Gastro

Question 1

Painless intermittent dysphagia with symptoms of iron deficiency anaemia.

Answer 1

Iron deficiency is associated with a postcricoid oeasophageal web

Affects middle aged women

Tx: Iron supplements
Dilation of the webs

Question 2

50YO man with severe pain on defecation. On examination, a tender reddish blue swelling is seen near the anal verge. Dx? Tx?

Answer 2

Perianal haematoma

This is a clotted venous saccule, looks like a 2-4mm dark blueberry (purple) under the skin at the anal margin. Seen as swollen and acutely tender perianal lumps.

Evacuated under local anesthesia or left to resolve spontaneously

Qx> relieves pain but the thrombosis often recurs and there may be persistent bleeding.

Conservative> analgesia, ice packs and stool softeners.
Calcium antagonist may help relieve pain.
Usually settles within 10-14 days.

Question 3

64YO male with lethargy and dull pain in right hypochondrium that has been worsening over the past months. He has a slight yellow tinge, palpation reveals a tender right upper quadrant with a firm, enlarged liver. TTF-1 (thyroid transcription factor 1) is positive.

Dx?

Answer 3

Primary pulmonary tumour.

TTF-1 is a protein seen by immunostaining used as a clinical marker of lung adenocarcinoma.

Liver Adenocarcinoma by haematogenous metastasis.

Question 4

High MCV and low Hb and history of gastrectomy. Loss of proprioception and vibration sense is noted.

Answer 4

Vitamin B12 deficiency.

High MCV and low Hb = Macrocytic anaemia.

These+ gastric resection hx = malabsorption of B12.

Question 5

Vit B12 deficiency

Answer 5

B12 deficiency causes
Malabsorption> pernicious anaemia.

Inflammation of small intestine (Coeliac, tropical sprue, Crohn disease)
Gastric resection (for reasons of obesity or cancer)

Low intake of cobalamin-rich foods.
Beef and Bacon = B12

Question 6

Folate deficiency

Answer 6

Poor bioavailability

Inflammation of small intestine (coeliac disease, tropical sprue, Crohn disease)

Low intake of folate-rich foods (usually vegetables)

Fruits and Fegetables = Folate

Question 7

Curling’s ulcers

Tx?

Answer 7

Stress-induced ulcers of the stomach.

May occur on massively burned patients.

IV proton pump inhibitors reduce the risk of bleeding.
Can switch oral after 72hrs.

Question 8

When to consider Irritable Bowel Syndrome?

Answer 8

Any of these lasting >6 months.
Abdominal pain or discomfort
Abdominal bloating
Change in bowel habits.

Other features:
Abdominal pain relieved by defecation
Change in stool frequency or form
Altered stool passage (straining, urgency, incomplete evacuation)
Symptoms aggravated by eating
Passage of mucus rectally.

Question 9

Which tests should be done for Irritable Bowel Syndrome?

Answer 9

There are no diagnostic tests, but other diseases should be excluded.

IgA tissue transglutaminase antibody > coeliac disease

Faecal calprotectin> inflammatory bowel disease

FIT sample > colon cancer (>50YO)

Ca-125 > ovarian cancer (>50YO women)

Question 10

Categories and management of IBS (Irritable Bowel Syndrome)

Answer 10

Constipation predominant
Diarrhoea predominant
Mixed

Tx
Low FODMAP diet (short chain CHs that are poorly absorbed in the small intestine)
Antispasmodics (mebeverine, peppermint oil)
Laxatives (isphahulas husk) for constipation predominant
Loperamide for diarrhoea predominant

Question 11

Px with dyspepsia for the past 6 months, he has been prescribed H2 blockers and PPI with minimal relief. He started with swallowing difficulty 2 weeks ago.

Most appropriate investigation?

Answer 11

OGD
Oesophagogastroduodenoscopy

Any px with dyspepsia should have an OGD if they have refractory symptoms while on optimal tx.

Question 12

Px with productive cough and moderate fever. She complains of central chest pain and regurgitation of undigested food. She has difficulty swallowing solids and liquids for the last 4 months.

Chest X-ray shows megaeasophagus.

Dx?

Answer 12

Achalasia.

Idiopathic loss of normal neural structure of the lower oeasophageal sphincter which results in the failure of relaxation of circular muscles at the distal oesophagus.

Question 13

Features, investigations and management of achalasia

Answer 13

Progressive dysphagia to both solids and liquids simultaneously, and can have regurgitation of stragnant food several hours after eating. (over the years)

Weight loss
Night-time coughing fits (due to aspiration-can result in recurrent lower respiratory tract infections)
Achalasia has no relationship with alcohol or tobacco use.

Barium swallow shows dilation of the oeasophagus, which narrows into a “bird’s peak” at the distal end.

The most accurate test is esophageal manometry. It shows increased lower oesophageal resting pressure.

Tx: Dilatation of the lower oesophageal sphincter.

Question 14

Tender epigastrium
Pain radiates to the back
Fever
Vomiting
Risk factors include gallstones and alcohol
Bending forward provides temporary relief.

Answer 14

Acute pancreatitis

Question 15

Peptic ulcer clinical features

Answer 15

Abdominal pain
Reflux symptoms
May have melaena

Question 16

Biliary colic clinical features

Answer 16

RUQ pain with radiation to the scapula
Secondary to gallstones
No fever

Question 17

Murphy’s sign (RUQ pain)
Fever
Vomiting
Raised white cell count

Answer 17

Acute cholecystitis

Like a biliary colic but with fever.

Question 18

What medication should be given for pxs with ascites due to cirrhosis?

Answer 18

Spironolactone.
Oedema and fluid overload in third spaces such as ascites are managed with diuretics.

Cirrhotics have intravascular volume depletion, which results in a high aldosterone state. Spironolactone is an aldosterone antagonist.

Question 19

Complications of Coeliac disease

Answer 19

Osteoporosis
T-cell lymphoma of the small intestine (rare)

Enteropathy-associated T-cell lymphoma (EATL). Derives from the neoplastic transformation of aberrant intraepithelial T lymphocytes emerging in coeliac patients unresponsive to a gluten-free diet.

Question 20

Crohn’s disease

Crohn’s vs Ulcerative colitis

Answer 20

Can affect any part of the GI tract from mouth to anus
Usually non-bloody diarrhoea
Abdominal mass palpable in RIF
Increased goblet cells on histology
Granulomas seen on histology (noncaseating granulomas)
Weight loss more prominent
Transmural, skip lesions, cobble stone appearance on endoscopy
Fistulas

Question 21

Ulcerative colitis

Crohn’s vs Ulcerative colitis

Answer 21

Affects mucous membrane starting from rectum
Bloody diarrhoea more common compared to Crohn’s disease
Abdominal pain in left lower quadrant
Decreased goblet cells on histology
Granulomas are infrequent on histology
Primary sclerosing cholangitis more common
Loss of haustration, drain pipe colon seen on barium enema.

Question 22

Bloody diarrhoea organisms

Answer 22

Campylobacter
Shigella
Salmonella

Question 23

Prodrome of headache, myalgia and fever
Can cause chronic diraahoea associated with weight loss
Non bloody diarrhoea

Organism?

Answer 23

Giardia Lamblia
Watery diarrhoea
Traveller’s diarrhoea with symptoms lasting more than 10 days.

Bloating
Flatulence
Abdominal pain
Loose stool
*Explosive diarrhoea