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Alimentary System > Clinical > Flashcards

Clinical Flashcards

1
Q

Name 5 disease of the upper GI tract which cause upper abdo or retrosternal discomfort.

A

Oesophageal reflux, oesophageal cancer, gastritis, peptic ulcers, gastric cancers

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2
Q

What causes a hiatus hernia?

A

Oesophageal reflux

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3
Q

Name 2 complications of oesophageal reflux

A

Healing by fibrosis

Barrett’s oesophagus (squamous to glandular)

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4
Q

Name the two histological types of oesophageal cancer.

A 
Squamous carcinoma (from smoking and alcohol)
Adenocarcinoma
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5
Q

What does adenocarcinoma develop from?

A

Barretts oesophagus

Obesity = risk

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6
Q

What is the prognosis of oesophageal cancer?

A

<5% 5 year survival

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7
Q

Describe helicobacter pylori

A

grame -ve
in gastric mucous
increases acid production

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8
Q

What does H. pylori cause?

A

Peptic ulceration, stomach cancer

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9
Q

Name the 3 types of gastritis.

A 
Type A (autoimmune) - atrophy, loss of acid secretion
Type B (bacterial) - H.Pylori
Type C (chemical injury) - e.g NSAIDs
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10
Q

What are complications of peptic ulceration?

A

Bleeding, perforation, healing by fibrosis

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11
Q

What is the 5 year survival for stomach cancer?

A

<20%

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12
Q

What is the histology of stomach cancer?

A

Adenocarcinoma

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13
Q

What are the 3 types of jaundice?

A

Pre-hepatic, hepatic and post-hepatic

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14
Q

Describe pre-hepatic jaundice

A

Breakdown of Hb in spleen

Doesn’t impact liver

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15
Q

Describe hepatic jaundice

A

Uptake of bilirubin by hepatocytes, conjugation occurs.

Cholestasis, intra-hepatic bile obstruction and hepatic cirrhosis can result

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16
Q

What is cholestasis?

A

Accumulation of bile within hepatocytes

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17
Q

What is cholelithiasis?

A

Gallstones

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18
Q

Describe post-hepatic jaundice

A

Chronic or acute inflammation of gall bladder or extra-hepatic duct obstruction
Causes = cholelithiasis, bile duct tumours, being stricture, external compression tumours

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19
Q

What blood results would be indicative of hepatic jaundice?

A

High ALT and GGT

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20
Q

What blood results would be indicative of obstructive (post-hepatic) jaundice?

A

High alkaline phosphatase and bilirubin

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21
Q

What are the causes of acute liver disease?

A

Viral (hepatitis), drugs, ischaemia, auto-immune, bile duct obstruction

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22
Q

How does acute liver disease present?

A

Malaise, abdo pain, anorexia, hepatomegaly, jaundice

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23
Q

What is the management for acute liver disease?

A

Fluid monitoring, microbiology, bloods, ? liver transplant, feeding

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24
Q

What is the difference in pathology of acute and chronic liver disease?

A 
Acute = inflammation
Chronic = fibrosis and cirrhosis
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25
Q

How does chronic liver disease present?

A

Oesophageal varices - haematemesis, melaena, splenomegaly, caput medusae, rectal varices, fetor hepaticus, coma, spider naevi, jaundice, ascites etc

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26
Q

Describe cirrhosis

A

Diffuse process of whole liver - normal liver structure replaced by nodules of hepatocytes of fibrous tissue

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27
Q

Where is diverticular disease most commonly found?

A

Sigmoid colon

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28
Q

What are the causes of acute cholecystitis?

A 
90% = gallstones
10% = blockage in cystic duct
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29
Q

Describe the neuronal control of intestinal motility.

A 
Intrinsic = myenteric plexus "Meissner's and Auerbach's"
Extrinsic = ANS
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30
Q

Describe idiopathic IBD.

A

Chronic inflammation from inappropriate or persistent activation of mucosal immune system driven by. normal intraluminal flora

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31
Q

Where is inflammation present in Crohn’s?

A

Mouth to anus

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32
Q

Where is inflammation present in Ulcerative Colitis?

A

Colon only

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33
Q

In what IBD condition would you find “skip lesions”, non-ceseating granulomas and “cobblestone” ulcerations?

A

Crohn’s

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34
Q

In what IBD condition would you find pseudopolyps and NO granulomas?

A

Ulcerative colitis

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35
Q

What does ischaemic enteritis effect?

A

SI, LI or both

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36
Q

Name 4 potential routes of spread of stomach cancer

A

Direct, lymphatics, blood, transcolemic

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37
Q

What are the causes of bilateRAL leg Swelling?

A

Right heart failure, Albumin low, Large abdo mass, Sitting

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38
Q

What are the causes of ascites?

A

Cancer, portal hypertension, cirrhosis

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39
Q

What causes portal hypertension?

A

Splenomegaly

Oesophageal varices

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40
Q

If cancer in lower oesophagus what is the likely diagnosis?

A

Adenocarcinoma (from Barrett’s oesophagus)

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41
Q

If cancer in upper oesophagus what is the likely diagnosis?

A

Squamous cell carcinoma (alcoholic)

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42
Q

Describe Dukes staging

A

A - limited to wall
B - spread beyond muscularis externally
C1 - positive lymph nodes, highest node (around mesenteric artery) spared
C2. - highest node involved

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43
Q

What is ERCP?

A

Endoscopic Retrograde Cholangio-pancreatography

  • visualises ampulla, biliary system and pancreatic ducts
  • stone removal, biopsy, stenting
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44
Q

What is enteroscopy used to visualise?

A

Small intestine

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45
Q

What are the pros and cons of MRCP?

A

Pro - no risk of pancreatitis

Con - can’t do interventional procedures

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46
Q

What are the relevant GI blood tests?

A

U&Es, Calcium (hypo = differential for D&V), Magnesium, LFTs, CRP, Albumin, TFTs, FBC, Coagulation (hepatic dysfunction), haematinios, hepatic screen, celiac serology, tumour markers

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47
Q

What are the causes of dysphagia?

A

Benign or malignant stricture, motility disorders, eosinophilic oesophagitis, extrinsic compression

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48
Q

What are the investigations for dysphagia?

A

Endoscopy, barium swallow, oesophageal pH and manometry

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49
Q

What is the treatment for dysphagia?

A

Endoscopic balloon dilatation, botulinum injection

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50
Q

Define achalasia.

A

Failure of relaxation of LOS (from functional loss of myenteric plexus)

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51
Q

What are the symptoms of achalasia?

A

Progressive dysphagia, weight loss, chest pain, regurgitation and chest infections

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52
Q

What tests are carries out for achalasia?

A

Manometry

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53
Q

What treatment is given for achalasia?

A

Nitrates, CCBs, pneumatic balloon, botulinum, myotomy (surgical)

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54
Q

What is GORD?

A

Acid and bile exposure in lower oesophagus

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55
Q

What are the risk factors for GORD?

A

Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcohol

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56
Q

What are the two types of hiatus hernia?

A

Sliding and para-oesophageal

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57
Q

What is the treatment for GORD?

A

Lifestyle change, antacids or alginates, add PPI and for refractory symptoms add H2 blocker

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58
Q

What is the treatment for Barrett’s oesophagus?

A

endoscopic mucosal resection
radio-frequency ablation
oesophagectomy (rare)

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59
Q

What are the symptoms of oesophageal cancer?

A

Progressive dysphagia, anorexia, weight. loss, odynophagia, chest pain, cough, pneumonia, vocal cord paralysis, haematemesis

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60
Q

What investigations are used for suspected oesophageal cancer?

A

Endoscopy and biopsy

Staging by CT, EUS, PET, Bone scan

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61
Q

What are the treatment options for oesophageal cancer?

A

Symptom palliation OR if localised = Surgical oesophagectomy +/- neoadjuvant or adjuvant chemotherapy

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62
Q

What are the treatment options for eosinophilic oesophagitis?

A

Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation

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63
Q

Describe the presentation of dyspepsia (organic vs functional).

A

Upper abdo discomfort, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety, heartburn

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64
Q

What can cause dyspepsia?

A

Upper GI: gastritis, peptic ulcer, gastric cancer, gall stones
Lower GI: IBS, Colon cancer, coeliac disease
Other: metabolic, cardiac, drugs

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65
Q

When should you refer to endoscopy?

A

ALARMS

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66
Q

What does ALARMS stand for?

A

Anorexia, Loss of weight, Anaemia, Recent onset >55y or persistent despite treatment, Melaena/hematemesis or Mass, Swallowing problems

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67
Q

What is the aetiology of peptic ulcers?

A 
Men>Women
Elderly
Smoking
NSAIDs
Zollinger-Ellison syndrome
Hyperparathyroidism
Crohn's
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68
Q

What are the symptoms of peptic ulcers?

A

Epigastric pain, nocturnal hunger/pain, back pain, nausea, weight loss

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69
Q

What is the second most common malignancy?

A

Gastric cancer

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70
Q

What is the Correa Hypothesis of gastric cancer?

A

2 histopathological subtypes - Intestinal (majority) and diffuse

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71
Q

What is the management of gastric cancer?

A

Endoscopy, biopsy, staging radiology, MDT discussion, surgery and chemotherapy (rarely radiotherapy)

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72
Q

Describe the structure of H.pylori.

A

Gram -ve
Spiral-shaped
Flagellated
Microaerophilic

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73
Q

Name a type 1 carcinogen?

A

H.pylori

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74
Q

Discuss the divergent responses to H.pylori.

A
  1. Antral predominant –> DU disease
  2. Mild mixed gastritis —> no significant disease
  3. Corpus predominant —> gastric CA
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75
Q

How is H.pylori diagnosed?

A

Serology (IgG), 13C/14C urea breath. test, stool Ag. test, endoscopy, rapid slide urease test

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76
Q

How is H.pylori eradicated?

A

Triple therapy for 7 days: Clarithromycin (500mg bd), Amoxycillin (1g bd), PPI (omeprazole 20mg bd)

  • If penicillin use tetracycline instead of amoxycillin
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77
Q

What conduits are used in oesophagectomy?

A

Stomach, transverse colon

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78
Q

When is surgery classed as bariatric?

A

BMI >35

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79
Q

What are the causes of acute pancreatitis?

A 
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia, hypothermia and hypercalcaemia
ERCP and emboli
Drugs
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80
Q

What suggested acute pancreatitis?

A

Elevated serum amylase

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81
Q

What are the symptoms of acute pancreatitis?

A

Gradual or sudden severe epigastric pain or central abdominal pain, vomiting, nausea, collapse

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82
Q

What are the signs of acute pancreatitis?

A

Pyrexia, jaundice, shock, paralytic ileus, rigid abdomen, Cullen’s sign, Grey Turner’s sign, Tachycardia

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83
Q

What criteria is used to diagnose acute pancreatitis?

A

MODIFIED GLASGOW CRITERIA

Pa02 <8kPa
Age >55y
Neutrophilia
Calcium <2mmol/l
Renal function urea>16mmol/l
Enzymes (LDH and AST)
Albumin <32g/l
Sugar >10mmol/l
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84
Q

What is the management of acute pancreatitis?

A

A-E
Resus: Analgesia, fluids, blood transfusion, monitor urine, NG tube, O2, may need insulin
Specific: lifestyle changes, ERCP for gallstones. etc

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85
Q

What are complications of acute pancreatitis?

A

Abscess, psuedocyst

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86
Q

What causes chronic pancreatitis?

A 
O A TIGER
Obstruction of MPD 
Autoimmune 
Toxin (alcohol = 80%)
Idiopathic
Genetic
Environmental
Recurrence injuries
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87
Q

What are the symptoms and signs of chronic pancreatitis?

A

Abdo pain, weight. loss, exocrine and/or endocrine insufficiency, jaundice, portal hypertension, GI haemorrhage

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88
Q

What are the investigations for chronic pancreatitis?

A

Plain AXR, CT, USS, EUS, Bloods (decrease albumin, increase LFTs), ERCP, MRCP

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89
Q

What are the treatment options for chronic pancreatitis?

A
  1. Pain control (avoid alcohol, opiates)

2. Exocrine and endocrine control (low fat diet, insulin, pancreatic enzyme supplements)

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90
Q

What are the risk factors for pancreatic cancer?

A

Smoking, alcohol, diet, chronic pancreatitis, DM, age 60-80

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91
Q

What are the symptoms of pancreatic cancer?

A

Upper abdo pain, painless obstructive jaundice, weight loss, fatigue, vomiting, ascites, DM

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92
Q

What are the signs of pancreatic cancer?

A

Jaundice, hepatomegaly, abdo mass, tenderness, ascites, splenomegaly

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93
Q

What tests are carried out for pancreatic cancer?

A

ERCP2, USS, CT, MRI, EUS, bloods, CXR

*Tumour markers NOT very sensitive

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94
Q

What are the management options for pancreatic cancer?

A

<10% operable (pancreatoduodenectomy - Whipple’s procedure)

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95
Q

What is the survival rate after Whipple’s procedure for pancreatic cancer?

A

15% 5y survival

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96
Q

What are the main types of surgery for pancreatic cancer?

A

Kausch-Whipple
PPPD
Palliative drainage when obstructive jaundice or duodenal obstruction

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97
Q

What types of viral hepatitis are enteric and cause self-limiting acute infections?

A

A & E

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98
Q

What types of viral hepatitis are parenteral and cause chronic disease?

A

B, C and D

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99
Q

What type of hepatitis is mainly found in topical areas?

A

Hep A

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100
Q

What type of hepatitis is mainly found in sub-saharan Africa, South East Asia etc?

A

Hep B

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101
Q

What type of hepatitis causes an initial increase in IgM?

A

Hep A

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102
Q

How is Hep A transmitted?

A

faecal-oral, sexual, blood

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103
Q

What is the treatment for Hep B?

A

Pegylated interferon, oral antiretroviral (entecavir, tenofovir)

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104
Q

What type of hepatitis evades the immune system like HIV (requiring reverse transcriptase)?

A

Hep C

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105
Q

What is Hep E usually co-infected with?

A

HBV

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106
Q

What is the commonest cause of acute hepatitis in Grampian?

A

Hep E

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107
Q

What is non-alcoholic fatty liver disease associated with?

A

DM, Obesity, HPT, Hypertriglycerideamia, age, ethnicity, genetic factors

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108
Q

How is non-alcoholic fatty liver disease diagnosed?

A 
AST/ALT ratio
Enhanced liver fibrosis panel
Cytokeratin - 18
USS
Fibroscan
mr/ct
LIVER. BIOPSY = GOLD STANDARD!
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109
Q

What antibodies are raised in autoimmune hepatitis?

A

IgG

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110
Q

What antibodies are raised in primary biliary cholangitis?

A

IgM

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111
Q

What is characteristic in primary sclerosis cholangitis?

A

pANCA +ve

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112
Q

When is jaundice detectable in relation to circulating bilirubin?

A

Plasma bilirubin >34umol/L

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113
Q

When is jaundice categorised as unconjugated and conjugated?

A 
Unconjugated = bilirubin complex with albumin in RBC. (pre-heaptic)
Conjugated = with glucuronic acid in liver, through gut and into fences and urine (hepatic and post-hepatic)
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114
Q

What colour is urine and stool in pre-hepatic (unconjugated jaundice)?

A

Normal and normal

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115
Q

What colour is urine and stool in hepatic (conjugated jaundice)?

A

High coloured urine and normal stool

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116
Q

What colour is urine and stool in post-hepatic (conjugated jaundice)?

A

High coloured urine, pale stools

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117
Q

What are the signs of a pre-hepatic cause of jaundice?

A

Pallor

Splenomegaly

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118
Q

What are the signs of a hepatic cause of jaundice?

A

Spider naevi, ascites, asterixis

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119
Q

What are the signs of a post-hepatic cause of jaundice?

A

Palpable gall bladder

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120
Q

What is more specific, ALT or AST?

A

ALT

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121
Q

An increase in alkaline phosphatase is a sign of…

A

Post-hepatic obstruction

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122
Q

An increase in gamma GT is a sign of…

A

Excess alcohol consumption

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123
Q

What does prothrombin time suggest?

A

Stage of liver disease and determines who gets transplant

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124
Q

What does creatinine suggest?

A

Kidney function and survival from liver disease

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125
Q

A low albumin is a sign of?

A

Kidney disorders and malnutrition

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126
Q

What is the most important test to differentiate between intra- and extrahepatic obstruction?

A

Ultrasound

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127
Q

What are cons against ERCP instead of MRCP?

A

Has radiation
Uses sedation
Only images ducts

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128
Q

How does compensated liver disease present?

A

Abnormal LFTs detected on screening tests

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129
Q

How does decompensated liver disease present?

A

Ascites, spider naevi, variceal bleeding, hepatic encephalopathy

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130
Q

What procedure is carried out for new onset ascites?

A

Diagnostic paracentesis

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131
Q

What is the treatment for ascites?

A

Diuretics, large vol paracentesis, liver transplant

132
Q

What causes a variceal haemorrhage?

A

Portal hypertension

133
Q

What is hepatic encephalopathy?

A 
Confusion from GI bleed, constipation, dehydration medication.
Unable to breakdown toxins ---> ammonia
Grade 1 (mild confusion) - grade 4 (coma)
134
Q

What are signs of hepatic encephalopathy?

A

Flap - asterixis, foetor hepaticus

135
Q

What does alcohol do to the liver?

A

Fatty liver (steatosis) and inflammation (steatohepatitis)

136
Q

What does alcohol do to the gut?

A

Obesity, D&V, gastric erosions, peptic ulcers, varices, pancreatitis

137
Q

What are signs of advanced alcohol related disease?

A 
Muscle wasting
Palmar erythema
Gynaecomastia
Encephalopathy
Ascites
Spider naevi
Jaundice
138
Q

What is the treatment for hepatic encephalitis?

A

Bowel clear out, lactulose, enemas, Abx, supportive (ITU airway), NG tube feeding

139
Q

What are the signs of spontaneous bacterial peritonitis?

A

Ascites, fever, rigors, renal impairment, sepsis signs

140
Q

What are the investigations for spontaneous bacterial peritonitis?

A

Ascitic tap, WBC, Neutrophil, protein, <25g/l transudate

141
Q

What is the treatment of spontaneous bacterial peritonitis?

A

IV Abx, ascitic fluid drainage, IV albumin infusion

142
Q

What type of liver failure occurs in context of cirrhosis?

A

Chronic

143
Q

What percentage of those with gallstones are symptomatic?

A

10-30%

144
Q

What are symptoms of gallstones?

A

Dyspepsia, biliary colic, acute cholecystitis (RUQ pain), empyema, jaundice, gallstone ileus

145
Q

What investigations are carried out for gallstones?

A

Blood tests, USS, EUS, Oral cholecystography, IV Cholangiography, MRCP, PTC, ERCP

146
Q

What are the treatment options for gallstones?

A

Non-operative: Dissolution or Lithotripsy

Operative: open cholecystectomy, laparoscopic cholecystectomy (GOLD STANDARD)

147
Q

What is a cholangiocarcinoma?

A

Malignant tumour originating in bile ducts.

Extrahepatic = most common

148
Q

What are the symptoms of a cholangiocarcinoma?

A

Painless obstructive jaundice
Itching
Non-specific symptoms

149
Q

What are the investigations for a cholangiocarcinoma?

A

Lab, radiology, ERCP, Cholangioscopy, Cytology

150
Q

What are the management options for a cholangiocarcinoma?

A

Surgery or palliation (ERCP then PCT stenting, radiotherapy, chemotherapy)

151
Q

When managing an acutely unwell surgical admission what is the ‘system of five’ investigations?

A 
Bedside obs
Microbiology
Blood tests
Imaging
Specialist tests
152
Q

When managing an acutely unwell surgical admission what is the ‘system of five’ management?

A 
O2
IV access
Drug chart
VTE Prophylaxis
Escalation and involvement of MDT
153
Q

What are the ethics of supplementary feeding?

A

Autonomy, beneficence, non-malefecience

Consider mental capacity

154
Q

What are the causes of malabsorption?

A

Coeliac, Crohn’s, chronic pancreatitis, infection

155
Q

What are symptoms of malabsorption?

A

Diarrhoea, weight loss, bloating, lethargy, steatorrhoea, increased appetite, dry pigment skin, easy bruising, hair loss, leuconychia

156
Q

What tests are carried out when malabsorption suspected?

A

Tests of structure: CT/MRI, biopsy by endoscopy

Tests of function: bloods, bacterial overgrowth (H2 breath test)

157
Q

What is the most reliable test for Coeliac?

A

IgA serology
Distal duodenal biopsy showing vilous atrophy
Gladin (fraction of gluten present from inflammatory response)

158
Q

What is the universal screening tool for undernutrition?

A

Malnutrition Universal Screening Tool (MUST)

159
Q

What are the clinical consequences of malnutrition?

A

Reduced muscle strength
Impaired immune response and wound healing
Poorer outcomes
Longer recovery from illness

160
Q

What are the causes of under-nutrition?

A

Appetite failure
Access failure
Intestinal failure

161
Q

What BMI is classed as underweight?

A

<20

162
Q

What BMI is classed as overweight?

A

> 25 (obese = >30)

163
Q

What are functional bowel disorders?

A

No detectable pathology

“software faults”

164
Q

Name 3 examples of functional bowel disorders.

A

IBS, Non-ulcer dyspepsia, slow transit constipation

165
Q

What differentiates between IBS and IBD?

A

Calprotectin (useful for Crohn’s)

166
Q

What is the treatment for functional bowel disorders?

A

Education, reassurance, dietetic review, may need drug therapy for symptoms e.g for bloating, abdo pain, constipation, diarrhoea

167
Q

What are the main causes of constipation?

A

Systemic (DM, Hypothyroidism)
Neurogenic (Parkinson’s, stroke, MS)
Organic (strictures, tumours, diverticular disease)
Functional (depression, megacolon)

168
Q

What is the aetiology of Ulcerative Colitis?

A

20-40 years

F>M

169
Q

What is the aetiology of Crohn’s disease?

A

Early adulthood or over 60

M>F

170
Q

What are the symptoms of UC?

A

Bloody diarrhoea
Abdo pain
Weight loss

171
Q

What are the symptoms of Crohn’s?

A

Diarrhoea, abdo pain, weight loss, malabsorption, malaise, lethargy, anorexia, N&V, low-grade fever

172
Q

What are the signs of a severe attack of ulcerative colitis?

A

Stool >6/day + blood

AND fever, tachy, increased ESR/CRP, anaemia, albumin, leucocytosis, thrombocytosis

173
Q

What blood results are indicative of IBD?

A

High ESR and CRP
High platelets, WCC
Low Hb
Low albumin

174
Q

What stool results are indicative of IBD?

A

Elevated calprotectin (>200)

175
Q

Where can extra-intestinal manifestations of IBD present?

A

Eyes, joints, renal calculi, skin, liver and biliary tree

176
Q

What is the management of IBD?

A 
5 step approach: 
5ASA
Prednisolone
Immunomodulators - thiopurines
Biologics (anti-TNFa)
Surgery
177
Q

What is the aetiology of colorectal cancer?

A 
85% = sporadic
10% = familial
1% = IBD
178
Q

What are the symptoms of colorectal cancer?

A

PAIRS
Palpable rectal or right lower abdominal mass
Altered bowel opening to loose stools >4weeks
Iron deficiency anaemia
Rectal bleeding
Systemic symptoms of malignancy (weight loss)

179
Q

What are the investigations for colorectal cancer?

A

Colonoscopy, barium enema, CT Colonography, CT abdo/pelvis

180
Q

What are the treatment options for colorectal cancer?

A 
80% = surgery (laparoscopic preferred)
Colostomy for all rectal tumours 
Dukes A ---> endoscopic or local resection
Dukes C ---> Chemotherapy
Radiotherapy for rectal tumours only
Advanced disease = palliative care
181
Q

What are the genetic conditions that predispose to colorectal cancer?

A

HNPCC, FAP

182
Q

Who is screened for colorectal cancer?

A

50-74 and those at high risk (IBD, HNPCC, FAP, previous adenomas/CRC)

183
Q

What test is used for colorectal screening?

A

Foecal immunochemical testing (FIT)

184
Q

What is the likely site of ischaemic colitis?

A

Splenic flexure (“water shed area”)

185
Q

What is important to consider during colorectal surgery?

A

Arterial supply
Lymphatic drainage
Venous and nerve supply
Anatomical relations

186
Q

What are the advantages of laparoscopy compared to laparotomy?

A

Less scarring, less pain, faster recovery, shorter hospital stay, quicker return to normal activity

187
Q

What are the cons of laparoscopy compared to laparotomy?

A

Longer op time, difficult visualisation, previous abdo surgery causes lesions

188
Q

What are the main steps of colorectal surgery?

A

Inspection
Mobilisation
Division of blood supply
Anastomosis

189
Q

What is a right hemicolectomy?

A

Removal of right colon

190
Q

What is a sigmoid colectomy?

A

Remove sigmoid

191
Q

What is a low anterior resection?

A

Remove rectum

192
Q

What are the potential specific complications of colonic resection?

A 
Intra-abdominal abscess
Anastomotic leakage
Drainage to surrounding structures
Hernia formation
Tumour recurrence
Adhesion formation causing obstruction
193
Q

What is an acute abdomen?

A

Combination of signs and symptoms including abdominal pain which results in a patient being referred for an urgent general surgical opinion

194
Q

What are the steps in management of the acute abdomen?

A

Assess and resuscitate
Investigate
Observe
Treat

195
Q

What should you consider in and acute abdomen?

A 
Intestinal obstruction
Peritonitis
Acute pancreatitis
Acute appendicitis
Malignancy
Ectopic pregnancy
196
Q

How is a large bowel obstruction described?

A

Like childbirth pain

197
Q

What are the signs and symptoms of intestinal obstruction?

A

Pain, vomiting, distension, constipation, borborygmi

198
Q

What is the difference between visceral and somatic pain?

A

Somatic is more episodic

Visceral has systemic upset

199
Q

What is the location of an upper GI bleed?

A

Oesophagus, stomach, duodenum

200
Q

What is the location of a lower GI bleed?

A

Distal to duodenum

201
Q

What are the symptoms of an upper GI bleed?

A

Haematemesis, melaena, increased urea, dyspepsia, reflux, epigastric pain

202
Q

What are the symptoms of a lower GI bleed?

A

Fresh blood clots, magenta stools, normal urea, painless

203
Q

What investigation is carried out for a suspected upper GI bleed?

A

Endoscopy

204
Q

What investigations are carried out for a suspected lower GI bleed?

A

Flexible sigmoidoscopy or full colonoscopy

205
Q

What is the management of GI bleeds?

A 
ABCDE
Wide bore IV access, fluids, blood transition, urgent blood samples (coag, group and save)
Major haemorrhage protocol
Reverse anticoagulants/antiplatelets
Consider HDU
Sengstaken-Blakemore
206
Q

What psychological problems are caused by GI disease?

A

Diarrhoea, conditioning (e.g vomit), loss of appetite, sexual problems, N&V

207
Q

What psychological present as GI disease?

A

Stress, anxiety, depression, eating disorders

208
Q

What is refeeding syndrome?

A

Adaptive starvation then refeeding with carbs (rapid increase in insulin, ATP, phosphate into cells causing hypophosphataemia)

209
Q

What drugs are used for acid suppression?

A

Antacids
H2 receptor antagonists
PPIs

210
Q

What drugs affect GI motility?

A

Anti-emetics
Anti-muscarinics
Anti-motility

211
Q

What drugs are given for IBD? Give specific examples.

A

Aminosalicylates
Corticosteroids
Immunosuppressants
Biologics

212
Q

What drugs affect intestinal secretions?

A

Bile acid sequestrates

Ursodeoxycholic acid

213
Q

Give an example of an H2 antagonist?

A

Rantidine

214
Q

What is the function of H2 antagonists?

A

Blocks histamine receptor, decreasing gastric acid secretion

215
Q

What is the function PPIs?

A

Inhibit proton pump and reduce gastric acid secretion

216
Q

Give an example of an anti-emetic.

A

Metoclopramide

217
Q

Name three laxatives.

A

Senna (bowel cleaner)
Isphagula (bulk forming)
Arachis oil (softener) - enema

218
Q

How is drug absorption affected in the GIT?

A

By pH, gut length and transit time

219
Q

How is drug distribution affected in GIT?

A

By low albumin

220
Q

How is drug metabolism affected in GIT?

A

Liver enzymes
Increased gut bacteria
Gut wall metabolism
Liver blood flow

221
Q

How is drug excretion affected in GIT?

A

By biliary excretion

222
Q

What are the pharmacodynamic effects of liver disease?

A

Exaggerated or reduced response

Raised toxicity

223
Q

What scoring system is used to assess the severity of liver disease?

A

Child-Pugh Calssification

224
Q

Name two hepatotoxic drugs?

A

Azathioprine

Methotrexate

225
Q

What is the treatment option for prolapse?

A

Stapled anopexy

226
Q

What is used to relax the internal anal sphincter?

A

Medical: topical NO, GTN paste, diltiazem calcium channel blocker
Surgical: internal lateral sphincterotomy

227
Q

What is the treatment option for anal squamous cancer?

A

Radiotherapy

228
Q

What are the treatment options for rectal adenocarcinoma?

A

Neoadjuvant chemotherapy and laparoscopic resection

229
Q

Name 4 complications of gallstones.

A

Pancreatitis
Empyema
Jaundice
Chronic inflammation of gallbladder

230
Q

Why does jaundice affect the clotting system?

A

Absence of bile in small bowel

Failure of absorption of fat soluble vitamins including vitamin K which is required for clotting factor synthesis

231
Q

Describe the process of developing gastric cancer.

A

Normal –> chronic gastritis —> Intestinal metaplasia —> dysplasia —> carcinoma

232
Q

State three complications of peptic ulceration.

A

Perforation, bleeding, stricture formation

233
Q

What is the cause of coeliac disease?

A

Sensitivity to gluten/a-gladin

234
Q

What procedure provides the diagnosis of coeliac disease?

A

Small bowel/duodenal biopsy

235
Q

What is the characteristic histological finding for coeliac disease?

A

Villous atrophy

236
Q

What skin condition is associated with coeliac disease?

A

Dermatitis herpetiformis

237
Q

What is the most common treatment for coeliac?

A

Exclude gluten from diet

238
Q

23yo male, h/o alcohol misuse presents with upper abdo pain and vomiting and raised serum amylase. What is his likely diagnosis?

A

Acute pancreatitis

239
Q

Stretch receptors in rectal wall activate what nervous centres in spinal cord during defection?

A

PNS

240
Q

50yo male presents to ED with 3/12 h/o epigastric pain and 2/7 h/o of vomiting. What is the most likely site of bowel obstruction?

A

Duodenum

241
Q

If the distal ileum is removed, what vitamin deficiency is likely to occur?

A

Vit B12

242
Q

55yo man 6/12 h/o progressive painless jaundice and weight loss. What is the likely diagnosis?

A

Pancreatic cancer

243
Q

30yo male, presents with jaundice, intermittent right hypochondrial pain and nausea, dark urine and pale stools. What is the appropriate imaging test first?

A

Abdominal ultrasound

244
Q

If vagus fibres cut around oesophagus what will result?

A

Delayed gastric emptying

245
Q

What is most likely to occur after total colectomy?

A

Hyponatremia

246
Q

70yo female, right abdo pain, altered bowl habits, hard craggy mass in right. iliac fossa and hepatomegaly. What is the most likely finding on liver after ultrasound?

A

Multiple liver metastases

247
Q

45yo smoker, presents with massive haematemesis and melaena. Endoscopy reveals active bleeding posterior ulcer in first part of duodenum. Which artery is most likely to bleed?

A

Gastro-duodenal

248
Q

Which two ingredients would make up a suitable oral rehydration therapy?

A

Sodium chloride and glucose

249
Q

A patient underwent a cholecystectomy for treatment of chronic cholecystitis. During procedure, arterial blood loss from gall bladder noted. What artery is most likely to have been injured?

A

Cystic artery

250
Q

If gastric antrum removed, gastric acid production is reduced. Why?

A

Decrease in gastrin production

251
Q

25yo female, 6/52 h/o diarrhoea and aphthous ulcers. Stool contains blood and mucous.

A

Crohn’s disease

252
Q

25yo presents with fever, bloody diarrhoea, cramping that doesn’t resolve with Abx. Proctosigmoidoscopy reveals red, raw mucosa and faecal calprotectin is 800g/ug stool (normal = 0-50). What is likely cause?

A

Ulcerative colitis

253
Q

Describe colicky pain.

A

Pain that starts and stops abruptly due to muscular contractions of a hollow tube (colon, ureter, gall bladder, etc) in an attempt to relieve an obstruction by forcing content out.

254
Q

20yo presents with 12 hour history of colicky periumbilical pain which shifts to right iliac fossa and loss of appetite. What is most likely diagnosis?

A

Acute appendicitis

255
Q

45yo admitted after ingesting 25mg of paracetamol 3 days earlier. What is the most likely sign?

A

Jaundice

256
Q

A tumour in the middle 1/3 of the oesophagus is most likely to be of what histological pathology?

A

Squamous cell carcinoma

257
Q

What could be the cause of pain in the left iliac fossa?

A

Diverticulitis

258
Q

What could be the cause of pain in the umbilical region?

A

Small bowel obstruction

Leaking aneurysm

259
Q

What could be the cause of pain in the right or left lumbar regions?

A

Ureteric/renal colic

Leaking aneurysm

260
Q

Name two causes of pain in the right iliac fossa.

A

Appendicitis

Crohn’s

261
Q

Name two causes of pain in the right hypochondrium.

A

Hepatitis

Cholecystitis

262
Q

What can cause pain in the left hypochondrium?

A

Splenic rupture or infarct

263
Q

What can cause pain in the epigastrium?

A

Peptic ulcer

Pancreatitis

264
Q

What can cause pain in the hypogastrium?

A 
Large bowel obstruction 
Fibroids
Urinary retention 
Ovarian cysts
Ectopic pregnancy
265
Q

What are the symptoms of dyspepsia?

A 
Pain/discomfort in upper abdomen 
Retrosternal pain
Anorexia
Nausea 
Vomiting 
Bloating 
Early satiety 
Heartburn
266
Q

What does foecal calprotectin have high sensitivity for?

A

GI inflammation

267
Q

A 45 year old man undergo a gastrectomy for treatment of a benign ulcer. What hormone is likely to be most deficient as a result?

A

Gastrin

268
Q

A 20 year old man consults hIs GP complaining of bloating of his stomach after eating. A barium meal shows normal gastric mucosal appearances but delayed gastric emptying. The excess production of what enzyme may be responsible?

A

Cholecystokinin

269
Q

A 34yo main undergoes pH monitoring of his stomach as part of a physiology trial. The pH of his gastric secretions is found to be 1. wHat mechanism is responsible for achieving this?

A

Hydrogen/potassium adenosine triphosphatase pumps

270
Q

A digestive tract enzyme may be initially released in an active form. what is the best term to describe this compound?

A

Zymogen

271
Q

A 19yo man eats a large bar of white chocolate. Which of the following digestive processes is most important to promote digestion of his food?

A

Emulsification

272
Q

A 34yo woman with jaundice undergoes investigation. Blood tests reveal a raised indirect serum bilirubin and a normal direct serum bilirubin. Urinalysis reveals absent urine bilirubin and an increased urobilinogen. Still tests identify increased urobilinogen. What is the most likely explanation?

A

Haemolytic anaemia

273
Q

What are the Cl- and K+ electrolyte disturbances most commonly seen with diarrhoea?

A

High Cl-, low K+ and low pH

274
Q

A 50yo man presents to A&E complaining of a 3 month history of epigastric pain and a 2 day history of a very high volume of urine. What is the most likely anatomical site of obstruction?

A

Third-part of duodenum

275
Q

A 45yo woman has surgical removal of her distal ileum to treat inflammatory bowel disease. Which enzyme is at risk of becoming deficient?

A

Vitamin A

276
Q

A 24yo main has an inherited defect and is unable to produce intrinsic factor. The absorption of which substances is most likely to be impaired?

A

Vitamin B12

277
Q

A 24 yo woman contracts cholera while on holiday and develops severe diarrhoea. To which receptor does the cholera toxin bind to cause the symptom?

A

Secretin

278
Q

A 30yo man presents acutely with jaundice. He has been complaining of intermittent right hypochondriac pain and nausea for several months but the pain has worsened. His urine is darker than usual and his stools pale. What imaging test is most appropriate in the first instance?

A

Abdominal ultrasound

279
Q

A 45yo man is stabbed in the lower chest. The knife cuts most of the vagus nerve fibres around the oesophagus. He makes a good recovery. What is most likely to occur as a result of the nerve injury?

A

Delayed gastric emptying

280
Q

A 40yo man has a total colectomy to treat colonic carcinoma. The operation is curative. What is most likely to occur as a result of the operation?

A

Hyponatraemia

281
Q

A 40yo patient presents with explosive watery diarrhoea. Stool cultures are negative. An abdo USS AND CT reveal mass in the pancreas which is found to be a VIPoma (pancreatic islet tumour). What biochemical abnormality is likely to be found?

A

Increased bicarbonate

282
Q

A 70yo man presents with abdominal pain, vomiting and abdominal distension. He reports absolute constipation, An abdo radiograph shows multiple dilated loops of bowel. What finding on radiograph would be keeping with a small bowel obstruction?

A

Central distribution of loops of bowel

283
Q

A 45yo smoker with massive haematemesis and melaena. Endoscopy reveals an actively bleeding posterior duodenal ulcer. What artery is most likely to be bleeding?

A

Gastro-duodenal

284
Q

A 30yo man is suspected of having impaired intestinal motility. Routine blood and imaging tests are normal. what could explain his impaired motility?

A

Segmentation contractions are reduced during a meal

285
Q

A patient undergo a cholecystectomy for treatment of chronic cholecystitis. During the operation, the surgeon notices arterial blood loss from the gall bladder neck. What artery is most likely to be injured?

A

Cystic artery

286
Q

A 50yo patient has chronic peptic ulcer disease that has not responded to drug therapy and undergo surgical removal of the gastric antrum to reduce gastric acid production. How does the surgical procedure reduce acid production?

A

Virtually eliminates gastrin production

287
Q

A 25yo woman presents with a 6 week history of diarrhoea, and oral pathos ulcers. Her stool contains blood and mucous. What is the most likely diagnosis?

A

Crohn’s disease

288
Q

A 25yo man presents with fever, bloody diarrhoea and cramping for several weeks which doesn’t respond with antibiotics. Proctosigmoidoscopy reveals red, raw mucosa and pseudopolyps. What is the most likely cause?

A

Ulcerative colitis

289
Q

A 20yo man presents with a 12 hour history of colicky periumbilical pain, which shifts to the right iliac fossa, fever and loss of appetite. what is the most likely diagnosis?

A

Acute appendicitis

290
Q

A 45yo heterosexual man was admitted to hospital after ingesting 25g of paracetamol 3 days earlier. He had no PMH of note, took no regular medications and rarely consumed alcohol. What sign would be consistent with his presentation?

A

Jaundice

291
Q

A new admission to the neonatal unit has a very rare tracheo-oesophageal fistula with an imperforate anus. While looking up the related embryology of the gut form an unverified internet source you come across the following info. What is incorrect?

A
  1. As a consequence of embryonic folding, part of the endodermal-lined amniotic cavity is incorporated into the gut.
  2. The parenchyma of glands developing when the gut is formed from endoderm
  3. The respiratory diverticulum helps form the oesophagus
  4. The superior mesenteric artery formation results in formation of the axis of rotation for a primary intestinal loop
  5. The distal part of the anal canal is formed from ectoderm

ANSWER = 1

292
Q

What would the consequence of bilateral vagotomy be on salivary secretion?

A

No effect since no vagal innervation of head and neck (CN VII and IX responsible)

293
Q

What would the consequence of bilateral vagotomy be on parietal cell HCL secretion?

A

Direct stimulation of parietal cell HCL secretion (via ACh) would be removed.
Reduced activation via vagal-stimulated histamine released by ECL cells and via vagus mediated gastrin release from G cells.

294
Q

What would the consequence of bilateral vagotomy be on parietal cell G cell gastrin secretion?

A

Stimulation of gastrin secretion during cephalic phase would be removed
However, distension/peptide - induced stimulation of G cells would remain

295
Q

What would the consequence of bilateral vagotomy be on gastric motility?

A

Gastric motility would be reduced but local enteric reflexes would maintain a degree of motility.

Gastric emptying into duodenum would be reduced

296
Q

What would the consequence of bilateral vagotomy be on defecation?

A

Limit ability to defecate in particular reflex contraction of rectum and control of internal and external anal sphincter tone

297
Q

A woman aged 55 presents with 3 week history of increasing jaundice and right upper quadrant pain. LFTs indicate normal aspirate and alanine aminotransferases and significantly increased alkaline phosphatase. What are 5 relevant questions to ask?

A
  • History of gallstones
  • Characteristics of pain
  • Colour/change in colour of urine
  • Colour/change in colour of stool
  • Relationship between meals and pain?
  • Foreign travel
  • Prescribed drug history
298
Q

A woman with jaundice and LFTs showing a high alkaline phosphatase. Does this indicate a hepatic or post-hepatic cause of jaundice?

A

Post-hepatic

299
Q

State 3 possible causes of obstructive jaundice.

A

Gall stone in common bile duct
Tumour in common bile duct
Carcinoma in head of pancreas
Tumour of ampulla of Vater

300
Q

What is the initial investigation to look at the biliary tree?

A

Ultrasound

301
Q

Give 4 complications of gallstones.

A 
Acute inflammation of gall bladder 
Perforation of gall bladder wall 
Empyema
Jaundice
Biliary colic
Carcinoma of gall bladder 
Pancreatitis
302
Q

State three risk factors for gallstones.

A 
Forty 
Fatty 
Fertile 
Female 
Diabetes
303
Q

Why does jaundice affect the clotting system?

A

Absence of bile in the small intestine –> Failure of absorption of fat soluble vitamins including vit K which is required for clotting

304
Q

A 65yo man presents with a single episode of haematemesis. He also complains of recent anorexia and weight loss. What investigation would you request?

A

Upper GI endoscopy

305
Q

Give 4 differential diagnoses for haematemesis.

A 
Gastritis
Peptic ulcer
Mallory Weiss Tear
Gastric carcinoma
Oesophageal carcinoma
Oesophageal varices
306
Q

During endoscopy, an irregular ulcer in the antrum was seen. How would a pathological diagnosis be established?

A

Biopsy of lesion

307
Q

Describe the process of development of gastric cancer.

A

Normal –> chronic gastritis –> intestinal metaplasia –> dysplasia –> carcinoma

308
Q

By which four routes does gastric cancer spread?

A

Direct
Lymphatic
Blood
Transcoelemic

309
Q

What is the prognosis of gastric cancer?

A

Less than 20% in 5 years

310
Q

Which bacterium is associated with the development of gastric cancer?

A

H pylori

311
Q

How do you eradicate H. pylori?

A

Triple therapy for 7 days: amoxycillin (or metronidazole) + clarithromycin + PPI

312
Q

State 3 complications of peptic ulceration.

A

Perforation
Bleeding
Stricture formation

313
Q

A 24yo patient is referred for investigation of malabsorption and weight loss. Coeliac disease is suspected. What is the cause of coeliac?

A

Sensitivity to gluten/ a-gliadin

314
Q

What procedure provides the diagnosis and what is the characteristic histological finding?

A

Smal bowel/duodenal biopsy –> vollus atrophy

315
Q

What skin condition is associated with coeliac disease?

A

Dermatitis herpetiformis

316
Q

What is the commonest treatment for coeliac disease?

A

Exclude gluten from the diet

317
Q

A 71yo man had a malignant tumour of the middle third of the oesophagus. What is the most likely histopathological diagnosis?

A

Squamous cell carcinoma

318
Q

What combination of monosaccharides make up lactose?

A

Glucose and galactose

319
Q

A 20yo female medical student suffers from severe secretory diarrhoea while bag packing in India. She remembers that ORT is an effective way to counter the dehydration caused by intestinal fluid loss. What ingredients would be required to make up a suitable ORT?

A

Sodium chloride and glucose

320
Q

A 70yo woman presents with jaundice. She has been complaining of right abdominal paining altered bowel habit fro several months. On examination she has a hard craggy mass in her right iliac fossa and hepatomegaly. What is the most likely finding on an abdominal USS?

A

Multiple liver metastases

321
Q

A 55yo man presents with 6 weeks history of progressive painless jaundice. Abdominal palpation is normal. What is the most likely diagnosis?

A

Pancreatic cancer

322
Q

A 45yo woman has surgical removal of her distal ileum to treat IBD. What vitamin is she likely to become deficient in?

A

Vit B12

323
Q

A 47yo man was referred for investigation of impaired defecation. What is the normal mechanism of defecation?

A

Stretch receptors in the rectal wall activate PNS centres in the spinal cord

324
Q

A 23yo male with a history of alcohol misuse presented with acute upper abdominal pain and vomiting. He was found to have raised serum amylase. What is the most likely diagnosis?

A

Acute pancreatitis

325
Q

Name two drugs that cause jaundice.

A

Flucolaxacillin and co-amoxiclav

Alimentary System (2 decks)

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