Gastro

Question 1

What is the test used for screening and for diagnosing coeliac disease?

Answer 1

These tests must be done with gluten re-introduced in the patients diet for a minimum of 6 weeks!

Screening:
Specific auto-antibodies
◆ Tissue tranglutaminase (TTG) antibodies (IgA)
◆ Endomysial antibody (IgA)

Diagnosis:
Jejunal/Duodenal biopsy

Question 2

What does the blood smear shows in megaloblastic anaemias?

Answer 2

Hypersegmented neutrophils

Question 3

What should you suspect in a patient with intractable peptic ulcerations?

Answer 3

Gastrinoma.

Neuroendocrine tumor found in the pancreas or duodenum, that secrete gastrin, which stimulates parietal cells of the stomach to secrete hydrochloric acid into the stomach.

Diagnosis is made by measurement of fasting gastrin levels or secretin stimulation test.

Question 4

What are the four main organisms associated with travelers diarrhea?

Answer 4

Bloody diarrhea:
- Campylobacter ➝ clarithromycin
- Salmonella ➝ ciprofloxacin

Watery diarrhea:
- Giardia ➝ Europe
- E. coli ➝ Africa

Question 5

What is the hystological change associated with Barret’s oesophagus?

Answer 5

Stratifies squamous epithelium is replaced by columnar epithelium, which is called “columnar metaplasia”.

Question 6

What are the key features of Crohn’s disease?

Answer 6

• can affect any part of the GI tract from mouth to anus
• bleeding is less common compared to ulcerative colitis but can still be present
• abdominal mass palpable in right iliac fossa
• increased goblet cells on histology
• granulomas/ granulomatos inflammation seen on histology
• weight loss more proeminent
• transmural, skip lesions, cobble stone appearance on endoscopy
• fistulas seen on colonoscopy and perianal fistulas

Question 7

What are the features of Ulcerative colitis?

Answer 7

• Affects the mucous membrane starting from rectum;
• Bloody diarrhoea (more common compared to Crohn’s);
• Abdominal pain in left lower quadrant;
• ⬇︎ goblet cell on histology;
• Granulomas are infrequent on histology;
• Primary sclerosing cholangitis more common;
• Loss of haustration (haustral markings), drain pipe;
• Colon seen on barium enema.

Question 8

What is faecal elastase used for?

Answer 8

Investigate chronic pancreatitis.

Question 9

What is the most common electrolyte imbalance associated with villous adenoma?

Answer 9

Hypokalaemia and hypoproteinaemia, since the villous adenoma secretes a mucous rich in protein and potassium.

Question 10

What is the Charcot’s triad and what does it represent?

Answer 10

Fever, RUQ pain and jaundice.

Represents ascending cholangitis.

Question 11

What disease is related to antimitochondrial antibodies (AMA)?

What is the M rule?

Answer 11

AMA are the hallmark for primary biliary cirrhosis.

M rule:
- IgM
- Anti-mitochondrial antibodies
- Middle aged females

Question 12

What is faecal calprotectin used for?

Answer 12

To discriminate between:
◆ Inflammatory bowel disease (⬆︎)
◆ Irritable bowel disease (⬇︎)

Question 13

Describe the following in regards to Autoimmune hepatitis:
- Symptoms
- Investigations
- Rx

Answer 13

Symptoms
- Amenorrhoea
- Jaundice
- Pruritus
- Fatigue

Investigations
- Anti-smooth muscle antibody;
- LFT;
- Liver biopsy;

Rx
- Prednisolone + Azathioprine

Question 14

What are the classic signs of alcoholic liver disease?

Answer 14

History of alcohol excess
raised AST
AST higher than ALT (70%)
raised GGT

end-stage alcoholic liver disease - GI bleed (oesophageal varices due to portal hypertension)

Mnemonic: when you drink you ToAST “to AST”

Question 15

Why is spironolactone the most useful diuretic in cirrhosis?

Answer 15

Because cirrhosis patients have intravascular volume depletion, which results in a high aldosterone state, and spironolactone is an aldosterone antagonist.

Other common spironolactone indications
- ascites: patients with cirrhosis develop secondary hyperaldosteronism
- hypertension: used as one of the last treatment options (step 4)
- heart failure
- nephrotic syndrome

Question 16

What test is used to ensure eradication of H pylori after treatment?

Answer 16

C13 urea breath test (stable, non-radioactive isotope)

Question 17

What are the Light’s criteria?

Question 18

Primary biliary cirrhosis

Answer 18

The classic presentation is itching in a middle-aged woman.
Often asymptomatic and diagnosed after finding alkaline phosphatase on routine
LFT.Lethargy, sleepiness, and pruritus may precede jaundice.
There is an association with Sjögren syndrome.
Antimitochondrial antibodies (AMA) are the hallmark for this disease
To help remember: Think of the M rule for Primary biliary cirrhosis
* IgM
* anti-Mitochondrial antibodies
* Middle aged females

Question 19

Virchow’s node

Answer 19

Lump in the left supraclavicular region is known as a Virchow’s node. It is indicative
of carcinoma of the stomach. weight loss and decreased appetite support the
diagnosis of gastric cancer.

Question 20

Describe the following in regards to pancreatic cancer?
- Risk factors
- Symptoms
- Investigations
- Rx

Answer 20

Risk factors
- Smoking
- Alcohol
- Obesity
- Family history
- DM
- Chronic pancreatitis

Symptoms
- Abdominal distension
- Obstructive jaundice (pale stools, dark urine)
- Abnormal LFTs
- Weight loss / Appetite loss
- Epigastric pain (radiates to the back, relieved by sitting forward)

Investigations
Initial: CT
Prognostic: CA 19-9

Rx
- W/out metastasis: Whipple’s resection
- With metastasis: ERCP with stent.

Question 21

What should be suspected in a patient with chest pain who has recently had an endoscopy?

Question 22

Describe the features of abdominal migraine.

Answer 22

Child with:
- Abdominal pain
- Episodic headaches
- No abnormal findings on examination and on investigations.

Management:
- Reassurance.

Question 23

What to suspect in a tender, reddish blue swelling in the anal verge?

Question 24

What are the features of toxic megacolon?

Complication of ulcerative colitis (mostly).

Answer 24

X- ray features:
- Thumb printing;
- Lead piping.

Question 25

Describe what is Plummer-Vinson syndrome.

Answer 25

Triad
➜ Iron defficiency anamemia;
➜ Atrophic glossitis;
➜ Oesophageal webs.

Symptoms:
* Dysphagia (painless & intermittent);
* Solids followed by liquids;
* Lethargy
* Pallor

Rx:
* Oral iron replacement;
* Endoscopic dilation for persistent dysphagia.

Question 26

Describe the following in regards to cholecystitis?
- Symptoms
- Investigation
- Rx

Answer 26

Symptoms
- Right upper quadrant / epigastric pain that radiates to the right shoulder;
- Nausea, vomiting, fever;
- Murphy sign

Investigation
- Ultrasound

Rx
- Laparoscopic cholecystectomy.

➜ Gallstone on asymptomatic patient: Reasurance.

Murphy sign: pain on deep inspiration as the finger touches the inflammed gallbladder.

Question 27

Which infecting organism should be suspected in a patient that presents with coeliac symptoms (diarrhoea, bloating, gresy stools) with a travel history?

Question 28

Oesophageal spasm

Answer 28

Chest pain associated with ingestion of liquids or solids

Question 29

Abdominal pain radiating to the back?

Answer 29

Pancreatitis

Aetiology
The vast majority of cases in the UK are caused by gallstones and alcohol.
A popular mnemonic to remember is GET SMASHED
* Gallstones
* Ethanol
* Trauma
* Steroids
* Mumps (other viruses include Coxsackie B)
* Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
* Scorpion venom
* Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
* ERCP
* Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide,furosemide,
pentamidine, steroids, sodium valproate)

Clinical features
* Gradual or sudden severe epigastric or central abdominal pain (radiates toback,
sitting forward may relieve it)
* Vomiting is prominent
* Tachycardia
* Fever,
* Jaundice
* Shock
* Rigid abdomen with local or general tenderness
* Periumbilical bruising (Cullen’s sign)
Investigation
* Raised serum amylase (>1000U/mL or around 3-fold upper limit of normal).However,
lipase levels are more sensitive and more specific.
* CT scan with contrast enhancement may be diagnostic where clinical andbiochemical
results are equivocal on admission

Question 30

Proctalgia fugax

Answer 30

Severe recurrent rectal pain (may be described as shooting) in the absence of any organic disease. Attacks may occur
atnight, after bowel actions, or following ejaculation. Anxiety is said to be an
associated feature.