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3b > Gastro > Flashcards

Gastro Flashcards

1
Q

Inguinal hernia
Risk factors
Types
Presentation

A

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

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2
Q

Dyspepsia
What
Red Flags
Early post prandial vs late

A

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

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3
Q

ROME criteria

A

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

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4
Q

Drugs causing dyspepsia (4)

A

Nitrates
Bisphosphonates
Corticosteroids
NSAIDs - Decrease mucus and bicarbonate secretion

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

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5
Q

Dyspepsia Mx

A

> 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

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6
Q

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

A

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

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7
Q 
H.pylori infection
Appearance
Mechanism 
Ix
Mx
A

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)

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8
Q

H.pylori anaemia mechanisms

A

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

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9
Q

Peptic ulcer disease
Types
Causes
Presentation

A

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

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10
Q

GORD Presentation (5)

A

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

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11
Q

Causes for GORD

A

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)

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12
Q

GORD Mx

A

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

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13
Q 
Hiatus hernia 
What
Causes
Types
Mx
A

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

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14
Q

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

A

Inferior thyroid/Striated/Stratified squamous

Aortic & Oesophageal/Mixed/Stratified squamous

Left gastric/Smooth/Columnar

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15
Q 
Barretts oesophagus 
What
Causes
Most common patient
Complications
Treatment
A

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

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16
Q

Oesophagus Ca
Types
Risk factors
Red flags (5)

A

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

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17
Q

Dysphagia causes

A

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

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18
Q 
Achalasia
What
Mechanism 
Presentation
Ix
Management
A

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

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19
Q

Upper GI bleed
Causes
Presentation

A

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

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20
Q

Upper GI bleed
Management
Score

A

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
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21
Q

Ileus vs paralytic ileus vs pseudoobstruction

A
  • Non-mechanical obstruction
  • Absence of normal peristalsis
  • Like mechanical but no cause found
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22
Q

Causes of intestinal obstruction
Small
Large

A

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

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23
Q

Toxic megacolon
What
Features
Causes

A

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,

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24
Q

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

A 
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
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25
Q

Bowel obstruction
Ix
Xray findings & SBO vs LBO

A

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)

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26
Q

Bowel obstuction management

A

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

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27
Q 
Sigmoid voluvlus 
What
Complications
Risk factors
Presentation
Xray sign
Management
A

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

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28
Q 
Ogilvie’s
What
Causes
Presentation
X-ray 
Management
A

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

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29
Q

Presentation
Abdominal abscess
Peritonitis

A

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

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30
Q

Ix and Management
Abdominal abscess
Peritonitis

A

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

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31
Q 
Anal fissure
What
Presentation
Cause
Management
A

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

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32
Q 
Anal fistula 
What
Causes
Ix
Management
A

Track communicates between skin and anorectal canal due to discharging abscess from blockage of intramuscular glands

Abscess, Crohns, rectal carcinoma

MRI

Surgery

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33
Q 
Anorectal abcess
What
Causes
Risk factors
Presentation
Management
Common causative organism
A

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

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34
Q

Pilonodal sinus
What
Complications
Management

A

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

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35
Q 
Perianal haematoma
What
Presentation
Innervation
Management
A

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

36
Q 
Haemorrhoids
What
Grading (1-4
Presentation
Mangement
A

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

37
Q

Appendicitis
What
Presentation
Rovsing’s sign

A

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)

38
Q

Appendicitis DDx

A

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

39
Q

Appendicitis management

A

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

40
Q

Diverticular disease
What
Common site
Risk factors

A

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)

41
Q

Diverticulitits

Presentation

A

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

42
Q

Complications of diverticulitits (5)

A

POFAS

Perforation, obstruction, fistula, abscess, stricture

43
Q

Diverticulitits

Ix

A

*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.

44
Q

Pneumoperitoneum causes (5)

A

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

45
Q

Diverticular disease Mx

Diverticulitis Mx

A

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

46
Q

Meckels diverticulum

A

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

47
Q

Acute mesenteric ischaemia
Pathophysiology
Causes
Presentation triad

A

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

48
Q

Acute mesenteric ischaemia
Ix
Complications (2)
Management

A

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%
49
Q 
Chronic mesenteric ischemia 
What
RF
Presentation
Ix
Management
A

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

50
Q

3 Types of bowl ischaemia

A
  1. Acute mesenteric ischemia
  2. Chronic mesenteric ischemia
  3. Chronic colonic ischaemia
51
Q 
Ischaemic colitits 
Pathology 
Presentation
Ix
Management
A

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

52
Q

Malabsorption presentation (5)

A

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)

53
Q 
Malabsoption causes
Mucosal, 
Intraluminal
Structural
Extra GI
A

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

54
Q

Malabsoption Ix

A 
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
55
Q

Coeliac disease
What
Pathology
Histology changes (3)

A

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

56
Q

Coeliac disease presentation
Classical
Non classical
Other manifestations (3)

A

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

57
Q

Coeliac Ix (5)

A

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

58
Q

Tropical sprue
What
Presentation
Managment

A

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

59
Q 
Gastric cancer
Where
Presentation
Ix
Spread
A

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

60
Q 
Gastric Ca referal
Referral (immed)
2 week (any age)
2 week (>55)
2 week (cond)
A

Sig acute GI bleed

Dyspepsia + dysphagia/wt loss/vomiting/IDA/mass

Recent onset dyspepsia

Worsening dyspepsia + Barrett’s/atrophic gastritis (pernicious anaemia)

61
Q

Gastrointestinal stromal tumour

A

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%)

62
Q 
MALT lymphoma
What
Why different to lymphoma
Presentation
Organisms
A

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

63
Q 
Carcinoid 
What
Secrete
Presentation 
Carcinoid syndrome
Management
A

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

64
Q

Colo rectal Ca
Where
Types
Presentation

A

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

65
Q

Colorectal Ca urgent referal (3)

Screening

A

> 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

66
Q

Staging for Colorectal Ca

A 
Duke’s + 5 year survival
A - mucosa 90
B - into muscularis propria through serosa 70
C - regional LN 30
D - distant mets/liver 5
67
Q

IBS
Criteria
Extra bowel symptoms
DDx

A

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)

68
Q

IBS
Ix (5)
Management

A 
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

69
Q

Crohns vs UC
Macro
Micro
On barium

A

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)

70
Q

Extra bowel manifistations of IBD

A

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

71
Q

Crohns
Presentation
Complications

A 
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

72
Q

Ix for IBD

A

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

73
Q

CD Management
To induce remission
Maintaining remission

A

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

74
Q

Presentation of UC

A

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

75
Q 
Management of UC
To induce remission
- Moderate
- Severe 
Maintain remission
A

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

76
Q

Constipation management

A

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

77
Q

Red flags of diarrhoea

Other things to consider

A

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

78
Q

Causes of diarrhoea

A

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

79
Q

Ix for chronic diarrhoea

A

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

80
Q

Features vitamin C deficiency

A

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

81
Q

Plummer-Vinson syndrome

A

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

82
Q

Oesphageal varicies prophylaxis

A

B Blockers/Band ligation

83
Q

Melanosis coli

A

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

84
Q

Interprete Abdo X-ray

A

Big cuddly spanish giants

Bones, Calcium, Soft tissue, Gas

85
Q

Starting biologics caution

A

TB reactivation - Do chest X-ray

86
Q

Coeliac increases risk of what cancer

A

Non hodgkins lymphoma

3b (15 decks)

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