Gastro

Question 1

Inguinal hernia
Risk factors
Types
Presentation

Answer 1

Obesity, constipation, chronic cough, heavy lifting, male

Direct (20%) - directly through weakness in posterior wall of inguinal canal medially to inferior epigastric vessels - easily reduced
Indirect (80%) - through deep inguinal ring ± superficial associated with patent inguinal canal - more likely to strangulate

A lump ± pain
Indirect may cause pain in scrotum + dragging
Cough impulse - finger through top of scrotum into external ring and palpate for lump when coughing

Question 2

Dyspepsia
What
Red Flags
Early post prandial vs late

Answer 2

Pain or discomfort in upper epigastric region may be heartburn or acid reflux

ALARMSAnaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena, Swallowing difficulty

Early post prandial: gastritis, GORD, gastric Ca
Late post prandial: duodenal ulcer

Question 3

ROME criteria

Answer 3

For functional dyspepsia: 6M Post-prandial fullness, early satiety, epigastric pain/burning + no struc

Question 4

Drugs causing dyspepsia (4)

Answer 4

Nitrates
Bisphosphonates
Corticosteroids
NSAIDs - Decrease mucus and bicarbonate secretion

N.b. PPI decreases expression of H+/K+ antiporter on luminal membrane of parietal cells

Question 5

Dyspepsia Mx

Answer 5

> 55 or alarms (Y) Endoscopy 2-week (N) Lifestlye

Lifestlye - stop offending drugs, decrease tobacco, avoid aggravating foods, lose weight+ over the counter antacids
Test for h.pylori (Y) triple therapy 1 week (N) GORD - PPI 4/52 - if no response H2 receptor antagonist (ranitidine) or long term

Question 6

Areas of the stomach (5)
Cells in the stomach (5)
Acid stimulating hormones
Acid suppressing hormone

Answer 6

Cardia, fundus, body, antrum, pylorus

Chief cells - pepsinogen (to pepsin by HCl)
G-cells - gastrin (antrum)
Parietal cells - intrinsic factor and HCl (fundus + body)
D-cells - somatostatin (antrum)
Goblet cells - mucus + bicarbonate

Gastrin (CCK-2), histamine (H2), ACh (M3)

Somatostatin

Question 7

H.pylori infection
Appearance
Mechanism 
Ix
Mx

Answer 7

G- curved bacillus

H.pylori through mucus layer
Urease secretor - urea + water -> ammonia + CO2 -> neutralise acid (for survival) + mucosal cell death, chronic inflammation -> ulceration

C13 urea breath test - may be done in primary care
Stool antigen test + CLO test (pink with h.pylori)
N.b. must stop PPI for 2 weeks before or ABX 4 weeks

TRIPLE THERAPY - PAM/PAC
PPI + amoxicillin + clarithromycin/metronidazole (1 week)

Question 8

H.pylori anaemia mechanisms

Answer 8

H.pylori uses iron for own growth
Decreases vitamin C
Micro-erosions and chronic bleeding

Question 9

Peptic ulcer disease
Types
Causes
Presentation

Answer 9

80% duodenal ulcer - Common at duodenal cap, may erode gastroduodenal artery
20% gastric ulcer - Common at lesser curve, may erode L gastric artery

H.pylori (95% DU, 80% GU), NSAIDs, smoking, alcohol, stress, bile acids, pepsin, Zollinger-Ellison syndrome

Epigastric pain point to pain with one finger
-DU - post prandially (1-3 hours), which is relieved by eating
-GU - on eating
Pain radiation to back if posterior duodenal ulcer as related pancreas
Nausea, oral flatulence, bloating, distension

Question 10

GORD Presentation (5)

Answer 10

Heartburn: burning feeling rising stomach to neck relieved by antacid. Related to meals, posture (lying down), straining
Water brash: excessive salivation
Acid brash: retrosternal discomfort - regurgitation of acid or bile
Odynophagia - painful swallowing related oesophagitis or stricture
Belching

Question 11

Causes for GORD

Answer 11

Increased intra-abdominal pressure - Obesity, pregnancy
Increased gastric pressure - Large meals, hiatus hernia
Lifestyle factors: smoking, alcohol, fat (*delays gastric emptying), coffee
Decreased oesophageal peristalsis
Systemic sclerosis
Smoking,
Drugs
-Affecting oesophageal motility (nitrates, anticholinergics, TCA)
Damage mucosa (NSAID, bisphosphonates)

Question 12

GORD Mx

Answer 12

Lifestyle: reduce weight, stop smoking, reduce alcohol, raise bed at night, regular small meals, avoid drugs

OTC: aluminium or magnesium salts (antacids), alginates (protective layer - gaviscon)
Initial nice first line: PPI for one month or H2 antagonist
Step down PPI for long-term suppression
If oesophagitis on endoscopy - PPI 2 months

Question 13

Hiatus hernia 
What
Causes
Types
Mx

Answer 13

Herniation of part of abdominal viscera through oesophageal aperture of diaphragm. Mainly gastric cardia

Widening of diaphragmatic hiatus, pulling up of stomach due to oesophageal shortening (e.g. chronic GORD), pushing up of stomach by intra-abdo pressure - Obesity, pregnancy, ascites, advanced age

Sliding (90%) - gastro-oesophago junction slides into thoracic cavity
Rolling (10%) - gastro-oesophago junction remains in place but stomach herniates next to oesophagus

Lifestlye as GORD + PPI longterm + surgery e.g. gastropexy if refractory

Question 14

Blood supply/muscle/epithelium of the oesophagus
Upper third
Middle third
Lower third

Answer 14

Inferior thyroid/Striated/Stratified squamous

Aortic & Oesophageal/Mixed/Stratified squamous

Left gastric/Smooth/Columnar

Question 15

Barretts oesophagus 
What
Causes
Most common patient
Complications
Treatment

Answer 15

Any portion of normal distal squamous epithelium is replaced by metaplastic columnar epithelium

Chronic GORD (comp at 5%) ± HH

50M
H.pylori and NSAIDs

5% progress to adenocarcinoma of the oesophagus in 10-20 years

Low grade: Lifestyle as for GORD + long term PPI ± ablation
High grade: oesophagectomy

Question 16

Oesophagus Ca
Types
Risk factors
Red flags (5)

Answer 16

80% SCC (upper ⅔) or adenocarcinoma (lower ⅓) - both are common and aggressive

Both - smoking (x10 for SCC, x2 for AC), alcohol
AC- Barrett’s, obesity and other GORD things
SCC - chronic inflammation and stasis e.g. achalasia

RED FLAG PRESENTATION:
Dysphagia (solids>liquids)
Vomiting
Anorexia and weight loss
Symptoms of GI related blood loss e.g. melaema
Symptoms of infiltration - intractable hiccups and persistent retrosternal pain
Upper ⅓ specific - hoarseness and cough - less common
Lymphadenopathy

Question 17

Dysphagia causes

Answer 17

Oesophageal: GORD, oesophagitis, oesophageal cancer (food sticking), pharyngeal cancer
Neurological: CVA, achalasia, diffuse oesophageal spasm, MS, MND
Others: pharyngeal pouch, external compression (mediastinal tumour), CREST or scleroderma

Question 18

Achalasia
What
Mechanism 
Presentation
Ix
Management

Answer 18

Disorder of motility of lower oesophageal sphincter
Smooth muscle layer has impaired peristalsis and sphincter fails to relax

Often an acquired aganglionic segment
Possible effect of interstitial cells of Cajal (pacemaker cells)

Dysphagia (solids>liquids) DDx: GORD/ stricture
Regurgitation (90%)
Chest pain in 50% - retrosternal and after eating
?Inhalation pneumonias

CXR - vastly dilated oesophagus behind heart
Barium swallow - characteristic bird’s beak dilated oesophagus with distal narrowing
Manometry - gold standard high resting pressure and incomplete relaxation on swallowing

CCB/nitrates - reduce pressure in LOS may lead to GORD
Surgery - endoscopic dilatation may lead to perforation

Question 19

Upper GI bleed
Causes
Presentation

Answer 19

Peptic ulcer (most common), oesophagitis, gastritis, varices, Mallory-Weiss tear, malignancy, drugs

Haematemesis
-Bright red - fresh - above stomach, active haemorrhage
-Altered - coffee ground - stomach or below
Melaena - black tarry stools usually due to UGIB but occasionally from small bowel
Haematochezia - fresh blood usually due to colonic bleeding
Abdominal pain - ?location
Features of underlying cause - dyspepsia, weight loss, jaundice
High urea levels can indicate an upper GI bleed versus lower GI bleed

Question 20

Upper GI bleed
Management
Score

Answer 20

If shock = fluid resuscitation + high flow O2
2 wide bore cannula and send bloods (FBC/UE/LFT/crossmatch/coag)
Fluid bolus 500ml over 15 mins (up to 2L) while waiting for bloods
Transfuse with blood, platelets (<50), FFP (INR or APTT >1.5x normal), prothrombin complex (if warfarin) according to major haemorrhage protocol
CXR, ECG, ABG, catheter, regular monitoring
Endoscopy (<24 hours)

Rockall risk score

• Pre endoscopy for mortality
• Post endoscopy for re bleed

Question 21

Ileus vs paralytic ileus vs pseudoobstruction

Answer 21

• Non-mechanical obstruction
• Absence of normal peristalsis
• Like mechanical but no cause found

Question 22

Causes of intestinal obstruction
Small
Large

Answer 22

Adhesions (75% - from prior operations), strangulated hernia, malignancy (caecum as small bowel malignancy rare) or volvulus

Colorectal malignancy - patients > 70, increased risk further down bowel as faeces more solid, diverticulum, sigmoid volvulus

Question 23

Toxic megacolon
What
Features
Causes

Answer 23

Acute form of colonic distension.

It is characterized by a very dilated colon (megacolon), accompanied by abdominal distension (bloating), and sometimes fever, abdominal pain, or shock.

IBD, C.diff, hursprungs,

Question 24

Bowel obstruction
Presentation (5)
SBO vs LBO (3)

Answer 24

Vomiting (early in SBO, faeculent in low level), Abdominal pain (diffuse, central, abdominal, colicky=SBO, constant=LBO), Constipation (early in low level, late in high-level)
Abdominal distension (SBO

Question 25

Bowel obstruction Ix Xray findings & SBO vs LBO

Answer 25

Fluid charts to monitor intake and output Plain AXR - supine and erect Bloods: FBC, UE, Amylase, group and crossmatch Distended loops of bowel proximal to obstruction Fluid levels and distended small bowel throughout = paralytic ileus Gas under diaphragm = perforation Valvular laddering small bowel in SBO Hausta in LBO Central vs Peripheral (SBO vs LBO)

Question 26

Bowel obstuction management

Answer 26

If uncomplicated: fluid resus + correct electrolytes, intestinal decompression e.g. endoscopy, NG Tube (Sip & Suck) If no clear diagnosis = laparotomy + consent for stoma Early surgery if peritonitis or evidence of perforation

Question 27

``` Sigmoid voluvlus What Complications Risk factors Presentation Xray sign Management ```

Answer 27

Chronic constipation - large elongated atonic bowel Faeces and gas filled sigmoid loop twists on mesentery to create closed-loop obstruction Venous infarction leading to perforation and faecal peritonitis - *shock and temp Elderly, constipation, megacolon, previous sigmoid volvulus Onset, colicky lower abdo pain, gross abdominal distension, failure to pass flatus or stool Tympanic distended abdomen with palpable mass *Empty rectum AXR - *coffee bean sign - grossly dilated sigmoid loop CT scan to assess bowel wall ischaemia Urgent admission and decompression - pass sigmoidoscope+ flatus tube alongside (in place for 24 hours) Elective surgery for recurrence - resection of sigmoid colon

Question 28

``` Ogilvie’s What Causes Presentation X-ray Management ```

Answer 28

Acute colonic pseudo-obstruction associated with massive dilatation in absence of mechanical obstruction Recent pelvic surgery or cardiac event Medications - opioids and antidepressants Recent trauma or bed rest Conditions affecting nerves or muscles (Parkinson’s or muscular dystrophy) Abdo pain, bloating, N+V, intermittent constipation, no faeces or flatus Massive distension, normal bowel sounds, minimal tenderness, empty air filled rectum on DRE AXR - massive dilatation of colon (megacolon) Treat cause NG tube to decompress stomach Antiemetic prokinetic e.g. metoclopramide IV neostigmine (AChE inhibitor) + IV fluids + ABX ± decompression with flexible scope

Question 29

Presentation Abdominal abscess Peritonitis

Answer 29

Abscess: fever + pain (psoas = flank to groin) Signs: swinging pyrexia + palpable mass Peritonitis: pain + anorexia + nausea + vomiting Signs: high fever, tachycardia, tenderness on palpation, guarding, rebound tenderness

Question 30

Ix and Management Abdominal abscess Peritonitis

Answer 30

FBC: leukocytosis, UE: dehydration, LFT, amylase, lipase: panc, blood culture, peritoneal fluid (culture and amylase level), imaging: AXR, CXR (air under diaphragm) Abscess: broad spec ABX: metronidazole + 3rd gen ceph + surgical drainage Peritonitis: support with IV fluid, IV ABX met + cefotaxime then open or laparoscopic surgery

Question 31

``` Anal fissure What Presentation Cause Management ```

Answer 31

Tear in mucosa of anal canal Pain on defecation (shards of glass), bright red blood on stool or paper Constipation, IBD Dietary fibre, adequate fluids, warm baths, topical ointment, laxatives (Adult = bulk forming ispaghula husk, child = osmotic e.g. lactulose) Pain relief: simple analgesia, warm baths, GTN ointment (relaxes smooth muscle reducing anal tone) 2x daily for 8 weeks Surgery

Question 32

``` Anal fistula What Causes Ix Management ```

Answer 32

Track communicates between skin and anorectal canal due to discharging abscess from blockage of intramuscular glands Abscess, Crohns, rectal carcinoma MRI Surgery

Question 33

``` Anorectal abcess What Causes Risk factors Presentation Management Common causative organism ```

Answer 33

Collection of pus in anal or rectal region (usually perianal abscess (60%)) Infection of fissure, STI, blocked anal gland Diabetes, immunocompromised, IBD, anal sex Discharging rectum, fever, perianal pain - throbbing, *worse on sitting - may be confirmed on DRE Perianal abscess- tender, inflamed, localised swellings Prompt drainage Gut organisms i.e. E.coli

Question 34

Pilonodal sinus What Complications Management

Answer 34

Small hole or tunnel at skin caused by obstruction of hair follicles at natal cleft May lead to abscess formation and sinus Excision of sinus tract and primary closure Advise: hygiene and hair removal

Question 35

``` Perianal haematoma What Presentation Innervation Management ```

Answer 35

Dilated vascular plexuses, below the dentate line. - External haemorrhoids 2-4mm dark blueberry under skin Bleeding uncommon, pain common Below dentate line is somatic nerve - very sensitive to pain - inferior rectal nerve May excise under LA or leave for 5 days or so

Question 36

``` Haemorrhoids What Grading (1-4 Presentation Mangement ```

Answer 36

Abnormally enlarged vascular mucosal cushions in anal canal - internal haemorrhoids Grade 1: no prolapse Grade 2: prolapse on strain, reduce spontaneously Grade 3: prolapse on strain, reduce manually Grade 4: permanent prolapse Painless as above dentate line therefore visceral innervation Constipation, prolonged straining, increased abdo P (ascites, pregnancy, chronic cough) Bright red painless rectal bleeding on defecation (on paper or dripping, not mixed in stool) Anal itch from chronic mucus discharge Refer on 2 week wait if suspect anal cancer Prevent constipation: fibre, fluid, bulk forming laxative + topical anaesthetic Rubber band ligation (grade 2), haemorrhoidectomy if large, refractory, v.painful

Question 37

Appendicitis What Presentation Rovsing's sign

Answer 37

Sudden obstruction to the lumen usually by obstruction of the lumen resulting in invasion of appendix by gut flora Early periumbilical pain (T10) moves to RIF as peritoneum involved (*McBurneys point ⅓ distance from anterior superior iliac spine to umbilicus) Pain aggravated by movement therefore shallow breathing + no coughing Nausea, vomiting, anorexia Low grade pyrexia Rovsing’s sign +ve - palpation of LLQ increases pain in RLQ (stretches peritoneal lining)

Question 38

Appendicitis DDx

Answer 38

GI obstruction, constipation, perforated ulcer, Meckel’s, diverticulitis, Crohn’s Urological: torsion, calculi, UTI Gynae: ectopic, ovarian cyst, PID DKA

Question 39

Appendicitis management

Answer 39

Admit all cases Laparoscopic or open appendicectomy IV fluids + opiate analgesia IV metronidazole and third gen cephalosporin

Question 40

Diverticular disease What Common site Risk factors

Answer 40

A herniation of mucosa through thickened colonic muscle Common at sigmoid and descending colon Age (>50 (50% @50 have diverticular)), obesity, low dietary fibre *increases luminal pressure (at complicated - smoking, NSAIDs)

Question 41

Diverticulitits | Presentation

Answer 41

Uncomplicated: incidental on colon screen, lower left sided abdo pain worse on eating, better on flatus/defecation ± bloating, bleeding, constipation Diverticulitis: LLQ pain (Asian’s RLQ) + *bleeding Intermittent pain with change in bowel habits Fever and tachycardia Anorexia, nausea, vomiting Localised tenderness and abdominal mass, reduced bowel sounds unless obstruction

Question 42

Complications of diverticulitits (5)

Answer 42

POFAS | Perforation, obstruction, fistula, abscess, stricture

Question 43

Diverticulitits | Ix

Answer 43

*Colonoscopy to rule out CoCa Flexi sig @ bleed FBC - normal at uncomp, raised WCC at diverticulitis, bleeding - raised Pt and anaemia Uncomplicated - BaEnema CXR (upright) for pneumoperitoneum AXR large/small bowel dilatation, ileus, obstruction etc.

Question 44

Pneumoperitoneum causes (5)

Answer 44

Perforated duodenal ulcer – The most common cause of rupture in the abdomen. Perforated peptic ulcer Bowel obstruction Ruptured diverticulum Penetrating trauma Ruptured inflammatory bowel disease (e.g., megacolon) Necrotising enterocolitis/pneumatosis coli[1] Bowel cancer Ischemic bowel

Question 45

Diverticular disease Mx | Diverticulitis Mx

Answer 45

Lifestyle advice - High fibre Admit if significant blood loss (?transfusion) Fluids + fibre Bulk forming laxative (ispaghula) Paracetamol for pain Admit if pain uncontrollable, hydration not maintained, significant bleeding, perforation Broad-spec ABX (co-amoxiclav) for 7d, paracetamol, clear liquids 2-3 days 30% require surgery: sepsis, fistula, obstruction, perforation resection + colostomy

Question 46

Meckels diverticulum

Answer 46

Vestigial remnant of vitellointestinal duct @ distal ileum (within 100cm of ileocaecal valve) Asymptomatic or haemorrhage (50% of complications) more common at children <2 or intestinal obstruction *Always consider in DDx of rectal bleed or intestinal obstruction

Question 47

Acute mesenteric ischaemia Pathophysiology Causes Presentation triad

Answer 47

Impaired blood to intestine, bacterial translocation (passage int bact to sterile tissue) and systemic inflammatory response ``` Arterial emboli (mural thrombus post MI, AF, endocarditis) Art thrombosis (atherosclerosis, AAA) Non Occlusive Mesenteric Ischemia (hypotension, vasopressors) ``` Severe abdo pain (usually RIF), no abdominal signs, rapid hypovolemia

Question 48

Acute mesenteric ischaemia Ix Complications (2) Management

Answer 48

AXR for obstruction, ileus, thickened bowel, thumbprinting (oedema and inflammation) *Gold standaard: angiography Septic peritonitis, SIRS-Sepsis ``` Resus O2, IV fluid Heparin for MVT Gentamycin and Metroidazole Surgical angioplasty to SMA Mortality 90% ```

Question 49

``` Chronic mesenteric ischemia What RF Presentation Ix Management ```

Answer 49

Intestinal angina - chronic atherosclerotic disease Smoking, HTN, DM, hyperlipidaemia Wt loss, postprandial pain, fear of eating, upper abdominal bruit FBC, LFT, UE for malnutrition and dehydration, arteriography is gold standard Nitrate therapy, anticoagulation, operate - bypass surgery

Question 50

3 Types of bowl ischaemia

Answer 50

1. Acute mesenteric ischemia 2. Chronic mesenteric ischemia 3. Chronic colonic ischaemia

Question 51

``` Ischaemic colitits Pathology Presentation Ix Management ```

Answer 51

Low flow in inferior mesenteric artery Acute pain LIF & bloody diarrhoea Metabolic acidosis Colonoscopy: blue swollen mucosa Barium enema: thumb printing in early phase - oedema Relieve hypoperfusion: bowel rest and supportive care

Question 52

Malabsorption presentation (5)

Answer 52

Change in weight and growth GI symptoms: chronic diarrhoea (3 or more for 4W), steatorrhoea Family history Coeliac, Crohn’s, CF Signs of deficiency: iron, folate, B12, bleeding (vit K), oedema (protein/calorie)

Question 53

``` Malabsoption causes Mucosal, Intraluminal Structural Extra GI ```

Answer 53

Coeliac, lactose intol, cow’s milk protein allergy, infection (giardiasis, whipple’s, tropical sprue, travellers), HIV enteropathy, lymphatic obstruction (lymphoma, TB, cardiac disease) Enzymes etc: *pancreatic insufficiency: CF, chronic panc, Ca panc, Zollinger-Ellison, *bile acid malabsorption: cholestatic jaundice or terminal ileum disease Intestinal hurry: post-gastrectomy, vagotomy, Crohn’s (fistulae etc), amyloidosis, short bowel syndrome Hyper/hypo thyroid/parathyroid, DM, carcinoid, eating disorder

Question 54

Malabsoption Ix

Answer 54

``` Blood testing: FBC, LFT, ESR, CRP Iron studies (ferritin), folate, B12 Albumin and corrected calcium Clotting screen + INR (vitamin K) Anti-endomysial, anti-reticulin, alpha-gliadin ``` ``` Stool testing: Faecal elastase (A1AT), microscopy and culture AUSS gallbladder, liver, pancreas Barium studies - structural Ileocolonoscopy + biopsy ```

Question 55

Coeliac disease What Pathology Histology changes (3)

Answer 55

An immune mediated gluten sensitive enteropathy leading to malabsorption Heightened immune response to gluten (gliadin protein produces immune reaction at HLA-DQ8 producing toxic T-cells) in genetically predisposed individuals Intraepithelial lymphcytes, villous atrophy & crypt hyperplasia

Question 56

Coeliac disease presentation Classical Non classical Other manifestations (3)

Answer 56

Classical: (20%) Diarrhoea, wt loss, steatorrhoea, failure to thrive, fatigue, abdo pain, anaemia 80% (mouth ulcer, angular stomatitis, iron/B12/folate) Non-classical: (80%) IBS bloating, fullness, chronic fatigue Skin: dermatitis herpetiformis: blistering at arms, legs, buttocks Neurological: Cerebellar ataxia, peripheral neuropathy, dementia, depression Other: amenorrhoea and subfertility

Question 57

Coeliac Ix (5)

Answer 57

Tissue transglutaminase tTG IgA Endomysial antibody EMA IgA FBC anaemia in 50%: iron/folate (DIJFIB) B12, ferritin, folate, calcium, albumin LFT - should be normal on GFD if not consider AI disease: PBC, PSC, AI hep Biopsy x4 from D2 or onwards showing subtotal villous atrophy and crypt hyperplasia

Question 58

Tropical sprue What Presentation Managment

Answer 58

Malabsorptive disease of small bowel characterised by inflammation and villous flattening found in topical areas: SE asia, caribbean Very similar presentation to coeliac disease: begins with acute diarrhoea, fever and malaise -> chronic steatorrhoea, malabsorption, malaise, weight loss, vitamin deficiencies (iron, folate, B12, A, D, K), ankle oedema (albumin) Fluid replacement Antibiotics - tetracycline 6-12 months

Question 59

``` Gastric cancer Where Presentation Ix Spread ```

Answer 59

50% pylorus, 25% lesser curve, 10% cardia, 5% lymphoma Vague: dyspepsia, wt loss, vomiting, dysphagia, anaemia RED FLAGS for dyspepsia: ALARMS: anaemia, loss of wt, anorexia, recent onset, swallowing difficulty With early cancer only have uncomplicated dyspepsia but MOST PRESENT LATE FBC (anaemia), LFT (to liver) Flexible endoscopy/gastroscopy + biopsy *should biopsy all ulcers (multiple ulcer edge biopsy) as all may heal on Rx Signet ring cells Local, lymphatic, blood-borne, transcoelomic *to ovary = Krukenberg’s tumour To lung and liver

Question 60

``` Gastric Ca referal Referral (immed) 2 week (any age) 2 week (>55) 2 week (cond) ```

Answer 60

Sig acute GI bleed Dyspepsia + dysphagia/wt loss/vomiting/IDA/mass Recent onset dyspepsia Worsening dyspepsia + Barrett’s/atrophic gastritis (pernicious anaemia)

Question 61

Gastrointestinal stromal tumour

Answer 61

The most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise pacemaker interstitial cell of Cajal, They are defined as tumors whose behavior is driven by mutations in the KIT receptor tyrosine kinase mutation gene (85%)

Question 62

``` MALT lymphoma What Why different to lymphoma Presentation Organisms ```

Answer 62

Subtype of non-Hodgkin’s lymphoma - extranodal marginal site lymphoma Lymphoid proliferation is in mucosa-associated lymphoid tissue not LNs, follow a different course to nodal B-cell lymphomas Gastric (⅓): most common, assoc H.pylori Present with dyspepsia ± fever, nausea, const, wt loss, pain + ulcer Or - Non gastric: head, neck, lung, eye H.pylori @ 90% gastric MALT C.jejuni @ small bowel MALT

Question 63

``` Carcinoid What Secrete Presentation Carcinoid syndrome Management ```

Answer 63

Rare, slow-growing neuroendocrine tumours occuring in tissue derived from embryonic gut often asymptomatic Vasoactive serotonin + bradykinin Pain, wt loss, palpable mass Vague R sided abdominal discomfort R sided mass, hepatomegaly, telangiectasia, tricuspid regurg, pellagra (niacin deficiency - dermatitis and diarrhoea) Flushing (post coffee, alcohol, food), diarrhoea, abdo pain, palpitations, hypotension, wheezing, abdo pain, wt loss, right sided palpable abdo mass If possible surgical resection If non-resectable somatostatin analogue e.g. *ocreotide which blocks 5-HT release, radiotherapy and chemotherapy

Question 64

Colo rectal Ca Where Types Presentation

Answer 64

⅔ in colon, ⅓ in rectum, 40% in rectum and sigmoid Mainly adenocarcinoma, also GIST, carcinoid Mainly local, mets to LIVER Age, Fam Hx, IBD, Obesity, smoking, high alcohol, sedentary, DM FAP - familial adenomatous polyposis - AD - mutation at APC gene 100% penetrance HNPCC - hereditary non-polyposis colorectal cancer, AD, 80% lifetime risk, Change in bowel habit, rectal bleeding + anaemia Right side: weight loss, anaemia, occult bleed, mass in RIF Left side: colicky pain, rectal bleed, obstruction, tenesmus, less advanced at pres Jaundice, hepatomegaly

Question 65

Colorectal Ca urgent referal (3) | Screening

Answer 65

>40 with rectal bleed and change of bowel habit for >6W >60 with rectal bleed alone Unexplained IDA 60 - 75, 2 yearly with FOB then +ve for colonoscopy

Question 66

Staging for Colorectal Ca

Answer 66

``` Duke’s + 5 year survival A - mucosa 90 B - into muscularis propria through serosa 70 C - regional LN 30 D - distant mets/liver 5 ```

Question 67

IBS Criteria Extra bowel symptoms DDx

Answer 67

6 month history of ABC (abdominal pain, bloating, change of bowel habit) + Relieved by defecation or altered bowel frequency + 2 or more of Mucus, worse on eating, abdominal bloating, altered passage (Straining, urgency) Migraine, backache, lethargy, urinary frequency/urgency, dyspareunia, depression Coeliac, IBD, gynaecological (ovarian cancer, endometriosis, PID)

Question 68

IBS Ix (5) Management

Answer 68

``` FBC, ESR, CRP Coeliac screen (EMA/TTG) Ca-125 (ovarian cancer) Faecal calprotectin (IBD) ± TFT, faecal occult blood, colonoscopy ``` Lifestyle, dietary and physical activity Decrease stress, relaxation, active physical activity, less caffeine, regular meals, fluids, decrease alcohol, high-fibre foods Medications - placebo effect -Diarrhoea - loperamide -Constipation - laxatives e.g. fibrogel -Abdo pain - antispasmodics - buscopan (hyoscine butylbromide) Psychological therapy

Question 69

Crohns vs UC Macro Micro On barium

Answer 69

Macrocytically CD - rectal sparing, skip lesions, mucus cobblestoning UC - non-rectal sparing, continuous disease, ulcers, polyps Microcytically CD - transmural inflammatory cell infiltrate, granuloma, focal crypt abscess, increased goblet cells UC - inflammatory cell infiltrate confined to mucosa and submucosa, focal crypt abscess, goblet cell depletion On barium CD - rose thorn ulcers, kantors string sign UC - loss of haustrations, narrow short colon (lead pipe)

Question 70

Extra bowel manifistations of IBD

Answer 70

JELCS - joints (large jt, anky spon, sacroilitis), eyes (conjunc, iritis, episcleritis), liver (fatty), colon (POMFAN), skin (Erythema nodosum, pyoderma gangrenosum, clubbing) + granulomata

Question 71

Crohns Presentation Complications

Answer 71

``` Diarrhoea (chronic >6W) ± blood Abdominal pain Weight loss *periods of acute exacerbation Systemic symptoms - malaise, anorexia, fever JELCS ``` POMFAN - perforation, oral ulcer/obstruction, malabsorption, fissure/fistula, anal skin tags/abscess), neoplasia

Question 72

Ix for IBD

Answer 72

FBC (all decreased), UE (renal disease as right ureter may be obstructed in ileocaecal disease), LFT (fatty liver) ESR/CRP - high CRP (>30) active disease Faecal calprotectin (IBS vs IBD) Stool culture and microscopy Ileocolonoscopy - CD/colonoscopy + biopsies AXR (obstruction) Malabsorption (iron, B12, folate, albumin) ASCA - CD/p-ANCA-UC

Question 73

CD Management To induce remission Maintaining remission

Answer 73

To induce remission If first presentation or single exacerbation in 12M Glucocorticoid monotherapy (oral pred/IV hydro) If 2 or more exacerbations in 12M Add azathioprine or mercaptopurine (or methotrexate + folic acid) Or surgery (if limited to distal ileum) Maintaining remission Monotherapy with azathioprine, mercaptopurine or methotrexate Smoking cessation Monitor for osteopenia/osteoporosis

Question 74

Presentation of UC

Answer 74

Bloody diarrhoea TOBUM, tenesmus (feel incomplete), oooo (colicky) pain, bloody diarrhoea, urgency, mucus Systemic: fever, malaise, wt loss, anorexia JELCS *If abdo tenderness associated with abdo distension -> ? toxic megacolon and arrange acute admission

Question 75

``` Management of UC To induce remission - Moderate - Severe Maintain remission ```

Answer 75

Mild/moderate Procto/sigmoiditis: topical mesalazine (suppository/enema) ± oral mesalazine Step 2 (both): if no improvement in 4 weeks + oral prednisolone Step 3 (both): if no improvement in 4 weeks + oral tacrolimus To induce remission: Acute/severe Admit + IV hydrocortisone + IV fluids Add IV ciclosporin if no response in 72 hours Consider surgery if toxic megacolon/>8 stools n.b. *surgery colectomy is curative Maintain remission Procto/sigmoiditis: topical or oral + topical mesalazine Infliximab

Question 76

Constipation management

Answer 76

Bulk forming - increase faecal mass, stimulating peristalsis - Fibrogel Stool softener - for impacted faeces: arachis oil enema Stimulant - increase motility e.g. senna, docusate Osmotic - retain fluid in bowel - e.g. lactulose Enema - good for rapid evacuation e.g. phosphate enema

Question 77

Red flags of diarrhoea | Other things to consider

Answer 77

Blood (CMV, shigella, salmonella, c.jej, e.histolytica), recent ABX (c.diff), vomiting, wt loss, watery + high volume (dehydration) Foreign travel, fever, food poisoning, stress

Question 78

Causes of diarrhoea

Answer 78

Infection esp viral gastroenteritis Drugs - ABX, cytotoxic, PPI, NSAID, metformin, thyroxine, SSRI, statin Constipation with overflow Food allergy + anxiety Chronic disease e.g. IBD *can’t confirm without stool culture

Question 79

Ix for chronic diarrhoea

Answer 79

Assess for red flags FBC - anaemia, or raised platelet (inflammation) LFT + albumin Malabsorption: B12, red cell folate, iron studies, calcium TFT Coeliac Ab Stool for culture and sensitivity

Question 80

Features vitamin C deficiency

Answer 80

gingivitis, loose teeth poor wound healing bleeding from gums, haematuria, epistaxis general malaise

Question 81

Plummer-Vinson syndrome

Answer 81

dysphagia, glossitis and iron-deficiency anaemia +/- chelitits

Question 82

Oesphageal varicies prophylaxis

Answer 82

B Blockers/Band ligation

Question 83

Melanosis coli

Answer 83

abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages. It is most commonly due to laxative abuse

Question 84

Interprete Abdo X-ray

Answer 84

Big cuddly spanish giants | Bones, Calcium, Soft tissue, Gas

Question 85

Starting biologics caution

Answer 85

TB reactivation - Do chest X-ray

Question 86

Coeliac increases risk of what cancer

Answer 86

Non hodgkins lymphoma