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1

A 65 year old lady presents with diarrhoea. She has struggled with infrequent bowel motions for most of her life so is surprised by this.

A. Gastroenteritis
B. UC
C. Crohn's Disease
D. Colorectal Carcinoma
E. Thyrotoxicosis
F. Chronic Pancreatitis
G. Pregnancy
H. Overflow Diarrhoea
I. Ischaemic Colitis
J. Lactose Intolerance
K. Laxative Abuse
L. Cimetidine Use

Overflow diarrhoea: History of chronic constipation/obstruction. Liquid stool passes obstruction.

Key words: Infrequent bowel motion

2

An 18 year old girl presents with diarrhoea. She reports no other changes other than starting the OCP. She has had similar episodes in the past which she manages with lifestyle modification but doesn't understand why this is happening now.

A. Gastroenteritis
B. UC
C. Crohn's Disease
D. Colorectal Carcinoma
E. Thyrotoxicosis
F. Chronic Pancreatitis
G. Pregnancy
H. Overflow Diarrhoea
I. Ischaemic Colitis
J. Lactose Intolerance
K. Laxative Abuse
L. Cimetidine Use

Lactose Intolerance:
- Hypersensitivity= reproducible adverse reaction (includes allergy and intolerance)
Intolerance is non-immune mediated
Allergy is either IgE or non-IgE mediated

Key Words: OCP, Lifestyle modifications.

OCP and POP both contain lactose

3

A 62 year old man presents with bloody diarrhoea and intense abdominal pain. He is currently on therapy for his heart palpitations.

A. Gastroenteritis
B. UC
C. Crohn's Disease
D. Colorectal Carcinoma
E. Thyrotoxicosis
F. Chronic Pancreatitis
G. Pregnancy
H. Overflow Diarrhoea
I. Ischaemic Colitis
J. Lactose Intolerance
K. Laxative Abuse
L. Cimetidine Use

Ischaemic Colitis: Bloody, abdo pain, palpitations

4

A 45 year old woman presents with diarrhoea. She also reports weight loss but states that her appetite has increased. You notice that her hands shake slightly when she is reaching for things around the room.

A. Gastroenteritis
B. UC
C. Crohn's Disease
D. Colorectal Carcinoma
E. Thyrotoxicosis
F. Chronic Pancreatitis
G. Pregnancy
H. Overflow Diarrhoea
I. Ischaemic Colitis
J. Lactose Intolerance
K. Laxative Abuse
L. Cimetidine Use

Thyrotoxicosis: Weight loss, appetite increase, fine tremor, heat intolerance, sweating, palpitations, eye signs & pretibial myxoedema (Graves' Disease)

5

A 24 year old man presents with diarrhoea. He is normally fit and well and complains of nothing else. He has not eaten anything dodgy recently, but returned from Malaysia 2 weeks ago.

A. Gastroenteritis
B. UC
C. Crohn's Disease
D. Colorectal Carcinoma
E. Thyrotoxicosis
F. Chronic Pancreatitis
G. Pregnancy
H. Overflow Diarrhoea
I. Ischaemic Colitis
J. Lactose Intolerance
K. Laxative Abuse
L. Cimetidine Use

Gastroenteritis: look for travel, dietary changes and contact history

6

A 56 year old man presents with constipation. He also reports abdominal pain, weight loss and suffers with depression. He has no FH of note, but has had some problems with kidney stones.

A. Aganglionosis
B. Dehydration
C. Colorectal Carcinoma
D. Hypokalaemia
E. Environmental
F. Furosemide use
G. Hypothyroidism
H. Fibroid
I. Diabetes
J. Anal fissure
K. Opiate use
L. Hypercalcaemia

Hypercalcaemia: "bones, stones, groan, psychic moans"

Abdo pain, vomiting, constipation, depression, FH kidney stones, polyuria, polydipsia, anorexia, pyrexia, fatigue, hypertension, confusion, ectopic calcification

Due to: Malignancy, primary hyperparathyroidism, sarcoidosis

7

A 26 year old woman presents with constipation. She has struggled with this for a few years but her GPs advice of topical GTN and dietary advice is not helping.

A. Aganglionosis
B. Dehydration
C. Colorectal Carcinoma
D. Hypokalaemia
E. Environmental
F. Furosemide use
G. Hypothyroidism
H. Fibroid
I. Diabetes
J. Anal fissure
K. Opiate use
L. Hypercalcaemia

Anal Fissue: Causes constipation due to pain

Tx: high fibre and fluid diet, topical lidocaine, topical GTN (SE - headaches), botox, surgical

8

A 70 year old woman presents with constipation. She has just been discharged from hospital following a #NOF. On admission she was found to be on a number of drugs for her heart which have not changed upon discharge.

A. Aganglionosis
B. Dehydration
C. Colorectal Carcinoma
D. Hypokalaemia
E. Environmental
F. Furosemide use
G. Hypothyroidism
H. Fibroid
I. Diabetes
J. Anal fissure
K. Opiate use
L. Hypercalcaemia

Opiate use: commonly prescribed for analgesia, also used as an anti-tussive in heart failure to provide patients symptomatic relief (desensitises central chemoreceptors to the response to PaCO2).

Acts on receptors on myenteric and submucosal plexus to decrease gastric motility and emptying, and increase gut water reabsorption = Constipation

Also lead to pupillary constriction (edinger Westphal nucleus), nausea&vomiting (CTZ), and priuritis, uricaria&hypotension (histamine release from mast cells)

Euphoric effects via action of dopamine release on nucleus accumbens

9

A 75 year old man presents with constipation. He also reports abdominal pain and weight loss.

A. Aganglionosis
B. Dehydration
C. Colorectal Carcinoma
D. Hypokalaemia
E. Environmental
F. Furosemide use
G. Hypothyroidism
H. Fibroid
I. Diabetes
J. Anal fissure
K. Opiate use
L. Hypercalcaemia

Colorectal carcinoma: over 50% of presentations in >70 years

Tenesmus, blood PR, weight loss

L sided = 25% can be obstructed

Tx: surgical excision - Upper third = anterior resection (colo-anal anastomoses)
Lower 2/3's = abdominoperineal resection (permanent colostomy - increased incidence sexual and urinary dysfunction

10

An 8 year old boy presents with constipation. His abdomen is also slightly distended. He is normally fir and his diet is balanced and healthy.

A. Aganglionosis
B. Dehydration
C. Colorectal Carcinoma
D. Hypokalaemia
E. Environmental
F. Furosemide use
G. Hypothyroidism
H. Fibroid
I. Diabetes
J. Anal fissure
K. Opiate use
L. Hypercalcaemia

Aganglionosis: e.g. Hirchsprung's disease
Absence of ganglion cells in the GIT therefore there is impaired/absent nervous control.
Usually diagnosed as infant

11

Hepatitis B Virus
sAg negative
eAg negative
eAb negative
cAb positive

sAg = surface antigen
eAg = e antigen
eAb = e antibody
cAb = core antibody

A. Acute Infection
B. Resolved Infection
C. Naive
D. Low infectivity carrier
E. High Infectivity carrier
F. Vaccinated

Resolved Infection

Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.

Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs

Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma

sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.

sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).

eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.

cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn't yet appeared.

eAg and sAg indicates a greater infectivity, high level of viral activity and replication.

12

Hepatitis B Virus
sAg positive
eAg negative/positive
eAb negative/positive
cAb positive

sAg = surface antigen
eAg = e antigen
eAb = e antibody
cAb = core antibody

A. Acute Infection
B. Resolved Infection
C. Naive
D. Low infectivity carrier
E. High Infectivity carrier
F. Vaccinated

Acute Infection

Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.

Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs

Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma

sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.

sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).

eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.

cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn't yet appeared.

eAg and sAg indicates a greater infectivity, high level of viral activity and replication.

13

Hepatitis B Virus
sAb positive
eAg negative
eAb negative
cAb negative

sAb = surface antibody
eAg = e antigen
eAb = e antibody
cAb = core antibody

A. Acute Infection
B. Resolved Infection
C. Naive
D. Low infectivity carrier
E. High Infectivity carrier
F. Vaccinated

Vaccinated

Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.

Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs

Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma

sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.

sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).

eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.

cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn't yet appeared.

eAg and sAg indicates a greater infectivity, high level of viral activity and replication.

14

Hepatitis B Virus
sAg positive
eAg negative
eAb positive
cAb positive

sAg = surface antigen
eAg = e antigen
eAb = e antibody
cAb = core antibody

A. Acute Infection
B. Resolved Infection
C. Naive
D. Low infectivity carrier
E. High Infectivity carrier
F. Vaccinated

Low Infectivity Carrier

Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.

Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs

Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma

sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.

sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).

eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.

cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn't yet appeared.

eAg and sAg indicates a greater infectivity, high level of viral activity and replication.

15

Hepatitis B Virus
sAg negative
eAg negative
eAb negative
cAb negative

sAg = surface antigen
eAg = e antigen
eAb = e antibody
cAb = core antibody

A. Acute Infection
B. Resolved Infection
C. Naive
D. Low infectivity carrier
E. High Infectivity carrier
F. Vaccinated

Naive

Hepatitis B: double stranded DNA virus, transmitted percutaneously and permucosally.

Signs: Fever, malaise, nausea, jaundice, hepatomegaly, arthralgia, urticaria, deranged LFTs

Long term consequences: fibrosis -> cirrhosis -> hepatocellular carcinoma

sAg = appears 2-10 weeks after exposure and is undetectable after 4-6 months in self limiting acute cases. Persistence >6 months indicates chronic infection.

sAb = appears several weeks after sAg disappears. Indicates a resolved infection and life long immunity (vaccine).

eAg = soluble viral protein in serum, part of early infection and disappears soon after peak ALT levels. Presence >3months indicates chronic infection is likely.

cAb = appears within weeks of acute infection and remains detectable for 4-8 months. May be only way to diagnose acute infection when sAg has disappeared and sAb hasn't yet appeared.

eAg and sAg indicates a greater infectivity, high level of viral activity and replication.

16

Drug Side Effects:

Isoniazid

A. Arrhythmias
B. Ototoxicity
C. Increased appetite
D. Hepatic enzyme inducer
E. Cushing's syndrome
F. Hepatic enzyme reducer
G. Peripheral neuropathy
H. Liver toxicity
I. OCP failure
J. Colour Blindness

Peripheral neuropathy

Used in treatment TB.
Prescribed with pyridoxine prophylactically.

17

Drug Side Effects:

Ethambutol

A. Arrhythmias
B. Ototoxicity
C. Increased appetite
D. Hepatic enzyme inducer
E. Cushing's syndrome
F. Hepatic enzyme reducer
G. Peripheral neuropathy
H. Liver toxicity
I. OCP failure
J. Colour Blindness

Colour Blindness - optic neuritis, colour vision is effected first

TB treatment

18

Drug Side Effects:

Rifampicin

A. Arrhythmias
B. Ototoxicity
C. Increased appetite
D. Hepatic enzyme inducer
E. Cushing's syndrome
F. Hepatic enzyme reducer
G. Peripheral neuropathy
H. Liver toxicity
I. OCP failure
J. Colour Blindness

Hepatic Enzyme Inducer

- Inactivates oral contraceptive, causes orange discolouration of bodily fluids, hepatitis

19

Drug Side Effects:

Pyrazinamide

A. Arrhythmias
B. Ototoxicity
C. Increased appetite
D. Hepatic enzyme inducer
E. Cushing's syndrome
F. Hepatic enzyme reducer
G. Peripheral neuropathy
H. Liver toxicity
I. OCP failure
J. Colour Blindness

Liver toxicity
Also arthralgia

20

Drug Side Effects:

Streptomycin

A. Arrhythmias
B. Ototoxicity
C. Increased appetite
D. Hepatic enzyme inducer
E. Cushing's syndrome
F. Hepatic enzyme reducer
G. Peripheral neuropathy
H. Liver toxicity
I. OCP failure
J. Colour Blindness

Ototoxicity

21

A 23 year old man comes into A&E with abdominal pain which started over his belly button and now is in his RLQ. he is tachycardic, has a tender RIF on palpation and is Rovsing's sign positive.

A. OGD
B. Colonoscopy
C. Barium Swallow
D. Flexi-Sig
E. Rigid Sig
F. CT KUB
G. CT CAP
H. USS
I. Abdo Xray
J. Proctoscopy
K. Barium Enema
L. None of the above

None of the above!

Appendicitis is a clinical diagnosis

Inflammation of the vermiform appendix due to faecolith, lymphoid hyperplasia, infection (parasitic/viral)

Tender over McBurney's point and Rovsing positive.

22

65 year old man is referred by his GP with altered bowel habit and rectal bleeding over the past 6 weeks. The blood is bright red and is not associated with any pain. He reports tenesmus and weight loss.

A. OGD
B. Colonoscopy
C. Barium Swallow
D. Flexi-Sig
E. Rigid Sig
F. CT KUB
G. CT CAP
H. USS
I. Abdo Xray
J. Proctoscopy
K. Barium Enema
L. None of the above

Flexible Sigmoidoscopy: visualisation rectum and sigmoid plus biopsies

Key words: altered bowel habit, rectal bleeding, tenesmus, weight loss

This patient has colorectal carcinoma: predisposing factors = IBD, polyps, FAP, smoking, low fibre diet

Genetics: one 1st degree relative 1:17, two first degree relatives 1:10

Stage using TMN, treat with chemoradiation/surgery

23

83 year old lady complains of tiredness and weight loss over the last 6 weeks. On examination a mass is felt in her right iliac fossa and currently weighs 40kgs, though she was over 50kg at her last appointment.

A. OGD
B. Colonoscopy
C. Barium Swallow
D. Flexi-Sig
E. Rigid Sig
F. CT KUB
G. CT CAP
H. USS
I. Abdo Xray
J. Proctoscopy
K. Barium Enema
L. None of the above

Colonoscopy:

Key words: tiredness, weight loss, mass

24

45 year old man complains to his GP of passing bloody stool without pain for the past 3 weeks. He reports a small amount of bright red blood with no mucus which he finds mostly on the paper.

A. OGD
B. Colonoscopy
C. Barium Swallow
D. Flexi-Sig
E. Rigid Sig
F. CT KUB
G. CT CAP
H. USS
I. Abdo Xray
J. Proctoscopy
K. Barium Enema
L. None of the above

Proctoscopy:

Key words: bloody stool, painless, on the paper

This patient has haemorrhoids = disrupted and dilated anal cushions. Usually at 3, 7, 11 o'clock when in lithotomy position.

1st degree: internal
2nd: Prolapse on defaecation, spontaneously reduce
3rd: Prolapse but requires digital reduction
4th: persistant prolapse

Treatment: Consevation, sclerosing agents, banding haemorrhoidectomy

25

45 year old woman complains of RUQ and shoulder pain. She has a fever and is Murphy's sign positive.

A. OGD
B. Colonoscopy
C. Barium Swallow
D. Flexi-Sig
E. Rigid Sig
F. CT KUB
G. CT CAP
H. USS
I. Abdo Xray
J. Proctoscopy
K. Barium Enema
L. None of the above

USS

Acute Cholecystitis = impaction at the neck of the gall bladder

Will show a thick walled, shrunken GB, dilated CBD, stones, pericholestatic fluid

Tx: NBM, pain relief, IV Abx, surgery

Always consider Courvoisier's Law - painless enlarged gall bladder and jaundice is unlikely to be gall stones

26

25 year old woman with UC involving the rectum has just undergone curative surgery.

A. Tracheostomy
B. Loop colostomy
C. End Ileostomy
D. Gastrostomy
E. De-functioning colostomy
F. Nephrostomy
G. Loop Ileostomy
H. End colostomy
I. Cystostomy
J. Urostomy
K. De-functioning ileostomy
L. None of the above

End Ileostomy: single lumen, spouted, right sided, liquid output.

When the entire colon is removed, the surgeon creates a stoma, in the abdominal wall. The tip of the lower small intestine is brought through the stoma. An external bag, or pouch, is attached to the stoma. This is called a permanent ileostomy. Stools pass through this opening and collect in the pouch. The pouch must be worn at all times.

Whereas an end colostomy has a single lumen, unspouted, left sided, stool like output.

27

A 50 year old man had surgery following mid-stage bladder cancer (T2-3) last year and is left with a stoma.

A. Tracheostomy
B. Loop colostomy
C. End Ileostomy
D. Gastrostomy
E. De-functioning colostomy
F. Nephrostomy
G. Loop Ileostomy
H. End colostomy
I. Cystostomy
J. Urostomy
K. De-functioning ileostomy
L. None of the above

Urostomy - most commonly performed after cystectomy or bladder cancer, for urinary diversion where drainage of the urine through the bladder and urethra isn't possible.

28

A 65 year old man with a high rectal carcinoma has had an anterior resection.


A. Tracheostomy
B. Loop colostomy
C. End Ileostomy
D. Gastrostomy
E. De-functioning colostomy
F. Nephrostomy
G. Loop Ileostomy
H. End colostomy
I. Cystostomy
J. Urostomy
K. De-functioning ileostomy
L. None of the above

Loop ileostomy: double lumen, spout, liquid output, mucous fistula.

Allows the distal bowel to rest - designed to be temporary and reversed at a later date.

29

89 year old lady with a known history of colorectal cancer in the transverse colon. She has ESRF. She presents with symptoms of large bowel obstruction.

A. Tracheostomy
B. Loop colostomy
C. End Ileostomy
D. Gastrostomy
E. De-functioning colostomy
F. Nephrostomy
G. Loop Ileostomy
H. End colostomy
I. Cystostomy
J. Urostomy
K. De-functioning ileostomy
L. None of the above

De-functioning Ileostomy

30

What is a hernia?

A. Protrusion of a viscous or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.