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CCE > Gastro > Flashcards

Gastro Flashcards

1
Q

A 35 year old woman complains of a cough for many months and is found to have TB. She is HIV positive and complains of painful swallowing. What is the likely cause? And why?

A

Oesophageal candidiasis
Immunocompromised patient
Causes odynophagia, dysphagia and substernal chest pain

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2
Q

What is a mallory Weiss tear? How do diagnose it?

A

Occur at gastro-oesophageal junction
Can be caused by repeated vomiting following alcohol consumption
Bleeding usually stops spontaneously within 2 days
Endoscopy needed for diagnosis

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3
Q

How does acute pancreatitis present?

A

Severe upper abdominal pain, can transmit to back and left shoulder blade
Eating or drinking might make it worse, particularly fatty foods
Nausea and vomiting
Diarrhoea
Fever

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4
Q

What is angiodysplasia?

A

Vascular lesion of GI tract, swollen fragile blood vessels which can result in blood loss from GI tract

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5
Q

What is an acute abdomen?

A

Condition of severe abdominal pain, usually requiring hospitalisation +/- emergency surgery
Caused by acute disease of or injury to the abdominal organs
History usually

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6
Q

What different pathological processes could be underlying an acute abdomen?

A 
Inflammation
Infection 
Distension 
Perforation 
Ischaemia 
Neoplasm
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7
Q

What would be on your differential list for a patient with acute abdominal pain in the right hypochondrium?

A

Gall bladder: gallstones
Stomach: peptic ulcer, gastritis
Hepatic flexure colon: cancer
Lung: pneumonia

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8
Q

What would be on your differential list for a patient presenting with acute abdominal pain in their epigastric region?

A 
Gall bladder: gallstones
Stomach: peptic ulcer, gastritis
Transverse colon: cancer 
Pancreas: pancreatitis
Heart: MI
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9
Q

What would be on your differential list for a patient with acute abdominal pain in the left hypochondrium?

A 
Spleen: rupture
Pancreas: pancreatitis
Stomach: peptic ulcer
Splenic flexure colon: cancer
Lung: pneumonia
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10
Q

What would be on your differential list for a patient with acute abdominal pain in the right lumbar region?

A

Ascending colon: cancer

Kidney: stone, hydronephrosis, UTI

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11
Q

What would be on your differential list for a patient with acute abdominal pain in the left lumbar region?

A

Descending colon: cancer

Kidney: stone, hydronephrosis, UTI

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12
Q

What would be on your differential list for a patient with acute abdominal pain in the umbilical region?

A

Small bowel: obstruction/ischaemia

Aorta: leaking AAA

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13
Q

What would be on your differential list for a patient with acute abdominal pain in the right iliac fossa?

A

Appendix: Appendicitis
Caecum: tumour, volvulus, closed loop obstruction
Terminal ileum: crohns, mekels
Ovaries/fallopian tube:ectopic, cyst, PID
Ureter: renal colic

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14
Q

What would be on your differential list for a patient with acute abdominal pain in the hypogastric region?

A

Uterus: fibroid, cancer
Bladder: UTI, stone
Sigmoid colon: diverticulitis

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15
Q

What would be on your differential list for a patient with acute abdominal pain in the left iliac fossa?

A

Sigmoid colon: diverticulitis, colitis, cancer
Ovaries/fallopian tube: ectopic, cyst, PID
Ureter: renal colic

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16
Q

What intestinal problems could cause an acute abdomen?

A

Acute appendicitis, mesenteric adenitis, Mekel’s diverticulitis, perforated peptic ulcer, gastroenteritis, diverticulitis, intestinal obstruction, strangulated hernia

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17
Q

What is mesenteric adenitis?

A

Abdominal lymphadenopathy which causes abdominal pain

Usually in children

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18
Q

What are potential hepatobiliary causes of an acute abdomen?

A

Biliary colic, cholecystitis, cholangitis, pancreatitis

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19
Q

What is cholecystitis?

A

Inflammation of gall bladder commonly due to blockage of the cystic duct with gallstones (Cholelithiasis) which causes a build up of bile and therefore increased pressure in the gallbladder

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20
Q

What is cholangitis?

A

Infection of the common bile duct commonly caused by infection secondary to a gallstone or tumour

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21
Q

What can be vascular causes for an acute abdomen?

A

Ruptured AAA, mesenteric ischaemia, ischaemic colitis

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22
Q

What are potential urological causes for an acute abdomen?

A

Renal colic, UTI, testicular torsion, urinary retention

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23
Q

What are potential gynaecological causes for an acute abdomen?

A

Ectopic pregnancy, ovarian cyst (rupture/haemorrhage/torsion), salpingitis, Mittelschmerz (ovulation pain)

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24
Q

What might be some medical causes for an acute abdomen?

A

Pneumonia, MI, DKA

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25
Q

What can cause right iliac fossa pain?

A 
APPENDICITIS acronym  
Appendix/ abscess 
Pelvic inflammation 
Period pain 
Ectopic/ endometriosis
Neoplasm 
Diverticulitis 
Intussusseption (inversion of one portion of intestine within another)
Chrohn’s/ Cyst 
IBD 
Torsion 
IBS 
Stones
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26
Q

What can cause left iliac fossa pain?

A 
SUPERCLOTS acronym 
Sigmoid diverticular disease 
Ureteric colic 
Pelvic inflammation/ period pain
Ectopic/ endometriosis 
Rectal abscess/haematoma
Colon cancer 
Left lower pneumonia 
Ovarian cyst 
Torsion 
Stones
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27
Q

What are important questions in a history for an acute abdomen?

A 
Site and duration 
Onset – sudden vs gradual 
Character – colicky, sharp, dull, burning 
Radiation – e.g. Into back or shoulder 
Associated symptoms 
Timing – constant, coming and going 
Exacerbating and relieveing factors 
Severity 
Have you had a similar pain previously? 
What do you think could be causing the pain?
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28
Q

What associated symptoms would you want to ask about in an acute abdomen history?

A

GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/melaena, dyspeptic symptoms, vomiting
Urine: dysuria, heamaturia, urgency/frequency
Gynae: normal cycle, LMP, dysmenorrhoea/menorrhagia, discharge
Others: fever, appetite, weight loss, distention

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29
Q

What is Rovsing’s sign?

A

Sign of appendicitis: palpation of left lower quadrant of persons abdomen increases pain felt in the right lower quadrant

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30
Q

A 55 year old male undergoes an endoscopy after being referred by his GP with recurrent indigestion. Endoscopy reveals a small duodenal ulcer and H. pylori is demonstrated to be present. How would you treat this patient?

A

Omeprazole, metronidazole and clarithromycin: triple therapy for a week. Continue PPI after this

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31
Q

What is Cullen’s sign?

A

Superficial oedema and bruising in subcutaneous fat around umbilicus
Takes 24-48 hours to appear and can predict acute pancreatitis

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32
Q

What is grey turners sign?

A

Bruising of the flanks - sign of retroperitoneal haemorrhage

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33
Q

What resuscitation management might be required for an acute abdomen?

A 
Secure airway 
Oxygen 
Fluid Balance: IVF, catheter, bloods, Xmatch
Analgesia 
IV Antibiotics 
Thromboprophylaxis
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34
Q

Describe the pathophysiology of Crohn’s disease

A

Has skip lesions between patches of inflammation
Can affect anywhere between mouth and anus
Has a particular predominance for terminal ilium
Intramural inflammation with lymphocyte infiltration
Inflammation spreads through layers of bowel including up to the serosa
May be granulomas present

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35
Q

What is bacterial overgrowth syndrome?

A

Occurs in patients who have had reconstructive bowel surgery, particularly on ileo caecal valve
Involves a change in the small bowel intestinal flora to more colonic, with increased numbers of organisms
Symptoms: diarrhoea, flatulence, abdominal distension and pain

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36
Q

What is cryptosporidiosis?

A

Protozoan infection pathogenic in immunocompromised disease

Can causes severe colitis in patients with AIDS

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37
Q

What is whipples disease?

A

Rare infection caused by tropheryma whipplei, bacteria which predominantly colonises the duodenum but can cause systemic upset
Main symptom: malabsorption

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38
Q

What is the duke classification for colorectal carcinoma?

A 
Duel stage A: confined to mucosa
Stage B1: involves muscularis propria
Stage B2: invades beyond muscularis propria, but doesn't invade local or regional lymph nodes
Stage C1: regional lymph nodes
Stage C2: apical lymph node
Stage D: distant metastases
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39
Q

A 72 year old man presents with acute severe abdominal pain. He has a history of ischaemic heart disease for which he takes nitrates, atenolol and amlodipine
On examination his pulse is 115 and irregularly irregular, a blood pressure of 104/72 and a temperature of 37.4. Examination of the abdomen reveals diffusely tender abdomen with absent bowel sounds. What is the likely diagnosis?

A

Mesenteric ischaemia - absent bowel sounds, AF and presence of vascular disease

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40
Q

Name 3 genetic causes for liver cirrhosis

A

Alpha 1 anti trypsin deficiency
Wilson’s disease
Haemochromatosis

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41
Q

What is the frames brief advice tool?

A

Feedback: on patient’s risk for alcohol problems
Responsibility: highlight that individual is responsible for change
Advice: advise reduction or give explicit direction to change
Menu: provide a variety of options for change
Empathy: emphasise a warm, reflective and understanding approach
Self-efficacy: encourage optimism about changing behaviour

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42
Q

What is toxic mega colon?

A

Rare but important complication in UC

Hallmarks are systemically compromised patient, abdominal radiograph showing colon dilation over 6cm

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43
Q

What are management options for toxic mega colon?

A

Conservative: fluid resuscitation, IV antibiotics, hydrocortisone, cyclosporine
Surgical: colectomy required if evidence of perforation, increased toxicity or persistent dilation

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44
Q

A 56 year old man is brought into a&e by the police. He was arrested for being drunk and disorderly. He complained of feeling unwell and vomited on route to the hospital. He is a known alcoholic with liver disease. What is the most appropriate immediate management?

A

Thiamine and vitamin B to prevent alcohol induced brain damage - wernickes Korsakoff’s syndrome

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45
Q

What is bupropion?

A

Atypical antidepressant used as a smoking cessation drug to reduce cravings but can also be used to reduce withdrawal symptoms in alcoholism

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46
Q

What are some surgical causes of abdominal pain?

A 
Obstruction
Perforation
Peptic ulcer disease
Malignancy
Biliary colic
Cholecystitis
Pancreatitis 
Ruptured AAA
Renal colic
Diverticulitis
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47
Q

What are some medical causes of abdominal pain?

A

Diabetic ketoacidosis
GORD
Hepatitis
Colitis

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48
Q

What is courvoisiers law?

A

Palpable gallbladder in the presence of jaundice is unlikely to be due to gallstones

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49
Q

What are ALARM symptoms for oesophageal cancer?

A 
Persistent dyspepsia in those over 55
Unintentional weight loss
Unexplained iron deficiency anaemia
GI bleeding
Odynophagia
Dysphagia
Persistent vomiting 
Epigastric mass
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50
Q

What are the components of the Glasgow prognostic score for acute pancreatitis?

A 
PANCREAS
PaO2 55
Neutrophils, WCC >15
Calcium 16
Enzymes, LDH >600, AST >200
Albumin 10
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51
Q

A 55 year old alcoholic presents with haematemesis. His pulse is 120, bp 108/70. He has numerous spider naevi over his chest. His abdomen is distended with ascites. What would you request next for this patient?

A

Urgent Endoscopy

Bleeding oesophageal varices top of differential list

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52
Q

What is charcots triad for ascending cholangitis?

A

Colicky right upper quadrant pain
Jaundice
Swinging fevers

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53
Q

A 44 year old female presents with 3 month history of fatigue, and malaise. IgG is raised. LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?

A

Autoimmune hepatitis

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54
Q

72 year old male discharged from hospital after suffering an MI. After discharge he presents with muscle aches and pains. His LFTs show: raised AST, ALT, ALP and gamma GT. What is the likely diagnosis?

A

Drug induced hepatitis - statins

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55
Q

An 18 year old female presents with a sore throat. LFTs show isolated raised bilirubin. What is the likely diagnosis?

A

Gilbert’s syndrome

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56
Q

A man has eaten some undercooked meat at a bbq and you suspect he has gastroenteritis caused by E. coli or v cholerae. What is the pathological mechanism causing diarrhoea in this man?

A

Endotoxins stimulating secretion of electrolytes into the intestinal lumen by activating and increasing cAMP. This increases the amounts of Na, K and bicarbonate in the apical side of the lumen which then draws water across

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57
Q

Why do patients with pancreatic insufficiency get diarrhoea?

A

Nutrients not broken down properly so biologically active in lumen exerting osmotic effects and increasing water content in large bowel

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58
Q

What is diarrhoea?

A

200ml of water per daily excrement

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59
Q

How is hepatitis b most frequently acquired worldwide?

A

Vertical transmission in the perinatal period

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60
Q

Describe the different types of hepatitis infections

A

A and E: always acute
B: chronic if in neonate, acute in adult
C: chronic only
D: only ever present if b is present

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61
Q

Which part of the intestine will contain a meckels diverticulum?

A

Ileum, two feet from ileocolic junction

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62
Q

What is a gallstone ileus?

A

Small bowel obstruction
Stones enter GI system via cholecystoduodenal fistula and migrate distally until they exit rectum or become lodged in the narrowest part of intestine - terminal ileum

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63
Q

What is a pilonidal sinus? How do you treat them?

A

Caused by ingrowing hairs
Painful redness and swelling at base of coccyx
People who are prone to them can be successfully treated by waxing the affected area. They often present as abscesses due to infection

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64
Q

A 35 year old man complains of sharp pains in anal region during defecation. There are small patches of blood on the tissue. What is the likely diagnosis?

A

Anal fissure

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65
Q

A 52 year old man presents with 3 month history of increasing discomfort in perineal region. He complains of throbbing and swelling and is struggling to sit down. What is the likely diagnosis?

A

Perianal abscess

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66
Q

How would a perianal haematoma present?

A 
Tenderness in perianal region 
Lump 
Pea sized 
Bluish in colour
Painful 
No history of weight loss or other red flag symptoms
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67
Q

What are classic symptoms of rectal cancer?

A

Fresh blood
Mucus
Tenesmus
Diarrhoea

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68
Q

What is biliary colic?

A

RUQ pain in absence of raised white cell count, normal LFTs and fever

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69
Q

What is the embryological origin of the digestive tract?

A

Endoderm

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70
Q

A patient has presented with signs and symptoms of hepatitis A. What red flag signs will you look out for that will make you consider emergency admission to hospital?

A

Severe illness: collapse, severe pain
Vomiting
Dehydrated
Signs of hepatic decompensation: consciousness level, bleeding tendency

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71
Q

What is the commonest reason for hospital admission in hepatitis A?

A

Supportive therapy: IV fluids

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72
Q

Is statutory notification of hepatitis A diagnosis required?

A

Yes, notifiable disease. Communicate to Local protection unit (public health department)

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73
Q

What advice should you give to a patient on preventing hepatitis A transmission?

A

Emphasis on hygiene measures, frequent and thorough hand washing

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74
Q

What is the typical duration of illness with hepatitis A?

A

2-10 weeks

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75
Q

What dietary advice should be given to a patient with hepatitis A?

A

High carb, low fat and protein
Avoid alcohol
Avoid medications metabolised in the liver

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76
Q

What is the transmission route of hepatitis A?

A

Faecal-oral route
Consuming contaminated food and water or coming into contact with food through compromised personal hygiene and poor sanitation associated with developing countries

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77
Q

Give some complications of a cholecystectomy

A

Biliary leak from cystic duct or gall bladder bed

Injury to bile duct leading to stricture and secondary biliary liver injury

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78
Q

List some complications of gallstones

A 
Acute cholecystitis 
Acute cholangitis 
Gallstone related pancreatitis 
Biliary enteric fistula 
Gallstone ileus 
Bowel obstruction
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79
Q

What LFT abnormality would you expect to see in a patient with a fatty liver?

A

Twofold elevation of AST and ALT

Mild elevation of ALP and gGT

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80
Q

What is the rule of 2s for a meckels diverticulum?

A

2% population
2 feet from ileocolic junction
2 inches long

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81
Q

What is a major side effect of clindamycin?

A

C diff - pseudomembranous colitis

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82
Q

What is the blood supply to the liver?

A

Dual circulation
Portal: blood from intestines via superior and inferior mesenteric and splenic veins
Systemic: hepatic vein and artery

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83
Q

What are the functions of the liver?

A 
Metabolism 
Bile production 
Detoxification 
Excretion - bilirubin, drugs 
Plasma protein synthesis - albumin, clotting factors
Storage - glycogen, vitamins, minerals
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84
Q

What carbohydrate metabolism occurs in the liver?

A

Glucose enters hepatocyte (insulin dependent) and is converted to glycogen
Gluconeogenesis occurs to produce glucose

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85
Q

What lipid metabolism occurs in the liver?

A

Triglyceride oxidation
Converts excess carbohydrate and protein into fatty acids and triglycerides which are exported and stored in adipose tissue
Synthesis of cholesterol, HDL and apolipoproteins

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86
Q

What protein metabolism occurs in the liver?

A

Catabolism - amino acid breakdown by transamination and deamination. ALT/AST
NH3 converted to urea

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87
Q

What protein metabolism abnormalities would exist in liver disease?

A

Blood urea nitrogen low due to decrease amino acid breakdown

Hyperammonemia - potentially fatal

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88
Q

What plasma proteins are made by the liver?

A

Albumin
Globulins
Fibrinogen and clotting factors

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89
Q

How is bilirubin modified and excreted?

A

Bilirubin formed from breakdown of haem
Bilirubin and albumin transported to liver
Conjugated to bilirubin glucuronide in the liver
Secreted in bile
Converted to urobilinogen by gut bacteria
80% excreted (converted to stercobilin)
20% reabsorbed and excreted in urine

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90
Q

What drug metabolism occurs in the liver?

A

First pass metabolism
Phase 1: oxidation, reduction, hydrolysis by cytochrome p450
Phase 2: glucuronidation, sulfation, acetylation
Enzymes like gamma GT

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91
Q

What components of the immune system are synthesised by the liver?

A

Acute phase proteins - CRP

Complement components

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92
Q

What do decreased albumin levels indicate?

A

Poor liver function: decreased production

Poor kidney function: increased loss

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93
Q

What bleeding/clotting tests are measures of liver function?

A

Prothrombin time and INR
Partial thromboplastin time
Individual factor deficiencies

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94
Q

Why do alkaline phosphatase levels rise in liver damage? What else could cause a rise?

A

Increased release from damaged hepatocytes
High levels with blocked ducts
Bone disease

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95
Q

What causes a rise in gamma GT?

A

If rise alongside ALP - liver disease/ bile duct obstruction
Persistently increased in chronic alcoholics

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96
Q

What causes ALT and AST to rise?

A

Acute liver injury

ALT usually increased more than AST except in alcoholic hepatitis where AST > ALT

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97
Q

What different measures of bilirubin are there? And what do these show?

A

Total: conjugated plus unconjugated
Unconjugated > conjugated: haemolysis, cirrhosis, Gilbert’s
Conjugated > unconjugated: decreased elimination - viral hepatitis, drugs, alcoholic liver disease, blockage of bile ducts

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98
Q

What type of bilirubin abnormalities might newborns have?

A

Unconjugated bilirubinaemia - increased haemolysis

Conjugated bilirubinaemia - biliary atresia, neonatal hepatitis

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99
Q

What is kernicterus?

A

Bilirubin encephalopathy

Blood brain barrier not developed in newborns

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100
Q

What are different patterns of liver injury?

A

Hepatocyte degeneration: Hepatocyte ballooning, Feathery degeneration, Steatosis - macro/micro vesicular, Accumulation of iron or copper
Necrosis: centrolobular, mid zonal, periportal
Inflammation: portal, lobular, interface
Fibrosis: portal fibrous expansion, bridging fibrosis, nodule formation

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101
Q

What can cause hepatic failure?

A

Hepatocyte necrosis: drugs, HAV, HBV
Progression of chronic liver disease - cirrhosis
Encephalopathy - raised blood ammonia levels

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102
Q

Describe the changes that occur in cirrhosis

A

Entire liver architecture disrupted
Portal/portal and portal/central bridging fibrosis
Nodules of proliferating hepatocytes surrounded by fibrosis
Vascular relationships lost - abnormal communication resulting in portal and arterial blood bypassing hepatocytes

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103
Q

What can lead to portal hypertension?

A

Cirrhosis: increased resistance to portal blood flow
Pre hepatic: portal vein thrombosis
Post hepatic: constrictive pericarditis, budd-Chiari

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104
Q

What types of neoplasia can occur in the liver?

A

Benign adenoma
Hepatocellular carcinoma
Cholangiocarcinoma
Mets

105
Q

What GI presentations can cause vomiting?

A 
Gastroenteritis
Appendicitis
Pyloric stenosis
Stenosing gastric cancer
Intestinal obstruction
106
Q

What GI presentations can cause dysphagia?

A 
Gastro-oesophageal Reflux Disease
Benign oesophageal stricture
Oesophageal cancer
Pharyngeal pouch
Pharyngeal cancer
107
Q

What GI causes can lead to acute abdominal pain?

A 
Perforated Peptic Ulcer
Appendicitis
Gastroenteritis
Obstruction
Diverticular disease
IBD
Ischaemia
Pancreaticobiliary
108
Q

What GI causes can lead to chronic abdominal pain?

A 
Irritable Bowel Syndrome
Chronic peptic ulcer
GORD
Gastritis
Gastric Cancer
IBD
109
Q

What GI presentations can cause haematemesis?

A 
Peptic Ulcer
Acute Gastritis
Mallory-Weiss Tear
Oesophageal cancer
Gastric Cancer
Oesophageal varices
GORD
110
Q

What are Peyers patches in the small intestine?

A

Organised lymphoid nodules mainly in ileum

Preventing growth of pathogenic bacteria in intestines

111
Q

Describe the morphology of oral ulcers

A

Surface Slough
Granulation Tissue
Fibrosis

112
Q

List some causes of oral ulceration

A 
Simple Apthous
Trauma (physical, heat, chemical, radiation)
Infections (viral, bacterial)
Drugs (cytotoxics, NSAIDS, bisphosphonates)
Bullous Disease
Allergic
Crohn’s Disease
Malignancy
113
Q

What are risk factors for oral cancer?

A 
Smoking/smokeless tobacco
Spirits
Older
Male
co-morbidities
114
Q

What factors might be present in a younger patient with oral cancer?

A 
HPV related (especially HPV16)
Over-express p16, inactivate p53 and Rb
115
Q

What can h pylori cause as a carcinogen?

A

Chronic Gastritis

Increases risk of Adenocarcinoma and Gastric MALT Lymphoma

116
Q

What problems will be present in a patient with autoimmune chronic gastritis?

A 
Antibodies to parietal cells, intrinsic factor
Reduced pepsinogen 1 secretion
Endocrine cell hyperplasia
B12 deficiency
Defective acid secretion
117
Q

What are some causes of chronic gastritis?

A

Autoimmune
Chemical: drugs (NSAIDs), alcohol
H pylori

118
Q

What virulence factors do h pylori possess?

A

Flagella (motile in mucus)
Urease (urea to ammonia, lower pH)
Adhesins
Cytotoxin associated gene A

119
Q

How does h pylori lead to gastric lymphoma?

A

H. pylori induces polyclonal B cell proliferation

120
Q

Name some causes of constipation

A 
Low-fibre diets
IBS
Hirschsprungs
Autonomic neuropathy
Parkinsons
colon tumours
121
Q

Name some causes of chronic diarrhoea

A 
IBD
IBS
coeliac
pancreatic insufficiency
colon tumours
carcinoid syndrome
122
Q

Name some causes of nausea and vomiting

A 
Bowel obstruction
Gastroenteritis 
Head injury
Raised ICP
Migraine
123
Q

What are some causes of localised abdominal distension?

A 
Organomegaly
Bladder obstruction
Hernia
Inflammatory mass
Tumours
124
Q

Give some differentials for rectal bleeding

A

Blood mixed with stool – colon carcinoma
Blood streaks on stool – rectal carcinoma
Blood after defecation – haemorrhoids
Blood mixed with mucus – colitis
Bleeding – diverticular disease
Bleeding and pain – anal fissure/carcinoma
Melena – upper GI bleed

125
Q

Describe the appearance of the bowel in crohns

A

Transmural inflammation: serosal fat wrapping, granulomas and lymphoid aggregates
Deep, fissuring ulcers
Stenosis and fistula formation

126
Q

Describe the inflammation present in IBD

A

Increased inflammatory cells in lamina propria
Gland architectural distortion
Metaplasia – paneth cell/ pyloric
Cryptitis and crypt abscesses
Goblet cell depletion
Deep fissuring ulcers in CD / Superficial ulcers in UC
Transmural inflammation with lymphoid aggregates in CD
Granulomas in CD
Normal areas in between inflamed areas in CD

127
Q

What different types of polyps can be present in the bowel?

A

Inflammatory polyps
Hyperplastic polyps (no neoplastic potential)
Hamartomatous polyps – Juvenile, Peutz-Jeghers
Sesile Serrated polyps
Adenomas – tubular, tubulo-villous, villous, Dysplasia - low vs high grade

128
Q

What is peutz jeghers syndrome?

A

Autosomal dominant disorder characterised by development of hamartomatous polyps in GI tract and hyperpigmented macules on lips and oral mucosa

129
Q

What cells do GIST tumours arise from?

A

Interstitial cells of Cajal – Gut pacemaker

130
Q

What tumours of the appendix can occur?

A

Mucocele
Low- grade Appendiceal Mucinous Neoplasm (LAMN)
Goblet cell carcinoid
Adenocarcinoma

131
Q

Which histocompatibility complex is associated with coeliac disease?

A

HLA B8

132
Q

What food types contain gluten which triggers coeliac?

A

Wheat
Rye
Barley

133
Q

What pathological changes are present in coeliac disease?

A

Subtotal or total villous atrophy

Crypt hyperplasia

134
Q

What may cause splenomegaly?

A

Blood oncological conditions: leukaemia, lymphoma
Cirrhosis: portal hypertension
Infections: malaria, glandular fever
Haemolytic anaemia

135
Q

What does whipples disease present with?

A 
Diarrhoea 
Abdominal pain
Lymphadenopathy
Fever
Weight loss
Arthritis
136
Q

What are some causes of hepatomegaly?

A 
Congestive cardiac failure
Alcoholic liver disease 
Chronic bronchitis 
Diabetes Mellitus 
Liver mets 
Leukaemia
Hepatitis 
Haemochromatosis
137
Q

What are some causes of intestinal pseudo obstruction?

A 
Hypothyroidism
Hypokalaemia 
Diabetes 
Uraemia
Hypocalcaemia
138
Q

Give some GI causes of vomiting

A 
Gastroenteritis 
Appendicitis 
Pyloric stenosis 
Stenosing gastric cancer
Intestinal obstruction
139
Q

Name some GI causes of dysphagia

A 
GORD
Benign oesophageal stricture
Oesophageal cancer 
Pharyngeal pouch
Pharyngeal cancer
140
Q

Name some GI causes of acute abdominal pain

A 
Perforated peptic ulcer
Appendicitis 
Gastroenteritis 
Obstruction 
Diverticular disease 
IBD 
Ischaemia 
Pancreaticobiliary
141
Q

Name some GI causes of chronic abdominal pain

A 
IBS 
Chronic peptic ulcer
GORD
Gastritis 
Gastric cancer
IBD
142
Q

Name some GI causes of haematemesis

A 
Peptic ulcer
Acute gastritis 
Mallory Weiss tear
Oesophageal cancer
Gastric cancer
Oesophageal varices 
GORD
143
Q

What is an ulcer?

A

Local defect in the surface of an organ produced by the shedding of inflamed necrotic tissue

144
Q

What is the morphology of an ulcer?

A

Surface Slough
Granulation tissue
Fibrosis

145
Q

Define lower GI bleed

A

Bleeding distal to ligament of treitz

146
Q

What commonly causes lower GI bleeds in children and adolescents?

A

Meckels diverticulum
Polyps
IBD
Intussusception

147
Q

What commonly causes lower GI bleeds in adults?

A

Diverticular disease
Angiodysplasia
Neoplasm
Ischaemic colitis

148
Q

What causes bleeding in diverticular disease?

A

Rupture of vasa recta

149
Q

What are the most common regions for angiodysplasia?

A

Caecum and ascending colon

150
Q

How can angiodysplasia be identified on colonoscopy?

A

Distinct red mucosal patches consisting of capillaries

151
Q

How does a lower GI bleed due to IBD tend to present?

A

Bloody diarrhoea

152
Q

What typically causes ischaemic colitis?

A

Hypoperfusion
Vasospasm
Occlusion

153
Q

How does a patient with ischaemic colitis typically present?

A

Abdominal pain accompanied with bloody diarrhoea

154
Q

What is the average age at which a patient with FAP will develop colon cancer?

A

39 years

155
Q

What resuscitation steps might you take for a patient with a severe lower GI bleed?

A 
Large bore IVs 
Aggressive volume replacement 
Cross match and transfuse as needed
Coagulation studies
Admission to a close monitoring unit
156
Q

What investigations can you do to localise the source of a lower GI bleed?

A 
Proctoscopy: anal outlet bleeding, proctitis, cancer
Flexible sigmoidoscopy: anus and rectum
Colonoscopy 
Radio nucleotide imaging
Angiography 
NGT lavage - rule out upper GI bleed
157
Q

What are advantages and disadvantages of a colonoscopy?

A 
High diagnostic yield
85% lesions identified 
Assess colon and ileum
Low complication rate 
Therapeutic
Diminished visualisation with profuse bleeding
Requires bowel prep
158
Q

What are advantages and disadvantages of radionucleotide imaging for GI bleeds?

A 
Sensitivity 
Can be repeated in 24 hours
Low complication rate 
Not a good localising study 
Precursor to angiogram
159
Q

What are advantages and disadvantages of mesenteric angiography?

A

Sensitivity
Diagnostic and therapeutic
Selective embolisation
Invasive study

160
Q

What are potential complications of mesenteric angiography?

A

Pseudoaneurysm
Bowel infarction
MI due to vasopressin

161
Q

What are advantages and disadvantages of CT angiography for GI bleeds?

A 
Accessible 
Quick
Sensitive 
Anatomic detail
No bowel prep needed
Not therapeutic
162
Q

What surgery is performed if the site of a GI bleed is identified vs if it isn’t identified?

A

Identified: segmental resection with anastamosis

Not identified: total colectomy and end ileostomy

163
Q

What proportion of polypectomys will result in post procedure bleeding?

A

6%

164
Q

How do you treat post polypectomy bleeding?

A

Endoscopic injection therapy
Electro coagulation
Endoscopic clipping

165
Q

What are most common causes of small intestine bleeding?

A 
Angiodysplasia 
Small bowel diverticula
Meckels diverticulum 
Neoplasia
Crohn's disease 
Aorto enteric fistula
166
Q

What are common organisms which can cause infective colitis?

A 
Campylobacter jejuni
E. coli
Shigella
C diff
Amoebiasis 
Cryptosporidium 
Giardia
167
Q

What is acute phase treatment for UC?

A

Enemas in distal disease

Steroids +/- Azathioprine in disease extending proximally

168
Q

What is the management for toxic megacolon?

A

Initially: IV steroids +/- cyclosporine with careful monitoring of clinical indices, FBC and CRP
If things deteriorate or fail to improve within 48 hours then surgical intervention

169
Q

When is caecal volvulus more common?

A

Pregnancy

Distal colonic obstruction

170
Q

How do you manage a caecal volvulus?

A

Laparotomy if fit, derotation, fixation/resection

If bowel looks non viable then hemicolectomy

171
Q

A 51 year old man is referred to open access endoscopy unit with Hx of new onset dyspepsia and iron deficiency anaemia. He undergoes endoscopy at which there is diffuse thickening of the gastric mucosa with occasional superficial erosions. What is the likely pathology?

A

Gastric lymphoma
T cell Hodgkin’s lymphoma related to h pylori infection
Symptoms mimic gastritis/peptic ulceration

172
Q

What are risk factors for developing a gastric ulcer?

A 
H pylori 
Smoking
Chronic liver disease
Chronic renal failure
Hyperparathyroidism
Drugs: aspirin, steroids, NSAIDs)
173
Q

What are risk factors for gastric carcinoma?

A

Diet: high salt, high starch, pickled and smoked food)
Cigarette smoking
Blood group A
Alcohol
Premalignant conditions: pernicious anaemia, menetriers disease, adenomatous polyposis, juvenile polyps, previous gastric resection)

174
Q

What is the treatment for gastric carcinoma?

A

D2 gastrectomy with pre op chemo: epirubicin, cisplatin and 5-fluorouracil

175
Q

A 34 year old man is admitted with suspected perforated acute appendicitis and undergoes an emergency laparotomy. On the ward 2 hours after, he is noted to have irregular tachycardia of 120bpm. His BP is 120/70 and he is pyrexial at 38.5. What is the likely problem?

A

Atrial fibrillation related to infection

176
Q

When is anastomotic leak a particular problem in colorectal surgery?

A

Low anterior resection

177
Q

What are signs and symptoms of thiamine deficiency?

A 
Muscle tenderness, weakness, reduced reflexes
Confusion, memory impairment
Impaired wound healing
Poor balance, falls
Constipation
Reduced appetite
Fatigue
178
Q

List some possible causes for a dupuytrens contracture

A 
Epilepsy 
Diabetes Mellitus 
Alcoholic liver disease 
Smoking
Trauma
Heavy manual labour
179
Q

What is the mutated gene defect in hereditary non polyposis colonic carcinoma?

A

Mismatch repair genes important for DNA surveillance

180
Q

What is the typical presentation for a patient with HNPCC?

A

Colon cancer at age 40

Females with endometrial and ovarian carcinoma

181
Q

What is von Hippel Lindau disease?

A

Autosomal dominant condition associated with presence of phaeochromocytomas, CNS haemangiomas and hypernephromas
Due to absence of tumour suppressor gene vHL

182
Q

What is peutz jeghers syndrome?

A

Autosomal dominant condition associated with mucocutaneous pigmentation and multiple GI hamartomas

183
Q

Name some drugs which associated with acute pancreatitis

A 
Steroids
Oestrogens
Thiazides
Valproate
Azathioprine 
Alcohol 
Chemo: cisplatin/vinca alkaloids
184
Q

A 68 year old female with difficulty swallowing. She has not lost any weight, she has a history of rheumatic fever as a child and on examination she is in atrial fibrillation. What is the likely cause of her dysphagia?

A

Left atrial dilatation

185
Q

A 60 year old has longstanding history of GORD. He complains of difficulty in swallowing but has not lost any weight. What is the likely cause of his dysphagia?

A

Benign stricture of the oesophagus

186
Q

A 67 year old male with a history of ischaemic heart disease and stroke presents with a few months progressive difficulty swallowing and weight loss of one stone. To begin with it affected solids more than liquids but he is now having difficulty with liquids as well. What is the likely cause of his dysphagia?

A

Carcinoma of the oesophagus

187
Q

A 35 year old male has longstanding difficulty swallowing. He has difficulty with both liquids and solids. He has not lost any weight. An endoscopy shows a dilated oesophagus with food debris in it. What is the likely cause of his dysphagia?

A

Achalasia of the cardia

188
Q

What are risk factors for dupuytrens contracture?

A 
Male sex 
Age over 40
Family history 
Diabetes mellitus 
High alcohol intake 
Smoking
Trauma
Anticonvulsant medication
189
Q

Give some causes for portal hypertension

A

Pre hepatic: portal vein thrombosis, splenic vein thrombosis, tumoral compression
Hepatic: cirrhosis, hepatitis, alcoholic hepatitis, primary biliary cirrhosis, Wilson’s disease, haemochromatosis
Post Hepatic: thrombosis of IVC, right HF, constrictive pericarditis, severe tricuspid regurgitation, budd chiari syndrome, arterial portal venous fistula

190
Q

What can be some causes of poor nutrition?

A 
Poverty
Isolation – eating alone
Sarcopenia
Physical ill health
Mental ill health 
Dementia
191
Q

What is malnutrition?

A

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

192
Q

What are some potential consequences of malnutrition in secondary care?

A

Increased Complications
Increased Sepsis
Increased length of stay
Increased Readmission Rate

193
Q

What are potential consequences of malnutrition in primary care?

A

Increased Hosp Admissions
Increased Dependency
Increased GP visits
Increased Treatment Costs

194
Q

Which types of patients are at risk of malnutrition?

A

Elderly (especially if institutionalised)
Chronic ill-health e.g. diabetes, renal, COPD, neuro
Cancer
Deprivation / poverty
GI disorders / post GI surgery
Alcoholics
Drug Dependency
Poor Dentition/oral care
Dysphagia
Patients with Altered Nutritional Requirements: Critical care, Sepsis, Cancer, Trauma, Surgery, Renal Failure, Liver Disease, GI and pancreatic disorders, COPD, Pregnancy

195
Q

What screening tool is used to identify patients at risk of malnutrition?

A

MUST: malnutrition universal screening tool

196
Q

What are the components of the MUST screening tool?

A

BMI: very underweight less than 18.5, underweight 18.5 - 19.9
Weight loss score: >10%, 5-10%
Acute disease effect score

197
Q

What tests can be done to look for h pylori? What special instructions should be given before?

A

Urea breath test: 2 weeks before, stop taking abx, bismuth and PPI
Blood test: antibodies to h pylori, can remain positive for years
Stool test: diagnose infection and confirm cure after treatment
Biopsy: usually done opportunistically during endoscopy

198
Q

What are aspects of a nutritional assessment?

A 
Weight
Height
BMI
Percentage weight loss
Anthropometrics (MUAC, TSF, Grip Strength, MAMC)
Biochemistry
Assessment of current intake
Subjective global assessment
Hydration
?Bowels and nausea
?Swallowing difficulties/oral health
Re-feeding syndrome
199
Q

What are some risk factors for hiatus hernia?

A

Obesity
Increased intra abdominal pressure
Previous hiatal operation

200
Q

What is the appropriate management for a patient who scores 0 on their must assessment?

A

Repeat screening weekly

If patient obese, consider outpatient referral to dietician

201
Q

What is the appropriate management for a patient who scores 1 on their must assessment?

A 
Observe and record food and drink intake
Highlight risk at nursing handover and medical rounds
Offer milky drinks and snacks
Encourage high calorie meal choices 
Repeat screening weekly
202
Q

What would be classed as clinically significant weight loss?

A

Unintentional weight loss greater than 10% in past 3-6 months

203
Q

What is the appropriate management for a patient who scores 2+ on their must assessment?

A 
Inform medical team 
Refer to dietician
Observe and record food and drink intake
Highlight risk at nursing handover and medical rounds
Offer milky drinks and snacks
Encourage high calorie meal choices
Repeat screening weekly
204
Q

What measurements can be taken to assess someone’s nutritional status?

A

% weight loss
MUAC: mid upper arm circumference
Hand grip strength
TSF: triceps skin fold

205
Q

What are some causes of low albumin?

A 
Sepsis 
Acute/chronic inflammatory conditions
Cirrhosis 
Nephrotic syndrome 
Malabsorption 
Malnutrition
206
Q

What are some benefits of adequate nutrition support?

A 
Increased immune function
Enhanced wound healing
Improved ventilation and respiratory reserve 
Mobility
Better psychological status 
Decreased length of stay
Decreased infectious complications
Decreased morbidity and mortality
207
Q

What is a potential complication of chronic liver disease for which you may need to do an ascitic tap?

A

Spontaneous bacterial peritonitis

208
Q

What type of diet should be advised in advanced chronic liver disease and why?

A

Low protein

Protein breakdown in bowel results in ammonia production which is implicated in precipitation of hepatic encephalopathy

209
Q

What are different types of nutritional support?

A 
Whole food by mouth
Nasogastric tube
Nasoduodenal tube
Nasojejunal tube 
Gastrostomy tube
Jejunostomy tube
Total parenteral nutrition
Peripheral parenteral nutrition
210
Q

What oral nutritional support can be provided?

A

High energy/protein diet
Little and often
Food fortification
Build up soups/shakes

211
Q

What are indications for enteral nutrition?

A 
Nil by mouth - dysphagia 
Sedated - low GCS
Unable to meet nutritional requirements orally - poor appetite, drowsy, high requirements due to disease 
Strictures
Pre op nutrition support
Oncology
212
Q

What are problems with enteral nutrition?

A

Tube removal
Loose stools
Vomiting and nausea
Aspiration

213
Q

What does nice guidance say about enteral feeding and dementia?

A

Artificial feeding should not be used in people with severe dementia for whom dysphagia or disinclination to eat is a manifestation of disease severity

214
Q

Why is parenteral nutrition used?

A

Intestinal failure - post op ileus, bowel obstruction, short bowel syndrome, fistulas

215
Q

What is refeeding syndrome?

A

Potentially life threatening complication in severely malnourished patients
Fluid and electrolyte shifts, metabolic complications

216
Q

Who is particularly at risk of refeeding syndrome?

A 
Chronic alcoholics
Chronic malnutrition
Anorexia nervosa
Prolonged fasting
Patients unfed for >5 days with evidence of stress and depletion
Chronic antacid users
Chronic diuretic users
Oncology patients on chemotherapy
Malabsorption
217
Q

What factors are levels of risk of refeeding syndrome based on?

A

BMI
Unintentional weight loss
Length of time with little/no nutrition
Electrolyte levels prior to initiation of feeding

218
Q

What electrolyte disturbances occur in refeeding syndrome?

A 
Hypokalaemia 
Hypomagnesaemia 
Hypophosphataemia 
Thiamine deficiency
Salt and water retention
219
Q

What are potential complications of refeeding syndrome?

A 
Cardiac failure
Cardiac arrest
Pulmonary oedema
Arrhythmias
Respiratory depression
Liver dysfunction
Polyuria 
Bowel disturbance
Weakness 
Confusion
Lethargy
Seizures
Tremors
Death
220
Q

When refeeding a patient, what precautions should be taken to avoid refeeding syndrome?

A

Introduce feed slowly
Vitamins prescribed to support metabolism: forceval, ketovite tablets, pabrinex, vit B co strong
Daily monitoring and replacement of electrolytes

221
Q

What conditions can lead to malabsorption?

A 
Coeliac disease 
Pancreatitis 
Surgical resection of ileum 
Crohn's 
Lactase deficiency
222
Q

What are symptoms of malabsorption?

A 
Weight loss
Abdominal distension 
Diarrhoea 
Steatorrhoea 
Pernicious anaemia 
Hypochromic anaemia
223
Q

What tests can be done for coeliac disease?

A

Endomysial antibody
IgG antigliadin antibody
Jejunal biopsy
Anti TTG (tissue transglutaminase)

224
Q

What tests can be done for chronic pancreatitis?

A

Function: faecal elastase
Form: cross-sectional imaging (CT)

225
Q

What are the Rome III criteria for diagnosing irritable bowel syndrome?

A

Recurrent abdominal pain or discomfort at least 3 days a month in past 3 months
Associated with two or more of following: improvement with defecation, onset associated with a change in frequency of
stool, onset associated with a change in appearance of stool

226
Q

What investigations can be done for irritable bowel syndrome?

A

Bloods: B12, folate, iron, tTG, thyroid function
Stool: Faecal calprotectin
Colonsocopy

227
Q

What stool volumes mean diarrhoea?

A

Stool volume >200mls/day

Stool weight >200g/day

228
Q

What is the treatment for pseudomembranous colitis?

A

Metronidazole

229
Q

Describe the colonic inflammation in ulcerative colitis

A

Superficial
Continuous
Always present in the rectum
Limited to the colon

230
Q

What features would make you suspect an acute severe colitis?

A 
Stools >6/day 
Temp >37.8 
Pulse >90 
Hb 30mm/hr
Truelove-Witts criteria
231
Q

What investigations would you do for acute severe colitis?

A 
Bloods 
Stool culture, blood culture 
Stool for c.difficile toxin 
Abdominal x-ray 
Sigmoidoscopy and biopsy
232
Q

What would you do to manage acute severe colitis?

A 
Admission 
Fluid resuscitation
Steroids: IV 5 days 
Antibiotics 
If not getting better:  Ciclosporin, Inflixamab, Colofixamab, Surgery
233
Q

What is the most common cause of upper GI haemorrhage?

A

Peptic ulcer disease

234
Q

List two risk factors for peptic ulcer formation

A

H. pylori
Drugs
Smoking

235
Q

What are the symptoms of dyspepsia?

A

Epigastric pain
Heartburn
Reflux

236
Q

How do you manage dyspepsia?

A 
Alarm signs or >55yrs: Upper GI endoscopy
Lifestyle
Antacids
PPI
If no improvement: H. pylori test
237
Q

How do we test for H. Pylori?

A

Carbon-13 urea breath test or a stool antigen test

238
Q

What treatment regimen is used to eradicate H pylori?

A

PPI, amoxicillin and either clarithromycin or metronidazole

239
Q

What are the alarms symptoms for dyspepsia?

A 
Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena / haematemesis
Swallowing difficulty
240
Q

What is the management for a mallory Weiss tear?

A

Most bleeds are minor and discharge is usual within 24 hours

OGD if necessary: Clip, Adrenaline

241
Q

A 27 year old presents with a 3 day Hx Melaena and has vomited a cup full of blood this morning. On examination pulse 105, BP 104/68, T 37.0, RR 14, Sats 98%, Pale conjunctive, Chest clear. HS normal. Abdomen soft. Mild epigastric tenderness. PR – black tarry stools. No fresh blood. What is the immediate management?

A

ABCDE approach
Consider need for 02
Large bore cannulas to each ACF
Blood for FBC, Xmatch, U+E, clotting, LFT
Start iv fluid replacement: Crystalloids, Blood, Consider clotting products
Calculate Blatchford score
Further management dependent upon likely cause/severity of bleeding

242
Q

A 42 year old unemployed man presents with a one hour history of vomiting fresh blood. He has a background history of excess alcohol usage. What is the likely diagnosis?

A

Ruptured oesophageal varices

243
Q

How do you manage ruptured oesophageal varices?

A

Initially manage as per all GI haemorrhage
Terlipressin
Prophylactic antibiotics
If endoscopy fails SB (Sengstaken–Blakemore) tube temporary salvage
Consider TIPSS (Transjugular intrahepatic portosystemic shunt)

244
Q

What is the appropriate follow up after a ruptured oesophageal varices event?

A

Repeat endoscopy initially after 3 months, then after 6 more months then yearly
Management of liver disease
Consider beta-blockade (prophylaxis)

245
Q

What bowel signs and symptoms require urgent referral for suspected bowel cancer?

A 
Bleeding and:
Abdominal pain
Change in bowel habit
Weight loss
Iron-deficiency anaemia
Rectal / abdominal mass
Faecal occult blood
246
Q

What is the management for diverticulitis?

A

Mild attacks managed at home with oral fluids and antibiotics
If more severe: NBM, IV fluid, Antibiotics, USS/CT to detect abscesses, CT-guided drainage of abscesses

247
Q

How does haemorrhoidal disease typically present?

A

Painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass

248
Q

What is the difference between internal and external haemorrhoids?

A

Internal haemorrhoids proximal to dentate line in anal canal

Eternal haemorrhoids distal to dentate

249
Q

What are treatment options for haemorrhoids?

A

Increase dietary fibre, rubber band ligation, infrared photocoagulation, sclerotherapy, surgical haemorrhoidectomy

250
Q

What are potential complications of haemorrhoids?

A

Recurrence or worsening of symptoms, excessive bleeding and non-reducible prolapse

251
Q

What are some causes of colitis?

A 
Infective inc. psueomembranous
IBD
Ischaemic
Radiation
Necrotizing enterocolitis in newborns
252
Q

List some associated symptoms of IBD

A

Eyes: episcleritis, uveitis
Kidneys: stones, hydronephrosis, fistulae, UTI
Skin: erythema nodosum, pyoderma gangrenosum
Mouth: stomatitis, apthous ulcers
Liver: steatosis
Biliary tract: gallstones, sclerosis cholangitis
Joints: spondylitis, Sacroiliitis, peripheral arthritis
Circulation: phlebitis

253
Q

How does angiodysplasia present?

A

Chronic, painless intermittent rectal bleeding

May be long periods of time between bleeds

254
Q

What can be seen on colonoscopy in a patient with angiodysplasia?

A

Abnormal epithelium

Small lesions with irregular edges and a draining vein

255
Q

What is the management for angiodysplasia?

A

Supportive care
Angiography with embolisation
Colonoscopy with: Cautery, Clips, Adrenaline, R colon is thin walled so risk of perforation

256
Q

Why does Crohn’s increase risk of gallstones?

A

Decreased bile salt content due to terminal ileum resection/disease involvement so higher concentration of cholesterol in bile

257
Q

Why can cholangitis lead to a prolonged prothrombin time?

A

Gallstone obstructs pancreas

This leads to reduced fat soluble vitamin uptake so reduced vit K and therefore increased PT

258
Q

Why do you not give morphine to a patient with acute pancreatitis?

A

Causes sphincter of oddi to contract so may make it worse

259
Q

What investigations would you do for suspected diverticulitis?

A 
FBC
ESR
CRP
CT colon 
Don't do colonoscopy during acute attack due to risk of perforation

CCE (20 decks)

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