3) GI System 2 + Endocrinology

Question 1

ACHALASIA
- what is it? describe the pathology?

Answer 1

= degeneration of myenteric plexus → impaired func of oesophageal smooth muscle and failure of lower oesophageal sphincter (LOS) to relax → a functional stenosis or oesophageal stricture → ↓motility and dysphagia

Question 2

ACHALASIA:
- initial symptoms? 3
- late symptoms / signs? 2

Answer 2

Dysphagia
– solids > fluids (most common feature)

Regurgitation (80%) and Reflux

Chest pain
– Sub-sternal or retrosternal cramping

Late signs
- nocturnal cough
- aspiration of reflux (pneumonia)

Question 3

ACHALASIA:
- most serious DDx to consider?
- red flags that may indicate this?

Answer 3

A
oesophageal or mediastinal cancer

• Weight loss
• loss of appetite
• fatigue
• haematemesis
• Supraclavicular node

→ urgent endoscopy (not barium enema)

Question 4

ACHALASIA:
- distinctive sign on barium swallow? 1
- gold-standard test? 1

Answer 4

oesophageal dilatation followed by stricture at lower oesophageal sphincter (BIRD BEAK SIGN)

nb aka rat tail sign (I think more accurate)

manometry = gold-standard

Question 5

GASTRITIS:
- most comon causes? 4
- symptoms? 3

Answer 5

• alcohol
• NSAIDs
• H.pylori
• reflux / hiatus hernia

Question 6

ALARMS symptoms which are red flags for more serious aetiology than gastritis? 6

Answer 6

Anaemia

Loss of weight

Anorexia

Recent onset or progressive symptoms

Melaena or Haematemesis

Swallowing difficulty (dysphagia)

also new onset over 50!

Question 7

GASTRITIS:
- test if suspect H.Pylori cause?
- investigation if suspect more serious pathology / redf flags? 1

Answer 7

H.Pylori test – carbon-13 urea breath test or stool Ag

For breath test, must stop PPI/H2 antagonist 2wks before, as it gives false –ve

Endoscopy + Biopsy if red flags
– stop PPI/H2 antagonist 2 wks prior due to false –ve

Question 8

GASTRITIS:
- management if H. Pylori-induced?
- management if not H Pylori induced? 2

Answer 8

H. Pylori = triple therapy
- 2 abx, 1 PPI

If NOT h pylori
- stop nsaids / alcohol
- PPI for 8 weeks

Question 9

CHRONIC PANCREATITIS:
- what is it?
- most common causes? 2

Answer 9

Irreversible inflammation of the pancreas. Precise pathophysiology unknown, thought to be related to decreased HCO3- excretion → activation of pancreatic enzymes → tissue necrosis.

• alcohol
• gallstones (or tumour) obstruction

also other causes of acute pancreatitis (get repeated acute attacks which can -> chronic

Question 10

CHRONIC PANCREATITIS:
- main two symptoms?
- symptoms / signs if exocrine mainly affected? 2
- symptoms if endocrine mainly affected/ 3

Answer 10

EPIGASTRIC PAIN bores through to back
– Relieved on sitting forward +/- hot water bottle on epigastrium
- Worse 15-30 mins post-meal

NAUSEA + VOMITING +/- Anorexia

Exocrine – Malabsorption (bloating, steatorrhoea)

Endocrine – Diabetes mellitus (polyuria, polydipsia, fatigue, etc.)

Question 11

CHRONIC PANCREATITIS:
- bloods to do? (and findings)
- findings on USS and CT scans? 1

Answer 11

FBC, U&Es, LFTs, CRP, ↑Glucose (DM), HbA1C,
↑Amylase, ↑Lipase

nb lipase and amylase may not be massively raised if chronic

Endo-USS (∆) – calcification, irregular duct walls, dilatation or cysts
CT (∆) – may show calcifications, atrophy, ductal dilatation
^basically CALCIFICATIONS!!!

Question 12

CHRONIC PANCREATITIS:
- diet modification? 2
- mainstay of medical management? 3
- possible indications for surgery? 3
- prognosis?

Answer 12

1 – Diet Modification: ↓alcohol; ↓fat intake

2 – Medication

ANALGESIA – Up WHO pain ladder +/- Coeliac Plexus Block

ENZYME replacement – e.g. CREON (lipase)

INSULIN – for diabetes (complication)

nb also ?Octreotide – Somatostatin analogue

3 – Surgery
Indications – persistent pain, narcotic abuse, weight loss
Pancreatectomy/Pancreaticojejunostomy

Question 13

SUBPHRENIC ABSCESS
- what is it?
- what two things is it normally caused by / secondary to? 2

Answer 13

localised collections of pus underneath the right or left hemi-diaphragm

norm occurs secondary to:

1) generalised PERITONITIS
- eg acute appendicitis, perf peptic ulcer, perf GB

2) BOWEL SURGERY

Question 14

SUBPHRENIC ABSCESS
- describe the clinical presentation?
- what is the timescale of the onset of presentation with respect to timeline of cause?

Answer 14

Typically a pt. that develops features of toxicity 2-21 days after initial recovery from peritonitis OR operation!!

• Swinging fever/pyrexia
• Malaise, Nausea and Weight loss
• Abdominal tenderness in subcostal region

± Upper abdo pain radiating to shoulder tip

± Dyspnoea (indicates lobe collapse or development of pleural effusion)

Question 15

What can be seen on a CXR of a person with a subphrenic abscess?

other imaging done?

Answer 15

CXR – high diaphragm on affected side, gas or fluid under diaphragm, ± pleural effusion or lobe collapse

also do a CT scan (to visualise location of pus)

nb WCC often > 20,000

Question 16

LIVER ABSCESS
- what is it?
- most common group of causative organisms in the UK? 1
- most common group of causative organisms worldwide? 1

(can give examples of specific organisms)

Answer 16

localised collections of pus in liver caused by bacterial, parasitic or fungal organisms

UK = norm bacterial cause

Usually Klebsiella or E.Coli (adult), S.Aureus (child)

worldwide = norm amoebic cause

Question 17

LIVER ABSCESS
- localised symptoms + signs? 2
- systemic symptoms? 5

Answer 17

• RUQ Pain + Tenderness → radiates to R shoulder
• Hepatomegaly + Abdo mass
• SWINGING pyrexia + Night sweats
• Nausea, Vomiting
• Anorexia, Weight loss
• Cough + dyspnoea – due to diaphragmatic irritation

± Jaundice

Question 18

PYOGENIC (ie bacterial) LIVER ABSCESS
- most common cause of pyogenic abscesses? (not organism but cause)
- other causes?
- broad principles of management?

Answer 18

Secondary to infection of abdo
- ascending cholangitis (most common!)
- diverticulitis
- appendicitis
- CD
- PUD

Can be complication of liver biopsy or blocked biliary stent also endocarditis and dental infection

Usually Klebsiella or E.Coli (adult), S.Aureus (child)

management = antibiotics AND ct/uss-guided percutaneous drainage

^ most pts won’t respond to Abx alone!

Question 19

AMOEBIC ABSCESS
- norm causative organism?
- what to ask in history in british patients to assess risk?
- broad principles of management?

Answer 19

Entamoeba Histolytica – common in tropical areas w/ poor sanitation or overcrowding

Faecal-oral transmission, check travel Hx

ANTIBIOTICS – Metronidazole (1st line)

95% pts. respond to Abx (if really large may need drainage!)

Question 20

What’s more common: primary liver tumours or liver metasteses from other primaries?

two main primary liver cancers? 2

most common tumour types which metastasise to the liver? 3

Answer 20

liver mets a lot more common that primary liver tumours

• Hepatocellular carcinoma (most common primary 90%)
• Choangio-carcinoma (2nd most common primary 10%)

mets from
- lung
- breast
- GI tract (incl stomach)

Question 21

risk factors for hepatocellular carcinoma:
- lifetyle? 1
- medical conditions (2 more common causes, 3 rarer causes)

Answer 21

= alcohol

= Viral hepatitis (C > B)
= primary biliary cirrhosis

• haemochromatosis
• A1-anti-trypsin deficiency
• diabetes mellitus

Question 22

CHOLANGIOCARCINOMA
- most common cause? 1
- what are findings of LFTs?
- management?

Answer 22

PRIMARY SCLEROSING CHOLANGITIS (associated with UC)

nb also Flukes and N-nitrosasmines

obstructive picture on LFTs (higher ALP than others)

nb CEA is also often raised (though not specific)

surgical resection

Question 23

Presentation of primary liver tumours:
- localised signs / symptoms? 3
- systemic signs / symptoms? 3