Diseases

Question 1

Defective mucosal absorption is caused by what?

Answer 1

• defective luminal digestion
• mucosal disease
• structural disorders

Question 2

Name some common causes of malabsorption

Answer 2

• coeliac disease
• crohns disease
• post infectious
• biliary obstruction
• cirrhosis

Question 3

Name some uncommon causes of malabsorption

Answer 3

• pancreatic cancer
• parasites
• bacterial overgrowth
• drugs
• short bowel (inc. resections

Question 4

Name some malabsorptive states

Answer 4

• protein
• fat
• carbohydrate
• vitamin and minerals

Question 5

Describe digestive protein malabsorption

Answer 5

• partial or total gastrectomy (poor mixing)
• exocrine pancreatic insufficiency
• trypsinogen deficiency
• congenital deficiency of intestinal enterokinase

Question 6

Describe absorptive protein malabsorption

Answer 6

• coeliac disease and tropical sprue
• methionine malabsorption syndrome and blue diaper syndrome
• short bowel syndrome
• jejunoileal bypass
• defects in neutral AA transporters
• cystinuria
• oculocerebral syndrome of lowe

Question 7

Describe digestive fat malabsorption

Answer 7

• less time to mix; gastric resection, autonomic neuropathy, amyloidosis
• dec micelle formation, decrease bile acids synthesis / secretion; cirrhosis, biliary obstruction, CCK deficiency, small intestinal bacterial overgrowth
• decreased lipolysis; chronic pancreatitis, cystic fibrosis, pancreatic ampullary tumours, low luminal pH, excessive calcium ingestion, lipase / co-lipase deficiency

Question 8

Describe absorptive fat malabsorption

Answer 8

• decreased chylomicron formation and / or mucosal absorption
• coeliac disease, abetalipoproteinaemia, chylomicron retention disease

Question 9

Describe post absorptive fat malabsorption

Answer 9

• defective lymphatic transport

- primary intestinal lymphangicestasia, lymphoma, whipple disease, trauma, retroperitoneal fibrosis

Question 10

Describe digestive carbohydrate malabsorption

Answer 10

• severe pancreatic insufficiency

- alpha- amylase deficiency

Question 11

Describe absorptive carbohydrate malabsorption

Answer 11

• primary or acquired lactase deficiency

- post infectious lactase deficiency, coeliac disease, crohns, sucrase isomaltase deficiency, trehalase deficiency

Question 12

What would cause vitamin B12 deficiency?

Answer 12

• atrophic gastritis (impaired peptin / acid secretion)
• deficiency of gastric intrinsic factor (pernicious anaemia / antrectomy)
• pancreatic insufficiency (reduced release of B12 from R binding protein)
• helminth infections
• ileal crohn disease / resection

Question 13

What could cause folic acid deficiency?

Answer 13

• caused by diseases affecting the proximal small bowel
• coeliac disease / whipple / tropical sprue
• alcoholism

Question 14

What could cause fat soluble vitamin (ADEK) deficiency?

Answer 14

• anything that disrupts fat absorption will result in one / more deficiency

Question 15

What could cause calcium deficiency?

Answer 15

• selective deficiency can occur
• renal disease / hypoparathyroidism
• inborn defect in the vit D receptor
• diseases that reduce intestinal surface area and / or cause formation of insoluble calcium soaps with long chain fatty acids
• coeliac disease
• bile acid deficiency

Question 16

What would cause magnesium deficiency?

Answer 16

• usually caused by loss of mucosal surface area and / or luminal binding by malabsorbed fatty acids

Question 17

What could cause iron deficiency?

Answer 17

• caused by reduced mucosal surface area but most often caused by GI bleeding

Question 18

What could cause zinc deficiency?

Answer 18

• acrodermatitis enteropathica

- defect in the zinc transport protein hZ1P4

Question 19

What could cause copper deficiency?

Answer 19

• menkes disease

- caused by an inherited disorder of cellular copper transport

Question 20

What is coeliac disease?

Answer 20

Exposure to wheat, barley or rye induces a characteristic mucosal lesion

Question 21

What causes coeliac disease?

Answer 21

• intestinal antigen presenting cells in people expressing HLA-DQ2, or HLA-DQ8 bind with dietary gluten peptides in their antigen-binding grooves activate specific mucosal T lymphocytes cytokines mucosal damage

Question 22

Describe the symptoms of coeliac disease

Answer 22

• spectrum asymptomatic to nutritional deficiencies
• weight loss
• diarrhoea
• excess flatus
• abdominal discomfort

Question 23

Describe the diagnosis of coeliac disease

Answer 23

• IgA anti-tissue transglutaminase test (tTGA)

- biopsy confimative

Question 24

Describe the treatment of coeliac disease

Answer 24

Gluten free diet

Question 25

What causes lactose malabsorption?

Answer 25

Deficiency of lactase

Question 26

Describe the symptoms of lactose malabsorption

Answer 26

- history of the induction of diarrhoea - abdominal discomfort - flatulence - following ingestion of dairy products

Question 27

Describe the diagnosis of lactose malabsorption

Answer 27

- clinical - the diagnosis is confirmed by the lactose breath hydrogen test - an alternative is the oral lactose intolerance test

Question 28

Describe the management of lactose malabsorption

Answer 28

Lactose free diet

Question 29

What is tropical sprue caused by?

Answer 29

Colonisation of the intestine by an infectious agent or alterations in the intestinal bacterial flora induced by the exposure to another environmental agent

Question 30

Describe the symptoms of tropical sprue

Answer 30

- diarrhoea - steatorrhea - weight loss - nausea - anorexia - anaemia

Question 31

Describe the treatment of tropical sprue

Answer 31

- tetracycline | - folic acid

Question 32

What causes whipples disease?

Answer 32

- tropheryma whipplei | - multi system involvement in the frequency of HLA-B27

Question 33

Describe the symptoms of whipples disease

Answer 33

- weight loss - diarrhoea - steatorrhea - abdominal distention - arthritis - fever - nutritional deficiency symptoms

Question 34

Describe the diagnosis of whipples disease

Answer 34

- the diagnosis is established by demonstration of t. whipplei in involved tissues by microscopy

Question 35

Describe the treatment of whipples disease

Answer 35

Antimicrobial

Question 36

Describe crohns disease

Answer 36

- crohn disease patients with extensive ileal involvement, extensive intestinal resections, enterocolic fistulas and stricture leading to small intestinal bacterial overgrowth may develop significant and occasionally devastating malabsorption

Question 37

Describe the symptoms of crohns disease

Answer 37

- abdominal pain - diarrhoea - fever and weight loss - abdominal tenderness - most classically in the right lower quadrant

Question 38

Describe the diagnosis of crohns disease

Answer 38

- endoscopy - barium imaging of the small bowel mucosal disease - including strictures - ulcerations - fistulae - CT - MRI - colonoscopy - punched out lesions

Question 39

Describe the treatment of crohns disease

Answer 39

- steroids - immunosuppressants - azathioprine 6-MP - biological therapy (anti TNF)

Question 40

What are the risk factors for giardia lamblia (parasitic infection)

Answer 40

- travel to areas where the water supply may be contaminated | - swimming in ponds

Question 41

Name the symptoms of giardia lamblia parasitic infections

Answer 41

- diarrhoea - flatulence - abdominal cramps - epigastric pain - nausea - 1/3 of symptomatic patients experience vomiting - significant malabsorption with steatorrhea and weight loss may develop

Question 42

Describe lab investigations of giardia lamblia parasitic infection

Answer 42

- stool examination for ova and parasites | - three separate stool samples increases the yield of positive examinations

Question 43

Describe treatment of giardia lamblia parasitic infection

Answer 43

1 week of metronidazole

Question 44

Describe small bowel bacterial overgrowth

Answer 44

- diarrhoea, steatorrhea and macrocytic anaemia (B12) | - e coli or bacteroides

Question 45

Name causes of small bowel bacterial overgrowth

Answer 45

- diverticula, fistulas and strictures related to crohns disease - bypass surgeries functional stasis

Question 46

Describe the lab tests for small bowel bacterial overgrowth

Answer 46

- low cobalamin and high folate levels - aerobic and /or anaerobic colonic type bacteria in a jejunal aspirate obtained by intubation - bacterial overgrowth is best established by a schilling test

Question 47

Describe the treatment of small bowel bacterial overgrowth

Answer 47

- surgical correction of an anatomical blind loop | - tetracyclines 2-3 weeks

Question 48

Describe acrodermatitis enteropathica

Answer 48

- skin - autosomal recessive - impaired zinc uptake - rash, perioral, acral, alopecia - life long zinc supplements

Question 49

Describe dermatitis herpetiformis

Answer 49

- skin - may indicate coeliac disease - itchy blisters - extensor surfaces - sub epithelial IgA deposition

Question 50

Glossitis and angular stomatitis indicates what

Answer 50

- B vitamins | - iron

Question 51

Spooning of nails indicates what?

Answer 51

- iron (thyroid)

Question 52

Name baseline investigation in GI

Answer 52

- FBC - coagulation - LFTs - albumin - calcium / magnesium - stool culture

Question 53

Describe oral ulceration

Answer 53

- discontinuity in the oral mucosa - multiple local and systemic disorders can give rise to oral ulceration - presentation; solitary ulcer, multiple ulcers

Question 54

Name an infective cause of solitary ulcers

Answer 54

TB - primary or secondary infection Tertiary syphilis

Question 55

Name the three types of multiple ulcers

Answer 55

- major - minor - herpetiform

Question 56

Describe bechets

Answer 56

- multiple ulcers - multisystem condition - hereditary systemic vasculitis - almost identical oral ulcers as RAU - additionally, genital ulceration, uveitis, erythema nodosum and other systemic features

Question 57

Describe oral signs of anaemia

Answer 57

- mucosal pallor - oral ulceration - glossitis - angular chelitis - predisposition to candida - disturbed taste

Question 58

Name some mucocutaneous disorders of multiple ulcers

Answer 58

- lichen planus - vesicolobullous disease - pemphigus and pemphigoid - lupus erythematosus

Question 59

Describe lichen planus

Answer 59

- bilateral - asymptomatic - can affect the skin - potentially malignant

Question 60

Describe the oral manifestations of lupus erythematosus

Answer 60

- ulceration - white patches - red and white patches - similar in appearance to lichen planus

Question 61

Describe VB disease - pemphigus vulgaris

Answer 61

- oral lesions are the first manifestations (50-80% of cases) - oral lesions precede skin lesions by 1 year or more - painful extensive oral ulceration - preceded by blisters, rupture easily - mikolsky sign

Question 62

Describe VB disease - pemphigoid

Answer 62

- benign mucous membrane pemphigoid - blisters more likely to be observed - painful oral ulceration - affects mucous membrane of other organs eg eye

Question 63

Pemphigoid has what type of bullae?

Answer 63

Sub epithelial

Question 64

Pemphigus has what type of bullae?

Answer 64

Intraepithelial bullae

Question 65

Name some GI diseases wit oral manifestations

Answer 65

- crohns - ulcerative colitis - peutz jeghers - gardeners syndrome

Question 66

Describe the oral manifestations of crohns disease

Answer 66

- in 0.5-20% of cases - oral lesions may precede abdominal symptoms - features; - cobble stoning of mucosa - localised mucogingivitis - linear ulceration - tissue tags / polyps - diffuse swelling - commonly of the lips - pyostomatitis vegetans

Question 67

Describe the oral manifestations of ulcerative colitis

Answer 67

- oral ulceration - pyostomatitis vegetans - angular stomatitis g - reflects severity of intestinal disease; exacerbation and remission

Question 68

Describe pigmentation

Answer 68

- racial pigmentation - melanotic macules - malignancy - smoking - addisons disease; excess ACTH / MSH released from pituitary in response to reduced cortisol levels

Question 69

What is xerostomia?

Answer 69

Dry mouth

Question 70

Describe Sjogren syndrome

Answer 70

- dry eyes and dry mouth - most commonly affects females - may primary or secondary - when secondary - associated with other autoimmune disease eg. rheumatoid arthritis

Question 71

Describe oral maifestations of Sjogren syndrome

Answer 71

- enlarged salivary glands - as a result of dry mouth; - increased caries - depapillated tongue, fissured - red dry wrinkled mucosa - increased predisposition to candida

Question 72

Describe dental erosion

Answer 72

- pH of stomach contents can go as low as 1 - erosion on palatal surfaces of upper anterior teeth - GORD - also remember bulimia - may have been dietary cause or previous problem

Question 73

Describe oral manifestations of leukaemia

Answer 73

- gingival enlargement - petechiae - mucosal bleeding - ulceration - infiltration by malignant cells - boggy gingivae - presentation due to underlying immuno-compromise; candida, herpes infection, opportunistic infection

Question 74

Describe oral manifestations of HIV

Answer 74

- ulceration - Kaposi sarcoma - HPV lesions - salivary gland swelling - as a result of immunosuppression - increased risk of malignancy

Question 75

What are the three main components of GORD?

Answer 75

- incompetent LOS - poor oesophageal clearance - barrier function / visceral sensitivity

Question 76

Name symptoms of GORD

Answer 76

- heartburn - acid reflux - waterbrash - dysphagia - odynophagia - weight loss - chest pain - hoarseness - coughing

Question 77

Describe the investigation of GORD

Answer 77

- endoscopy - BA swallow - oesophageal manometry and pH studies - nuclear studies

Question 78

What are the aims of management of GORD?

Answer 78

- symptom relief - healing oesophagitis - prevent complications

Question 79

Describe gastroparesis

Answer 79

- delayed gastric emptying | - no physical obstruction

Question 80

Describe symptoms of gastroparesis

Answer 80

- feeling of fullness - nausea - vomiting - weight loss - upper abdominal pain

Question 81

Describe causes of gastroparesis

Answer 81

- idiopathic - diabetes mellitus - cannabis - medication eg. opiates, anticholinergics - systemic diseases eg. systemic sclerosis

Question 82

Describe investigation of gastroparesis

Answer 82

Gastric emptying studies

Question 83

Describe management of gastroparesis

Answer 83

- removal of precipitating factors eg. drugs - liquid / sloppy diet - eat little and often - promotility agents - gastric pacemaker

Question 84

What is dyspepsia?

Answer 84

- symptom / constellation of symptoms - epigastric pain or burning (epigastric pain syndrome) - postprandial fullness (postprandial distress syndrome) - early satiety (postprandial distress syndrome)

Question 85

Describe the organic causes of dyspepsia

Answer 85

- peptic ulcer disease - drugs (esp NSAIDs, COX2 inhibitors) - gastric cancer

Question 86

Name functional causes of dyspepsia

Answer 86

- idiopathic, NU - no evidence of culprit structural disease (OGD, other tests) - associated with other functional gut disorders eg. IBS

Question 87

Describe examination findings of dyspepsia

Answer 87

- if uncomplicated; epigastric tenderness only | - if complicated; cachexia, mass, evidence of gastric outflow obstruction, peritonism

Question 88

Describe the modern management of dyspepsia

Answer 88

- in the absence of alarm symptoms - non-invasive test and treat strategy - check h pylori status - eradicate if infected - cures ulcer disease - removes risk of gastric cancer - if HP -ve treat with acid inhibition as required

Question 89

Describe peptic ulcer disease

Answer 89

- a common cause of organic dyspepsia - pain predominant dyspepsia (to back) - often also nocturnal - aggravated or relieved by eating - relapsing and remitting chronic illness - lower > higher socio-economic groups - family history common

Question 90

Describe causes of peptic ulcer disease

Answer 90

- h pylori - approx. 90% of DU - approx. 60% of GU - NSAIDs

Question 91

Describe h pylori

Answer 91

- acquired in infancy - gm-ve microaerophilic flagellated bacillus - oral oral / faecal oral spread - consequences of infection do not arise until later in life

Question 92

Describe the consequences of h pylori

Answer 92

1. no pathology - the majority 2. peptic ulcer disease 3. gastric cancer

Question 93

Describe the diagnosis of h pylori

Answer 93

- gastric biopsy; urease test, histology, culture / sensitivity - urease breath test - FAT faecal antigen test - serology (IgA antibodies), not accurate with increasing patient age

Question 94

Describe treatment of peptic ulcer disease

Answer 94

- all antisecretory therapy (PPI) - all tested for presence of h pylori - h pylori +ve, eradicate and confirm - h pylori -ve, antisecretory therapy - withdraw NSAIDs - lifestyle - non-Hp/non-NSAID ulcers, nutrition and optimise comorbidities - no firm dietary recommendations - surgery - infrequent

Question 95

Describe eradication therapy of h pylori

Answer 95

- triple therapy for 1 week commonest - PPI + amoxicillin 1g BD + clarithromycin 500mg BD - PPI + metronidazole 400mg BD + clarithromycin 350mg BD

Question 96

Describe complications of peptic ulcer disease

Answer 96

- anaemia - bleeding - perforation - gastric outlet / duodenal obstruction, fibrotic scar

Question 97

Describe the post therapy follow up of duodenal ulcers

Answer 97

- uncomplicated DU requires no f/u | - only if ongoing symptoms

Question 98

Describe the post therapy follow up of gastric ulcers

Answer 98

- f/u endoscopy at 6-8 weeks | - ensure healing and no malignancy

Question 99

Name causes of upper GI bleeding

Answer 99

- duodenal ulcer - gastric erosions - gastric ulcer - varices - Mallory Weiss tear - oesophagitis - erosive duodenitis - neoplasm - stomach ulcer - oesophageal ulcer - miscellaneous

Question 100

How do you assess the severity of haemorrhage?

Answer 100

- the 100 rule - systolic BP <100 mmhg - pulse >100 min - Hb <100g/l - age >60 - comorbid disease - postural drop in blood pressure

Question 101

Describe treatment of peptic ulcers

Answer 101

- endoscopic treatment (high risk ulcers) - acid suppression (infusions) - surgery - h pylori eradication, secondary prevention

Question 102

Describe endoscopic treatment of peptic ulcers

Answer 102

- injection - heater probe coagulation - combinations - clips - haemospray

Question 103

How does haemospray work?

Answer 103

When hemospray comes into contact with blood, the powder absorbs water, then acts both cohesively and adhesively, forming a mechanical barrier over the bleeding site

Question 104

Describe causes of obstruction

Answer 104

- within the lumen (gallstone, food, bezoar) - within the wall (tumour, crohns, radiation) - outside the wall (adhesions, herniation)

Question 105

Describe the typical presentation of obstruction

Answer 105

- distension - borborygmic - vomiting - pain - faeculent vomiting - presence of a cause

Question 106

Describe investigations for obstruction

Answer 106

- assessing the state of the patient - urinalysis - blood - gases - confirming diagnosis - AXR - contrast CT scan of abdomen - gastrograffin studies - identifying those who need surgery and those who will settle

Question 107

Describe the surgical management of obstruction

Answer 107

- laparotomy - operative principles; antibiotics, antithromboembolic measures, usually a midline incision, can be laparoscopic, find the obstruction by following collapsed or dilated bowel

Question 108

Describe mesenteric ischaemia

Answer 108

- embolus, thrombosis (arterial and venous) - chronic; SMA, cramps, like angina of the guts, atherosclerosis - acute; small bowel usually gets infarcted, colon lives (marginal artery)

Question 109

Describe causes of mesenteric ischaemia

Answer 109

- embolus usually from AF, forms in LA, stick in a narrow SMA - in situ thrombosis, virchows triad

Question 110

Describe diagnosis of mesenteric ischaemia

Answer 110

- pain out of proportion to the clinical findings - acidosis on gases (low pH, high H+ concentration, high BE) - lactate elevated - CRP may be normal - WCC may be elevated - CT angiogram - at laparotomy - intervene before your patient is moribund

Question 111

Describe treatment of mesenteric ischaemia

Answer 111

- quickly - prepare patient and family for the worst - resect if non-viable - re-anastomose or staple and planned return - if viable you can rarely perform an SMA embolectomy

Question 112

Describe management of small bowel haemorrhage

Answer 112

- ABC - exclude upper source - vascular malformations - ulceration - CT angiogram - can often be managed by interventional radiology

Question 113

Describe meckels diverticulum

Answer 113

- 60cm from IC valve - 2% of population - present before 2 years of age - usually incidental - remnant of the omphalomesenteric duct - complications; bleed, ulcerate, meckels diverticulitis, obstruction, malignant change

Question 114

Describe the aetiology of appendicitis

Answer 114

- no unifying hypothesis - obstructions of the lumen with faecolith - bacterial - viral - parasites

Question 115

Describe the pathology of appendicitis

Answer 115

- huge variation in macroscopic disease - lumen may or may not be occluded - mucosal inflammation - lymphoid hyperplasia - obstruction - build up of mucus and exudate - venous obstruction - ischaemia, bacterial invasion through wall - perforation - presence of inflammation in abdomen brings the greater omentum - small bowel adheres - phlegomonous mass - peritonitis can be fatal

Question 116

Describe the signs and symptoms of appendicitis

Answer 116

- central pain that migrates to RIF - anorexia - nausea - one or two vomits - may not have moved bowels - pelvic; vaguer pain localisation, rectal tenderness - elderly - mild pyrexia - mild tachycardia - localised pain in RIF - guarding - rebound

Question 117

Describe the specific signs of appendicitis

Answer 117

- Rosvings; pressing on the left causes pain on the right - psoas; patient keeps the right hip flexed as this lifts an inflamed appendix off the psoas - obturator; if appendix is touching obturator internus, flexing the hip and internally rotating will cause pain

Question 118

Describe the differential diagnosis of appendicitis in children

Answer 118

- gastroenteritis - mesenteric adenitis - meckels diverticulum - intussusception - Henoch schonlein purpura - lobar pneumonia

Question 119

Describe the differential diagnosis of appendicitis in adults

Answer 119

- terminal ileitis - ureteric colic - acute pyelonephritis - perforated ulcer - pancreatitis - rectus sheath haematoma

Question 120

Describe the differential diagnosis of appendicitis in women

Answer 120

- mittelschmerz - ovarian cyst - salpinigitis - ectopic pregnancy

Question 121

Describe the differential diagnosis of appendicitis in the elderly

Answer 121

- sigmoid diverticulitis - intestinal obstruction - carcinoma of the caecum

Question 122

Describe investigations of appendicitis

Answer 122

- clinical diagnosis - USS useful in women and kids - AXR to exclude other causes - bloods (CRP, WCC) - urinalysis

Question 123

Describe the management of appendicitis

Answer 123

- analgesia - antipyretics - theatre - antibiotics - appendicectomy

Question 124

Describe the management of an appendix mass

Answer 124

- antibiotics first line - can operate or not - theatre if fails or complicated; tachycardia, worsening pain, increase in size, vomiting or copious NG aspirates

Question 125

Describe appendix abscess

Answer 125

- not an appendix mass - usually delayed - usually has liquidised - radiological drains

Question 126

Name neoplasms of the appendix

Answer 126

- involved in normal adenocarcinoma of the caecum - pseudomyxoma peritonei - carcinoid

Question 127

Describe carcinoid of the appendix

Answer 127

- crypts of lieberkuhn - stains for chromagrannin - metastatic risk relates to size - if less than 1cm appendicectomy alone - if greater than 2cm completion right hemi

Question 128

Define malnutrition

Answer 128

A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue, body form (body shape, size and composition), function and clinical outcome

Question 129

Name disease related causes of malnutrition

Answer 129

- decreased intake - impaired digestion and or absorption - increased nutritional requirements - increased nutrient losses

Question 130

Describe psychosocial causes of malnutrition

Answer 130

- inappropriate food provision - lack of assistance - poor eating environment - self neglect - bereavement - inability to access food - deprivation - loneliness - lack of cooking skills or facilities

Question 131

Describe the effects of starvation

Answer 131

- decreases metabolic rate - weight; slow loss, almost all from fat stores - nitrogen losses decrease - hormones; early small increases in catecholamines, cortisol, GH, then slow fall. Insulin decreased - water and sodium; initial loss, late retention

Question 132

Describe the effects of malnutrition

Answer 132

- impaired immune responses - impaired wound healing - reduced muscle strength and fatigue - reduced respiratory muscle strength - inactivity, especially in bed bound patient - water and electrolyte disturbances - impaired thermoregulation - menstrual irregularities / amenorrhoea - impaired psycho-social function

Question 133

What is anthropometry?

Answer 133

- a form of nutritional assessment - mid arm muscle circumference - triceps - grip strength - refer to validated charts

Question 134

Name some biochemical assessment of nutritional status

Answer 134

- albumin - transferrin; synthesis reduced in protein restriction - transthyretin (prealbumin) - retinol binding protein - urinary creatinine; reflect s muscle mass - IGF1 ; reduced in acute and chronic malnutrition - micro nutrients

Question 135

Describe parenteral nutrition

Answer 135

- administration of nutrient solutions via a central or peripheral vein

Question 136

Describe features of refeeding syndrome

Answer 136

- hypokalaemia - hypophosphataemia - hypomagnesaemia - altered glucose metabolism - fluid overload - arrhythmias - altered level of consciousness - seizure - respiratory failure - cardiovascular collapse - death

Question 137

What screening tool is used for malnutrition?

Answer 137

MUST

Question 138

Describe intestinal failure

Answer 138

- results from an inability to maintain adequate nutrition or fluid status via the intestines - can occur due to obstruction, dysmotility, surgical resection, congenital defect or disease associated loss of absorption - is characterised by the inability to maintain protein-energy, fluid, electrolyte or micronutrient balance - the reduction in function below the minimum necessary for the absorption of macronutrient and or water and electrolytes such that IV supplementation is required to maintain health a/o growth

Question 139

Describe type 1 intestinal failure

Answer 139

- short term - self limiting intestinal failure - wards; HDU/ICU

Question 140

Describe type 2 intestinal failure

Answer 140

- medium term - significant and prolonged PN support (>28days) - HDU/ICU wards

Question 141

Describe type 3 intestinal failure

Answer 141

- long term - chronic IF - long term PN support - wards to home

Question 142

Name causes of type 1 intestinal failure

Answer 142

- surgical ileus - critical illness - GI problems; vomiting, dysphagia, pancreatitis, GI obstruction, diarrhoea, oncology, chemo/ DXT, GVHD

Question 143

Name causes of type 2 intestinal failure

Answer 143

- post surgery awaiting reconstruction | - disaster, crohns, SMA, radiation, adhesions, fistulae

Question 144

Name causes of type 3 intestinal failure

Answer 144

- short bowel syndrome +/- other pathology - crohns +/- SBS - radiation +/- SBS - dysmotility - malabsorption, scleroderma, CV immunodeficiency - inoperable obstruction

Question 145

Describe management of type 1 intestinal failure

Answer 145

- common, short term - normal / moderately malnourished - replace fluid, correct electrolytes - parenteral nutrition if unable to tolerate oral food / fluids >7days post op - acid suppression; PPI - octreotide - alpha hydroxycholecalciferol to preserve Mg - intensive multi-disciplinary input - allow some diet / enteral feeding

Question 146

Describe management of type 2 intestinal failure

Answer 146

- septic patients - abdominal fistulae - perioperative who may develop a complication of feeding - weeks / months of care - parenteral +/- some enteral feeding

Question 147

Describe short bowel syndrome

Answer 147

- length of small bowel 250-1050cm - <200cm is short bowel - insufficient length of small bowel to meet nutritional needs without artificial nutritional support - most common indication for HPN

Question 148

Describe types of short bowel

Answer 148

- jejunostomy - jejuno-colic anastomosis - ileostomy - ileo-colic anastomosis

Question 149

Describe complications of parenteral nutrition

Answer 149

- sepsis - svc thrombosis - line fracture - line leakage - line migration - metabolic bone disease - nutrient toxicity / insufficiency - liver disturbance - metabolic disturbance - psycho-social - inappropriate usage

Question 150

Describe treatment type 3 if

Answer 150

- home parenteral nutrition - intestinal transplantation - glucagon like peptide 2 (teduglutide) treatment for SBS - bowel lengthening

Question 151

Describe specialised types of endoscope

Answer 151

- gastroscope - colonoscope - side viewing (ERCP) scope - enteroscope (push, double balloon) - capsule - endoscopic ultrasound

Question 152

Endoscope can provide visual diagnosis for which conditions?

Answer 152

- oesophagitis - gastritis - ulceration - coeliac disease - crohns disease - ulcerative disease - sclerosing cholangitis

Question 153

Describe vascular abnormalities that can be viewed with endoscope

Answer 153

- varices - ectatic blood vessels (GAVE, dieulafoy) - angiodysplasia

Question 154

Describe variceal bleeding

Answer 154

- life threatening medical emergency - ABC, resuscitate - injection fibrinogen - banding - histocryl glue

Question 155

Define chrons disease

Answer 155

- chronic inflammatory and ulcerating condition of the GI tract that can affect anywhere from the mouth to the anus - most common in the terminal ileum and colon

Question 156

Who usually gets crohns disease?

Answer 156

- young patients - can occur in children - more common in males

Question 157

Name the sites of crohns disease

Answer 157

- 2/3 patients have small bowel involvement only - 1/6 have colonic / anal disease - 1/6 have both - variable involvement of stomach, oesophagus and mouth

Question 158

Describe the presentation of crohns disease

Answer 158

- abdominal pain - small bowel obstruction - diarrhoea - bleeding PR - anaemia - weight loss

Question 159

Describe the microscopic changes in crohns disease

Answer 159

- chronic active colitis with granuloma formation - increased chronic inflammatory cells in the lamina propria and crypt branching with granulomas - large non-caseating granulomas - patchy chronic active colitis

Question 160

Describe the pathology of crohns disease

Answer 160

- segmental disease (patchy) - ileal and or colonic chronic active mucosal inflammation including; cryptitis, crypt abscesses - transmural inflammation - deep knife-life fissuring ulcers - granulomas, 50%, non-caseating

Question 161

Describe the complications of crohns disease

Answer 161

- malabsorption - fistulas - anal disease - intractable disease - bowel obstruction - perforation - malignancy - amyloidosis - rarely toxic megacolon

Question 162

Describe malabsorption in relation to crohns

Answer 162

- iatrogenic (short bowel syndrome) due to repeated resections and recurrences - hypoproteinemia, vitamin deficiency, anaemia of all types - gallstones (interrupted enterohepatic circulation)

Question 163

Describe fistulas in relation to crohns disease

Answer 163

- vesicocolic - enterocolic - gastrocolic - recto vaginal - tuboovarian abscess - blind loop syndrome

Question 164

Describe anal disease in relation to crohns disease

Answer 164

- sinuses - fissures - skin tags - abscesses - perineum falls apart

Question 165

Describe intractable disease in relation to crohns disease

Answer 165

- failure to tolerate or respond to medical therapy - continuous diarrhoea or pain - may require surgery, not curative

Question 166

Describe the environmental triggers of crohns

Answer 166

- smoking increases risk - infectious agents (viral, mycobacterial) cause similar pathology - vasculitis could explain the segmental distribution - sterile environment theory

Question 167

Describe the abberant immune response of crohns

Answer 167

- persistent activation of T cells and macrophages (failure to switch off) - excess proinflammatory cytokine production - may be alterable by changing intestinal microflora

Question 168

Define ulcerative colitis

Answer 168

- chronic inflammatory disorder confined to colon and rectum - mucosal and submucosal inflammation - unknown aetiology

Question 169

Who typically gets ulcerative colitis?

Answer 169

- young patients - peak incidence in the third decade - can present in the elderly - can occur in children - more common in males

Question 170

Name the sites of ulcerative colitis

Answer 170

- disease confined to the colon and rectum - nearly always involves the rectum - continuous and confluent extending proximally for varying lengths

Question 171

Describe the clinical presentation of ulcerative colitis

Answer 171

- diarrhoea - mucus - blood PR

Question 172

Describe the pathology of ulcerative colitis

Answer 172

- continuous, diffuse disease - rectal involvement, almost always - superficial ulceration and inflammation - chronic active colitis, cryptitis, crypt abscess - no granulomas

Question 173

Describe the complications of ulcerative colitis

Answer 173

- intractable disease - toxic megacolon - colorectal carcinoma - blood loss - electrolyte disturbance - anal fissures - eyes; uveitis - liver; primary sclerosing cholangitis - joints; arthritis, ank spondylitis - skin; pyoderma gangrenosum, erythema nodusum

Question 174

Describe intractable disease in relation to ulcerative colitis

Answer 174

- continuous diarrhoea - flares may be due to intercurrent infection by enteric bacteria or CMV - total colectomy

Question 175

Describe toxic megacolon in relation to ulcerative colitis

Answer 175

- acute or acute on chronic fulminant colitis - colon swells up to massive size - will rupture unless removed - emergency colectomy

Question 176

Describe colorectal carcinoma in relation to ulcerative colitis

Answer 176

- chronic inflammation leads to epithelial dysplasia and then carcinoma - risk increased if; pancolitis, disease longer than 10 yeas - requires surveillance

Question 177

Describe the aberrant immune response of ulcerative colitis

Answer 177

- persistent activation of T cells and macrophages - autoantibodies eg ANCA present - excess proinflammatory cytokine production and bystander damage due to neutrophilic inflammation - may be alterable by changing intestinal microflora

Question 178

Describe the different types of colitis

Answer 178

- ulcerative colitis - crohns colitis - collagenous colitis - lymphocytic colitis - radiation colitis - diversion colitis - drug induced - ischaemic colitis - antibiotic induced colitis - infective colitis - indeterminate colitis - necrotising enterocolitis - others

Question 179

What is a polyp?

Answer 179

- a polyp is a protrusion above an epithelial surface | - it is a tumour

Question 180

Describe the differential diagnosis of a colonic polyp

Answer 180

- adenoma - serrated polyp - polypoid carcinoma - other

Question 181

Why must all adenomas be removed?

Answer 181

As they are all premalignant

Question 182

Dukes staging predicts prognosis of what?

Answer 182

Colorectal carcinoma

Question 183

Describe dukes staging

Answer 183

- Dukes A; confined by muscularis propris - Dukes B; through muscularis propria - Dukes C; metastatic to lymph nodes

Question 184

Describe the presenting complaint of left sided colorectal carcinoma

Answer 184

- rectum, sigmoid, descending | - blood PR, altered bowel habit, obstruction

Question 185

Describe the presenting complaint of right sided colorectal carcinoma

Answer 185

- caecum, ascending | - anaemia, weight loss

Question 186

Describe the pathology of the large bowel in terms of colorectal carcinoma

Answer 186

- varied gross appearance (polypoid, structuring, ulcerating) - typical histopathological appearance (adenocarcinomas)

Question 187

Describe the pattern of spread of colorectal carcinoma

Answer 187

- local invasion; mesorectum, peritoneum, other organs - lymphatic spread; mesenteric nodes - hematogenous; liver, distant sites

Question 188

Describe hereditary non polyposis coli

Answer 188

- late onset - autosomal dominant - defect in DNA mismatch repair - inherited mutation in MLH-1, MSH-2, PMS-1 or MSH6 genes - right sided tumours - <100 polyps - mucinous tumours - crohns like inflammatory response - associated with gastric and endometrial carcinoma

Question 189

Describe familial adenomatous polyposis

Answer 189

- early onset - autosomal dominant - defect in tumour suppression - inherited mutation in FAP gene - throughout colon - >100 polyps - adenocarcinoma NOS - no specific inflammatory response - associated with desmoid tumours and thyroid carcinoma

Question 190

Name common large bowel diseases

Answer 190

- carcinoma of the colon and rectum - colonic polyps - crohns colitis and ulcerative colitis - diverticular disease - functional disorders

Question 191

Name less common large bowel disease

Answer 191

- colonic volvulus - colonic angiodysplasia - ischaemic colitis - pseudo-obstruction

Question 192

Describe diverticular disease

Answer 192

- mucosal herniation through muscle coat - sigmoid colon - low fibre intake - incidental finding

Question 193

Describe diagnosis of diverticulosis

Answer 193

- clinical - barium enema - sigmoidoscopy

Question 194

Describe the clinical features of diverticulitis

Answer 194

- LIF pain / tenderness - septic - altered bowel habit

Question 195

Describe complications of diverticular disease

Answer 195

- pericolic abscess - perforation - haemorrhage - fistula - stricture

Question 196

What classification is used for acute diverticulitis?

Answer 196

- Hickney classification

Question 197

Describe treatment of complex diverticulitis

Answer 197

- hartmanns procedure - primary resection / anastomosis - percutaneous drainage - laparoscopic lavage and drainage

Question 198

Describe causes of acute and chronic colitis

Answer 198

- infective colitis - ulcerative colitis - crohns colitis - ischaemic colitis

Question 199

Describe symptoms of acute and chronic colitis

Answer 199

- diarrhoea +/- blood - abdominal cramps - dehydration - sepsis - weight loss, anaemia

Question 200

Describe investigations of acute and chronic colitis

Answer 200

- plain x-ray - sigmoidoscopy + biopsy - stool cultures - barium enema

Question 201

Describe treatment of ulcerative colitis / crohns colitis

Answer 201

- iv fluids - iv steroids; once infective / ischaemic colitis ruled out - GI rest

Question 202

Describe ischaemic colitis

Answer 202

- elderly - arteriopaths - acute or chronic occlusion - inferior mesenteric artery

Question 203

Describe colonic angiodysplasia

Answer 203

- submucosal lakes of blood - obscure cause of rectal bleeding - usually right side of colon

Question 204

Describe diagnosis of colonic angiodysplasia

Answer 204

- difficult - angiography - coloscopy - injection or surgical resection

Question 205

Describe treatment of colonic angiodysplasia

Answer 205

- embolization - endoscopic ablation - surgical resection

Question 206

Name causes of large bowel obstruction

Answer 206

- colorectal cancer - benign stricture - volvulus

Question 207

Name the cause of sigmoid volvulus

Answer 207

- bowel twists on mesentery | - may become gangrenous

Question 208

Describe diagnosis of sigmoid volvulus

Answer 208

- plain X-ray | - rectal contrast

Question 209

Describe treatment of sigmoid volvulus

Answer 209

- flatus tube | - surgical resection

Question 210

Describe pseudo-obstruction

Answer 210

- no real mechanical obstruction - elderly / debilitated - hypoxia - biochem

Question 211

Describe c diff

Answer 211

- common cause of healthcare associated diarrhoea | - carried as part of normal bacteria flora in particularly in elderly (and infants)

Question 212

Describe the mechanism of action of c diff

Answer 212

- organisms produces 2 toxins; toxin A (enterotoxin) and toxin B (cytotoxin)

Question 213

Describe the source / vehicle of infection of c diff

Answer 213

- c diff often present in small numbers in bowel - infection occurs when antibiotics are prescribed that kill off normal competitive bowel flora and allows c diff to overgrow - organism produces spores that survive in the environment and are more resistant to disinfectants and the organism can be transmitted from one patient to another

Question 214

Describe symptoms of c diff

Answer 214

- diarrhoea sometimes bloody - abdominal pain - severe cases may progress to pseudomembranous colitis or bowel perforation

Question 215

Describe management of c diff

Answer 215

- depends on the severity assessment - less severe; oral metronidazole - severe = oral vancomycin

Question 216

Describe prevention of c diff

Answer 216

- good antimicrobial prescribing stewardship is key - use narrow spectrum antibiotics where possible, avoid the 4 c's - insolation of patients, handwashing and cleaning of the environment

Question 217

Describe the lab diagnosis of c diff

Answer 217

- no on good test - screening test for presence of the organism (GDH) - if GDH positive, test for presence of toxin (A and B) - culture can be done if strain needs to by typed, not done routinely

Question 218

Describe the lab results for c diff

Answer 218

- screening test neg; negative result - screening test +ve, toxin test +ve; positive result - screening test +ve, toxin test -ve ; indeterminate results, asses patient, repeat specimen - if repeat is indeterminate, clinical decision is required q

Question 219

Describe rotavirus

Answer 219

- common cause of vomiting and diarrhoea in children <3 years - person person spread, direct or indirect - commoner in winter months - subclinical or mild in adults, can be severe in immunocompromised children - self limiting, lasts around 1 week - low infectious dose - survives in environment - billions shed in faeces when diarrhoea - increased absorption of fluids and increased secretion in bowel, causing dehydration

Question 220

Describe diagnosis and management of rotavirus

Answer 220

- children may develop post-infection malabsorption, causing more diarrhoea - diagnosis by PCR test on faeces - management; rehydration is key - rotavirus vaccine (oral); live attenuated vaccine, excreted in faeces, 2 doses aged 2 & 3 months

Question 221

Describe norovirus

Answer 221

- winter vomiting disease - affects all ages, highly infectious - faecal oral/ droplet routes of spread - person to person (or on contaminated food / water) - environmental survival on formite for days to weeks - low infectious dose required - community circulations is the reservoir - short incubation - sudden onset explosive d & v lasts 2-4 days - vomiting leads to widespread contamination of the environment

Question 222

Describe diagnosis and treatment of norovirus

Answer 222

- diagnosis; faeces specimen or vomit swab for PCR test - treatment; rehydration is key, especially young, elderly - asymptomatic shedding occurs for to 48 hours post cessation of symptoms - outbreaks common

Question 223

Name other infections spread by faecal-oral route

Answer 223

- hepatitis a and e - resistant bacteria that are carried in the GI tract, eg. vancomycin resistant enterococci, highly resistant gram negative organisms (CPEs)

Question 224

Describe aetiology of oral malignancy

Answer 224

- tobacco - alcohol - diet and nutrition ' - HPV - UVL - candida - syphilis / dental factors

Question 225

Name some potentially malignant lesions of the mouth

Answer 225

- erythroplakia - erythroleukoplakia - leukoplakia - erosive lichen planus - submucous fibrosis - dyskeratosis congenita - sideropenic dysphagia

Question 226

Name warning signs for oral cancer

Answer 226

- red / white lesions - ulcer - numb feeling, eg lip, face - unexplained pain in mouth or neck - change in voice - dysphagia

Question 227

Name other orofacial manifestations of cancer

Answer 227

- drooping eye lid or facial palsy - fracture of mandible - double vision - blocked or bleeding from nose - facial swelling

Question 228

IBD consists of what?

Answer 228

- 2 idiopathic chronic inflammatory diseases | - ulcerative colitis and crohns disease

Question 229

Describe the genetic factors of crohns

Answer 229

- NOD2/ CARD15 (IBD-1) - disease susceptibility gene located on chromosome 16q12 - a mutated form of NOD2 is found in 10-20% of Caucasian patients with crohns - homozygotes have 20-40 fold increased risk of disease - heterozygotes have 2-4 fold increased risk of disease - encodes a protein involved in bacterial recognition

Question 230

Describe the immunological factors of crohns

Answer 230

- the immune system of normal intestine is geared towards tolerance to dietary antigens and commensal flora - innate immune responses are linked to the generation of corresponding adaptive immune responses - innate immunity; tight junctions regulate epithelial permeability, hydrophobic mucus protects the epithelial cell layer, defensins (cationic anti-microbial peptides) can be activated constitutively or in response to bacterial components, NOD2 contributes to normal mucosal defences - adaptive immunity; t lymphocytes are critical to the orchestration of adaptive mucosal immunity, normal conditions are characterised by a balance between effector and regulatory t cell responses. maladaptive responses may arise from either overactive effector t cells, absence of regulatory t cells

Question 231

Crohns disease is what type of immune response?

Answer 231

- TH1 mediated disease

Question 232

Ulcerative colitis is what type of immune response?

Answer 232

Mixed TH1 / TH2 mediated disease /NKTC

Question 233

Describe antimicrobial activity in crohns

Answer 233

- reduced antimicrobial activity in colonic crohns

Question 234

Describe smoking and IBD

Answer 234

- smoking aggravates crohns disease | - protects against ulcerative colitis

Question 235

Describe ulcerative colitis

Answer 235

- inflammation of colon of unknown aetiology - incidence 8-10/100000 - peak incidence 20-30s - relapsing course - affects rectum extending proximally

Question 236

Describe ulcerative colitis symptoms

Answer 236

- diarrhoea and bleeding - increased bowel frequency - urgency - tenesmus - incontinence - night rising - lower abdominal pain esp. lif - proctitis can cause constipation

Question 237

Describe the truelove and witt criteria

Answer 237

- severe ulcerative colitis = 30% risk of colectomy - >6 bloody stools / 24 hr - 1 or more of; - fever (>37.8) - tachycardia (>90/min) - anaemia (haemoglobin <10.5g/dl) - elevated ESR (>30mm/hr)

Question 238

Describe a plain AXR for ulcerative colitis

Answer 238

- stool distribution; absent in inflamed colon - mucosal oedema / thumb printing - toxic megacolon; transverse >5.5cm caecum >9cm

Question 239

Describe endoscopy findings for ulcerative colitis

Answer 239

- define extent - confluent inflammation extending proximally from anal margin to a transition zone - loss of vessel pattern - granular mucosa - contact bleeding

Question 240

Describe the histological findings of ulcerative colitis

Answer 240

- crypt distortion and abscess - absence of goblet cells - affects mucosal layer only

Question 241

Describe the longterm complications of ulcerative colitis

Answer 241

- increased risk of colorectal cancer - determined by; severity of inflammation, duration of disease, disease extent - extensive colitis (to beyond splenic flexure) at risk and require surveillance after 10 years of disease

Question 242

Describe extra-intestinal features of ulcerative colitis

Answer 242

- mouth; stomatitis, aphthous ulcers - liver; steatosis - biliary tract; gallstones, sclerosing cholangitis - joints; spondylitis, sacrolitis, peripheral arthritis - circulation; phlebitis - skin; erythema nodosum, pyoderma gangrenosum - kidneys; stones, hydronephrosis, fistulae, urinary tract infection - eyes; uvetis, episcleritis

Question 243

Describe primary sclerosing cholangitis

Answer 243

- chronic inflammatory disease of biliary tree - 80% have associated IBD - most asymptomatic OR itch, rigors - cholestatic LFTs - median time to death / liver transplant 10 years

Question 244

Describe the distribution of crohns

Answer 244

- can affect any region of GI tract from mouth to anus - skip lesions - transmural inflammation - colonic crohns increasing in incidence

Question 245

Describe peri-anal disease

Answer 245

- recurrent abscess formation - pain - can lead to fistula with persistent leakage - damaged sphincters

Question 246

Describe crohns symptoms

Answer 246

- small intestine; abdominal cramp (peri-umbilical), diarrhoea, weight loss - colon; abdominal cramps (lower abdomen), diarrhoea with blood, weight loss - mouth; painful ulcers, swollen lips, angular cheilitis - anus; peri-anal abscess

Question 247

Describe the aims of IBD therapy

Answer 247

- control inflammation and heal mucosa - restore normal bowel habit - improve quality of life - balance the effects of disease with side effects of treatment - avoid long term complications - be a good advocate for the patient

Question 248

Describe drug therapy for ulcerative colitis

Answer 248

- 5ASA (mesalazine) - steroids - immunosuppressant - anti-TNF therapy

Question 249

Describe drug therapy for crohns disease

Answer 249

- steroids - immunosuppressants - anti-TNF therapy

Question 250

Describe the mechanism of action of 5ASA

Answer 250

- topical effect - anti-inflammatory properties - reduces risk of colon cancer - side effects; diarrhoea, idiosyncratic nephritis

Question 251

Name 5ASA drugs in use

Answer 251

- sulphasalazine - balsalazide - mezavant - mesalazine - pH release (asacol) - delayed release (pentasa)

Question 252

Describe corticosteroid use in IBD

Answer 252

- systemic anti-inflammatory properties - eg. prednisolone; oral / topical - budesonide - to induce remission - short course; high dose initially, reducing over 6-8 weeks

Question 253

Describe steroid side effects

Answer 253

- avascular necrosis - osteoporosis - acne - thinning of skin - weight gain - diabetes - hypertension - cataracts - growth failure

Question 254

Describe azathioprine

Answer 254

- slow onset of action (6 weeks) - TPMT activity contributes to toxicity - avoid co-prescription of allopurinol (XO inhibitor) - regular blood monitoring required - side effects; pancreatitis - leucopaenia - hepatitis - small risk of lymphoma, skin cancer

Question 255

Describe anti-TNF therapy

Answer 255

- tumour necrosis factor alpha, proinflammatory cytokine - antibodies to TNF; chimeric (infliximab; IV infusion), humanised (adalimumab; S/C injection) - promote apoptosis of activated t lymphocytes - rapid onset of action

Question 256

Describe surgery for crohns

Answer 256

- minimise amount of bowel resected - not curative - repeated resection of small intestine can result in short gut syndrome and requirement of lifelong total parenteral nutrition (reduced life expectancy)

Question 257

Describe surgery for ulcerative colitis

Answer 257

- curative | - option of permanent ileostomy or restorative proctocolectomy and pouch

Question 258

Name elective operations for crohns

Answer 258

- resection - stricturoplasty - fistulas - anal disease

Question 259

Describe elective operating for ulcerative colitis

Answer 259

- proctocolectomy with end ileostomy | - proctocolectomy with ileorectal anastomosis

Question 260

Describe indications for elective surgery in UC

Answer 260

- medically unresponsive disease - intolerability - dysplasia / malignancy - growth retardation in children - attempted resolution of extra-intestinal disease

Question 261

Describe a subtotal colectomy

Answer 261

- first aid operation - subtotal colectomy - lap or open depending on expertise - rectal stump can be brought out as a mucous fistula - stapled and left in (riskier)

Question 262

Describe toxic megacolon

Answer 262

- sepsis - distension - pain - requires decompression - may perforate - can be fatal

Question 263

Describe indications for surgery in crohns

Answer 263

- stenosis causing obstruction - enterocutaneous fistulas - intra-abdominal fistulas - abscesses - bleeding (acute or chronic) - free perforation

Question 264

Describe fistulating disease and abscess

Answer 264

- enterocutaneous - intra-abdominal - SNAP; sepsis, nutrition, anatomy, plan

Question 265

Describe intra-abdominal fistulae

Answer 265

- may be occult - any organ can be affected (vagina, bladder) - resect en-bloc primary defect and close secondary organ

Question 266

Name psychological factors associated with GI disorders

Answer 266

- current burdensome life events - abnormal relationships with parents - history or present abuse - anxiety - depression or low mood - neuroticism (anxious personality) - inadequate social support - difficulties in interpersonal relationships

Question 267

Describe globus

Answer 267

- globus sensation, sensation of a lump in the throat - accounts for 4-6% of ENT clinic referrals - up to 46% of healthy people experience this symptoms - incidence peaks in middle age

Question 268

Name causes of globus sensation

Answer 268

- foreign body - reflux - inflammation of pharynx - pharyngeal pouch - cancers - polled food syndrome / oral allergy syndrome - neurological conditions

Question 269

Describe globus management

Answer 269

- reassurance - anti-reflux treatment - stopping smoking - referral to speech and language therapy - neck shoulder relaxation techniques and exercises - vocal hygiene - treatment for stress - antidepressant medication - CBT

Question 270

Describe functional dysphagia

Answer 270

- the sensation of solid or liquid food sticking on the way down the oesophagus - prevalence not known

Question 271

Describe management of functional dysphagia

Answer 271

- reassurance - dietary adjustments including avoidance of food that triggers dysphagia - advising carful chewing of food - avoiding fizzy drinks

Question 272

Describe management of IBS

Answer 272

- diet modifications; consider fibre, caffeine, regular meals - exercise - reducing stress - medication; antispasmodics, laxatives, antimotility medicines, low dose antidepressants, reducing / stopping opiod analgesics

Question 273

Describe anorexia nervosa

Answer 273

- significant weight loss (BMI <17.5 kg/m2) - in children; failure to make expected weight gain during growth - weight loss is self induced; avoidance of fatty foods, progressive dietary restriction, calorie counting / excessive weighing, self induce vomiting (russels sign), diuretics / laxatives / appetite suppressants - excessive exercise

Question 274

Describe the core psychopathology of anorexia nervosa

Answer 274

- Intrusive, overvalued idea - obesity represents failure and chaos - slimness represents success and control - described as morbid fear of fatness, preoccupation with weight and shape - associated body image distortion, abdomen, thighs

Question 275

Describe the widespread endocrine abnormality associated with anorexia nervosa

Answer 275

- decreased Na, K, PO4, insulin, glucose, thyroid (secondary to starvation) - cardiovascular / arrhythmias - bond health - amenorrhoea / loss of sexual interest / potency - elevated GY / cortisol/ cholesterol

Question 276

Describe bulimia nervosa

Answer 276

- core psychopathology identical to anorexia nervosa - attempts to restrict intake fail > binges - low / normal/ increased weight - no endocrine abnormalities - 30% past history of anorexia

Question 277

Describe the treatment of anorexia nervosa and bulimia nervosa

Answer 277

- establish therapeutic alliance - weight gain is essential - psychological interventions - antidepressants - antipsychotics

Question 278

Describe diagnosis of IBS

Answer 278

- exclude organic disease relevant to patient - examination - nutritional status - anaemia - EIM of IBD - masses, PR

Question 279

Describe treatment of IBS

Answer 279

- validate - reassure - inform

Question 280

Describe osmotic laxatives in IBS

Answer 280

- polyethylene glycol - widely used - less s/e bloating, pain - NaH CO3, NaCl, KCl - prevents water absorption - improves constipation but not pain - one small adolescent study - lactulose - MgOH (milk of magnesia) - stimulant laxatives - avoid, only infrequent short term use

Question 281

Describe guanylate cyclase agonists

Answer 281

- linaclotide (constella) - peptide agonist of guanylate cyclase 2C - increases intracellular cyclic GMP - increased intestinal secretion and transit - reduces abdominal pain - 2 large RCTS - longterm effects unknown - limited to failure / intolerance PEG laxatives

Question 282

Describe selective C-2 chloride channel activators

Answer 282

- lubiprostone (amitiza, 24mcg od, 24mcg bd) - placebo for global IBS-C symptoms in women - IBS-C, CIC and opiate induce - bicyclic fatty acid derived from prostaglandin E - chloride rich secretion - soften stool, increase motility and promote SBMs

Question 283

Describe risk factors for STIs

Answer 283

- <25 years old - changes sexual partner - non condom use - men who have sex with men - past history of STI - large urban areas - social deprivation - black ethnicity

Question 284

Describe rectal gonorrhoea

Answer 284

- Neisseria gonorrhoea - transmission; direct contact of mucosal surface with infected secretions. For proctitis; anal sex, transmucosal spread, fomite - symptoms; short incubation period, lower abdo pain, diarrhoea, rectal bleeding, anal discharge, tenesmus, may have associated symptoms, may be asymptomatic - proctoscopy; inflamed mucosae, purulent exudate - complications; abscess formation, increased susceptibility / transmissibility of HIV

Question 285

Describe rectal chlamydia

Answer 285

- symptoms; asymptomatic, milder than gonorrhoea, anal discomfort / itch, discharge, associated symptoms - proctoscopy; less sevee - gram stain rectal swab; CT, PCR - treatment; doxycycline, better clearance at rectal site, test of cure, comprehensive STI testing, public health interventions

Question 286

Describe primary and secondary syphilis

Answer 286

- primary; solitary painless ulcer - secondary syphilis; mucosal patches and ulcers, mouth, anogenital, rectal, condylomata lata, systemic inflammation, hepatitis, procto-colitis

Question 287

Name risk factors for bowel cancer

Answer 287

- older age - low intake of fibre - high intake of fat, sugar, alcohol, red meat, processed meats - obesity - smoking - lack of physical exercise

Question 288

Name signs and symptoms of right sided colorectal cancers

Answer 288

- unexplained iron deficiency anaemia - persistent tiredness - a persistent and unexplained change in bowel habit - unexplained weight loss - abdominal pain (colicky in nature) - lump in the abdomen

Question 289

Describe signs and symptoms of left side and rectum colorectal cancers

Answer 289

- rectal bleeding - feeling of incomplete emptying - worsening constipation

Question 290

Describe symptoms of intestinal obstruction

Answer 290

- vomiting - pain - constipation - distension - complete obstruction - incomplete obstruction

Question 291

Describe vomiting in relation to intestinal obstruction

Answer 291

- the more proximal the obstruction, the earlier vomiting develops - can occur even if nothing is taken by mouth, GI secretions continue to be produced, saliva, gastric, pancreatic, bile, small intestine - nature of vomitus gives clues to the level of obstruction

Question 292

How does the nature of the vomitus give clues to the level of obstruction

Answer 292

- semi digested food eaten a day or two previously (no bile) suggest gastric outlet obstruction - copious bile stained fluid suggest upper small bowel obstruction - thicker, brown, foul-smelling vomitus (faeculent) suggests a more distal obstruction

Question 293

Describe constipation

Answer 293

- propulsion of bowel contents is arrested - bowel gas is absorbed distal to the obstruction - absolute constipation (neither faeces or flatus passed rectally) is pathognomonic of bowel obstruction

Question 294

Describe physical signs of intestinal obstruction

Answer 294

- dehydration (dry mouth, loss of skin turgor and elasticity) - abdominal distension - visible peristalsis - relative lack of abdominal tenderness - obstructing abdominal mass may be palpable - on percussion the centre of the abdomen tends to be resonant due to gaseous distension - groins must be examined for an obstructing hernia - bowel sounds are traditionally described as high-pitched and tinkling In practice they may be absent at the time of auscultation, echoing (cavernous quality) or may sound like water lapping against a boat

Question 295

Describe investigation of suspected bowel obstruction

Answer 295

- most useful initial investigation is a supine abdominal x ray - bowel proximal to the obstruction is distended with gas - distended small bowel loops tend to lie in a central position and have valvulae coniventes - distended large bowel tends to lie in its anatomical position and has haustra coli - CT scan is often subsequently performed to confirm the diagnosis and look for a cause - transition point on CT scan with distended bowel proximal and collapsed bowel distal to the site of obstruction

Question 296

Name mechanical causes of bowel obstruction

Answer 296

- adhesions or bands - incarcerated abdominal wall hernia - internal hernia - volvulus - tumour - inflammatory strictures - bolus obstruction - intussusception

Question 297

Describe adhesions or bands

Answer 297

- congenital or resulting from previous abdominal surgery or peritonitis

Question 298

Describe volvulus

Answer 298

- a mobile loop of bowel rotates causing obstruction at its neck

Question 299

Describe bolus obstruction

Answer 299

- food bolus - impacted faeces - impacted gallstone ileus - trichobezoar

Question 300

Describe intussusception

Answer 300

- a segment of bowel wall becomes telescoped into the segment distal to it - usually initiated by a mass in the bowel wall, enlargement of lymphatic tissue or tumour

Question 301

Describe bowel strangulation

Answer 301

- a segment of bowel becomes trapped - venous return is obstructed - with rising local intra vascular pressure, subsequently arterial inflow is compromised - if strangulation is not relieved this will progress to infarction and perforation - pain over hernia - urgent surgical intervention - can occur in external hernia or volvulus

Question 302

Describe adynamic bowel obstruction

Answer 302

- paralytic ileus | - pseudo-obstruction

Question 303

Describe paralytic ileus

Answer 303

- disruption of the normal propulsive activity of the GI tract, due to failure of peristalsis - risk factors; recent GI surgery, inflammation with peritonitis, diabetic keto acidosis - symptoms and signs; similar to bowel obstruction and although pain and high pitched bowel sounds are less common - treatment; drip and suck while awaiting restoration of peristalsis

Question 304

Describe pseudo-obstruction (ogilvies syndrome)

Answer 304

- acute dilatation of the colon in the absence of colonic obstruction in acutely unwell patients - associated with; hip replacement surgery, coronary artery bypass grafts, spinal, pneumonia, frail / elderly patients

Question 305

Describe the three major factors of cirrhosis

Answer 305

- reduced liver blood flow - reduced metabolic function - reduced plasma proteins

Question 306

Describe moderate hepatic impairments

Answer 306

- decrease renal clearance - effect on unbound drug masked by decrease protein binding - renal function reduced (creatinine and Cr clearance misleading)

Question 307

Describe consequences of moderate hepatic impairments

Answer 307

- gut oedema, poor absorption - liver and kidney congestion, reduced function - gross oedema and ascites - CHF

Question 308

Describe nausea

Answer 308

- subjective, highly unpleasant, sensation normally felt in throat and stomach as a sinking sensation - acute nausea interferes with mental and physical activity, often relieved by vomiting - chronic nauseas is greatly debilitating - nausea usually involves; pallor, sweating excessive salivation and relaxation of the stomach and lower oesophagus, upper intestinal contractions, forcing intestinal contents by reverse peristalsis into the stomach - nauseas usually precedes vomiting but either may occur in isolation

Question 309

Describe retching and vomiting

Answer 309

- retching involves; rhythmic reverse peristalsis of the stomach and oesophagus, forceful, involuntary contraction of abdominal muscles and the diaphragm - cardiac portion of the stomach pushed into the thorax, upper intestinal contractions, forcing intestinal contents by reverse peristalsis into the stomach, pallor, sweating, excessive salivation - retching is dry, no efflux of vomitus - vomiting (emesis) is the forceful expulsion of gastric / intestinal contents out of the mouth

Question 310

Describe the overall events in vomiting

Answer 310

- commences with forceful inspiration, reflex closure of the glottis and elevation of the soft palate to close off the airways and nasal passages - is not due to stomach contraction, stomach, oesophagus and associated sphincters are relaxed - vomiting is co-ordinated by the vomiting centre in the medulla oblongata of the brainstem - suspension of intestinal slow wave activity - retrograde contractions from ileum to stomach - suspension of breathing (closed glottis, prevents aspiration) - relaxation of LOS- contraction of diaphragm and abdominal muscles compresses stomach - ejection of gastric contents through open UOS - repeats of the cycle - vomiting is frequently preceded by profuse salivation, sweating, elevated heart rate and the sensation of nausea

Question 311

Describe the vomiting centre

Answer 311

- a historically useful term, but not a discrete anatomical centre - instead a group of interconnected neurones within the medulla that are driven by a central pattern generator (CPG) that in turn receives input from the NTS

Question 312

Describe the consequences of severe vomiting

Answer 312

- dehydration - loss of gastric protons and chloride (causes hypochloraemic metabolic alkalosis, raising blood pH) - hypokalaemia, mediated by the kidney, proton loss is accompanied by potassium excretion - rarely, loss of duodenal bicarbonate may cause metabolic acidosis - rarely, oesophageal damage (mallor-weiss tear)

Question 313

Describe drug and radiation induced emesis

Answer 313

- many classes of drug (or treatments) predictably cause nausea and vomiting - cancer chemotherapy (eg. cisplatin, doxorubicin) and radiotherapy (release of 5-HT and substance P from enterochromaffin cells in the gut) - operations involving the administration of a general anaesthetic (post-operative nausea and vomiting) - agents with dopamine agonist properties (eg. levodopa used in parkinsons disease) dopamine D2 receptors are prevalent in the CTZ - morphine and other opiate analgesics (tolerance develops) - cardiac glycosides (eg. digoxin) - drugs enhancing 5-HT function (eg. SSRIs, 5-HT3 receptors are prevalent in the CTZ)

Question 314

Describe 5-HT3 receptor antagonists - setrons (eg. ondansetron, palonsetron)

Answer 314

- used to suppress chemotherapy and radiation induced emesis and post-operative nausea and vomiting - block peripheral and central 5-HT3 receptors (cat ion selective ion channels) - reduce acute nausea, retching and vomiting in cancer patients receiving emetogenic treatments (day 1) - less effective during subsequent treatments (delayed phase), improved by the addition of a corticosteroid (mechanism uncertain) and a neurokinin 1 (NK1) receptor antagonist - not effective against motion sickness, or vomiting induced by agents increasing dopaminergic transmission - generally well tolerated, most common unwanted effects are constipation and headaches

Question 315

Describe muscarinic acetylcholine receptor antagonists (Eg. hyoscine / scopolamine)

Answer 315

- used for prophylaxis and treatment of motion sickness (can be delivered by transdermal patch ) - probably block muscarinic acetylcholine receptors at multiple sites (eg. vestibular nuclei, NTS, vomiting centre) - direct inhibition of GI movements and relaxation of the GI tract may contribute(modestly) to anti-emetic effects - have numerous unwanted effects resulting from blockade of the parasympathetic ANS (eg. blurred vision, urinary retention, dry mouth) and centrally mediated sedation

Question 316

Histamine H1 receptor antagonists (eg. cyclizine, cinnarizine and many others)

Answer 316

- many agents in this class also exert significant blockade of muscarinic receptors that probably contributes to their activity - used for prophylaxis and treatment of motion sickness and acute labyrinthitis and nausea and vomiting caused by irritants in the stomach, less effective against substances that act directly on the CTZ - action attributed to the blockade of H1, receptors in vestibular nuclei and NTS - generally cause CNS depression and sedation - drowsiness may affect performance of skilled tasks (but sedation might actually be desirable in palliative care)

Question 317

Describe dopamine receptor antagonists (eg. domperidone and metoclopramide)

Answer 317

- used for drug induced vomiting (eg cancer chemotherapy, treatment of parkinsons disease with agents stimulating dopaminergic transmission) and vomiting in GI disorders - use in children is restricted - complex mechanism of action (a lack of understanding of the source of dopamine to stimulate dopamine receptors in many circumstances) - centrally block dopamine D2 (and D3) receptors inn the CTZ - peripherally exert a prokinetic action on the oesophagus, stomach and intestine - domperidone does not cross the blood brain barrier and is less likely to result in the many unwanted effects of metoclopramide (eg. disorders of movement (extrapyramidal effects)) - not effective against motion sickness - phenothiazines; which owe part of their action to dopamine D2 blockade - are used for severe nausea and vomiting

Question 318

Describe NK1 receptor antagonists (aprepitant)

Answer 318

- used in combination with a 5-HT3 receptor antagonist and dexamethasone in the acute phase of highly emetogenic chemotherapy. in combination with dexamethasone in the delayed phase - exact site of action is uncertain, but antagonism of substance P (which causes vomiting and is released by vagal afferents) is assumed

Question 319

Describe cannabinoid (CB1) receptor agonists (nabilone)

Answer 319

- used ideally in in-patient setting for treatment of cytotoxic chemotherapy this is unresponsive to other anti-emetics - decreases vomiting induced by agents stimulating the CTZ. evidence suggests that opiate receptors are involved in drug effect - numerous unwanted effects; drowsiness, dizziness, dry mouth, mood changes are common

Question 320

The portal vein carries outflow to where?

Answer 320

- spleen - oesophagus - stomach - pancreas - small and large intestine

Question 321

Describe the portal system

Answer 321

- superior mesenteric - splenic vein - gastric - part from inferior mesenteric - all combined create portal vein

Question 322

Describe hepatic blood flow

Answer 322

- oxygenated blood from hepatic artery and nutrient rich, deoxygenated blood from hepatic portal vein - liver sinusoids - central vein - hepatic vein - inferior vena cava - right atrium of heart

Question 323

Describe portocaval anastomosis (portal vein collaterals)

Answer 323

- the portal venous system has several anastomosis with the systemic venous system - four collateral pathways; oesophageal and gastric venous plexus - umbilical vein from the left portal vein to the epigastric venous system - retroperitoneal collateral vessels - the haemorrhoidal venous plexus - in cases of portal hypertension these anastomoses may become engorged, dilated or varicosed and subsequently rupture

Question 324

Describe portal hypertension (PH)

Answer 324

- portal vein pressure above the normal range of 5 to 8 mmHg - portal vein; hepatic vein pressure gradient greater than 5mmHg - represents an increase of the hydrostatic pressure within the portal vein or its tributaries

Question 325

Describe causes of portal hypertensions classification according to site of obstruction

Answer 325

- not just cirrhosis - prehepatic; blockage of the portal vein before the liver, due to portal vein thrombosis or occlusion secondary to congenital portal venous abnormalities - intrahepatic; due to distortion of the liver architecture either; presinusoidal (eg. schistosomiasis or non-cirrhotic portal hypertension), postsinusoidal (cirrhosis), budd chiari syndrome and veno-occlusive disease

Question 326

Portal hypertension results from both what?

Answer 326

- increased resistance to portal flow | - increased portal venous return

Question 327

Describe signs of compensated cirrhosis

Answer 327

- spider naevi - plamar erythema - clubbing - gynaecomastia - hepatomegaly - splenomegaly - or none

Question 328

Describe signs of decompensated cirrhosis

Answer 328

- jaundice - ascites - encephalopathy - bruising

Question 329

Name complications of cirrhosis

Answer 329

- ascites - encephalopathy - variceal bleeding - liver failure

Question 330

Describe the general principles of treatment of decompensated cirrhosis

Answer 330

- remove or treat the underlying cause - look for and treat infection - the physiology is not normal - low threshold to switch to gluconeogenesis and lipolysis and catabolism

Question 331

Describe treatment of encephalopathy

Answer 331

- look for cause; infection, metabolic, drugs, liver failure - treat it - lactulose to clear gut / reduce transit time; rifaximin - maintain nutritional status with small frequent meal / snack pattern and bedtime CHO - if spontaneous consider transplantation

Question 332

Describe acute effects of excess alcohol use

Answer 332

- accidents - violence - oesophagitis, gastritis / ulceration - acute pancreatitis - overdose - aspiration

Question 333

Describe chronic effects of excess alcohol use

Answer 333

- GI; stomach, liver, gallbladder - cardio; hypertension, cardiomyopathy, MI, stroke - CNS; neuropathies - - cerebellar degeneration - dementia - Wernicke- korsakoffs syndrome

Question 334

Describe clinical features of haemangioma

Answer 334

- the most common liver tumour - female > male - hypervascular tumour - usually single small - well demarcated capsule - usually asymptomatic

Question 335

Describe diagnosis and management of haemangioma

Answer 335

- ultrasound; echogenic spot, well demarcated - ct; venous enhancement from periphery to centre - MRI; high intensity area - no need for FNA - no need for treatment

Question 336

Describe clinical features of focal nodular hyperplasia (FNH)

Answer 336

- benign nodule formation of normal liver tissue - congenital vascular anomaly; associated with osler-weber-rendu and liver haemangioma - classically central scar containing a large artery, radiating branches to the periphery - hyperplastic response to abnormal arterial flow - sinusoids, bile ductules and Kupffer cells present on histology - more common in young and middle age women - no relation with sex hormones - usually asymptomatic, may cause minimal pain

Question 337

Describe diagnosis and management of focal nodular hyperplasia (FNH)

Answer 337

- ultrasound; nodule with varying echogenicity - ct; hypervascular mass with central scar - MRI; iso or hypo intense - FNA; normal hepatocyte and Kupffer cells with central core - no treatment necessary

Question 338

Describe clinical features of hepatic adenoma

Answer 338

- benign neoplasm composed of normal hepatocytes, no portal tract, central veins or bile ducts - more common in women - associated with contraceptive hormones and anabolic steroids - usually asymptomatic but may have RUQ pain - may present with rupture, haemorrhage or malignant transformation (very rare) - malignant transformation risk higher in males

Question 339

Describe the demographics of hepatic adenoma

Answer 339

- most are solitary fat containing lesions - incidence is increasing - often found incidentally on imaging - usually in the right lobe - symptoms (pain, bleeding) are size related - multiple adenomas (adenomatosis) is a rare condition associated with glycogen storage diseases

Question 340

Describe hepatic adenoma and oral contraceptive / androgenic steroids

Answer 340

- association is well documented, but no large epidemiologic studies to quantify risk - mechanism of hepatocyte transformation poorly understood identifiable oncogene mutations within adenomas that confer malignant risk - risk of adenomas related to duration of OC use (>2 years) and oestrogen component, but adenomas have been described with even 6 month of OC use - regression can occur after discontinuation

Question 341

Describe diagnosis and management of hepatic adenomas

Answer 341

- ultrasound; filling defect - CT; diffuse arterial enhancement - MRI; hypo or hyper intense lesion - FNA; may be needed - stop hormones, weight loss - males (irrespective of size); surgical incision - females; imaging after 6 months

Question 342

Describe adenomas in young patients

Answer 342

- hypervascular - purely a hepatocyte tumour, cold on nuclear sulfur colloid scan - may cause pain and can bleed - malignant degeneration

Question 343

Describe focal nodular hyperplasia in young patients

Answer 343

- hypervascular - contains all the liver ultrastructure including RES and bile ductules (isointense on sulfur colloid scan) - may cause pain - central scar - no malignant risk - minimal bleeding risk

Question 344

Name types of cystic lesions

Answer 344

- simple - hydatid - atypical - polycystic lesion - pyogenic or amoebic abscess

Question 345

Describe clinical features of a simple cyst

Answer 345

- liquid collection lined by an epithelium - no biliary tree communication - most of the time asymptomatic - solitary and uniloculated - symptoms can be related to intracystic haemorrhage, infection, rupture (rare), compression

Question 346

Describe management of a simple cyst

Answer 346

- no follow up necessary - if doubt, imaging in 3-6 months - if symptomatic or uncertain diagnosis (complex cystic lesion), then consider surgical intervention

Question 347

Describe clinical features of hydatid cyst

Answer 347

- enchinoccocus granulosus - endemic regions; eastern Europe, central America and south America, middle east and north America - patients may present with disseminated disease, or erosion of cysts into adjacent structure and vessels (IVC) - clinical diagnosis based on history, appearance and serologic testing detection of anti-echinococcus antibodies

Question 348

Describe management of a hydatid cyst

Answer 348

- surgery - conservative; open cystectomy, marsupialization - radical; pericystectomy, lobectomy - risks; operative morbidity, anaphylaxis, dissemination of infection - medical; albendazole - percutaneous drainage; PAIR

Question 349

Describe polycystic liver disease (PLD)

Answer 349

- embryonic ductal plate malformation of the intrahepatic biliary tree - numerous cysts throughout liver parenchyma - three types; von meyenburg complexes (VMC), polycycstic liver disease, autosomal dominant polycystic kidney disease

Question 350

Describe von meyenburg complexes (VMC)

Answer 350

- von meyenburg complexes (microhamartomas) benign cystic nodules throughout the liver - cystic bile duct malformations, originating from the peripheral biliary tree - remnants develop into small hepatic cysts and usually remain silent during life - not germline genetically driven - incidental finding

Question 351

Describe management of polycystic liver disease

Answer 351

- C/O abdominal pain, abdominal distension, atypical symptoms due to voluminous cysts resulting in compression of adjacent tissue or failure of the affected organ - conservative treatment is recommended to halt cyst growth to allow abdominal decompression and ameliorate symptoms - invasive procedures are rarely required only in selective patient group with advanced PCLD, ADKPD or liver failure, defenestration / aspiration, liver transplantation - pharmacological therapy by somatostatin analogues lead to beneficial outcome of PLD in terms of symptom relief and liver volume reduction

Question 352

Describe clinical features of a liver abscess

Answer 352

- high fever - leucocytosis - abdominal pain - complex liver lesion - history of abdominal or biliary infection, dental procedures

Question 353

Describe management of liver abscesses

Answer 353

- initial empiric broad spectrum antibiotics - aspiration / drainage percutaneously - echocardiogram - operation if no clinical improvement; open drainage, resection - 4 weeks antibiotic therapy with repeat imaging

Question 354

Name malignant liver tumours

Answer 354

- hepatocellular carcinoma (HCC) - fibro-lamellar carcinoma of the liver - hepatoblastoma - intrahepatic cholangiocarcinoma - others - metastases

Question 355

Name risk factors for hepatocellular carcinoma

Answer 355

- most important risk factor is cirrhosis from any cause - hepatitis B (integrates in DNA) - hepatitis C - alcohol - aflatoxin - other

Question 356

Describe clinical features of hepatocellular carcinoma

Answer 356

- weight loss and RUQ pain (most common) - asymptomatic - worsening of pre-existing chronic liver disease - acute liver failure - signs of cirrhosis - hard enlarged RUQ mass - liver bruit (rare)

Question 357

Describe metastases of hepatocellular carcinoma

Answer 357

- rest of the liver - portal vein - lymph nodes - lung - bone - brain

Question 358

Describe labs for hepatocellular carcinoma

Answer 358

- labs of liver cirrhosis - AFP (alfa fetoprotein) - is an HCC tumour marker - values >100ng/ml highly suggestive of HCC - elevation seen in 60-80% of patients - AFP sensitivity of 41-65% and specificity of 80-94% when the cut off value is 20ng/L

Question 359

Diagnosis of hepatocellular carcinoma

Answer 359

- clinical presentation - elevated AFP - US - triphasic CT scan; very early arterial perfusion - MRI - biopsy

Question 360

Describe prognosis of hepatocellular carcinoma

Answer 360

- tumour size - extrahepatic spread - underlying liver disease - pt performance status

Question 361

Describe fibro-lamellar carcinoma

Answer 361

- presents in young patient (5-35) - not related to cirrhosis - AFP is normal - CT shows typical stellate scar with radial septa showing persistent enhancement - surgical resection or transplantation is the standard of care for fibrolamellar carcinoma - TACE for patients with unresectable tumour

Question 362

Describe secondary liver metastases

Answer 362

- the most common site for blood born metastases - common primaries; colon, breast, lung, stomach, pancreas and melanoma - mild cholestatic picture (ALP) with preserved liver function - Dx imaging or FNA - treatment depends on the primary cancer - in some cases resection or chemoembolization is possible

Question 363

Describe functions of the pancreas

Answer 363

- exocrine function; acinar cells secrete pancreatic enzymes - endocrine function; islets of Langerhans secrete hormones into blood

Question 364

Describe islets of Langerhans

Answer 364

- beta cells ; secrete insulin - alpha cells; which secrete glucagon - delta cells; secrete somatostatin - F cells; secrete pancreatic polypeptide

Question 365

Describe pancreatic fluid

Answer 365

- secretions regulated by vagus nerve and gastrin levels - secretions from the acinar cells - protease; trypsin and chymotrypsin, polypeptides to peptides - pancreatic lipase; triglycerides into fatty acids and monoglycerides - pancreatic amylase; carbohydrates into disaccharides / monosaccharides - other enzymes; ribonuclease, deoxyribonuclease, gelatinase and elastase - secretion from epithelial cells lining the ducts; bicarbonate, base that is critical to neutralise acidic gastric juice, water

Question 366

Define pancreatitis

Answer 366

- an acute inflammation process in the pancreas, involves more regional tissues and remote organs - common cause for acute hospital admissions - incidence is rising - 80% of cases are managed with only analgesia and IV fluids

Question 367

Describe aetiology of pancreatitis

Answer 367

- idiopathic - gallstones - ethanol - trauma - steroids - mumps (other infections coxsackie B and viral hepatitis) - autoimmune (IgG4 related disease, polyarteritis nodose) - scorpion bite - hypercalcaemia, hyperparathyroidism, hyperlipidaemia - ERCP - drugs (azathoprin)

Question 368

Describe symptoms of pancreatitis

Answer 368

- acute onset epigastric pain - radiating through to back - very severe - double over - nausea and vomiting - jaundice - a trigger identified, eg. ERCP, gallstones, ETOH

Question 369

Describe examination findings of pancreatitis

Answer 369

- diffuse upper abdominal tenderness - soft - normal BS - fullness in epigastrium, pseudocyst - if severe; can present like peritonitis with widespread guarding and absent BS

Question 370

Name classic signs of pancreatitis

Answer 370

- erythema abigne - cullens sign - grey turners sign

Question 371

Describe initial investigations for pancreatitis

Answer 371

- IV access - bloods; haematology; FBC and coagulation, biochem; u and es, LFTs, calcium, glucose, amylase / lipase, CRP and lactate - arterial blood gas; hypoxia, ARDS

Question 372

Describe CT scanning and pancreatitis

Answer 372

- to assess severity of pancreatitis, day 5 from onset of symptoms - as follow up - for potential intervention - to look for complications; fluid collections, pancreatic / peripancreatic necrosis, ascites, bleeding, abscess

Question 373

Describe complications of pancreatitis

Answer 373

- fluid collection - pseudocysts - abscess - necrosis +/- infection - ascites - pleural effusion - pulmonary failure - renal failure - shock - sepsis - metabolic acidosis - hyperglycaemia - hypocalcaemia - MODS

Question 374

Describe principles of management of pancreatitis

Answer 374

- conservative in the first instance - fluid resuscitation - correct electrolytes - careful fluid balance - oxygen - antibiotics - nutrition - index admission laparoscopic cholecystectomy

Question 375

Describe pancreatic pseudocysts

Answer 375

- complication of acute and chronic pancreatitis; due to +/- PD communication, can cause biliary obstruction, gastric outlet obstruction - diagnosis; pain, nausea, vomiting, jaundice, weight loss - treatment; nothing, endoscopic drainage

Question 376

Describe pancreatic pseudocysts

Answer 376

- complication of acute and chronic pancreatitis - due to +/- PD communication - can cause biliary obstruction, gastric outlet obstruction - diagnosis; pain, nausea, vomiting, jaundice, weight loss - treatment; nothing, endoscopic drainage, radiological drainage, surgical drainage

Question 377

Describe pancreatic abscesses

Answer 377

- abscess drained to control sepsis | - CT/US guided retroperitoneal or trans-peritoneal drainage

Question 378

Describe pancreatic necrosis

Answer 378

- CT for assessment - sterile or infected - FNA for micro - percutaneous drain - open vs minimal invasive - necrosectomy and lavage

Question 379

Describe chronic pancreatitis

Answer 379

- progressive and irreversible damage - loss of exocrine +/- endocrine function - presentation; very similar to acute pancreatitis, alcohol Hx; smokers, medications etc, masses / ascites / jaundice on examination - imaging; CXR/ASR, USS, CT pancreas, MRI, ERCP

Question 380

Describe aetiology of chronic pancreatitis

Answer 380

- alcohol - idiopathic - PD obstruction - autoimmune - tropical countries - hereditary

Question 381

Describe management of chronic pancreatitis

Answer 381

- manage any acute episodes appropriately - creon as enzyme replacement therapy if pancreatic insufficiency; bloating, pain, loose, fatty pale stools, weight loss, increase stool frequency - surgical options

Question 382

Describe complications of chronic pancreatitis

Answer 382

- splenic vein thrombosis - pseudoaneurysm - splenic artery - pleural effusions - ascites - pancreatic cancer - pseudocysts

Question 383

Describe pseudocysts

Answer 383

- 25-30% with PD communication - biliary obstruction - gastric outlet obstruction - management; endoscopic drainage, surgical drainage, resection

Question 384

Describe complications of pseudocysts

Answer 384

- splenic vein thrombosis - pseudoaneurysm; splenic artery - pleural effusions - ascites - pancreatic cancer - biliary obstruction - duodenal obstruction

Question 385

Describe duodenal obstruction

Answer 385

- oedema due to acute flare up - fibrosis and pancreatic head tumour - pseudocyst - management; stent, bypass, resection

Question 386

Name types of pancreatic tumour

Answer 386

- exocrine; adenocarcinoma | - endocrine; gastrinoma, insulinoma, glucagonoma

Question 387

Describe symptoms of pancreatic tumours

Answer 387

- jaundice (painless) - loose pale stools - dark urine - weight loss - back pain

Question 388

Describe gallstones

Answer 388

- common - most asymptomatic - colic, cholecystitis, jaundice, pancreatitis, bowel obstruction

Question 389

Describe risk factors of gallstones

Answer 389

- age >40 - female - high fat diet - obesity - pregnancy - hyperlipidaemia - bile salt loss (crohns) - diabetes - dysmotility of GB - prolonged fasting - TPN

Question 390

Why do we get gallstones?

Answer 390

- abnormal bile composition - bile stasis - infection - excess cholesterol - excess bilirubin

Question 391

Describe categories of gallstones

Answer 391

- mixed - cholesterol - pigment - primary bile duct stones (rare)

Question 392

Describe biliary colic

Answer 392

- stone impacts in cystic duct - gradual build-up pain in RUQ - radiates to back / shoulder - may last 2-6 hours - associated with indigestion / nausea

Question 393

Describe severe acute epigastric pain

Answer 393

- biliary colic - peptic ulcer disease - oesophageal spasm - myocardial infarction - acute pancreatitis

Question 394

Describe diagnosis of gallstones

Answer 394

- ultrasound - CT scan - MRCP / ERCP - HIDA - EUS

Question 395

Describe treatment of biliary colic

Answer 395

- pain killers - low fat diet / lose weight if obese - observe 3-6 months - recurrent episodes pain / colic - consider / refer for surgery - cholecystectomy - unfit; ursodeoxycholic acid 10mg/kg/day

Question 396

Describe acute cholecystitis

Answer 396

- inflammation in GB, obstruction of cystic duct | - initially sterile, then becomes infected

Question 397

Treatment of acute cholecystitis

Answer 397

- IV antibiotics and IV fluids - nil by mouth - US to confirm diagnosis - urgent cholecystectomy ASAP - interval cholecystectomy

Question 398

Describe complications of gallstones

Answer 398

- stone may migrate into CBD; jaundice, cholangitis, acute pancreatitis - gallstone ileus

Question 399

Describe diagnosis of CBD pathology

Answer 399

- itch, nausea, anorexia - jaundice - abnormal LFTs - ERCP; ES and stone removal - surgical exploration; CBD (open vs lap)

Question 400

Describe gallstone ileus

Answer 400

- small bowel obstruction - fistula gallbladder + duodenum - large gallstone passes into small intestine - move down SB causing intermittent colic - present with distal SB obstruction

Question 401

Describe treatment of gallstone ileus

Answer 401

- urgent laparotomy; SB enterotomy to remove stone | - interval cholecystectomy in 3 months

Question 402

Name the best single test for gallstones

Answer 402

- ultrasonography

Question 403

Describe cholangiocarcinoma

Answer 403

- second most common hepatobiliary cancer | - increased incidence in UK since mid 1990s

Question 404

Describe clinical presentation and staging / assessment of cholangiocarcinoma

Answer 404

- usually presents late - jaundice, weight loss, anorexia, lethargy - duplex ultrasound - spiral CT, ERCP, PTC - MRI, MRCP, MRA

Question 405

Describe visceral pain

Answer 405

- receptors are located on the serosal surface, in the mesentery, within the intestinal muscle and mucosa of the hollow organ - these pain receptors respond to mechanical and chemical stimuli, such as stretching, tension and ischaemia - because visceral pain fibres are c fibres, pain is often dull, poorly localised and perceived in the middle - there are 3 broad pain areas with anatomic association; foregut felt in the middle (stomach, pancreas) - midgut felt in suprapubic (small intestine) - hindgut felt in lower abdomen (colon)

Question 406

Describe somato-parietal pain

Answer 406

- the receptors are located in the parietal peritoneum, the muscle and the skin - the pain resulting from; inflammation, stretching or tearing of the parietal peritoneum - it is transmitted through mialinated A, delta to specific dorsal root ganglia - this pain is characterised by sharp, more intense and more localised sensation - movement may aggravate pain so patient very often lay still

Question 407

Describe referred pain

Answer 407

- it is well localised but felt in distant areas of the cutaneous dermatome as the effected organ - it occurs when organs share common nerve pathways - for example; gall bladder pain may be felt in the right should tip

Question 408

Define the acute abdomen

Answer 408

- refers to a sudden, severe abdominal pain, that is less than 24 hours of duration

Question 409

Name causes of acute abdomen

Answer 409

- acute appendicitis - acute pancreatitis - acute peptic ulcer - acute diverticulitis - diabetic ketoacidosis - bowel perforation - volvulus - acute pyelonephritis - acute cholecystitis - acute intestinal ischaemia - acute renal colic - leaking AAA - peritonitis - strangulated hernia

Question 410

Name vital signs of acute abdomen

Answer 410

- is patient hypotensive, tachycardic, haemodynamically unstable - MI, AAA, ruptured ectopic, mesenteric ischaemia, rupture spleen liver, septic, dehydrated

Question 411

Describe an abdominal mass

Answer 411

- abnormal growth in the abdomen - an abdominal mass causes visible swelling and may change the shape of the abdomen - masses in the abdomen are often described by their location - or by the origin of the mass; fat, faeces, flatus, foetus, fluid or fatal growth

Question 412

What is a hernia?

Answer 412

An abnormal protrusion of a cavitys contents through a weakness in the wall of the cavity

Question 413

Describe causes of abdominal hernias

Answer 413

- anatomical eg. sites where structure exit through and opening in the cavity - inherited collagen disorders - sites where surgical incisions are made

Question 414

Name types of abdominal hernias

Answer 414

- epigastric - umbilical / paraumbilical - inguinal hernia - femoral hernia - Spigelian hernia - lumbar hernia - incisional hernia - parastomal hernia - port-site hernia

Question 415

Describe classification of hernias

Answer 415

- reducible; hernia can be easily pushed back into the abdomen - incarcerated or irreducible hernia; when a hernia cannot be manipulated back to the abdomen - strangulated hernia; vascular supply to the contents contained within the hernia is compromised, resulting in ischaemic and gangrenous tissue

Question 416

Describe treatment of hernias

Answer 416

- conservative / non-surgical management | - surgical management

Question 417

Describe epigastric hernias

Answer 417

- is defined as a fascial defect in the linea alba between the xiphoid process and the umbilicus - main presentation is a midline lump - asymptomatic (75%) or can present with pain - if incarcerated or strangulated symptoms depend on organ involved - management is either conservative or surgical

Question 418

Describe paraumbilical hernias

Answer 418

- acquired hernias occur in all age groups - aetiological factors include stretching of the abdominal wall by obesity, multiple pregnancy and ascites - frequently symptomatic presenting with pain - para-umbilical hernias do not resolve spontaneously and have a high incidence of incarceration and strangulation - management nearly always surgical

Question 419

Describe adult umbilical hernias

Answer 419

- usually results from persistent elevation of intraabdominal pressure - the clinical presentation, management and complications of adult umbilical hernia are very similar to those of para-umbilical hernia

Question 420

Describe the anatomy of the inguinal canal

Answer 420

- 4cm in length, starts at deep inguinal ring and ends in superficial inguinal ring - boundaries; anterior - external oblique aponeurosis, floor - ligament, roof - conjoint tendon, posterior - transversalis fascia - transmits the spermatic cord and ilioinguinal nerve in the males and the round ligament of the uterus and ilioinguinal nerve in the female

Question 421

Describe the contents of the spermatic cord

Answer 421

- three coverings; internal spermatic fascia, cremasteric fascia, external spermatic fascia - six contents; vas deferens, pampiniform plexus (veins), lymphatics, remain of the processus vaginalis, nerves; genital branch of genitofemoral nerve and sympathetic twigs, 3 arteries; testicular artery, artery to the vas and cremasteric artery

Question 422

Describe the hesselbach triangle

Answer 422

- laterally; inferior epigastric artery - medially; lateral border of the rectus muscle - inferiorly; inguinal ligament

Question 423

Name types of inguinal hernia

Answer 423

- indirect inguinal hernia | - direct inguinal hernia

Question 424

Describe diagnosis of inguinal hernia

Answer 424

- groin swelling which usually disappears when lying down - usually located above and medial to the pubic tubercle - palpable cough impulse on examination - if in doubt dynamic ultrasound scan can be helpful

Question 425

Describe management of inguinal hernia

Answer 425

- non surgical | - surgical ; open, laparoscopic

Question 426

Describe the anatomy of the femoral ring

Answer 426

- anteriorly; inguinal ligament - posteriorly; iliopectineal ligament - medially; lacunar ligament - laterally; femoral vein

Question 427

Describe an incisional hernia

Answer 427

- iatrogenic | - commonest complication of a laparotomy (exploration of the abdomen)

Question 428

Describe haemorrhoids

Answer 428

- enlarged vascular cushions in the lower rectum and anal canal - at least 10% of the population have symptomatic haemorrhoids at some time in their life

Question 429

Describe the presentation of haemorrhoids

Answer 429

- painless bleeding - fresh, bright red blood, not mixed with stool, usually on the paper - perianal itchiness - no change in bowel habit, no weight loss or other associated symptoms

Question 430

Describe clinical findings of haemorrhoids

Answer 430

- external inspection can be normal - maceration of the perianal skin - obvious haemorrhoids if 3rd degree piles presents - DRE - normal unless thrombosed

Question 431

Describe the classical position of haemorrhoids

Answer 431

- corresponds to the branches of the superior haemorrhoidal artery occurring at 3,7 and 11 o'clock position with the patient in the lithotomy position

Question 432

Describe investigations of haemorrhoids

Answer 432

- PR exam - rigid sigmoidoscopy - proctoscopy - flexible sigmoidoscopy if patients is above 50

Question 433

Describe treatment of haemorrhoids

Answer 433

- symptomatic - sclerosation therapy with 5% phenol in almond oil - rubber band ligation - open haemorrhoidectomy - stapled haemorrhoidectomy - HALO / THD procedure

Question 434

Describe the HALO/THD procedure

Answer 434

- haemorrhoidal artery ligation - devised by Japanese surgeons in 1995 - the operation is best performed under general or spinal anaesthesia

Question 435

Describe the HALO procedure

Answer 435

- miniature doppler ultrasound device locates branches of arteries supplying the haemorrhoids - these blood vessels are tied off, and the haemorrhoid shrinks over the subsequent days and weeks - because the stitch is placed in the lower rectum where there are virtually no sensory nerves the procedure is pain free

Question 436

Name the types of rectal prolapse

Answer 436

- partial (anterior mucosal prolapse) | - complete (full thickness)

Question 437

Describe the presentation of rectal prolapse

Answer 437

- protruding mass from anus especially during defecation - may reduce spontaneously - bleeding and passing mucus per rectum is common - examination usually shows poor anal tone

Question 438

Describe management of complete rectal prolapse

Answer 438

- many patients too frail for surgery - bulking agent and education on manual reduction - delormes procedure - perineal rectopexy - abdominal rectopexy - anterior resection

Question 439

Describe management of incomplete prolapse

Answer 439

- in children; dietary advice and treatment of constipation | - in adults; treatment similar to that of haemorrhoids

Question 440

Describe anal fissures

Answer 440

- tear in the anal margin due to passage of a constipated stool - usually in the midline posteriorly but may be occasionally anterior - multiple fissures may be due to crohns disease

Question 441

Describe the presentation of anal fissures

Answer 441

- acute onset of severe anal pain usually following episode of constipation - 'glass passing through the back passage' - pain lasts for up to 1/2 hr after defecation - bright rectal bleeding

Question 442

Describe treatment of anal fissures

Answer 442

- dietary advice, stool softeners - pharmacological sphincterotomy (GTN ointment, diltiazem ointment) PR for 6/52 - lateral sphincterotomy - botox injection

Question 443

Describe fistula in ano

Answer 443

- abnormal communication between two epithelial surfaces - there is an internal opening in the anal canal and one or more external openings on the peri-anal skin - also rarely caused by crohns disease, TB and carcinoma

Question 444

Describe the presentation of fistula in ano

Answer 444

- majority arise from delay in treatment or inadequate treatment of anorectal abscess - could have crohns disease, carcinoma or TB as an underlying pathology

Question 445

Describe investigations of fistula in ano

Answer 445

- EUA of anorectum - rigid sigmoidoscopy, proctoscopy - flexible sigmoidoscopy - MRI

Question 446

Describe management of fistula in ano

Answer 446

- laying open - two stage procedure - insertion of seton (draining, cutting) - LIFT procedure - glue / Permacol - defunctioning colostomy

Question 447

Describe complications of fistula in ano

Answer 447

- pain - bleeding - incontinence of flatus or stool - recurrence - further surgery

Question 448

Describe cardiovascular surgery complications

Answer 448

- haemorrhage - MI - DVT

Question 449

Describe the presentation of haemorrhage

Answer 449

- overt - tachycardia - hypotension - oliguria

Question 450

Describe prevention of haemorrhage

Answer 450

- meticulous technique - avoidance of sepsis - correction of coagulation disorders

Question 451

Describe prevention of MI

Answer 451

- delay surgery after MI - avoidance of perioperative hypotension - correction of ischaemic heart disease

Question 452

Name respiratory surgical complications

Answer 452

- atelectasis - pneumonia - PE

Question 453

Describe atelectasis / pneumonia

Answer 453

- collapse of lung tissue >> infection - anaesthesia; increases secretion, inhibits cilia - postoperative pain; inhibits coughing - aspiration; stomach contents

Question 454

Describe GI surgical complications

Answer 454

- ileus - anastomotic dehiscence - ashesions

Question 455

Describe ileus

Answer 455

- paralysis of intestinal motility - caused by; handling of bowel - peritonitis - retroperitoneal injury - immobilisation - hypokalaemia - drugs

Question 456

Describe presentation of ileus

Answer 456

- vomiting - abdominal distension - dehydration - silent abdomen

Question 457

Describe the prevention of ileus

Answer 457

- minimal operative trauma - laparoscopy - avoidance of intra-abdominal sepsis

Question 458

Describe anastomotic dehiscence

Answer 458

- breakdown of anastomosis; intestinal, vascular, urological - caused by; poor technique, poor blood supply, tension on anastomosis

Question 459

Describe the presentation anastomotic dehiscence

Answer 459

- intestinal; peritonitis, abscess, ileus, fistula - vascular; bleeding / haematoma - urological; leakage of urine / urinoma

Question 460

Describe adhesions

Answer 460

- fibrin to fibrous tissue; bowel to bowel, bowel to abdominal wall and other structures, lung to chest wall - caused by; inflammatory response, ischaemia

Question 461

Describe the presentation of adhesions

Answer 461

- asymptomatic; to chest wall | - intestinal obstruction; vomiting, pain, distension, constipation

Question 462

Describe the presentation of wound infection

Answer 462

- pyrexia (5-8 days) - redness - pain - swelling - discharge

Question 463

Describe the prevention of wound infection

Answer 463

- pre-op preparation - skin cleansing - aseptic technique - avoidance of contamination - prophylactic antibiotics

Question 464

Describe urinary complications of surgery

Answer 464

- acute retention of urine - urinary tract infection - urethral stricture - acute renal failure

Question 465

Describe neurological complications of surgery

Answer 465

- confusion - stroke - peripheral nerve lesions; ulnar nerve, radial nerve, sciatic nerve, common peroneal nerve

Question 466

Describe causes of confusion

Answer 466

- hypoxia; chest infections, PE, MI - oversedation - sepsis - electrolyte imbalance - stroke - hyper or hypoglycaemia - alcohol or tranquiliser withdrawal

Question 467

Describe the presentation of confusion

Answer 467

- disorientation; time, place - paranoia - hallucinations

Question 468

Describe how to minimise complications and their effect

Answer 468

- patient selection and preparation - careful surgery - constant vigilance

Question 469

Describe the unique blood supply to the liver

Answer 469

- blood flow out of the liver through 3 hepatic veins into a big vein called the IVC - oxygen rich blood flows into the liver through the hepatic artery - nutrient rich blood coming from the bowel flows into the liver through the portal vein - bile flows out of the liver through the bile duct

Question 470

Name functions of the liver

Answer 470

- protein metabolism - carbohydrate metabolism - lipid metabolism - bile acid metabolism - bilirubin metabolism - hormone and drug metabolism - immunological defence

Question 471

Describe acute liver disease

Answer 471

- any insult to the liver causing damage in previously normal liver - less than 6 months duration - acute liver failure defined as causing encephalopathy and prolonged coagulation - wilsons disease may allow classification od an acute presentation as acute liver failure

Question 472

Describe clinical features of acute liver disease

Answer 472

- none - jaundice - lethargy - nausea - anorexia - pain - itch - arthralgia - abnormal LFTs

Question 473

Describe causes of acute liver disease

Answer 473

- viral A,B,C,D,E,CMV,EBC and toxoplasmosis - drugs - shock liver - cholangitis - alcohol - malignancy - chronic liver disease - ask about paracetamol - rare; budd chiari, acute fatty liver of pregnancy, cholestasis of pregnancy

Question 474

Describe investigations of acute liver disease

Answer 474

- LFTs (including albumin and bilirubin) - prothrombin time - history and examination - ultra sound including vascular - virology - investigations of chronic liver disease - rarely liver biopsy

Question 475

Describe the treatment of acute liver disease

Answer 475

- rest, up to 3 months for recovery, may be 6 months - fluids, no alcohol - increase calories, high fat food poorly tolerated - for itch; sodium bicarbonate bath, cholestyramine or ursodeoxycholic acid - observation for fulminant hepatic failure

Question 476

Describe hepatic drug reactions

Answer 476

- 6 weeks exposure to effect; first effect may not have been noticed, liver may not have been normal to start - any drug - multiple mechanisms; therefore multiple patterns of LFTs and symptoms, may overlap with other toxic effects

Question 477

Describe fulminant hepatic failure (FHF)

Answer 477

- acute episode of severe liver dysfunction (jaundice and encephalopathy) in a patient with a previous normal liver

Question 478

Describe causes for FHF

Answer 478

- common; paracetamol, fulminant viral, drugs, HBV, non A-E | - rare; AFLP, mushrooms, malignancy, wilsons, budd chiari, HAV

Question 479

Describe FHF clinical cause and complications

Answer 479

- encephalopathy - hypoglycaemia - coagulopathy - circulatory failure - renal failure - infection

Question 480

Describe FHF assessment

Answer 480

- exclude cirrhosis, alcohol induced injury or malignant infiltration - initiate early discussion with tertiary liver / transplant centre, even if not immediately relevant - screen intensively for hepatic encephalopathy - determine aetiology - to guide treatment and determine prognosis - assess suitability for liver transplant - contraindications should not preclude transfer to tertiary liver / transplant centre - if the patient has an INR >1.5 and onset of hepatic encephalopathy or other poor prognostic features

Question 481

Describe FHF treatment

Answer 481

- supportive - inotropes and fluids - renal replacement - management of raised ICP - transplantation

Question 482

Name the first line investigation of cholecystitis / biliary colic

Answer 482

Ultrasound

Question 483

Describe pancreatitis and imaging

Answer 483

- main purpose of imaging is to evaluate complications - necrosis - intra-abdominal collections - vascular complications - best performed around 1 week following onset of symptoms

Question 484

Name the first line investigation of perforation

Answer 484

Erect CXR

Question 485

Name the first line investigation for appendicitis

Answer 485

- ultrasound

Question 486

Name the investigation for diverticulitis

Answer 486

CT

Question 487

Describe chronic liver disease

Answer 487

- duration greater than 6 months - can present acutely - duration may be sub clinical - outcome; progression to cirrhosis - signs and symptoms dependent on underlying disease or features of cirrhosis - pathology recurrent inflammation and repair with fibrosis and regeneration

Question 488

Name causes of chronic liver disease; cirrhosis causes

Answer 488

- alcohol - NAFLD - hepatitis C - primary biliary cholangitis - autoimmune hepatitis - hepatitis B - haemochromatosis - primary sclerosing cholangitis - wilsons disease - alpha 1 anti-trypsin - budd-chiari - methotrexate

Question 489

Describe NAFLD

Answer 489

- commonest disease in the world - 20-30% of general population have fatty liver - 20-30% will have NASH - of these 20% will have cirrhosis within 20 years - in obesity rate up to 60^ - a spectrum - steatosis - NASH (fibrosis)

Question 490

Describe histological features of NASH

Answer 490

- spectrum; steatosis > steatohepatitis > steatohepatitis with fibrosis > cirrhosis - steatohepatitis; inflammation usually mild, lobular, and mixed mononuclear and neutrophilic - hepatocyte degeneration; ballooning and Mallory bodies - fibrosis; initially pericellular, later bridging - cirrhosis; occurs in up to 20£ over 10 years

Question 491

Describe the aetiology of primary biliary cholangitis

Answer 491

- first described 1851 gull and Addison - autoimmune component 1960s, 1970s - 1980s AMAs M1-M12 - 1980s target ME-E2 E3 subunits of PDC-E2 n inner leaflet of mitochondrial membrane - t-cell mediated, CD4 cells reactive to M2 target, why loss of tolerance

Question 492

Describe the presentation of primary biliary cholangitis

Answer 492

- middle aged women (f:m 10:1) - usually asymptomatic / incidental - symptoms; fatigue, itch without rash, xanthesalma, xanthomas - complications

Question 493

Describe primary biliary cholangitis diagnosis and treatment

Answer 493

- 2 of 3; positive AMA, cholestatic LFTs, liver biopsy | - treatment; ursodeoxycholic acid, obeticholic acid

Question 494

Describe PBC outcomes

Answer 494

- most will not develop symptoms in their life time - the majority with PBC symptoms do not develop liver failure; itch can be particularly problematic - many developing liver failure will be unfit for transplant - still a common cause of liver transplantation

Question 495

Describe auto-immune hepatitis type one and type 2 immunology

Answer 495

- type 1; adult (twin peaks), ANA, ASMA 1 in 40 actin, SLA severity, uncommon - type 2; children and young adults, LKM1, exclusive, AMA, very rare

Question 496

Describe type 1 auto-immune hepatitis

Answer 496

- bimodal age distribution (ages 10-20 and 45-70) - female: male 3.6:1 - associated with extrahepatic manifestations: autoimmune thyroiditis, graves disease, chronic UC. Les commonly with RA, pernicious anaemia, systemic sclerosis, ITP, SLE - 40% present with acute onset of symptoms similar to toxic hepatitis or acute viral hepatitis

Question 497

Describe the clinical presentation of type 1 auto-immune hepatitis

Answer 497

- hepatomegaly - jaundice - stigmata of chronic liver disease - splenomegaly - elevated AST and ALT - elevated PT - non-specific symptoms; malaise, fatigue, lethargy, nausea, abdominal pain, anorexia

Question 498

Describe diagnosis of type 1 auto-immune hepatitis

Answer 498

- elevated AST and ALT - elevated IgG - rule out other causes; wilsons disease, alpha 1 antitrypsin deficiency, viral hepatitis (A,B,C), drug induced liver disease (alcohol, minocycline, nitrofurantoin, INH, PTU, methyldopa etc) - presence of autoimmune antibodies - liver biopsy

Question 499

Describe the pathogenesis of type 1 auto-immune hepatitis -

Answer 499

- unknown mechanism but several proposed mechanisms - genetically predisposed individual with exposure to an environmental agent triggers the autoimmune pathogenic process - genetic predisposing factors; HLA-DR3; early onset, severe form - HLA-DR4; Caucasian, late onset, better response to steroids, higher incidence of extrahepatic manifestations - IgG; part of the IgG molecule (mainly the heavy chain) - t cell receptors

Question 500

Describe the treatment of type 1 autoimmune hepatitis

Answer 500

- corticosteroids - azathioprine - children: azathioprine or 6MP, combination therapy - prednisolone and azathioprine - prednisolone; start AT 30MG daily and taper down to 15mg at week 4, then maintain on 5mg daily until therapy endpoint - azathioprine 50-100mg daily

Question 501

Describe the prognosis of autoimmune hepatitis

Answer 501

- 40% of all patients with AIH develop cirrhosis - 54% develop oesophageal varices within 2 years - poor prognosis if has presence of ascites or hepatic encephalopathy - 13-20% of patients can have spontaneous resolution - of patients who survive the most early and active stage of disease, approximately 41% of them develop inactive cirrhosis - of patients who have severe initial disease and survive the first 2 years, typically survive long term

Question 502

Describe primary sclerosing cholangitis

Answer 502

- autoimmune destructive disease of large and medium sized bile ducts - commonest liver disease in scandanavia - clinical recurrent cholangitis - diagnosis imaging of biliary tree - treatment maintain bile flow, monitor for cholangiocarcinoma and colo-rectal cancer

Question 503

Describe haemochromatosis

Answer 503

- genetic iron overload syndrome - mono-genetic autosomal recessive disease of iron overload, C282Y or H63D, mutations in HFE gene - gene carrier frequency 10%, genetic haemochromatosis 1 in 200 but partial penetrance - cirrhosis, cardiomyopathy, pancreatic failure, the bronzed diabetic - treatment = venesection

Question 504

Describe Wilsons disease

Answer 504

- lenticulo-hepatic degeneration - mono-genetic autosomal recessive disease - loss of function or loss of protein mutations in caeruloplasmin - copper binding protein, loss of copper regulation massive tissue deposition of copper, especially liver and basal ganglia - clinical either or rarely both; neurological (chorea-athetoid movements), hepatic (cirrhosis or sub-fulminant liver failure), Kaiser Fleisher rings - treatment; copper chelation drugs

Question 505

Alpha 1 anti-trypsin deficiency

Answer 505

- genetic mutations in the A1AT genes, multiple sites, causes variable phenotype - protein function lost excess tryptic activity - clinical; lung emphysema, liver deposition of mutant protein, cell damage - treatment; supportive management

Question 506

Describe budd-chiari

Answer 506

- thrombosis of the hepatic veins; congenital webs, thrombotic tendency, protein c or s deficiency - clinical; acute-jaundice, tender hepatomegaly, chronic ascites - diagnosis u/s visualisation of hepatic veins - treatment; recanalization or TIPS

Question 507

Describe methotrexate

Answer 507

- drugs used to treat rheumatoid arthritis and psoriasis - dose dependent on liver toxin; progressive fibrosis - clinical; no signs, monitor fibrosis - treatment; stop the drug

Question 508

Describe cardiac cirrhosis

Answer 508

- secondary to high right heart pressures; incompetent tricuspid valve, congenital, rheumatic fever, constrictive pericarditis - clinical; CCF, with too much ascites and or liver impairment - treatment; treat the cardiac condition