Clinical Flashcards
Name 5 disease of the upper GI tract which cause upper abdo or retrosternal discomfort.
Oesophageal reflux, oesophageal cancer, gastritis, peptic ulcers, gastric cancers
What causes a hiatus hernia?
Oesophageal reflux
Name 2 complications of oesophageal reflux
Healing by fibrosis
Barrett’s oesophagus (squamous to glandular)
Name the two histological types of oesophageal cancer.
Squamous carcinoma (from smoking and alcohol) Adenocarcinoma
What does adenocarcinoma develop from?
Barretts oesophagus
Obesity = risk
What is the prognosis of oesophageal cancer?
<5% 5 year survival
Describe helicobacter pylori
grame -ve
in gastric mucous
increases acid production
What does H. pylori cause?
Peptic ulceration, stomach cancer
Name the 3 types of gastritis.
Type A (autoimmune) - atrophy, loss of acid secretion Type B (bacterial) - H.Pylori Type C (chemical injury) - e.g NSAIDs
What are complications of peptic ulceration?
Bleeding, perforation, healing by fibrosis
What is the 5 year survival for stomach cancer?
<20%
What is the histology of stomach cancer?
Adenocarcinoma
What are the 3 types of jaundice?
Pre-hepatic, hepatic and post-hepatic
Describe pre-hepatic jaundice
Breakdown of Hb in spleen
Doesn’t impact liver
Describe hepatic jaundice
Uptake of bilirubin by hepatocytes, conjugation occurs.
Cholestasis, intra-hepatic bile obstruction and hepatic cirrhosis can result
What is cholestasis?
Accumulation of bile within hepatocytes
What is cholelithiasis?
Gallstones
Describe post-hepatic jaundice
Chronic or acute inflammation of gall bladder or extra-hepatic duct obstruction
Causes = cholelithiasis, bile duct tumours, being stricture, external compression tumours
What blood results would be indicative of hepatic jaundice?
High ALT and GGT
What blood results would be indicative of obstructive (post-hepatic) jaundice?
High alkaline phosphatase and bilirubin
What are the causes of acute liver disease?
Viral (hepatitis), drugs, ischaemia, auto-immune, bile duct obstruction
How does acute liver disease present?
Malaise, abdo pain, anorexia, hepatomegaly, jaundice
What is the management for acute liver disease?
Fluid monitoring, microbiology, bloods, ? liver transplant, feeding
What is the difference in pathology of acute and chronic liver disease?
Acute = inflammation Chronic = fibrosis and cirrhosis
How does chronic liver disease present?
Oesophageal varices - haematemesis, melaena, splenomegaly, caput medusae, rectal varices, fetor hepaticus, coma, spider naevi, jaundice, ascites etc
Describe cirrhosis
Diffuse process of whole liver - normal liver structure replaced by nodules of hepatocytes of fibrous tissue
Where is diverticular disease most commonly found?
Sigmoid colon
What are the causes of acute cholecystitis?
90% = gallstones 10% = blockage in cystic duct
Describe the neuronal control of intestinal motility.
Intrinsic = myenteric plexus "Meissner's and Auerbach's" Extrinsic = ANS
Describe idiopathic IBD.
Chronic inflammation from inappropriate or persistent activation of mucosal immune system driven by. normal intraluminal flora
Where is inflammation present in Crohn’s?
Mouth to anus
Where is inflammation present in Ulcerative Colitis?
Colon only
In what IBD condition would you find “skip lesions”, non-ceseating granulomas and “cobblestone” ulcerations?
Crohn’s
In what IBD condition would you find pseudopolyps and NO granulomas?
Ulcerative colitis
What does ischaemic enteritis effect?
SI, LI or both
Name 4 potential routes of spread of stomach cancer
Direct, lymphatics, blood, transcolemic
What are the causes of bilateRAL leg Swelling?
Right heart failure, Albumin low, Large abdo mass, Sitting
What are the causes of ascites?
Cancer, portal hypertension, cirrhosis
What causes portal hypertension?
Splenomegaly
Oesophageal varices
If cancer in lower oesophagus what is the likely diagnosis?
Adenocarcinoma (from Barrett’s oesophagus)
If cancer in upper oesophagus what is the likely diagnosis?
Squamous cell carcinoma (alcoholic)
Describe Dukes staging
A - limited to wall
B - spread beyond muscularis externally
C1 - positive lymph nodes, highest node (around mesenteric artery) spared
C2. - highest node involved
What is ERCP?
Endoscopic Retrograde Cholangio-pancreatography
- visualises ampulla, biliary system and pancreatic ducts
- stone removal, biopsy, stenting
What is enteroscopy used to visualise?
Small intestine
What are the pros and cons of MRCP?
Pro - no risk of pancreatitis
Con - can’t do interventional procedures
What are the relevant GI blood tests?
U&Es, Calcium (hypo = differential for D&V), Magnesium, LFTs, CRP, Albumin, TFTs, FBC, Coagulation (hepatic dysfunction), haematinios, hepatic screen, celiac serology, tumour markers
What are the causes of dysphagia?
Benign or malignant stricture, motility disorders, eosinophilic oesophagitis, extrinsic compression
What are the investigations for dysphagia?
Endoscopy, barium swallow, oesophageal pH and manometry
What is the treatment for dysphagia?
Endoscopic balloon dilatation, botulinum injection
Define achalasia.
Failure of relaxation of LOS (from functional loss of myenteric plexus)
What are the symptoms of achalasia?
Progressive dysphagia, weight loss, chest pain, regurgitation and chest infections
What tests are carries out for achalasia?
Manometry
What treatment is given for achalasia?
Nitrates, CCBs, pneumatic balloon, botulinum, myotomy (surgical)
What is GORD?
Acid and bile exposure in lower oesophagus
What are the risk factors for GORD?
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcohol
What are the two types of hiatus hernia?
Sliding and para-oesophageal
What is the treatment for GORD?
Lifestyle change, antacids or alginates, add PPI and for refractory symptoms add H2 blocker
What is the treatment for Barrett’s oesophagus?
endoscopic mucosal resection
radio-frequency ablation
oesophagectomy (rare)
What are the symptoms of oesophageal cancer?
Progressive dysphagia, anorexia, weight. loss, odynophagia, chest pain, cough, pneumonia, vocal cord paralysis, haematemesis
What investigations are used for suspected oesophageal cancer?
Endoscopy and biopsy
Staging by CT, EUS, PET, Bone scan
What are the treatment options for oesophageal cancer?
Symptom palliation OR if localised = Surgical oesophagectomy +/- neoadjuvant or adjuvant chemotherapy
What are the treatment options for eosinophilic oesophagitis?
Topical/swallowed corticosteroids
Dietary elimination
Endoscopic dilatation
Describe the presentation of dyspepsia (organic vs functional).
Upper abdo discomfort, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety, heartburn
What can cause dyspepsia?
Upper GI: gastritis, peptic ulcer, gastric cancer, gall stones
Lower GI: IBS, Colon cancer, coeliac disease
Other: metabolic, cardiac, drugs
When should you refer to endoscopy?
ALARMS
What does ALARMS stand for?
Anorexia, Loss of weight, Anaemia, Recent onset >55y or persistent despite treatment, Melaena/hematemesis or Mass, Swallowing problems
What is the aetiology of peptic ulcers?
Men>Women Elderly Smoking NSAIDs Zollinger-Ellison syndrome Hyperparathyroidism Crohn's
What are the symptoms of peptic ulcers?
Epigastric pain, nocturnal hunger/pain, back pain, nausea, weight loss
What is the second most common malignancy?
Gastric cancer
What is the Correa Hypothesis of gastric cancer?
2 histopathological subtypes - Intestinal (majority) and diffuse
What is the management of gastric cancer?
Endoscopy, biopsy, staging radiology, MDT discussion, surgery and chemotherapy (rarely radiotherapy)
Describe the structure of H.pylori.
Gram -ve
Spiral-shaped
Flagellated
Microaerophilic
Name a type 1 carcinogen?
H.pylori
Discuss the divergent responses to H.pylori.
- Antral predominant –> DU disease
- Mild mixed gastritis —> no significant disease
- Corpus predominant —> gastric CA
How is H.pylori diagnosed?
Serology (IgG), 13C/14C urea breath. test, stool Ag. test, endoscopy, rapid slide urease test
How is H.pylori eradicated?
Triple therapy for 7 days: Clarithromycin (500mg bd), Amoxycillin (1g bd), PPI (omeprazole 20mg bd)
- If penicillin use tetracycline instead of amoxycillin
What conduits are used in oesophagectomy?
Stomach, transverse colon
When is surgery classed as bariatric?
BMI >35
What are the causes of acute pancreatitis?
GET SMASHED Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia, hypothermia and hypercalcaemia ERCP and emboli Drugs
What suggested acute pancreatitis?
Elevated serum amylase
What are the symptoms of acute pancreatitis?
Gradual or sudden severe epigastric pain or central abdominal pain, vomiting, nausea, collapse
What are the signs of acute pancreatitis?
Pyrexia, jaundice, shock, paralytic ileus, rigid abdomen, Cullen’s sign, Grey Turner’s sign, Tachycardia
What criteria is used to diagnose acute pancreatitis?
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
What is the management of acute pancreatitis?
A-E
Resus: Analgesia, fluids, blood transfusion, monitor urine, NG tube, O2, may need insulin
Specific: lifestyle changes, ERCP for gallstones. etc
What are complications of acute pancreatitis?
Abscess, psuedocyst
What causes chronic pancreatitis?
O A TIGER Obstruction of MPD Autoimmune Toxin (alcohol = 80%) Idiopathic Genetic Environmental Recurrence injuries
What are the symptoms and signs of chronic pancreatitis?
Abdo pain, weight. loss, exocrine and/or endocrine insufficiency, jaundice, portal hypertension, GI haemorrhage
What are the investigations for chronic pancreatitis?
Plain AXR, CT, USS, EUS, Bloods (decrease albumin, increase LFTs), ERCP, MRCP
What are the treatment options for chronic pancreatitis?
- Pain control (avoid alcohol, opiates)
2. Exocrine and endocrine control (low fat diet, insulin, pancreatic enzyme supplements)
What are the risk factors for pancreatic cancer?
Smoking, alcohol, diet, chronic pancreatitis, DM, age 60-80
What are the symptoms of pancreatic cancer?
Upper abdo pain, painless obstructive jaundice, weight loss, fatigue, vomiting, ascites, DM
What are the signs of pancreatic cancer?
Jaundice, hepatomegaly, abdo mass, tenderness, ascites, splenomegaly
What tests are carried out for pancreatic cancer?
ERCP2, USS, CT, MRI, EUS, bloods, CXR
*Tumour markers NOT very sensitive
What are the management options for pancreatic cancer?
<10% operable (pancreatoduodenectomy - Whipple’s procedure)
What is the survival rate after Whipple’s procedure for pancreatic cancer?
15% 5y survival
What are the main types of surgery for pancreatic cancer?
Kausch-Whipple
PPPD
Palliative drainage when obstructive jaundice or duodenal obstruction
What types of viral hepatitis are enteric and cause self-limiting acute infections?
A & E
What types of viral hepatitis are parenteral and cause chronic disease?
B, C and D
What type of hepatitis is mainly found in topical areas?
Hep A
What type of hepatitis is mainly found in sub-saharan Africa, South East Asia etc?
Hep B
What type of hepatitis causes an initial increase in IgM?
Hep A
How is Hep A transmitted?
faecal-oral, sexual, blood
What is the treatment for Hep B?
Pegylated interferon, oral antiretroviral (entecavir, tenofovir)
What type of hepatitis evades the immune system like HIV (requiring reverse transcriptase)?
Hep C
What is Hep E usually co-infected with?
HBV
What is the commonest cause of acute hepatitis in Grampian?
Hep E
What is non-alcoholic fatty liver disease associated with?
DM, Obesity, HPT, Hypertriglycerideamia, age, ethnicity, genetic factors
How is non-alcoholic fatty liver disease diagnosed?
AST/ALT ratio Enhanced liver fibrosis panel Cytokeratin - 18 USS Fibroscan mr/ct LIVER. BIOPSY = GOLD STANDARD!
What antibodies are raised in autoimmune hepatitis?
IgG
What antibodies are raised in primary biliary cholangitis?
IgM
What is characteristic in primary sclerosis cholangitis?
pANCA +ve
When is jaundice detectable in relation to circulating bilirubin?
Plasma bilirubin >34umol/L
When is jaundice categorised as unconjugated and conjugated?
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)
What colour is urine and stool in pre-hepatic (unconjugated jaundice)?
Normal and normal
What colour is urine and stool in hepatic (conjugated jaundice)?
High coloured urine and normal stool
What colour is urine and stool in post-hepatic (conjugated jaundice)?
High coloured urine, pale stools
What are the signs of a pre-hepatic cause of jaundice?
Pallor
Splenomegaly
What are the signs of a hepatic cause of jaundice?
Spider naevi, ascites, asterixis
What are the signs of a post-hepatic cause of jaundice?
Palpable gall bladder
What is more specific, ALT or AST?
ALT
An increase in alkaline phosphatase is a sign of…
Post-hepatic obstruction
An increase in gamma GT is a sign of…
Excess alcohol consumption
What does prothrombin time suggest?
Stage of liver disease and determines who gets transplant
What does creatinine suggest?
Kidney function and survival from liver disease
A low albumin is a sign of?
Kidney disorders and malnutrition
What is the most important test to differentiate between intra- and extrahepatic obstruction?
Ultrasound
What are cons against ERCP instead of MRCP?
Has radiation
Uses sedation
Only images ducts
How does compensated liver disease present?
Abnormal LFTs detected on screening tests
How does decompensated liver disease present?
Ascites, spider naevi, variceal bleeding, hepatic encephalopathy
What procedure is carried out for new onset ascites?
Diagnostic paracentesis
What is the treatment for ascites?
Diuretics, large vol paracentesis, liver transplant
What causes a variceal haemorrhage?
Portal hypertension
What is hepatic encephalopathy?
Confusion from GI bleed, constipation, dehydration medication. Unable to breakdown toxins ---> ammonia Grade 1 (mild confusion) - grade 4 (coma)
What are signs of hepatic encephalopathy?
Flap - asterixis, foetor hepaticus
What does alcohol do to the liver?
Fatty liver (steatosis) and inflammation (steatohepatitis)
What does alcohol do to the gut?
Obesity, D&V, gastric erosions, peptic ulcers, varices, pancreatitis
What are signs of advanced alcohol related disease?
Muscle wasting Palmar erythema Gynaecomastia Encephalopathy Ascites Spider naevi Jaundice
What is the treatment for hepatic encephalitis?
Bowel clear out, lactulose, enemas, Abx, supportive (ITU airway), NG tube feeding
What are the signs of spontaneous bacterial peritonitis?
Ascites, fever, rigors, renal impairment, sepsis signs
What are the investigations for spontaneous bacterial peritonitis?
Ascitic tap, WBC, Neutrophil, protein, <25g/l transudate
What is the treatment of spontaneous bacterial peritonitis?
IV Abx, ascitic fluid drainage, IV albumin infusion
What type of liver failure occurs in context of cirrhosis?
Chronic
What percentage of those with gallstones are symptomatic?
10-30%
What are symptoms of gallstones?
Dyspepsia, biliary colic, acute cholecystitis (RUQ pain), empyema, jaundice, gallstone ileus
What investigations are carried out for gallstones?
Blood tests, USS, EUS, Oral cholecystography, IV Cholangiography, MRCP, PTC, ERCP
What are the treatment options for gallstones?
Non-operative: Dissolution or Lithotripsy
Operative: open cholecystectomy, laparoscopic cholecystectomy (GOLD STANDARD)
What is a cholangiocarcinoma?
Malignant tumour originating in bile ducts.
Extrahepatic = most common
What are the symptoms of a cholangiocarcinoma?
Painless obstructive jaundice
Itching
Non-specific symptoms
What are the investigations for a cholangiocarcinoma?
Lab, radiology, ERCP, Cholangioscopy, Cytology
What are the management options for a cholangiocarcinoma?
Surgery or palliation (ERCP then PCT stenting, radiotherapy, chemotherapy)
When managing an acutely unwell surgical admission what is the ‘system of five’ investigations?
Bedside obs Microbiology Blood tests Imaging Specialist tests
When managing an acutely unwell surgical admission what is the ‘system of five’ management?
O2 IV access Drug chart VTE Prophylaxis Escalation and involvement of MDT
What are the ethics of supplementary feeding?
Autonomy, beneficence, non-malefecience
Consider mental capacity
What are the causes of malabsorption?
Coeliac, Crohn’s, chronic pancreatitis, infection
What are symptoms of malabsorption?
Diarrhoea, weight loss, bloating, lethargy, steatorrhoea, increased appetite, dry pigment skin, easy bruising, hair loss, leuconychia
What tests are carried out when malabsorption suspected?
Tests of structure: CT/MRI, biopsy by endoscopy
Tests of function: bloods, bacterial overgrowth (H2 breath test)
What is the most reliable test for Coeliac?
IgA serology
Distal duodenal biopsy showing vilous atrophy
Gladin (fraction of gluten present from inflammatory response)
What is the universal screening tool for undernutrition?
Malnutrition Universal Screening Tool (MUST)
What are the clinical consequences of malnutrition?
Reduced muscle strength
Impaired immune response and wound healing
Poorer outcomes
Longer recovery from illness
What are the causes of under-nutrition?
Appetite failure
Access failure
Intestinal failure
What BMI is classed as underweight?
<20
What BMI is classed as overweight?
> 25 (obese = >30)
What are functional bowel disorders?
No detectable pathology
“software faults”
Name 3 examples of functional bowel disorders.
IBS, Non-ulcer dyspepsia, slow transit constipation
What differentiates between IBS and IBD?
Calprotectin (useful for Crohn’s)
What is the treatment for functional bowel disorders?
Education, reassurance, dietetic review, may need drug therapy for symptoms e.g for bloating, abdo pain, constipation, diarrhoea
What are the main causes of constipation?
Systemic (DM, Hypothyroidism)
Neurogenic (Parkinson’s, stroke, MS)
Organic (strictures, tumours, diverticular disease)
Functional (depression, megacolon)
What is the aetiology of Ulcerative Colitis?
20-40 years
F>M
What is the aetiology of Crohn’s disease?
Early adulthood or over 60
M>F
What are the symptoms of UC?
Bloody diarrhoea
Abdo pain
Weight loss
What are the symptoms of Crohn’s?
Diarrhoea, abdo pain, weight loss, malabsorption, malaise, lethargy, anorexia, N&V, low-grade fever
What are the signs of a severe attack of ulcerative colitis?
Stool >6/day + blood
AND fever, tachy, increased ESR/CRP, anaemia, albumin, leucocytosis, thrombocytosis
What blood results are indicative of IBD?
High ESR and CRP
High platelets, WCC
Low Hb
Low albumin
What stool results are indicative of IBD?
Elevated calprotectin (>200)
Where can extra-intestinal manifestations of IBD present?
Eyes, joints, renal calculi, skin, liver and biliary tree
What is the management of IBD?
5 step approach: 5ASA Prednisolone Immunomodulators - thiopurines Biologics (anti-TNFa) Surgery
What is the aetiology of colorectal cancer?
85% = sporadic 10% = familial 1% = IBD
What are the symptoms of colorectal cancer?
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)
What are the investigations for colorectal cancer?
Colonoscopy, barium enema, CT Colonography, CT abdo/pelvis
What are the treatment options for colorectal cancer?
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
What are the genetic conditions that predispose to colorectal cancer?
HNPCC, FAP
Who is screened for colorectal cancer?
50-74 and those at high risk (IBD, HNPCC, FAP, previous adenomas/CRC)
What test is used for colorectal screening?
Foecal immunochemical testing (FIT)
What is the likely site of ischaemic colitis?
Splenic flexure (“water shed area”)
What is important to consider during colorectal surgery?
Arterial supply
Lymphatic drainage
Venous and nerve supply
Anatomical relations
What are the advantages of laparoscopy compared to laparotomy?
Less scarring, less pain, faster recovery, shorter hospital stay, quicker return to normal activity
What are the cons of laparoscopy compared to laparotomy?
Longer op time, difficult visualisation, previous abdo surgery causes lesions
What are the main steps of colorectal surgery?
Inspection
Mobilisation
Division of blood supply
Anastomosis
What is a right hemicolectomy?
Removal of right colon
What is a sigmoid colectomy?
Remove sigmoid
What is a low anterior resection?
Remove rectum
What are the potential specific complications of colonic resection?
Intra-abdominal abscess Anastomotic leakage Drainage to surrounding structures Hernia formation Tumour recurrence Adhesion formation causing obstruction
What is an acute abdomen?
Combination of signs and symptoms including abdominal pain which results in a patient being referred for an urgent general surgical opinion
What are the steps in management of the acute abdomen?
Assess and resuscitate
Investigate
Observe
Treat
What should you consider in and acute abdomen?
Intestinal obstruction Peritonitis Acute pancreatitis Acute appendicitis Malignancy Ectopic pregnancy
How is a large bowel obstruction described?
Like childbirth pain
What are the signs and symptoms of intestinal obstruction?
Pain, vomiting, distension, constipation, borborygmi
What is the difference between visceral and somatic pain?
Somatic is more episodic
Visceral has systemic upset
What is the location of an upper GI bleed?
Oesophagus, stomach, duodenum
What is the location of a lower GI bleed?
Distal to duodenum
What are the symptoms of an upper GI bleed?
Haematemesis, melaena, increased urea, dyspepsia, reflux, epigastric pain
What are the symptoms of a lower GI bleed?
Fresh blood clots, magenta stools, normal urea, painless
What investigation is carried out for a suspected upper GI bleed?
Endoscopy
What investigations are carried out for a suspected lower GI bleed?
Flexible sigmoidoscopy or full colonoscopy
What is the management of GI bleeds?
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
What psychological problems are caused by GI disease?
Diarrhoea, conditioning (e.g vomit), loss of appetite, sexual problems, N&V
What psychological present as GI disease?
Stress, anxiety, depression, eating disorders
What is refeeding syndrome?
Adaptive starvation then refeeding with carbs (rapid increase in insulin, ATP, phosphate into cells causing hypophosphataemia)
What drugs are used for acid suppression?
Antacids
H2 receptor antagonists
PPIs
What drugs affect GI motility?
Anti-emetics
Anti-muscarinics
Anti-motility
What drugs are given for IBD? Give specific examples.
Aminosalicylates
Corticosteroids
Immunosuppressants
Biologics
What drugs affect intestinal secretions?
Bile acid sequestrates
Ursodeoxycholic acid
Give an example of an H2 antagonist?
Rantidine
What is the function of H2 antagonists?
Blocks histamine receptor, decreasing gastric acid secretion
What is the function PPIs?
Inhibit proton pump and reduce gastric acid secretion
Give an example of an anti-emetic.
Metoclopramide
Name three laxatives.
Senna (bowel cleaner)
Isphagula (bulk forming)
Arachis oil (softener) - enema
How is drug absorption affected in the GIT?
By pH, gut length and transit time
How is drug distribution affected in GIT?
By low albumin
How is drug metabolism affected in GIT?
Liver enzymes
Increased gut bacteria
Gut wall metabolism
Liver blood flow
How is drug excretion affected in GIT?
By biliary excretion
What are the pharmacodynamic effects of liver disease?
Exaggerated or reduced response
Raised toxicity
What scoring system is used to assess the severity of liver disease?
Child-Pugh Calssification
Name two hepatotoxic drugs?
Azathioprine
Methotrexate
What is the treatment option for prolapse?
Stapled anopexy
What is used to relax the internal anal sphincter?
Medical: topical NO, GTN paste, diltiazem calcium channel blocker
Surgical: internal lateral sphincterotomy
What is the treatment option for anal squamous cancer?
Radiotherapy
What are the treatment options for rectal adenocarcinoma?
Neoadjuvant chemotherapy and laparoscopic resection
Name 4 complications of gallstones.
Pancreatitis
Empyema
Jaundice
Chronic inflammation of gallbladder
Why does jaundice affect the clotting system?
Absence of bile in small bowel
Failure of absorption of fat soluble vitamins including vitamin K which is required for clotting factor synthesis
Describe the process of developing gastric cancer.
Normal –> chronic gastritis —> Intestinal metaplasia —> dysplasia —> carcinoma
State three complications of peptic ulceration.
Perforation, bleeding, stricture formation
What is the cause of coeliac disease?
Sensitivity to gluten/a-gladin
What procedure provides the diagnosis of coeliac disease?
Small bowel/duodenal biopsy
What is the characteristic histological finding for coeliac disease?
Villous atrophy
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis
What is the most common treatment for coeliac?
Exclude gluten from diet
23yo male, h/o alcohol misuse presents with upper abdo pain and vomiting and raised serum amylase. What is his likely diagnosis?
Acute pancreatitis
Stretch receptors in rectal wall activate what nervous centres in spinal cord during defection?
PNS
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?
Duodenum
If the distal ileum is removed, what vitamin deficiency is likely to occur?
Vit B12
55yo man 6/12 h/o progressive painless jaundice and weight loss. What is the likely diagnosis?
Pancreatic cancer
30yo male, presents with jaundice, intermittent right hypochondrial pain and nausea, dark urine and pale stools. What is the appropriate imaging test first?
Abdominal ultrasound
If vagus fibres cut around oesophagus what will result?
Delayed gastric emptying
What is most likely to occur after total colectomy?
Hyponatremia
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?
Multiple liver metastases
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?
Gastro-duodenal
Which two ingredients would make up a suitable oral rehydration therapy?
Sodium chloride and glucose
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?
Cystic artery
If gastric antrum removed, gastric acid production is reduced. Why?
Decrease in gastrin production
25yo female, 6/52 h/o diarrhoea and aphthous ulcers. Stool contains blood and mucous.
Crohn’s disease
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?
Ulcerative colitis
Describe colicky pain.
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.
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?
Acute appendicitis
45yo admitted after ingesting 25mg of paracetamol 3 days earlier. What is the most likely sign?
Jaundice
A tumour in the middle 1/3 of the oesophagus is most likely to be of what histological pathology?
Squamous cell carcinoma
What could be the cause of pain in the left iliac fossa?
Diverticulitis
What could be the cause of pain in the umbilical region?
Small bowel obstruction
Leaking aneurysm
What could be the cause of pain in the right or left lumbar regions?
Ureteric/renal colic
Leaking aneurysm
Name two causes of pain in the right iliac fossa.
Appendicitis
Crohn’s
Name two causes of pain in the right hypochondrium.
Hepatitis
Cholecystitis
What can cause pain in the left hypochondrium?
Splenic rupture or infarct
What can cause pain in the epigastrium?
Peptic ulcer
Pancreatitis
What can cause pain in the hypogastrium?
Large bowel obstruction Fibroids Urinary retention Ovarian cysts Ectopic pregnancy
What are the symptoms of dyspepsia?
Pain/discomfort in upper abdomen Retrosternal pain Anorexia Nausea Vomiting Bloating Early satiety Heartburn
What does foecal calprotectin have high sensitivity for?
GI inflammation
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?
Gastrin
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?
Cholecystokinin
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?
Hydrogen/potassium adenosine triphosphatase pumps
A digestive tract enzyme may be initially released in an active form. what is the best term to describe this compound?
Zymogen
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?
Emulsification
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?
Haemolytic anaemia
What are the Cl- and K+ electrolyte disturbances most commonly seen with diarrhoea?
High Cl-, low K+ and low pH
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?
Third-part of duodenum
A 45yo woman has surgical removal of her distal ileum to treat inflammatory bowel disease. Which enzyme is at risk of becoming deficient?
Vitamin A
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?
Vitamin B12
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?
Secretin
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?
Abdominal ultrasound
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?
Delayed gastric emptying
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?
Hyponatraemia
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?
Increased bicarbonate
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?
Central distribution of loops of bowel
A 45yo smoker with massive haematemesis and melaena. Endoscopy reveals an actively bleeding posterior duodenal ulcer. What artery is most likely to be bleeding?
Gastro-duodenal
A 30yo man is suspected of having impaired intestinal motility. Routine blood and imaging tests are normal. what could explain his impaired motility?
Segmentation contractions are reduced during a meal
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?
Cystic artery
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?
Virtually eliminates gastrin production
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?
Crohn’s disease
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?
Ulcerative colitis
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?
Acute appendicitis
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?
Jaundice
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?
- As a consequence of embryonic folding, part of the endodermal-lined amniotic cavity is incorporated into the gut.
- The parenchyma of glands developing when the gut is formed from endoderm
- The respiratory diverticulum helps form the oesophagus
- The superior mesenteric artery formation results in formation of the axis of rotation for a primary intestinal loop
- The distal part of the anal canal is formed from ectoderm
ANSWER = 1
What would the consequence of bilateral vagotomy be on salivary secretion?
No effect since no vagal innervation of head and neck (CN VII and IX responsible)
What would the consequence of bilateral vagotomy be on parietal cell HCL secretion?
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.
What would the consequence of bilateral vagotomy be on parietal cell G cell gastrin secretion?
Stimulation of gastrin secretion during cephalic phase would be removed
However, distension/peptide - induced stimulation of G cells would remain
What would the consequence of bilateral vagotomy be on gastric motility?
Gastric motility would be reduced but local enteric reflexes would maintain a degree of motility.
Gastric emptying into duodenum would be reduced
What would the consequence of bilateral vagotomy be on defecation?
Limit ability to defecate in particular reflex contraction of rectum and control of internal and external anal sphincter tone
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?
- 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
A woman with jaundice and LFTs showing a high alkaline phosphatase. Does this indicate a hepatic or post-hepatic cause of jaundice?
Post-hepatic
State 3 possible causes of obstructive jaundice.
Gall stone in common bile duct
Tumour in common bile duct
Carcinoma in head of pancreas
Tumour of ampulla of Vater
What is the initial investigation to look at the biliary tree?
Ultrasound
Give 4 complications of gallstones.
Acute inflammation of gall bladder Perforation of gall bladder wall Empyema Jaundice Biliary colic Carcinoma of gall bladder Pancreatitis
State three risk factors for gallstones.
Forty Fatty Fertile Female Diabetes
Why does jaundice affect the clotting system?
Absence of bile in the small intestine –> Failure of absorption of fat soluble vitamins including vit K which is required for clotting
A 65yo man presents with a single episode of haematemesis. He also complains of recent anorexia and weight loss. What investigation would you request?
Upper GI endoscopy
Give 4 differential diagnoses for haematemesis.
Gastritis Peptic ulcer Mallory Weiss Tear Gastric carcinoma Oesophageal carcinoma Oesophageal varices
During endoscopy, an irregular ulcer in the antrum was seen. How would a pathological diagnosis be established?
Biopsy of lesion
Describe the process of development of gastric cancer.
Normal –> chronic gastritis –> intestinal metaplasia –> dysplasia –> carcinoma
By which four routes does gastric cancer spread?
Direct
Lymphatic
Blood
Transcoelemic
What is the prognosis of gastric cancer?
Less than 20% in 5 years
Which bacterium is associated with the development of gastric cancer?
H pylori
How do you eradicate H. pylori?
Triple therapy for 7 days: amoxycillin (or metronidazole) + clarithromycin + PPI
State 3 complications of peptic ulceration.
Perforation
Bleeding
Stricture formation
A 24yo patient is referred for investigation of malabsorption and weight loss. Coeliac disease is suspected. What is the cause of coeliac?
Sensitivity to gluten/ a-gliadin
What procedure provides the diagnosis and what is the characteristic histological finding?
Smal bowel/duodenal biopsy –> vollus atrophy
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis
What is the commonest treatment for coeliac disease?
Exclude gluten from the diet
A 71yo man had a malignant tumour of the middle third of the oesophagus. What is the most likely histopathological diagnosis?
Squamous cell carcinoma
What combination of monosaccharides make up lactose?
Glucose and galactose
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?
Sodium chloride and glucose
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?
Multiple liver metastases
A 55yo man presents with 6 weeks history of progressive painless jaundice. Abdominal palpation is normal. What is the most likely diagnosis?
Pancreatic cancer
A 45yo woman has surgical removal of her distal ileum to treat IBD. What vitamin is she likely to become deficient in?
Vit B12
A 47yo man was referred for investigation of impaired defecation. What is the normal mechanism of defecation?
Stretch receptors in the rectal wall activate PNS centres in the spinal cord
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?
Acute pancreatitis
Name two drugs that cause jaundice.
Flucolaxacillin and co-amoxiclav
