Presentations

Question 1

what are the most common causes of severe intra-abdominal bleeding and what signs indicate this

Answer 1

ruptured AAA

ruptured ectopic pregnancy

bleeding gastric ulcer

trauma

these patients typically go into hypovolaemic shock; tachycardia, hypotension, pale and clammy on inspection and cool to touch

Question 2

sings and symptoms of hypovolaemic shock

Answer 2

tachycardia

hypotension

pale and clammy on inspection

cool to touch

Question 3

what is peritonitis and what is broadly the most common cause

Answer 3

inflammation of the peritoneum

most commonly caused by perforation of an abdominal organ

Question 4

what are some causes of perforation in the abdomen

Answer 4

peptic ulceration

small or large bowel obstruction

diverticular disease

inflammatory bowel disease

Question 5

signs and symptoms of generalised peritonitis

Answer 5

lay completely still and look very unwell

tachycardia and potential hypotension

rigid abdomen with percussion tenderness

involuntary guarding (tensing of abdo muscles when palpating the abdomen)

reduced or absent bowel sounds (paralytic ileus)

Question 6

any patient who presents with severe acute abdomen pain out of proportion to the clinical signs is immediately suspected to have what

Answer 6

ischaemic bowel

Question 7

what do patients with ischaemic bowel usually complain of

Answer 7

diffuse severe constant abdo pain - however examination is often unremarkable

Question 8

what laboratory tests are required in all cases of acute abdominal pain

Answer 8

urine dipstick - infection or haematuria

pregnancy test for women of reproductive age

ABG - useful in bleeding and septic patients; pH, pCO2, pO2, lactate (tissue hypoperfusion) and haemoglobin levels

routine bloods - include amylase (pancreatitis) and group and save (surgery)

blood cultures - ?infection

Question 9

imaging and tests required for all acute abdo pain cases

Answer 9

ECG and CXR - ?cardiac pathology or ?free air in abdomen

USS KUB (KUB = kidney, ureters, bladder)

USS of liver and biliary tree

Transvaginal USS - ?tubo-ovarian pathology

CT abdomen

Question 10

basic management for all cases of acute abdo pain (and severe acute malaise in general) prior to any definitive action

Answer 10

IV access, NBM status, analgesia, anti-emetics, initial imaging, VTE prophylaxis, urine dip and routine bloods, catheter or NG tube if required, resus fluids

Question 11

what is biliary colic

Answer 11

RUQ pain, intermittent in nature and worse after eating

Question 12

what are oesophageal varices

Answer 12

dilations of the porto-systemic venous anastamoses in the oesophagus

Question 13

what are some emergency causes of haematemesis

Answer 13

oesophageal varices

gastric ulceration

Question 14

what is the most common cause (60%) of haematemesis cases

Answer 14

gastric ulceration

Question 15

how does gastric ulceration cause haematemesis

Answer 15

ulceration can result in erosion into the blood vessels supplying the upper GI tract - most commonly on the lesser curve of the stomach or posterior duodenum

Question 16

what is a mallory-weiss syndrome tear and what is the most common history

Answer 16

tear in the epithelial lining of the oesophagus - history of severe or recurrent vomiting followed by minor haematemesis

Question 17

what are some causes of oesophagitis

Answer 17

GORD

infection (most commonly candida)

ingestion of toxic substances

medications

Question 18

what are some non-emergency causes of haematemesis

Answer 18

mallory-weiss tear

oesophagitis

gastritis

gastric malignancy

Question 19

investigations into haematemesis

Answer 19

FBC and VBG + group and save

definitive investigation is oesophagogastroduodenoscopy (OGD)

erect CXR if perforated peptic ulcer is suspected - in such a case pneumoperitoneum may be seen

CT abdomen with IV contrast can also be useful if endoscopy is contraindicated

Question 20

if a patient presents with haematemesis and upon investigation is found to have air in the peritoneum on eCXR - what is the most likely diagnosis

Answer 20

perforated peptic ulcer

Question 21

definitive management of peptic ulcer disease

Answer 21

first line; A to E + IV cannulas, start fluid resus and crossmatch blood

OGD needed to visualise

definitive; adrenaline injections and cauterisation of the bleeding followed by high dose IV PPI therapy to reduce acid secretion, and finally H.pylori eradication therapy if necessary

Question 22

definitive management of oesophageal varices

Answer 22

first line; active resus + blood + prophylactic abx

definitive; endoscopic banding, vasopressors to reduce splanchnic blood flow and reduce bleeding

Question 23

what plain film radiographic sign may indicate a perforated gastric ulcer

Answer 23

subdiaphragmatic free gas

Question 24

what are some mechanical causes of dysphagia

Answer 24

oesophageal or gastric malignancy

benign oesophageal strictures

pharyngeal pouch

foreign body

extrinsic compression

Question 25

what are some neuromuscular causes of dysphagia

Answer 25

post-stroke achalasia myasthenia gravis diffuse oesophageal spasm

Question 26

what are red flag symptoms for dysphagia

Answer 26

weight loss sensation of food becoming stuck hoarse voice referred ear or neck pain

Question 27

investigations into dysphagia

Answer 27

OGD + biopsy if relevant routine bloods

Question 28

what is the blood supply to the inferior third of the oesophagus

Answer 28

left gastric artery

Question 29

what is the most common neuromuscular cause of acute dysphagia in a 70 year old male

Answer 29

stroke

Question 30

what is Gastric Outlet obstruction

Answer 30

describes a mechanical obstruction of the proximal GI tract, occurring at some point between the gastric pylorus and the proximal duodenum, resulting in an inability to empty the stomach

Question 31

what are some causes of gastric outlet obstruction

Answer 31

gastric or small bowel malignancy peptic ulcer disease - causing stricture of stomach/duodenum stricture following surgery pancreatic cyst bouveret syndrome

Question 32

what is Bouveret syndrome

Answer 32

gastric outlet obstruction secondary to a gallstone impacted at the pylorus or proximal duodenum occurs in patients with a cholecystoduondenal fistula

Question 33

clinical features of gastric outlet obstruction

Answer 33

epigastric pain vomiting post eating early satiety often no change in bowel habit initially dehydrated due to persistent vomiting and obstruction - also tachycardic and hypotensive (hypovolaemic)

Question 34

investigations into gastric outlet obstruction

Answer 34

routine bloods - FBC, CRP, U&Es, clotting, group and save CT abdo with IV contrast + endoscopy (following decompression of stomach)

Question 35

what is the main first line step in managing gastric outlet obstruction

Answer 35

decompress the stomach via NG tube then start on IV PPI therapy

Question 36

most common causes of small bowel obstruction

Answer 36

adhesions and herniae

Question 37

most common causes of large bowel obstruction

Answer 37

malignancy, diverticular disease and volvulus

Question 38

what are the cardinal signs of bowel obstruction

Answer 38

abdominal pain - colicky or cramping in nature (secondary to peristalsis) vomiting - early in proximal obstructions and late in distal obstructions abdominal distension absolute constipation - early in distal obstructions but late in proximal obstructions

Question 39

what are characteristic signs that an obstructed bowel is becoming ischaemic

Answer 39

guarding and rebound tenderness percussion tenderness

Question 40

tinkling bowel sounds indicate what?

Answer 40

bowel obstruction

Question 41

laboratory tests into suspected bowel obstruction

Answer 41

routine bloods - important to monitor for electrolyte changes VBG - check lactate (high = sign of ischaemia)

Question 42

imaging for a suspected bowel obstruction

Answer 42

gold standard = CT abdo pelvis with IV contrast AXR still used in some settings

Question 43

what are the AXR findings that would indicate small bowel vs large bowel obstruction

Answer 43

small bowel = dilated >3cm, central location, valvulae conniventes visible (lines completely crossing the bowel) large bowel = dilated >6cm, peripheral location, haustral lines visible (lines not completely crossing the bowel - go Halfway as they are Haustra)

Question 44

management of bowel obstruction

Answer 44

conservative; IV fluids, urinary catheter, analgesia, NBM and insert NG tube to decompress the bowel (non-surgical treatment only suitable in those with no signs of ischaemia or strangulation) surgical; laparotomy and possible stoma (indicated in those with signs of ischaemia or closed bowel obstruction)

Question 45

what measurement in an ABG is most indicative of bowel ischaemia

Answer 45

high lactate levels

Question 46

causes of gastrointestinal perforation

Answer 46

diverticulitis peptic ulcer disease GI malignancy iatrogenic e.g. routine endoscopy trauma foreign body appendicitis mesenteric ischaemia bowel obstruction

Question 47

clinical features of GI perforation

Answer 47

pain - rapid onset and sharp in nature systemically unwell - malaise, vomiting and lethargy signs of sepsis signs of peritonism - rigid abdomen, guarding, etc.

Question 48

imaging in suspected GI perforation

Answer 48

gold standard = CT scan

Question 49

management of GI perforation

Answer 49

broad spectrum abx, NBM, NG tube, IV fluids and analgesia surgery - identify, manage and washout

Question 50

what artery provides the blood supply to the ascending colon

Answer 50

superior mesenteric artery

Question 51

what is malaena

Answer 51

black tarry stools occurring as a result of upper GI bleeding - usually have a very offensive smell

Question 52

what is the most common cause of malaena

Answer 52

peptic ulcer disease

Question 53

common causes of maleana

Answer 53

peptic ulcer disease oesophageal varices upper GI malignancy gastritis, oesophagitis, mallory-weiss tear

Question 54

investigations into malaena

Answer 54

routine bloods + group and save ABG - pH and lactate OGD - definitive investigation in most cases of malaena CT abdo with IV contrast - if contraindications to OGD

Question 55

how does a drop in haemoglobin and rise in urea:creatinine ratio indicate upper GI bleed

Answer 55

digested Hb produces urea as a by-product and is readily absorbed by the intestine; therefore urea levels increase

Question 56

what is the role of somatostatin analogues in variceal bleeding

Answer 56

reduces splanchnic blood flow to the GI tract - thereby reducing bleeding

Question 57

what is haematochezia

Answer 57

passage of fresh blood via the rectum caused by bleeding from the lower GI tract

Question 58

what are some common causes of acute lower GI bleeding

Answer 58

diverticular disease ischaemic or infective colitis haemorrhoids malignancy angiodysplasia crohn's disease ulcerative colitis

Question 59

what is the most common cause of lower GI bleeding

Answer 59

diverticulosis

Question 60

what first line examination is essential in any patient presenting with haematochezia

Answer 60

DRE

Question 61

investigations into haematochezia

Answer 61

routine bloods - baseline group and save - surgery stool cultures - ?infection unstable patients require CT angiogram - to identify location of bleed stable patients require flexible sigmoidoscopy - to exclude left colonic malignancy

Question 62

what investigations are required in stable vs unstable patients with haematochezia

Answer 62

stable = flexible sigmoidoscopy unstable = CT angiogram

Question 63

what is the blood supply to the ileum

Answer 63

superior mesenteric artery

Question 64

what is the first line investigation in an haemodynamically unstable patient presenting with haematochezia

Answer 64

CT angiogram