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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
How does chronic liver disease present?
Oesophageal varices - haematemesis, melaena, splenomegaly, caput medusae, rectal varices, fetor hepaticus, coma, spider naevi, jaundice, ascites etc
26
Describe cirrhosis
Diffuse process of whole liver - normal liver structure replaced by nodules of hepatocytes of fibrous tissue
27
Where is diverticular disease most commonly found?
Sigmoid colon
28
What are the causes of acute cholecystitis?
``` 90% = gallstones 10% = blockage in cystic duct ```
29
Describe the neuronal control of intestinal motility.
``` Intrinsic = myenteric plexus "Meissner's and Auerbach's" Extrinsic = ANS ```
30
Describe idiopathic IBD.
Chronic inflammation from inappropriate or persistent activation of mucosal immune system driven by. normal intraluminal flora
31
Where is inflammation present in Crohn's?
Mouth to anus
32
Where is inflammation present in Ulcerative Colitis?
Colon only
33
In what IBD condition would you find "skip lesions", non-ceseating granulomas and "cobblestone" ulcerations?
Crohn's
34
In what IBD condition would you find pseudopolyps and NO granulomas?
Ulcerative colitis
35
What does ischaemic enteritis effect?
SI, LI or both
36
Name 4 potential routes of spread of stomach cancer
Direct, lymphatics, blood, transcolemic
37
What are the causes of bilateRAL leg Swelling?
Right heart failure, Albumin low, Large abdo mass, Sitting
38
What are the causes of ascites?
Cancer, portal hypertension, cirrhosis
39
What causes portal hypertension?
Splenomegaly | Oesophageal varices
40
If cancer in lower oesophagus what is the likely diagnosis?
Adenocarcinoma (from Barrett's oesophagus)
41
If cancer in upper oesophagus what is the likely diagnosis?
Squamous cell carcinoma (alcoholic)
42
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
43
What is ERCP?
Endoscopic Retrograde Cholangio-pancreatography - visualises ampulla, biliary system and pancreatic ducts - stone removal, biopsy, stenting
44
What is enteroscopy used to visualise?
Small intestine
45
What are the pros and cons of MRCP?
Pro - no risk of pancreatitis | Con - can't do interventional procedures
46
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
47
What are the causes of dysphagia?
Benign or malignant stricture, motility disorders, eosinophilic oesophagitis, extrinsic compression
48
What are the investigations for dysphagia?
Endoscopy, barium swallow, oesophageal pH and manometry
49
What is the treatment for dysphagia?
Endoscopic balloon dilatation, botulinum injection
50
Define achalasia.
Failure of relaxation of LOS (from functional loss of myenteric plexus)
51
What are the symptoms of achalasia?
Progressive dysphagia, weight loss, chest pain, regurgitation and chest infections
52
What tests are carries out for achalasia?
Manometry
53
What treatment is given for achalasia?
Nitrates, CCBs, pneumatic balloon, botulinum, myotomy (surgical)
54
What is GORD?
Acid and bile exposure in lower oesophagus
55
What are the risk factors for GORD?
Pregnancy, obesity, drugs lowering LOS pressure, smoking, alcohol
56
What are the two types of hiatus hernia?
Sliding and para-oesophageal
57
What is the treatment for GORD?
Lifestyle change, antacids or alginates, add PPI and for refractory symptoms add H2 blocker
58
What is the treatment for Barrett's oesophagus?
endoscopic mucosal resection radio-frequency ablation oesophagectomy (rare)
59
What are the symptoms of oesophageal cancer?
Progressive dysphagia, anorexia, weight. loss, odynophagia, chest pain, cough, pneumonia, vocal cord paralysis, haematemesis
60
What investigations are used for suspected oesophageal cancer?
Endoscopy and biopsy | Staging by CT, EUS, PET, Bone scan
61
What are the treatment options for oesophageal cancer?
Symptom palliation OR if localised = Surgical oesophagectomy +/- neoadjuvant or adjuvant chemotherapy
62
What are the treatment options for eosinophilic oesophagitis?
Topical/swallowed corticosteroids Dietary elimination Endoscopic dilatation
63
Describe the presentation of dyspepsia (organic vs functional).
Upper abdo discomfort, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety, heartburn
64
What can cause dyspepsia?
Upper GI: gastritis, peptic ulcer, gastric cancer, gall stones Lower GI: IBS, Colon cancer, coeliac disease Other: metabolic, cardiac, drugs
65
When should you refer to endoscopy?
ALARMS
66
What does ALARMS stand for?
Anorexia, Loss of weight, Anaemia, Recent onset >55y or persistent despite treatment, Melaena/hematemesis or Mass, Swallowing problems
67
What is the aetiology of peptic ulcers?
``` Men>Women Elderly Smoking NSAIDs Zollinger-Ellison syndrome Hyperparathyroidism Crohn's ```
68
What are the symptoms of peptic ulcers?
Epigastric pain, nocturnal hunger/pain, back pain, nausea, weight loss
69
What is the second most common malignancy?
Gastric cancer
70
What is the Correa Hypothesis of gastric cancer?
2 histopathological subtypes - Intestinal (majority) and diffuse
71
What is the management of gastric cancer?
Endoscopy, biopsy, staging radiology, MDT discussion, surgery and chemotherapy (rarely radiotherapy)
72
Describe the structure of H.pylori.
Gram -ve Spiral-shaped Flagellated Microaerophilic
73
Name a type 1 carcinogen?
H.pylori
74
Discuss the divergent responses to H.pylori.
1. Antral predominant --> DU disease 2. Mild mixed gastritis ---> no significant disease 3. Corpus predominant ---> gastric CA
75
How is H.pylori diagnosed?
Serology (IgG), 13C/14C urea breath. test, stool Ag. test, endoscopy, rapid slide urease test
76
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
77
What conduits are used in oesophagectomy?
Stomach, transverse colon
78
When is surgery classed as bariatric?
BMI >35
79
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 ```
80
What suggested acute pancreatitis?
Elevated serum amylase
81
What are the symptoms of acute pancreatitis?
Gradual or sudden severe epigastric pain or central abdominal pain, vomiting, nausea, collapse
82
What are the signs of acute pancreatitis?
Pyrexia, jaundice, shock, paralytic ileus, rigid abdomen, Cullen's sign, Grey Turner's sign, Tachycardia
83
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 ```
84
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
85
What are complications of acute pancreatitis?
Abscess, psuedocyst
86
What causes chronic pancreatitis?
``` O A TIGER Obstruction of MPD Autoimmune Toxin (alcohol = 80%) Idiopathic Genetic Environmental Recurrence injuries ```
87
What are the symptoms and signs of chronic pancreatitis?
Abdo pain, weight. loss, exocrine and/or endocrine insufficiency, jaundice, portal hypertension, GI haemorrhage
88
What are the investigations for chronic pancreatitis?
Plain AXR, CT, USS, EUS, Bloods (decrease albumin, increase LFTs), ERCP, MRCP
89
What are the treatment options for chronic pancreatitis?
1. Pain control (avoid alcohol, opiates) | 2. Exocrine and endocrine control (low fat diet, insulin, pancreatic enzyme supplements)
90
What are the risk factors for pancreatic cancer?
Smoking, alcohol, diet, chronic pancreatitis, DM, age 60-80
91
What are the symptoms of pancreatic cancer?
Upper abdo pain, painless obstructive jaundice, weight loss, fatigue, vomiting, ascites, DM
92
What are the signs of pancreatic cancer?
Jaundice, hepatomegaly, abdo mass, tenderness, ascites, splenomegaly
93
What tests are carried out for pancreatic cancer?
ERCP2, USS, CT, MRI, EUS, bloods, CXR | *Tumour markers NOT very sensitive
94
What are the management options for pancreatic cancer?
<10% operable (pancreatoduodenectomy - Whipple's procedure)
95
What is the survival rate after Whipple's procedure for pancreatic cancer?
15% 5y survival
96
What are the main types of surgery for pancreatic cancer?
Kausch-Whipple PPPD Palliative drainage when obstructive jaundice or duodenal obstruction
97
What types of viral hepatitis are enteric and cause self-limiting acute infections?
A & E
98
What types of viral hepatitis are parenteral and cause chronic disease?
B, C and D
99
What type of hepatitis is mainly found in topical areas?
Hep A
100
What type of hepatitis is mainly found in sub-saharan Africa, South East Asia etc?
Hep B
101
What type of hepatitis causes an initial increase in IgM?
Hep A
102
How is Hep A transmitted?
faecal-oral, sexual, blood
103
What is the treatment for Hep B?
Pegylated interferon, oral antiretroviral (entecavir, tenofovir)
104
What type of hepatitis evades the immune system like HIV (requiring reverse transcriptase)?
Hep C
105
What is Hep E usually co-infected with?
HBV
106
What is the commonest cause of acute hepatitis in Grampian?
Hep E
107
What is non-alcoholic fatty liver disease associated with?
DM, Obesity, HPT, Hypertriglycerideamia, age, ethnicity, genetic factors
108
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! ```
109
What antibodies are raised in autoimmune hepatitis?
IgG
110
What antibodies are raised in primary biliary cholangitis?
IgM
111
What is characteristic in primary sclerosis cholangitis?
pANCA +ve
112
When is jaundice detectable in relation to circulating bilirubin?
Plasma bilirubin >34umol/L
113
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) ```
114
What colour is urine and stool in pre-hepatic (unconjugated jaundice)?
Normal and normal
115
What colour is urine and stool in hepatic (conjugated jaundice)?
High coloured urine and normal stool
116
What colour is urine and stool in post-hepatic (conjugated jaundice)?
High coloured urine, pale stools
117
What are the signs of a pre-hepatic cause of jaundice?
Pallor | Splenomegaly
118
What are the signs of a hepatic cause of jaundice?
Spider naevi, ascites, asterixis
119
What are the signs of a post-hepatic cause of jaundice?
Palpable gall bladder
120
What is more specific, ALT or AST?
ALT
121
An increase in alkaline phosphatase is a sign of...
Post-hepatic obstruction
122
An increase in gamma GT is a sign of...
Excess alcohol consumption
123
What does prothrombin time suggest?
Stage of liver disease and determines who gets transplant
124
What does creatinine suggest?
Kidney function and survival from liver disease
125
A low albumin is a sign of?
Kidney disorders and malnutrition
126
What is the most important test to differentiate between intra- and extrahepatic obstruction?
Ultrasound
127
What are cons against ERCP instead of MRCP?
Has radiation Uses sedation Only images ducts
128
How does compensated liver disease present?
Abnormal LFTs detected on screening tests
129
How does decompensated liver disease present?
Ascites, spider naevi, variceal bleeding, hepatic encephalopathy
130
What procedure is carried out for new onset ascites?
Diagnostic paracentesis
131
What is the treatment for ascites?
Diuretics, large vol paracentesis, liver transplant
132
What causes a variceal haemorrhage?
Portal hypertension
133
What is hepatic encephalopathy?
``` Confusion from GI bleed, constipation, dehydration medication. Unable to breakdown toxins ---> ammonia Grade 1 (mild confusion) - grade 4 (coma) ```
134
What are signs of hepatic encephalopathy?
Flap - asterixis, foetor hepaticus
135
What does alcohol do to the liver?
Fatty liver (steatosis) and inflammation (steatohepatitis)
136
What does alcohol do to the gut?
Obesity, D&V, gastric erosions, peptic ulcers, varices, pancreatitis
137
What are signs of advanced alcohol related disease?
``` Muscle wasting Palmar erythema Gynaecomastia Encephalopathy Ascites Spider naevi Jaundice ```
138
What is the treatment for hepatic encephalitis?
Bowel clear out, lactulose, enemas, Abx, supportive (ITU airway), NG tube feeding
139
What are the signs of spontaneous bacterial peritonitis?
Ascites, fever, rigors, renal impairment, sepsis signs
140
What are the investigations for spontaneous bacterial peritonitis?
Ascitic tap, WBC, Neutrophil, protein, <25g/l transudate
141
What is the treatment of spontaneous bacterial peritonitis?
IV Abx, ascitic fluid drainage, IV albumin infusion
142
What type of liver failure occurs in context of cirrhosis?
Chronic
143
What percentage of those with gallstones are symptomatic?
10-30%
144
What are symptoms of gallstones?
Dyspepsia, biliary colic, acute cholecystitis (RUQ pain), empyema, jaundice, gallstone ileus
145
What investigations are carried out for gallstones?
Blood tests, USS, EUS, Oral cholecystography, IV Cholangiography, MRCP, PTC, ERCP
146
What are the treatment options for gallstones?
Non-operative: Dissolution or Lithotripsy | Operative: open cholecystectomy, laparoscopic cholecystectomy (GOLD STANDARD)
147
What is a cholangiocarcinoma?
Malignant tumour originating in bile ducts. | Extrahepatic = most common
148
What are the symptoms of a cholangiocarcinoma?
Painless obstructive jaundice Itching Non-specific symptoms
149
What are the investigations for a cholangiocarcinoma?
Lab, radiology, ERCP, Cholangioscopy, Cytology
150
What are the management options for a cholangiocarcinoma?
Surgery or palliation (ERCP then PCT stenting, radiotherapy, chemotherapy)
151
When managing an acutely unwell surgical admission what is the 'system of five' investigations?
``` Bedside obs Microbiology Blood tests Imaging Specialist tests ```
152
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 ```
153
What are the ethics of supplementary feeding?
Autonomy, beneficence, non-malefecience | Consider mental capacity
154
What are the causes of malabsorption?
Coeliac, Crohn's, chronic pancreatitis, infection
155
What are symptoms of malabsorption?
Diarrhoea, weight loss, bloating, lethargy, steatorrhoea, increased appetite, dry pigment skin, easy bruising, hair loss, leuconychia
156
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)
157
What is the most reliable test for Coeliac?
IgA serology Distal duodenal biopsy showing vilous atrophy Gladin (fraction of gluten present from inflammatory response)
158
What is the universal screening tool for undernutrition?
Malnutrition Universal Screening Tool (MUST)
159
What are the clinical consequences of malnutrition?
Reduced muscle strength Impaired immune response and wound healing Poorer outcomes Longer recovery from illness
160
What are the causes of under-nutrition?
Appetite failure Access failure Intestinal failure
161
What BMI is classed as underweight?
<20
162
What BMI is classed as overweight?
>25 (obese = >30)
163
What are functional bowel disorders?
No detectable pathology | "software faults"
164
Name 3 examples of functional bowel disorders.
IBS, Non-ulcer dyspepsia, slow transit constipation
165
What differentiates between IBS and IBD?
Calprotectin (useful for Crohn's)
166
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
167
What are the main causes of constipation?
Systemic (DM, Hypothyroidism) Neurogenic (Parkinson's, stroke, MS) Organic (strictures, tumours, diverticular disease) Functional (depression, megacolon)
168
What is the aetiology of Ulcerative Colitis?
20-40 years | F>M
169
What is the aetiology of Crohn's disease?
Early adulthood or over 60 | M>F
170
What are the symptoms of UC?
Bloody diarrhoea Abdo pain Weight loss
171
What are the symptoms of Crohn's?
Diarrhoea, abdo pain, weight loss, malabsorption, malaise, lethargy, anorexia, N&V, low-grade fever
172
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
173
What blood results are indicative of IBD?
High ESR and CRP High platelets, WCC Low Hb Low albumin
174
What stool results are indicative of IBD?
Elevated calprotectin (>200)
175
Where can extra-intestinal manifestations of IBD present?
Eyes, joints, renal calculi, skin, liver and biliary tree
176
What is the management of IBD?
``` 5 step approach: 5ASA Prednisolone Immunomodulators - thiopurines Biologics (anti-TNFa) Surgery ```
177
What is the aetiology of colorectal cancer?
``` 85% = sporadic 10% = familial 1% = IBD ```
178
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)
179
What are the investigations for colorectal cancer?
Colonoscopy, barium enema, CT Colonography, CT abdo/pelvis
180
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 ```
181
What are the genetic conditions that predispose to colorectal cancer?
HNPCC, FAP
182
Who is screened for colorectal cancer?
50-74 and those at high risk (IBD, HNPCC, FAP, previous adenomas/CRC)
183
What test is used for colorectal screening?
Foecal immunochemical testing (FIT)
184
What is the likely site of ischaemic colitis?
Splenic flexure ("water shed area")
185
What is important to consider during colorectal surgery?
Arterial supply Lymphatic drainage Venous and nerve supply Anatomical relations
186
What are the advantages of laparoscopy compared to laparotomy?
Less scarring, less pain, faster recovery, shorter hospital stay, quicker return to normal activity
187
What are the cons of laparoscopy compared to laparotomy?
Longer op time, difficult visualisation, previous abdo surgery causes lesions
188
What are the main steps of colorectal surgery?
Inspection Mobilisation Division of blood supply Anastomosis
189
What is a right hemicolectomy?
Removal of right colon
190
What is a sigmoid colectomy?
Remove sigmoid
191
What is a low anterior resection?
Remove rectum
192
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 ```
193
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
194
What are the steps in management of the acute abdomen?
Assess and resuscitate Investigate Observe Treat
195
What should you consider in and acute abdomen?
``` Intestinal obstruction Peritonitis Acute pancreatitis Acute appendicitis Malignancy Ectopic pregnancy ```
196
How is a large bowel obstruction described?
Like childbirth pain
197
What are the signs and symptoms of intestinal obstruction?
Pain, vomiting, distension, constipation, borborygmi
198
What is the difference between visceral and somatic pain?
Somatic is more episodic | Visceral has systemic upset
199
What is the location of an upper GI bleed?
Oesophagus, stomach, duodenum
200
What is the location of a lower GI bleed?
Distal to duodenum
201
What are the symptoms of an upper GI bleed?
Haematemesis, melaena, increased urea, dyspepsia, reflux, epigastric pain
202
What are the symptoms of a lower GI bleed?
Fresh blood clots, magenta stools, normal urea, painless
203
What investigation is carried out for a suspected upper GI bleed?
Endoscopy
204
What investigations are carried out for a suspected lower GI bleed?
Flexible sigmoidoscopy or full colonoscopy
205
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 ```
206
What psychological problems are caused by GI disease?
Diarrhoea, conditioning (e.g vomit), loss of appetite, sexual problems, N&V
207
What psychological present as GI disease?
Stress, anxiety, depression, eating disorders
208
What is refeeding syndrome?
Adaptive starvation then refeeding with carbs (rapid increase in insulin, ATP, phosphate into cells causing hypophosphataemia)
209
What drugs are used for acid suppression?
Antacids H2 receptor antagonists PPIs
210
What drugs affect GI motility?
Anti-emetics Anti-muscarinics Anti-motility
211
What drugs are given for IBD? Give specific examples.
Aminosalicylates Corticosteroids Immunosuppressants Biologics
212
What drugs affect intestinal secretions?
Bile acid sequestrates | Ursodeoxycholic acid
213
Give an example of an H2 antagonist?
Rantidine
214
What is the function of H2 antagonists?
Blocks histamine receptor, decreasing gastric acid secretion
215
What is the function PPIs?
Inhibit proton pump and reduce gastric acid secretion
216
Give an example of an anti-emetic.
Metoclopramide
217
Name three laxatives.
Senna (bowel cleaner) Isphagula (bulk forming) Arachis oil (softener) - enema
218
How is drug absorption affected in the GIT?
By pH, gut length and transit time
219
How is drug distribution affected in GIT?
By low albumin
220
How is drug metabolism affected in GIT?
Liver enzymes Increased gut bacteria Gut wall metabolism Liver blood flow
221
How is drug excretion affected in GIT?
By biliary excretion
222
What are the pharmacodynamic effects of liver disease?
Exaggerated or reduced response | Raised toxicity
223
What scoring system is used to assess the severity of liver disease?
Child-Pugh Calssification
224
Name two hepatotoxic drugs?
Azathioprine | Methotrexate
225
What is the treatment option for prolapse?
Stapled anopexy
226
What is used to relax the internal anal sphincter?
Medical: topical NO, GTN paste, diltiazem calcium channel blocker Surgical: internal lateral sphincterotomy
227
What is the treatment option for anal squamous cancer?
Radiotherapy
228
What are the treatment options for rectal adenocarcinoma?
Neoadjuvant chemotherapy and laparoscopic resection
229
Name 4 complications of gallstones.
Pancreatitis Empyema Jaundice Chronic inflammation of gallbladder
230
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
231
Describe the process of developing gastric cancer.
Normal --> chronic gastritis ---> Intestinal metaplasia ---> dysplasia ---> carcinoma
232
State three complications of peptic ulceration.
Perforation, bleeding, stricture formation
233
What is the cause of coeliac disease?
Sensitivity to gluten/a-gladin
234
What procedure provides the diagnosis of coeliac disease?
Small bowel/duodenal biopsy
235
What is the characteristic histological finding for coeliac disease?
Villous atrophy
236
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis
237
What is the most common treatment for coeliac?
Exclude gluten from diet
238
23yo male, h/o alcohol misuse presents with upper abdo pain and vomiting and raised serum amylase. What is his likely diagnosis?
Acute pancreatitis
239
Stretch receptors in rectal wall activate what nervous centres in spinal cord during defection?
PNS
240
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
241
If the distal ileum is removed, what vitamin deficiency is likely to occur?
Vit B12
242
55yo man 6/12 h/o progressive painless jaundice and weight loss. What is the likely diagnosis?
Pancreatic cancer
243
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
244
If vagus fibres cut around oesophagus what will result?
Delayed gastric emptying
245
What is most likely to occur after total colectomy?
Hyponatremia
246
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
247
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
248
Which two ingredients would make up a suitable oral rehydration therapy?
Sodium chloride and glucose
249
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
250
If gastric antrum removed, gastric acid production is reduced. Why?
Decrease in gastrin production
251
25yo female, 6/52 h/o diarrhoea and aphthous ulcers. Stool contains blood and mucous.
Crohn's disease
252
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
253
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.
254
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
255
45yo admitted after ingesting 25mg of paracetamol 3 days earlier. What is the most likely sign?
Jaundice
256
A tumour in the middle 1/3 of the oesophagus is most likely to be of what histological pathology?
Squamous cell carcinoma
257
What could be the cause of pain in the left iliac fossa?
Diverticulitis
258
What could be the cause of pain in the umbilical region?
Small bowel obstruction | Leaking aneurysm
259
What could be the cause of pain in the right or left lumbar regions?
Ureteric/renal colic | Leaking aneurysm
260
Name two causes of pain in the right iliac fossa.
Appendicitis | Crohn's
261
Name two causes of pain in the right hypochondrium.
Hepatitis | Cholecystitis
262
What can cause pain in the left hypochondrium?
Splenic rupture or infarct
263
What can cause pain in the epigastrium?
Peptic ulcer | Pancreatitis
264
What can cause pain in the hypogastrium?
``` Large bowel obstruction Fibroids Urinary retention Ovarian cysts Ectopic pregnancy ```
265
What are the symptoms of dyspepsia?
``` Pain/discomfort in upper abdomen Retrosternal pain Anorexia Nausea Vomiting Bloating Early satiety Heartburn ```
266
What does foecal calprotectin have high sensitivity for?
GI inflammation
267
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
268
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
269
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
270
A digestive tract enzyme may be initially released in an active form. what is the best term to describe this compound?
Zymogen
271
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
272
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
273
What are the Cl- and K+ electrolyte disturbances most commonly seen with diarrhoea?
High Cl-, low K+ and low pH
274
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
275
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
276
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
277
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
278
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
279
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
280
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
281
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
282
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
283
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
284
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
285
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
286
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
287
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
288
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
289
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
290
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
291
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?
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
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)
293
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.
294
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
295
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
296
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
297
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
298
A woman with jaundice and LFTs showing a high alkaline phosphatase. Does this indicate a hepatic or post-hepatic cause of jaundice?
Post-hepatic
299
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
300
What is the initial investigation to look at the biliary tree?
Ultrasound
301
Give 4 complications of gallstones.
``` Acute inflammation of gall bladder Perforation of gall bladder wall Empyema Jaundice Biliary colic Carcinoma of gall bladder Pancreatitis ```
302
State three risk factors for gallstones.
``` Forty Fatty Fertile Female Diabetes ```
303
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
304
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
305
Give 4 differential diagnoses for haematemesis.
``` Gastritis Peptic ulcer Mallory Weiss Tear Gastric carcinoma Oesophageal carcinoma Oesophageal varices ```
306
During endoscopy, an irregular ulcer in the antrum was seen. How would a pathological diagnosis be established?
Biopsy of lesion
307
Describe the process of development of gastric cancer.
Normal --> chronic gastritis --> intestinal metaplasia --> dysplasia --> carcinoma
308
By which four routes does gastric cancer spread?
Direct Lymphatic Blood Transcoelemic
309
What is the prognosis of gastric cancer?
Less than 20% in 5 years
310
Which bacterium is associated with the development of gastric cancer?
H pylori
311
How do you eradicate H. pylori?
Triple therapy for 7 days: amoxycillin (or metronidazole) + clarithromycin + PPI
312
State 3 complications of peptic ulceration.
Perforation Bleeding Stricture formation
313
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
314
What procedure provides the diagnosis and what is the characteristic histological finding?
Smal bowel/duodenal biopsy --> vollus atrophy
315
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis
316
What is the commonest treatment for coeliac disease?
Exclude gluten from the diet
317
A 71yo man had a malignant tumour of the middle third of the oesophagus. What is the most likely histopathological diagnosis?
Squamous cell carcinoma
318
What combination of monosaccharides make up lactose?
Glucose and galactose
319
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
320
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
321
A 55yo man presents with 6 weeks history of progressive painless jaundice. Abdominal palpation is normal. What is the most likely diagnosis?
Pancreatic cancer
322
A 45yo woman has surgical removal of her distal ileum to treat IBD. What vitamin is she likely to become deficient in?
Vit B12
323
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
324
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
325
Name two drugs that cause jaundice.
Flucolaxacillin and co-amoxiclav

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