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Flashcards in GI II Deck (50):
1

He is taken to theatre and an EUA demonstrates the presence of a fistula to the abscess cavity. The abscess is situated to the left and posterior to the anus (5 o'clock position in the lithotomy position).
Where would you expect the internal opening to be located?

Directly posterior to the centre of the anus (6 o'clock)

Goodsall's rule for fistula in ano states that if the external opening of a fistula lies behind a line drawn transversely across the anus the track should curve in a horseshoe manner towards an internal opening in the midline posteriorly.

If the external opening is in front of the transverse anal line the track tends to pass radially in a straight line towards the internal opening.

2

Gastroscopy and H.Pylori test

The rapid urease biopsy or Campylobacter-like organism (CLO) test is often used to test for Helicobacter pylori at endoscopy.

Histological biopsies are frequently obtained at the same time as the CLO.

Serology and breath tests may be performed independently of the endoscopy, for example, in the GP surgery or clinic.

3

A 76-year-old man presents with weight loss, dark urine, and pale stools which are difficult to flush away.
An excess of which of the following would account for this history?

The history is suggestive of obstructive jaundice. In this condition there is an excess of conjugated bilirubin in the plasma which is water soluble and can be excreted in the urine.

Reduced stercobilinogen causes the typical pale stools.

Unconjugated bilirubin is strongly bound to albumin and is not water soluble so is not excreted in the urine.

Urobilinogen is formed from stercobilinogen that escapes into the plasma from the colon and is colourless.

4

Blood supply to sigmoid colon

The blood supply to the sigmoid colon being predominantly from the inferior mesenteric artery (IMA).

We are therefore looking for the stem which describes the anatomy of the IMA. The coeliac, superior mesenteric artery (SMA) and IMA are ventral branches of the aorta arising at T12, L1 and L3 respectively.

5

Sigmoid volvulus

The loop of sigmoid colon has a classical bean shape, with the apex over the S2/3 junction in the left iliac fossa with the loop of sigmoid colon distending covering the liver and descending colon.

The most important feature of a sigmoid volvulus rather than a large redundant distended loop of sigmoid colon is the absence of haustra.

6

splenic rupture

High impact injuries to the left flank may cause damage the spleen or kidney as well as the ribs and soft tissue. If there are fractured ribs and the patient is hypotensive suspect rupture of the spleen.

If the patient responds to fluid resuscitation, an ultrasound can be arranged to confirm the diagnosis. If there is a subcapsular haematoma but no free rupture this may be managed conservatively.

If the patient remains hypotensive then a laparotomy is indicated.

Renal trauma rarely renders the patient hypotensive unless other organs are also injured, and more force would be required for aortic dissection.

7

Small bowel obstruction due to inguinal hernia

The history is consistent with small bowel obstruction secondary to an irreducible inguinal hernia (above and medial to tubercle).

This x ray actually shows a loop of small bowel leading towards the position of an inguinal hernia. The concern here is that the bowel is ischaemic and is at risk of perforation, which would put the patient at significant risk. Initial management should then aim to prepare him for emergency surgery on the day of presentation.

Bowel obstruction is initially managed by a 'drip and suck' approach. A nasogastric tube is placed to remove the stomach contents and prevent vomiting. Intravenous fluids are prescribed to make up the deficit from losses and provide maintenance requirements. The patient is allowed nil by mouth both to prevent vomiting and in preparation for surgery.

Ideally, patients are fluid resuscitated and optimised before theatre. CT scans are often obtained to get a more accurate picture of the intra-abdominal pathology.

8

sigmoid volvulus

The x ray shows the classical appearance of a sigmoid volvulus. A volvulus is defined as a rotation of an organ around its mesentery.

The sigmoid is the commonest site (75%) followed by caecum, transverse colon and splenic flexure. The stomach, gallbladder and small bowel may also be affected by the process.

Sigmoid volvulus is associated with chronic constipation and is not infrequent in institutionalised patients taking psychiatric or neurological medications, such as treatment for Parkinson's disease.

It is far more common in Africa than the West.

9

colon cancer

Elderly patients with per rectal bleeding, change in bowel habits, and weight loss should be considered to have colonic cancer unless proven otherwise. Increase in age is a risk factor for developing colonic cancer. The other risk factors, among others, include

A family history of colon cancer
Familial adenomatous polyposis
Diet rich in red meat
Longstanding ulcerative colitis or Crohn's disease.
The clinical presentation of patients with colonic malignancy depends on the site of the tumour.

Right-sided colonic carcinoma commonly presents with

Anaemia
Tiredness
Malaise
Pallor
Loss of weight.
The left sided colonic carcinoma presents with

Change in the bowel habits
Bleeding per rectum
Intestinal obstruction.
Rectal carcinoma, in addition to the features seen in left-sided colonic carcinoma, is associated with a sense of incomplete evacuation of the bowel (tenesmus). Tumours of the caecum affecting the ileocaecal valve can also present with symptoms of lower small bowel obstruction.

Investigations for suspected colonic malignancy include

Full blood cell count
Renal function and electrolytes
Liver function tests (to rule out hepatic involvement)
Plain x ray of the abdomen
Ultrasound and CT scans.
Carcinoembryonic antigen (CEA) is the commonly used tumour marker to diagnose colonic malignancy and subsequently to assess the progress, including recurrence.

Surgery remains the mainstay of management of colonic tumours. Radiotherapy and chemotherapy have their roles in selected patients. A temporary or a permanent colostomy is frequently required following the surgical treatment of left-sided colonic tumours.

10

Crohns disease

The precise aetiology of Crohn's disease remains unclear, however

An altered response by the body's immune system to normal intestinal bacteria
Smoking
Environmental factors
Familial predisposition
Pathogenic bacteria
Viruses
have all been implicated.

The most common presentation of patients with Crohn's disease is related to a chronic inflammatory process involving the ileocaecal region which includes low-grade fever, loss of appetite, weight loss, anaemia and general fatigue.

The patients may have crampy or constant pain over the umbilical region or over the right iliac fossa. The pain may be relieved by defecation. Diarrhoea may be troublesome. This is usually non-bloody and intermittent. If the colon is involved, patients may present with diffuse abdominal pain accompanied by mucus, blood and pus in the stool. Perianal fissures or fistulae may be present.

Acute exacerbation of Crohn's disease affecting the terminal ileum (terminal ileitis) may be difficult to differentiate from acute appendicitis, although the symptoms associated with Crohn's disease tend to be of insidious onset.

Abdominal ultrasound, small bowel enemas and CT scan may help to establish the diagnosis. However, if the diagnosis remains uncertain and the patient becomes clinically unstable, a laparotomy may be indicated.

The management of Crohn's disease depends on the severity and the stage of the disease. The treatment may be conservative (including medical) or surgical. Some important complications of Crohn's disease include

Fistula formation (for example, entero-colic, entero-cutaneous)
Abscesses (for example, perianal)
Haemorrhage
Intestinal obstruction.

11

bowel cancer tumour pathology

The cyclin-dependent kinase inhibitor p27 is a negative regulator of the cell cycle and a potential tumour suppressor gene. Its down regulation is associated with occurrence of sporadic colon cancer.

ß-catenin accumulation, not suppression, initiates adenoma formation.

p53 is a tumour suppressor gene.

Activation of K ras oncogene is seen in sporadic colon cancer.

Bcl-2 is an oncogene first described in haemotological malignancies but also implicated in other malignancies such as breast and prostate. Its up regulation makes cells resistant to apoptosis.

Expression may be affected in colon cancer but it is not considered one of the key mutations in the tumourigenesis of sporadic colonic adenocarcinoma.

12

Cholangitis

Cholangitis is an acute infection of the biliary tree due to obstruction of the common bile duct, which subsequently becomes infected. The causative organisms are usually gut-derived coliform bacteria.

Obstructions result from:

Strictures
Stenosis
Tumours
Following endoscopic retrograde cholangiopancreatography (ERCP).
Cholangitis is treated with intravenous fluid resuscitation and broad-spectrum antibiotics while awaiting sensitivities from blood culture.

Emergency ERCP and decompression of the common bile duct is usually necessary to relieve the obstruction and to allow the drainage of pus from the bile ducts.

Left untreated the mortality from cholangitis is 100%.

13

Modified Glasgow score for pancreatitis

Acute pancreatitis is associated with alcohol or gallstones in more than 80% of patients, although the ratio of these two causes has a wide geographical variation. Gallstone disease predominates in the UK.

Acute pancreatitis is usually self-limiting, however 15-20% of patients develop severe acute pancreatitis (pancreatic necrosis and associated cytokine activation), which results in multiple organ dysfunction syndrome if not aggressively treated. Early identification of patients with a severe attack allows prompt treatment.

The modified Glasgow criteria are used to predict patients with severe acute pancreatitis and include:

Age >55 years
Albumin 10 mmol/L
Calcium 600 U/L
Urea >16 mmol/L
White cell count >15 ×109/L.
Severe disease is present if three factors are detected within 48 hours.

14

oesophageal cancer and dysphagia

Patients with oesophageal cancer tend to present late with progressive dysphagia, weight loss and anaemia.

Oesophagectomy is reserved for early cancers which have not invaded locally.

Traditionally malignant dysphagia was treated with repeated endoscopic dilatations.

Endoscopic placement of self-expanding metal stents (SEMS) are now placed most frequently in patients presenting with malignant dysphagia. Early complications of SEMS are

Malposition
Oesophageal perforation
Bleeding
Stent migration.
Late complications are most frequently related to eating (food bolus) or tumour overgrowth.

Initially, management of a food bolus blocking a stent is for the patient to consume a fizzy drink, which helps to break up the food bolus, otherwise endoscopy is required to dislodge the food bolus.

15

mallory-weiss tears

Mallory-Weiss tears occur in the region of the gastro-oesophageal junction from forceful or prolonged coughing or vomiting, often after excessive alcohol intake. They may also be caused by epileptic convulsions. These tears result in vomiting bright red blood or by passing blood per rectum (melaena). Although bleeding can be profuse, it usually stops spontaneously.

Aortoduodenal fistula results from erosion of the duodenum into the aorta due to tumour or previous repair of the aorta with a synthetic graft.

Meckel's diverticulum occasionally occurs in the ileum and may contain ectopic gastric mucosa, which may result in rectal bleeding.

Oesophageal varices represent dilated venous collaterals and result from portal hypertension in patients with liver cirrhosis.

Bleeding from peptic ulcers is the commonest cause of upper gastrointestinal bleeds. Mucosal erosions develop, commonly due to non-steroidal anti-inflammatory drugs, steroids or prolonged alcohol abuse.

16

pilonidal abscess

A sacrococcygeal pilonidal sinus is an inflammatory condition associated with hair producing a sinus.

Pilonidal abscesses are usually found in or adjacent to the midline close to the natal cleft. Pilonidal disease is more common in Caucasian males in their third decade of life. Generally the condition is more common in obese or hirsute individuals.

Pilonidal abscess are treated with incision and drainage procedures at the time of presentation, a more definitive procedure (for example, excision) is required if the disease becomes non-healing or recurrent.

Perianal and ischiorectal abscesses result from infection of the anal glands found in the intersphincteric space.

17

femoral hernia

This patient has developed a small bowel obstruction. The most likely diagnosis is an obstructed femoral hernia, as the irreducible lump in the left groin arises below and lateral to the pubic tubercle. An inguinal hernia would produce a lump above and medial to the pubic tubercle.

Femoral hernias are the third most common hernia with a male to female ratio of 1:4, with the hernia occurring most frequently in elderly multiparous women. All femoral hernias should be repaired, as 40% are strangulated on first presentation.

Erythema of the overlying skin occurs in strangulation and is a sign of poor outcome.

Obturator hernias are very rare and do not usually present with a lump.

18

perforated peptic ulcer

The classic presentation of a perforated peptic ulcer is a sudden onset of epigastric pain and peritonitis (usually upper abdominal).

In elderly patients, especially on steroids, there may be an absence of symptoms and signs initially.

The diagnosis is aided by the signs of gas under the diaphragm on an erect chest radiograph, although this may be absent. Radiological investigations where water-soluble contrasts are given orally also aid the diagnosis, but may also be negative if the ulcer has sealed.

The risk factors for peptic ulceration include

Non-steroid anti-inflammatory drugs
Steroids
Helicobacter pylori infection.
The optimum management is resuscitation, laparotomy and repair of the ulcer with an omental patch, and peritoneal lavage.

19

wilsons disease inheritance

Wilson's disease which is inherited in an autosomal recessive fashion due to a mutation on the long arm of chromosome 13

20

UC

The patient has ulcerative colitis. The presence of distended small bowel loops would suggest incompetence of the ileocaecal valve, indicating right colonic involvement.

There is often constipation proximal to the inflammed bowel. The distal limit of contipation provides a crude estimate of the proximal limit of colonic inflammation.

Tachycardia
Hypoalbuminaemia and
A high C reactive protein level (particularly which does not respond to steroid therapy)
are markers of severe disease (which may fail medical therapy) but do not help define the anatomical extent of disease.

21

Acute pancreatitis mortality epidemiology

Mortality in acute pancreatitis varies according to age, co-morbidities and severity and is scored through the Ranson scoring system.

However, average mortality has remained pretty much unchanged over the last two decades with severe disease, and is approximately 20%.

22

Refeeding syndrome

The patient appeasr to have developed the refeeding syndrome.

Refeeding malnourished patients increases basal metabolic rate with glucose being the predominant energy source.

This anabolic response causes intracellular movement of minerals, and serum levels may fall significantly. These rapid changes in metabolism and electrolyte movement may lead to severe cardiorespiratory and neurological problems resulting in cardiac and respiratory failure, oedema, lethargy, confusion, coma, convulsions, and death.

The symptoms of the refeeding syndrome are thought to be due predominantly to hypophosphataemia, but metabolic changes in potassium, magnesium, glucose, and thiamine can also contribute.

The probable answer here is therefore phosphate as hypophosphataemia seems probable.

Calcium depletion is possible but there is absence of tetany.

Zinc deficiency causes skin rashes periorally and around nostrils.

It is extremely difficult to measure vitamin B concentrations plus her presentation does not sound like Wernicke's - neurophthalmological features.

23

A 48-year-old woman with chronic pancreatitis due to gallstones is noted to have a macrocytic anaemia.
What is the most likely cause of the anaemia?

Chronic pancreatitis and the resultant pancreatic insufficiency results in the failure of splitting of dietary B12 from R-binders, a reaction that requires trypsin.

This inhibits the binding of intrinsic factor to the vitamin B12 so it is not absorbed.

24

Gilberts disease

The diagnosis of Gilbert's is based on a bilirubin of less than 102 micromol/l and otherwise normal liver function.

Patients with Crigler-Najjar type I do not survive to adulthood, whereas those with type II do. Both syndromes are due to defects in the glucuronosyl transferase enzyme complex, responsible for the conjugation of bilirubin.

Gilbert's affects 2-7% of the population and there is a family history of jaundice in 5-15% of patients.

Bilirubin rises on fasting and mild illness.

25

Hirschsprung's disease

Hirschsprung's disease is a common cause of neonatal large bowel obstruction.

It results from failure of migration of ganglion cells to the affected segment of bowel. This always involves the distal colon but the proximal extent of the involvement is variable and in rare cases may involve the whole of the large bowel.

Eighty percent of cases present in the neonatal period.

Contrast studies show the affected segment to be tonically contracted.

Rectal irrigation or an emergency colostomy may be required before a definitive 'pull-through' procedure.

Patients present typically with constipation and present late with vomiting and obstruction.

26

A 70-year-old male is admitted with haematemesis.
He is currently being treated with warfarin for atrial fibrillation and his INR returns as 10.
Which of the following is the most appropriate immediate treatment of his INR?

This gentleman is having a potentially life threatening bleed in the setting of a grossly elevated INR.

Due to his warfarin therapy he will have reduced levels of factors II, VII, IX and X and requires replacement to correct his INR rapidly. This is most effectively achieved by the administration of prothrombin complex concentrate (Beriplex or Octaplex, 25-50 units/kg IV).

These result in complete reversal of the warfarin-induced anticoagulation within 10 minutes but the clotting factors have a finite half life and therefore 5 mg IV vitamin K should be given at the same time.

Fresh frozen plasma (FFP ) contains more dilute clotting factors and therefore produces inferior correction and should not be used in the management of life threatening bleeding (unless prothrombin complex concentrate is not available).

Cryoprecipitate and oral vitamin K are not recommended for the management of life threatening bleeding.

27

Helicobacter pylori

Helicobacter pylori is Gram negative.

Infection results in a chronic gastritis which, if it involves the body of the stomach, reduces acid secretion resulting in an increased gastrin synthesis.

Sixty per cent of gastric and 95% of duodenal ulcers are related to Helicobacter pylori.

Mucosa associated lymphoid tissue (MALT) lymphomas result from active infection and 80% regress after successful eradication of the organism.

28

Coeliac disease

These histological features are typical of coeliac disease with

Villous atrophy
Crypt hyperplasia/hypertrophy
Inflammatory infiltrate of the lamina propria and
Intra-epithelial lymphocytes.
Useful serology includes anti-TTG antibodies which would be expected in over 90% of cases.

Treatment of this case would therefore entail gluten-free diet.

29

GORD and surgery

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

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

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

30

dysphagia

Motor neurone disease presents with bulbar weakness and fasciculations are typical.

The sudden onset of dysphagia would suggest a stroke as the cause for the dysphagia in this male.

A long history of regurgitation of unchanged foodstuffs, with no weight loss and halitosis, strongly suggests the presence of a pharyngeal pouch.

Foreign body ingestion is suggested by profound salivary secretions.

31

Amoebic hepatitis

Amoebic hepatitis
The businessman returning from India with a diarrhoeal illness with blood and pus, associated with hepatitis suggests amoebiasis. This is usually due to Entamoeba histolytica, which often causes a hepatitis and can be mistaken for viral hepatitis. The absence of jaundice in this case would argue against the latter. Treatment is with metronidazole.

32

Duodenal vs gastric ulcer

Typical symptoms of a duodenal ulcer:
Relief on eating, and the pain tending to recur two to three hours later.

In contrast, a gastric ulcer is associated with pain precipitated by foods. Anaemia may be associated with both.

33

Dysphagia and corkscrew appearance

This lady has diffuse oesophageal spasm which is a severe form of abnormal oesophageal motility. Treatment with calcium - channel blockers may help.

34

A 30-year-old man presents to the Emergency department after collapsing. He initially complained of severe chest pain following two episodes of forceful vomiting. A chest x ray shows air in the mediastinum and neck and a pleural effusion.

This patient has perforated his oesophagus after forceful vomiting, which is known as Boerhaave's syndrome. A gastrograffin (not barium) swallow will confirm the diagnosis.

35

Achalasia

This lady has achalasia. Treatment is with endoscopic pneumatic dilatation of the oesophagus. Endoscopic injection of botulinum toxin and surgical division of the sphincter can also be used.

36

Diverticuli complications

Diverticular disease is common in patients over 60-years-old. It may be asymptomatic or there may be altered bowel habit.

Complications are

Diverticulitis (as in this patient)
Haemorrhage
Abscess formation
Post infective strictures
Fistulae.

37

A 65-year-old woman presents with dysphagia. She has a malar flush and her pulse is irregular. On examination a tapping apex beat is felt in the fifth left intercostal space.

Enlargement of the left atrium due to mitral stenosis may cause dysphagia in patients with mitral valve disease due to extrinsic compression of the mid and lower third of the oesophagus by the enlarged left atrium.

Other cardiovascular causes of dysphagia are:

Dysphagia aortica - compression by thoracic aortic aneurysm
Dysphagia lusoria - compression by aberrant vessels such as double aortic arch, right aortic arch and retro-oesophageal left subclavian artery.

38

Osler-Weber-Rendu syndrome

This woman has Osler-Weber-Rendu syndrome, also known as hereditary haemorrhagic telangiectasia. It presents with

- Epistaxis or GI bleeding
- Fragile punctiform lesions on mucous membranes.

39

An 11-year-old boy presents to the Emergency department after a massive haematemesis. He is found to be very tall and thin and has loose, lax, and wrinkled skin.


This patient has pseudoxanthoma elasticum, which is a disorder characterised by abnormalities in collagen and elastic tissue, affecting the skin, eye and blood vessels. It causes GI bleeding.

40

Gastric cancer

This patient has gastric cancer, which is very common in Japan. Clinical signs include

An epigastric mass
Jaundice
Ascites
An enlarged supraclavicular (Virchow's) node (Troisier's sign).

41

Oesophageal rupture

Rupture of the oesophagus typically occurs after eating a large meal and consuming a large volume of alcohol, hence most victims are young males.

Prompt diagnosis is essential to maximise chances of a successful outcome, as delayed presentation and management is associated with a significant mortality.

When there is an appropriate history, and if there are chest x ray changes, such as mediastinal emphysema and a pleural effusion (such as this case), the diagnosis needs to be confirmed by either a contrast swallow or CT scan.

The patient should then be referred to an upper GI or cardiothoracic surgeon, depending on local guidelines.

42

Carcinoid tumour marker

5HIAA

43

Crohns vs UC

Ulcerative colitis is characterised by mucosal inflammation with

General inflammatory cell infiltration
Goblet-cell mucus depletion
Crypt abscesses
Crypt shortening
Branching.
There is continuous inflammation, worsening from caecum to rectum.

In contrast, Crohn's disease is characterised by transmural inflammation, with

Lymphocytic infiltrates and lymphoid aggregates
Fissures
Preservation of crypt architecture
Non-caseating granulomata.
There is patchy inflammation from mouth to anus.

44

Meconium plug syndrome

Meconium plug syndrome is as a result of a plug of meconium causing obstruction. There is usually an underlying disease such as cystic fibrosis, Hirschsprung's disease, infant of a diabetic mother or maternal drug abuse.

45

Zollinger-Ellison syndrome

Zollinger-Ellison syndrome occurs most often in the fifth decade of life. Most patients have a triad of clinical symptoms:

Peptic ulceration
Gastric acid hypersecretion
An islet cell tumour of the pancreas (gastrinoma).
Twenty per cent of patients with the syndrome will have MEN-1.

The symptoms the patient experiences are due to gastric acid hypersecretion; the diarrhoea is due to increased transit times and malabsorption.

The diagnosis is confirmed by a fasting serum gastrin level >100 pg/ml and an elevated basal acid output.

46

C.Diff

Up to 40% of patients receiving antibiotics have a diarrhoeal illness and a quarter of these may be due to enterotoxigenic strains of Clostridium difficile. It is the production of toxin A and B that is responsible for the diarrhoeal illness.

Generally the organism is nosocomially acquired and usually comes to light after antibiotic therapy particularly broad spectrum agents such as Augmentin, amoxicillin, macrolides, ciprofloxacin and cephalosporins.

The culture of non-toxigenic Clostridium difficile does not itself require any treatment and in this patient's case, he may have acquired an antibiotic related diarrhoea. Therefore, stopping the antibiotic may be all that is required.

In asymptomatic patients or patients with mild disease and toxigenic Clostridium difficile, again no treatment is required. However, the patient with profuse watery diarrhoea merits treatment with metronidazole as the first line agent.

Vancomycin should be reserved for severe, life-threatening cases of C. difficile infection, for patients unable to tolerate metronidazole, or for patients without symptom resolution after completing a course of metronidazole. Vancomycin is more expensive than metronidazole and the emergence of vancomycin-resistant enterococci is also a concern.

Alternative therapies for cases of mild C. difficile infection include bacitracin, teicoplanin, or a binding resin such as cholestyramine or colestipol. However, these agents are not as reliable or as effective as vancomycin or metronidazole.

47

Tumour markers

Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumour markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumour markers do not have sufficient sensitivity or specificity for use in screening.

Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer.

Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses.

CA 125 is useful for evaluating pelvic masses in postmenopausal women, monitoring response to therapy in women with ovarian cancer, and detecting recurrence of this malignancy.

Alpha-fetoprotein (AFP), a marker for hepatocellular carcinoma, sometimes is used to screen highly selected populations and to assess hepatic masses in patients at particular risk for developing hepatic malignancy.

Testing for the beta subunit of human chorionic gonadotropin (b-hCG) is an integral part of the diagnosis and management of gestational trophoblastic disease.

Combined AFP and b-hCG testing is an essential adjunct in the evaluation and treatment of nonseminomatous germ cell tumours, and in monitoring the response to therapy.

AFP and b-hCG also may be useful in evaluating potential origins of poorly differentiated metastatic cancer.

PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary.

48

LFTs

Liver function tests (LFTs) are among the most commonly used investigations in clinical medicine. A sound understanding of why they become abnormal and a rational, cost effective approach to their investigation is essential.

Marked elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with only modest rises of alkaline phosphatase and gamma GT suggest hepatitis whereas markedly raised alkaline phosphatase and gamma GT reflect a cholestatic picture. The cholestatic picture with elevated bilirubin suggests biliary obstruction and with a palpable gall bladder would suggest carcinoma of the head of the pancreas (Courvoisiers law).

Features of chronic liver disease include palmar erythema, spider naevi, etc., which together with xanthelasma and a cholestatic picture suggest primary biliary cirrhosis. This is an autoimmune condition and is typically associated with the presence of anti-mitochondrial antibodies.

The young female who presents after drinking heavily has probably acquired infectious mononucleosis which is associated with a mild hepatitic picture. This is a self limiting condition and requires only supportive measures.

49

Glasgow score in pancreatitis

Despite its importance in establishing the diagnosis, amylase is not part of the scoring system devised by Clement Imrie a contemporary Glaswegian surgeon.

The scoring system allots 1 point for each of the following

PaO2 15 x 109/L
AST/ALT > 200 IU/L
LDH > 600 IU/L
Glucose > 10 mmol/L
Urea > 16 mmol/L.
A score of 3 or more predicts a severe acute pancreatitis although this is not synonymous with severe acute pancreatitis as this is defined as acute pancreatitis associated with organ failure and/or local complication such as necrosis (+/- infection), pseudocyst or abscess.

50

Left side of the oesophagus

The left side of the oesophagus is related to the thoracic duct, the pleura, the aortic arch, the left recurrent laryngeal nerve and the left subclavian artery.

The left bronchus crosses the oesophagus and is thus an anterior relation, as well as the trachea, pericardium and diaphragm.

The azygous vein and pleura are the right sided relations.

The thoracic vertebrae are the posterior relations of the diaphragm.