief. - Prescribe metoclopramide (for 5 days) or cyclizine for nausea. - Prescribe chlorphenamine for pruritus.

Answer 193

- Sharing of drug injecting equipment. - Travelling to areas of high prevalence. - Receiving regular blood or blood products (such as people with haemophilia). - Occupational hazards including needle stick injuries or direct exposure of mucous membranes to infected blood. - Tattoos, body piercing, or acupuncture. - Sexual transmission via mucous membranes. Having sex unprotected sex or having multiple sexual partners produces the greatest risk. - Transmission during childbirth (perinatal transmission).

Answer 194

- Prodromal illness that includes fever, arthralgia or a rash. - Right upper quadrant abdominal pain. - Jaundice with dark urine or pale stools. - Extrahepatic manifestations, including glomerulonephritis, vasculitis, polyarteritis.

Answer 195

- Spider naevi. - Finger clubbing. - Jaundice. - Hepatosplenomegaly. - In severe cases: thin skin, bruising, ascites, liver flap, encephalopathy.

Answer 196

- Elevated ALT and AST - Elevated ALP - Elevated bilirubin - Prolonged PT

Answer 197

- A positive HBsAg and IgM | - negative IgG

Answer 198

- A positive HBsAg and IgG | - a negative IgM

Answer 199

- paracetamol, ibuprofen, or a weak opioid for pain relief. - Metoclopramide for nausea. - Chlorphenamine for pruritus

Answer 200

- Aged 30 years and older. - HBV DNA greater than 2000 IU/L and an ALT greater than 30 IU/L. - Evidence of necroinflammation or fibrosis on liver biopsy.

Answer 201

a) entecavir or tenofovir | b) peg-interferon alpha-2a

Answer 202

- Unsafe medical practices. - Intravenous drug use. - HIV. - Prisoners. - Multiple sexual partners, men who have sex with men. - Infected mother, especially if the mother is co-infected with HIV.

Answer 203

- Fatigue. - Myalgia. - Arthralgia. - Signs of advanced liver disease include ascites and signs of hepatic encephalopathy, including confusion, altered consciousness, and coma

Answer 204

- For patients with acute hepatitis in whom there is no spontaneous resolution (HCV RNA after 6 months). - For patients with chronic hepatitis.

Answer 205

- Peri-umbilical severe abdominal pain. | - Rapid forceful bowel evacuation.

Answer 206

- Poorly localised abdominal pain after meals. - Sitophobia and associated weight loss. - Nausea and vomiting. - History of smoking.

Answer 207

- Peripheral severe abdominal pain and tenderness. | - Frequent bloody stools, characteristic maroon or red blood.

Answer 208

-thumbprint sign

Answer 209

- Offer adequate fluid resuscitation and oxygenation. - Offer empirical antibiotics (ceftriaxone and metronidazole). - Perform endovascular therapy. - Perform exploratory laparotomy if there is infarction, perforation or peritonitis.

Answer 210

-Consider endovascular treatment

Answer 211

- Most cases resolve spontaneously and only supportive care is needed. - Perform segmental colectomy for severe disease if there is generalised peritonitis or perforation.

Answer 212

- colorectal malignancy - Colonic volvulus (sigmoid or caecal). - Benign stricture (diverticulum). - Pelvic abscess. - Endometriosis.

Answer 213

- Colicky abdominal pain. - Tympanic abdomen. - Hard faeces. - Recent weight loss (suggests underlying malignancy). - Rectal bleeding (suggests underlying malignancy).

Answer 214

- Gaseous distension of large bowel | - Coffee bean shape in volvulus

Answer 215

- adhesions from previous surgery - Appendicitis. - Intestinal malignancy. - Crohn’s disease. - Inguinal hernia.

Answer 216

- Cramping abdominal pain. - Nausea and vomiting. - Abdominal distension. - Constipation.

Answer 217

- Offer supportive care with fluid resuscitation and analgesia. - Perform nasogastric decompression for complete or complicated small bowel obstruction. - Declare the patient nil by mouth.

Answer 218

- Fever. - Malaise - Right upper quadrant pain. - Anorexia. - Vomiting.

Answer 219

Hypo-dense liver lesion.

Answer 220

- Offer piperacillin with tazobactam and fluid resuscitation for haemodynamically unstable patients - Offer metronidazole and ciprofloxacin for patients who are haemodynamically stable. - Offer metronidazole in patients with suspected amoebic abscess. -Perform ultrasound guided percutaneous drainage in all patients in addition to antibiotic therapy. -Offer anticandidal therapy (caspofungin) when liver abscess is diagnosed in an immunocompromised patient.

Answer 221

- Obesity, hypertension, type 2 diabetes and hyperlipidaemia - Hypertension - Medications including amiodarone, corticosteroids, diltiazem, methotrexate, tamoxifen

Answer 222

- Typically asymptomatic - Fatigue - Malaise - Pruritus - Hepatosplenomegaly - RUQ pain

Answer 223

- Elevated ALT and AST - Elevated ALP and GGT - Elevated bilirubin - Decreased serum albumin.

Answer 224

-steatosis

Answer 225

- Offer lifestyle advice on gradual weight loss (rapid weight loss is a risk factor for NAFLD) through diet and exercise. - Offer metformin for patients with diabetes. - Offer a statin for patients with hyperlipidaemia. - For patients with advanced liver disease: - --Monitor for hepatocellular cancer using ultrasound scans and alpha-fetoprotein. - --Offer vitamin E or pioglitazone for advanced liver fibrosis. - --Refer for liver transplantation.

Answer 226

- inflammation associated with mucosal injury

Answer 227

- epithelial cell damage and regeneration without inflammation.

Answer 228

- Recurrent, burning epigastric pain which the patient can identify with a single finger. - Pain on hunger and at night suggests duodenal ulcer. - Pain worsened by eating suggests gastric ulcer. - Back pain suggests a penetrating duodenal ulcer into the pancreas. - Persistent vomiting suggests gastric outlet obstruction. - Haematemesis and melaena suggests haemorrhage. - Examination reveals epigastric tenderness on palpation.

Answer 229

- carbon-13 urea breath test | - stool antigen test

Answer 230

- older than 55 | - have alarm symptoms such as dysphagia, weight loss, vomiting, anorexia, haematemesis or melaena.

Answer 231

- Lose weight if overweight or obese. - Avoid trigger food such as coffee, chocolate, tomatoes, fatty or spicy foods. - Eat smaller meals and avoid eating an evening meal 3 - 4 hours before bed. - Smoking cessation and reduced alcohol consumption. - Relaxation strategies if stress or anxiety. - Avoid NSAIDs, bisphosphonates, and corticosteroids.

Answer 232

- Offer omeprazole 20 mg twice daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily. - Offer metronidazole 400 mg twice daily in place of amoxicillin in patients who are allergic to penicillin. - Offer tetracycline hydrochloride 500 mg four times daily in place of clarithromycin in patients who have had previous exposure to clarithromycin.

Answer 233

- Female (F:M ratio of 10:1). - Increasing age (peak incidence between 45 and 60). - Family history of PBC or autoimmune disease. - Smoking. - Urinary tract infection.

Answer 234

- Pruritus. - Fatigue. - Dry eyes and mouth (associated Sjogren’s syndrome). - Sleep disturbance. - Postural dizziness. - Hepatomegaly.

Answer 235

- anti-mitochondrial antibody - ANA - anti-M2

Answer 236

- raised ALP | - presence of AMA.

Answer 237

- Offer a bile acid analogue (ursodeoxycholic acid) to modify disease progression. - Offer cholestyramine for pruritus.

Answer 238

liver transplant

Answer 239

- Male sex. - Inflammatory bowel disease. - Genetic predisposition.

Answer 240

- Right upper quadrant pain. - Pruritus (excoriations on examination). - Fatigue. - Fever. - Jaundice

Answer 241

- Offer lifestyle advice such as maintaining a healthy diet and weight, and limiting alcohol consumption. - Offer cholestyramine for pruritus.

Answer 242

- Refer for ERCP and balloon dilatation of the structure. | - Offer percutaneous transhepatic cholangiogram if ERCP is unsuccessful

Answer 243

- Cirrhosis. - Chronic hepatitis B infection. - Chronic hepatitis C infection. - Chronic heavy alcohol use. - Diabetes. - Obesity.

Answer 244

- Weight loss. - Anorexia. - Fever. - Stigmata of chronic liver disease. - Clinical features of the complications of cirrhosis. - Examination reveals an enlarged, irregular tender liver.

Answer 245

serum alpha-fetoprotein

Answer 246

- Offer liver transplantation for early disease (BCLC stage A). - Offer trans-arterial chemoembolisation (TACE) in intermediate disease (BCLC stage B). - Offer sorafenib or lenvatinib for advanced disease (BCLC stage C). - Offer hospice care for end-stage disease (BCLC stage D).

Answer 247

- Increasing age. - Choledocholithiasis. - Primary sclerosing cholangitis. - Ulcerative colitis.

Answer 248

- serum CA19-9 | - serum CEA

Answer 249

- Perform partial liver resection for intrahepatic tumours. - Perform surgical excision of extrahepatic tumours. - Offer pre-operative portal vein embolisation.

Answer 250

- Offer liver transplant and chemoradiotherapy. | - Offer palliative care.

Answer 251

- Hepatitis. - Behavioural. - Tremor. - Dysarthria. - Dystonia. - Incoordination. - Sloppy or small handwriting. - Dysdiadochokinesia. - Abnormal extraocular movement. - Kayser-Fleischer ring, which appears as a greenish brown pigment at the corneoscleral junction. - neuropsychiatric features are more common in those presenting from second decade onwards

Answer 252

- Offer lifelong treatment with penicillamine. - Offer trientine or zinc if patient experiences severe adverse effects with penicillamine such as nephropathy, lupus like syndrome and bone marrow depression. - Offer liver transplantation for fulminant hepatic failure or decompensated cirrhosis.

Answer 253

- >100mcg urinary copper - Reduced blood caeruloplasmin - >250mcg copper on liver biopsy

Answer 254

- increase fibre, fruits high ins orbital and veg - increase fluid intake - develop a toilet routine

Answer 255

- manage secondary causes - increase fibre, fluid and activity - bulk-forming laxative (ispaghula) - osmotic laxative (macrogol or lactulose) - stimulant laxative

Answer 256

increase fibre, fluid and activity - bulk-forming laxative (ispaghula) - osmotic laxative (macrogol or lactulose) - consider prucalopride

Answer 257

- with hard stool give macrogol - with soft stool give stimulant laxative - if laxative response is inadequate, give bisacodyl suppository or mini docusate/sodium citrate enema - if response is still inadequate, give sodium phosphate or arachis oil retention enema overnight before giving sodium phosphate or sodium citrate enema - regular laxatives

Answer 258

- disimpaction regimen of stool softeners, initially with a macrogol osmotic laxative, e.g. polyethylene glycol + electrolytes (Movicol Paediatric Plain). - An escalating dose regimen is administered over 1–2 weeks or until impaction resolves. - If this proves unsuccessful, a stimulant laxative, e.g. senna, or sodium picosulphate, may also be required. - If the polyethylene glycol + electrolytes is not tolerated, an osmotic laxative can be substituted.

Answer 259

- Abdominal pain - Cramps - Nausea - Vomiting - Dysentry

Answer 260

- systemically unwell - blood or pus in the stool. - Persistent diarrhoea with suspected giardiasis. - Patient is immunocompromised.

Answer 261

erythromycin

Answer 262

ciprofloxacin

Answer 263

ciprofloxacin

Answer 264

- incubation of few hours to 6 days. - profuse painless diarrhoea - vomiting - rice-water stools - hypovolaemic shock - muscle cramps

Answer 265

- clinical - rapid dipstick test - stool and rectal swabs for culture

Answer 266

-oral rehydration

Answer 267

- chronic, with mild intermittent diarrhoea and abdominal discomfort - may progress to bloody diarrhoea with mucus

Answer 268

- Tender hepatomegaly - high swinging fever - profound malaise

Answer 269

-microscopic examination or colonic exudate obtained at sigmoidoscopy

Answer 270

- metronidazole or tinidazole | - bowel should then be cleared of parasites with diloxanide furoate

Answer 271

- diarrhoea, often watery - nausea - anorexia - abdominal discomfort - bloating - steatorrhoea - weight loss

Answer 272

- stool examination | - duodenal aspirate

Answer 273

- metronidazole | - Alternative drugs include tinidazole, mepacrine and albendazole.

Answer 274

- Increasing age (more than 65 years old). - Antibiotic treatment. - Hospitalisation or residence in a nursing home. - History of C.difficile-associated disease. - Use of acid suppressing drugs. - Inflammatory bowel disease. - Solid organ or haematopoietic stem cell transplant recipients. - Chronic kidney disease. - HIV infection.

Answer 275

- Clinical features commence anything from 2 days to some months after antibiotics. - Mild diarrhoea to profusely, water, haemorrhagic diarrhoea. - Abdominal pain. - Fever. - Abdominal tenderness. - Hypotension (suggests life-threatening infection).

Answer 276

-Measure stool PCR or ELISA which is diagnostic: Toxin A or B present

Answer 277

- oral metronidazole for 10 days for mild/moderate infection - oral vancomycin for severe infection

Answer 278

sub-optimal weight gain in infants and toddlers.

Answer 279

- feeding problems - insufficient or unsuitable foods - lack of regular feeding - infant difficult to feed - conflict over feeding - intolerance of normal feeding behaviour - problems with finances - low socioeconomic status - poor maternal-infant interaction - maternal depression - poor maternal education - neglect or child abuse

Answer 280

- oromotor dysfunction - neurological disorder - cleft palate

Answer 281

- vomiting | - severer GORD

Answer 282

- coeliac - CF - cow's milk protein allergy - cholestatic liver disease - short gut syndrome - post-NEC

Answer 283

- syndromes - chromosomal disorders - IUGR - extreme prematurity - congenital infection - metabolic disorders

Answer 284

- thyrotoxicosis - CF - malignancy - chronic infection - CHD - chronic renal failure

Answer 285

- a fall across 1 or more weight centile spaces, if birth weight was below the 9th centile. - a fall across 2 or more weight centile spaces, if birth weight was between the 9th and 91st centiles. - a fall across 3 or more weight centile spaces, if birth weight was above the 91st centile. - when current weight is below the 2nd centile for age, whatever the birth weight.

Answer 286

-when the digestive tract is functioning

Answer 287

- weight for height more than -3 standard deviations from the median - wasted, wizened appearance - withdrawn and apathetic

Answer 288

- a ‘flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation - a distended abdomen and enlarged liver (usually due to fatty infiltration) - angular stomatitis - hair which is sparse and depigmented - diarrhoea, hypothermia, bradycardia and hypotension - low plasma albumin, potassium, glucose and magnesium.

Answer 289

- Hypoglycaemia–common; correct urgently, particularly if coma or severely ill. - Hypothermia–wrap, especially at night. - Dehydration–correct, but avoid being overzealous with intravenous fluids, as may lead to heart failure. - Electrolytes–correct deficiencies, especially potassium. - Infection–give antibiotics; fever and other signs may be absent. Treat oral candida if present. - Micronutrients–give vitamin A and other vitamins - Initiate feeding–small volumes, frequently, including through the night.

Answer 290

- northern latitudes - dark skin - decreased exposure to sunlight - poor diet - intestinal malabsorption

Answer 291

- misery - failure to thrive - frontal bossing of skull - craniotabes - delayed closure of anterior fontanelle - delayed dentition - rickety rosary - harrison sulcus - expansion of metaphases - bowing of legs - hypotonia - seizures

Answer 292

- dietary history - low serum calcium - low phosphorus - plasma alkaline phosphatase - low 25-hydroxyvitamin D - elevated PTH

Answer 293

- advice about a balanced diet - correction of predisposing risk factors - daily administration of vitamin D3 (cholecalciferol).

Answer 294

- blindness - xerophthalmia - increased susceptibility to measles

Answer 295

- GORD - Feeding problems - infection - dietary protein intolerance - intestinal obstruction - inborn errors of metabolism - congenital adrenal hyperplasia - renal failure

Answer 296

- gastroenteritis - infection - appendicitis - intestinal obstruction - raised ICP - coeliac - renal failure - inborn errors of metabolism - testicular torsion

Answer 297

- gastroenteritis - infection - peptic ulceration and H.pylori - appendicitis - migraine - raised ICP - coeliac - renal failure - DKA - alcohol and drug use - cyclical vomiting syndrome - Eating disorder - pregnancy - testicular torsion

Answer 298

- Reddening and swelling of the gum margins | - Bleeding of gums with toothbrushing, flossing, gentle probing or eating hard foods such as an apple

Answer 299

- Halitosis - Foul taste in the mouth - Drifting/loosening of teeth causing difficulty in eating - Periodontal abscess which may cause pain - Bleeding, pus and debris expressible from gingival pockets - Loosening or drifting of teeth - Periodontal abscess

Answer 300

- Intensely painful gums, particularly when brushing teeth - Bleeding gums with no or minimal trauma - Severe halitosis - Anorexia - Malaise or fever - Punched out gingival ulcers covered with a white, yellowish or grey pseudomembrane - Cervical lymphadenopathy

Answer 301

- Advise routine regular review by a dentist - Give advice on oral hygiene - Smoking cessation

Answer 302

- Urgently see a dentist - Give metronidazole 400mg three times daily for 3 days in adults, or 200-250mg 3 times daily for 12-18 year olds - Give amoxicillin 500mg three times daily for 3 days if metronidazole inappropriate - Paracetamol or ibuprofen for pain relief - Chlorhexidine or hydrogen peroxide - Regular review by a dentist - Give advice on oral hygiene

Answer 303

- urticaria - facial swelling - anaphylaxis - usually occurring 10–15 min after ingestion of a food.

Answer 304

- diarrhoea - vomiting - abdominal pain - failure to thrive - colic - eczema

Answer 305

- skin prick tests | - RAST

Answer 306

- vomiting - fever - diarrhoea - metabolic consequences of water and electrolyte loss.

Answer 307

- PCR for genome detection | - ELISA for antigen detection in faeces

Answer 308

- 3-6 day incubation period - high fever - headache - Retrobulbar pain - myalgia - arthralgia - flushed face - suffused conjunctivae - epigastric pain - vomiting - relative bradycardia - jaundice - hepatomegaly - ecchymosis, bleeding from the gums, haematemesis and melaena - coma

Answer 309

- mid-zone necrosis | - eosinophilic degeneration of hepatocytes (Councilman bodies)

Answer 310

- regional lymphadenopathy - fever - rigors - headache - vomiting - blanching rash, which initially occurs on the neck but rapidly becomes punctate, erythematous and generalised - typically rash is absent from the face, palms and soles - circumoral pallor - strawberry tongue - raspberry tongue

Answer 311

penicillin V - amoxicillin - clarithromycin - for 10 days.

Answer 312

- raised urinary urobilinogen - raised bilirubin - normal serum ALP, AST, ALT and albumin

Answer 313

- asymptomatic | - raised bilirubin

Answer 314

autosomal recessive

Answer 315

-black due to melanin deposition

Answer 316

- jaundice - pale stools and dark urine - hepatomegaly

Answer 317

- fasting abdominal USS shows contracted or absent gallbladder - Radioisotope scan with iminiodiacetic acid derivatives shows good uptake but no excretion into the bowel

Answer 318

- surgical bypass of the fibrotic ducts - hepatoportoenterostomy (Kasai procedure), in which a loop of jejunum is anastomosed to the cut surface of the porta hepatis, facilitating drainage of bile from any remaining patent ductules.

Answer 319

- abdominal pain - a palpable mass - jaundice - cholangitis.

Answer 320

ultrasound or radionuclide scanning

Answer 321

surgical excision of the cyst with the formation of a Roux-en-Y anastomosis to the biliary duct

Answer 322

- poor feeding - vomiting - jaundice - hepatomegaly when fed milk. - Liver failure, cataracts and developmental delay are inevitable if galactosaemia is untreated. - A rapidly fatal course with shock, haemorrhage and disseminated intravascular coagulation, often due to Gram-negative sepsis, may occur.

Answer 323

- prolonged (persistent) jaundice, by detecting galactose, a reducing substance, in the urine. - measuring the enzyme galactose-1-phosphate-uridyl transferase in red cells.

Answer 324

galactose-free diet

Answer 325

- peripheral neuropathy - haemolysis - ataxia

Answer 326

- Loose cotton clothing, avoiding overheating - Emollients or evening primrose oil - Phenobarbital to stimulate bile flow - cholestyramine - ursodeoxycholic acid

Answer 327

- Severe malnutrition unresponsive to intensive nutritional therapy - Recurrent complications (bleeding varices, resistant ascites) - Failure of growth and development - Poor quality of life.

Answer 328

- hepatic steatosis is the most common | - cirrhosis and portal hypertension develop in some

Answer 329

- Haematemesis or melaena from rupture of gastro-oesophageal varices or portal hypertensive gastropathy - Ascites - Breathlessness due to pulmonary hypertension or hepatopulmonary syndrome - splenomegaly - haemorrhoids - caput medusae

Answer 330

- Constipation with prolonged straining is a key factor - Diarrhoea - Effects of gravity due to posture - Congestion from a pelvic tumour, pregnancy, portal hypertension - Anal intercourse

Answer 331

- 1st - Remain in rectum - 2nd - Prolapse through the anus on defecation but spontaneously reduce - 3rd - Prolapse but can be reduced manually - 4th - Remain persistently prolapsed - external haemorrhoids originate the dentate line

Answer 332

- Bright red rectal bleeding (since blood from capillaries) that often coats stools, seen on tissue or drips into toilet - Mucus discharge and pruritus ani (itchy bottom) - Severe anaemia may occur - Weight loss and change in bowel habit should prompt thoughts of pathology

Answer 333

-Abdominal examination to rule out other disease - PR (per rectum) exam: - --Prolapsing piles are obvious - --Internal haemorrhoids are not palpable - Proctoscopy (rectal scope) to see internal haemorrhoids - Sigmoidoscopy to see rectal pathology higher up

Answer 334

- Increase fluid and fibre | - Topical analgesic and stool softener

Answer 335

- Rubber band ligation: Cheap, produces an ulcer to anchor the mucosa (side effects are bleeding, infection and pain) - Infra-red coagulation: Locally coagulates vessels and tethers mucosa to subcutaneous tissue

Answer 336

- Excisional haemorrhoidectomy - excision of piles | - Stapled haemorrhoidopexy

Answer 337

- analgesia - ice packs - stool softeners

Answer 338

• An abnormal connection between the epithelised surface of the anal canal and skin

Answer 339

- Perianal sepsis - Abscesses - Crohn’s - TB - Diverticular disease - Rectal carcinoma

Answer 340

- Pain - Discharge (bloody or mucus) - Pruritus ani (itchy bottom) - Systemic abscess if it becomes infected

Answer 341

- MRI: To exclude sepsis and to detect associated conditions e.g. Crohn’s or TB - Endoanal ultrasound: To determine tracks location and underlying causes

Answer 342

- Surgical - Fistulotomy and excision - Drain abscess with antibiotics if infected

Answer 343

- Hard faeces - Spasm may constrict the inferior rectal artery resulting in ischaemia which makes healing difficult and perpetuates the problem - Syphilis - Herpes - Trauma - Crohn’s - Anal cancer

Answer 344

- Extreme pain especially on defecation - Bleeding - Anal spasm and a tearing sensation on passing stool

Answer 345

- Increase dietary fibre and fluids to make stools softer - Advise that sitting in a shallow warm bath several times a day may help relieve pain - lidocaine ointment for extreme pain on defecation - GTN ointment for those with symptoms for 1 week without improvement - If anal fissure is unhealed after 6-8 weeks, prescribe topical diltiazem ointment - Surgery if medication fails

Answer 346

- Painful swellings - Tender - Discharge

Answer 347

- MRI | - Endoanal ultrasound

Answer 348

- drainage | - antibiotics

Answer 349

- Obese caucasians and those from Asia, Middle East and Mediterranean are at increased risk - Large amount of body hair - Sedentary job - Occupation involving sitting or driving - Family history

Answer 350

- Painful swelling over days - Pus filled with foul smell from abscess - Systemic signs of infection

Answer 351

- Arrange for urgent same day incision and drainage - Offer paracetamol for pain - Following I and D, advise meticulous hygiene and buttock hair removal

Answer 352

- Magnesium salts cause diarrhoea | - Aluminium salts cause constipation.

Answer 353

- Reduce serum concentration of --ACE inhibitors - -antibiotics - -bisphosphonate - -digoxin - -levothyroxine - -proton pump inhibitors.

Answer 354

- GI disturbances - Headache - Hypomagnesaemia leading to tetany and ventricular arrhythmias

Answer 355

- Caution in patients presenting with ‘red-flag features’ of gastric cancer as PPIs can disguise symptom - Caution in patients at risk of osteoporosis due to increased risk of fractures

Answer 356

- Increases anticoagulant effect of warfarin | - Decreases anti-platelet effect of clopidogrel.

Answer 357

- Nausea and vomiting - Diarrhoea - Abdominal cramps - Uterine constrictions.

Answer 358

- Black tongue and faeces | - Nausea and vomiting.

Answer 359

- Avoid in children due to risk of Reye’s syndrome | - Caution in clotting disorders and gout.

Answer 360

- Eradication of H.pylori in peptic ulcer disease - Respiratory and skin infections when penicillin is contraindicated by allergy - Severe pneumonia added to penicillin to cover Legionella pneumophilia and Mycoplasma pneumoniae.

Answer 361

- Nausea and vomiting and less frequently antibiotic-associated colitis - cholestatic jaundice - prolongation of QT syndrome - ototoxicity.

Answer 362

- Increased risk of bleeding with warfarin - increased risk of myopathy with statins - increased risk of prolonging QT interval with amiodarone, antipsychotics, SSRIs.

Answer 363

- Eradication of H.pylori in peptic ulcer disease - Pneumonia caused by gram positive (S.pneumonia) or gram negative (H.influenza) - urinary tract infections (mostly E.coli) - combination treatment for hospital acquired infection or sepsis - combination treatment for peptic ulcers (H.pylori).

Answer 364

- Nausea and diarrhoea and less frequently antibiotic-associated colitis - penicillin allergy presenting as a IgG-mediated skin rash or less commonly IgE mediated anaphylactic reaction - cholestatic jaundice with co-amoxiclav.

Answer 365

- Reduced renal excretion of methotrexate, increasing risk of toxicity - Enhance anticoagulant effect of warfarin by killing gut flora that synthesise vitamin K.

Answer 366

- Prophylaxis and treatment of nausea and vomiting due to reduced gut motility - GORD in patients who do not respond to proton pump inhibitors and H2-receptor antagonists.

Answer 367

- Diarrhoea - Acute dystonias (metoclopramide) - QT prolongation (domperidone).

Answer 368

- Avoid with GI obstruction, perforation, haemorrhage or recent surgery - Avoid domperidone with long QT syndrome - Caution with metoclopramide in patients under 20 and epilepsy.

Answer 369

- Dopaminergic agents - Antipsychotics - Drugs that prolong the QT interval (e.g. clarithromycin, fluconazole, diltiazem).

Answer 370

- Drowsiness due to H1 antagonism | - Dry mouth, blurred vision, urinary retention and constipation due to antimuscarinic effects.

Answer 371

- patients with prostatic hypertrophy and hepatic encephalopathy - in neonates.

Answer 372

- Irritable Bowel Syndrome - Bradycardia - Reducing respiratory secretions.

Answer 373

- dry mouth - tachycardia - urinary retention - blurred vision - drowsiness - confusion.

Answer 374

- Caution in angle-closure glaucoma | - Caution with arrhythmias.

Answer 375

- GI disturbances - Headache - Leucopenia and thrombocytopenia - Renal impairment - Oligospermia - Hypersensitivity reactions.

Answer 376

- Reduced efficacy with drugs that alter gut pH (PPIs in stomach, lactulose in gut) - Increased risk of leucopenia with azathioprine, mercaptopurine.

Answer 377

pierces the posterior abdominal wall and the abdominal contents are forced through a defect in the inguinal canal.

Answer 378

does not pierce the posterior abdominal wall and the abdominal contents pass through the deep inguinal ring.

Answer 379

- Male sex. - Old age. - Smoking. - Family history. - Abdominal aortic aneurysm. - Marfan’s syndrome or Ehlers-Danlos syndrome.

Answer 380

- Groin discomfort or pain with bulge. - Groin mass. - Abdominal discomfort and pain is uncommon. - Acute abdomen and an irreducible abdomen suggests strangulation.

Answer 381

- Refer for urgent surgical repair if the hernia is irreducible which suggests a strangulated hernia. - Refer urgently to a paediatric surgeon (preferably to be seen within 2 weeks) if an infant or young boy presents with a hernia. - Refer all others for routine surgical repair unless: - --They have minimally symptomatic hernias. - --They have significant comorbidity. - --They do not wish to have surgery. -Cefazolin prophylaxis for repair

Answer 382

- Chronic, painless, low-grade, intermittent bleeding | - Symptoms of anaemia

Answer 383

- Abnormal epithelium - small lesions with irregular edges - a draining vein

Answer 384

- Upper GI endoscopy employing electrocautery, photocoagulation, clips and adrenaline to treat a lesion - If upper GI endoscopy is negative, mesenteric angiogram with or without embolisation, and supportive care - If angiography unavailable, perform colonoscopy employing electrocautery, photocoagulation, clips and adrenaline, or subtotal hemicolectomy if large bleed

Answer 385

- Perform interventional endoscopy, angiography with embolisation or wireless capsule enteroscopy as needed - Surgery may be required if the above techniques are unavailable - If the patient is not a surgical candidate, consider octreotide, conjugated oestrogens or thalidomide.

GI AND LIVER Flashcards

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