gastro Flashcards
Alpha-1-antitrypsin deficiency: pathophysiology:
alpha-1-antitrypsin is a gene for a protease inhibitor
Elastase is an enzyme secreted by neutrophils. This enzyme digests connective tissues. Alpha-1-antitrypsin (A1AT) is mainly produced in the liver, travels around the body and offers protection by inhibiting the neutrophil elastase enzyme. A1AT is coded for on chromosome 14. In A1AT deficiency, there is an autosomal recessive defect in the gene for A1AT.
which organs does A1AT deficiency effect?
lungs and liver
- cirrhosis (50yos)
- bronchiectasis and emphysema (30yos)
cx of A1AT deficiency in liver over time?
hepatocellular carcinoma
which condition are all new T1DM’s investigated for as they are linked?
coeliac disease
what 2 findings will endoscopy and biopsy show in coeliac disease? (duodenal biopsy)
villous atrophy
crypt hypertrophy
how do you test for coeliac antibodies in a patient with IgA deficiency?
so anti-TTG and anti-EMA are both IgA - when these are tested for its important to test for total IgA abs too - if deficient they can be false negative
–> test for the IgG version of anti-TTG or anti-EMA antibodies or simply do an endoscopy with biopsies.
name some cx of untreated coeliac disease? (5)
vitamin deficiency anaemia OP ulcerative jejunitis EATL of the intestine NHL adenocarcinoma of small bowel
rare neurological presentation of coeliac?
peripheral neuropathy
cerebellar ataxia
epilepsy
what rash may be seen in coeliac disease - describe?
Dermatitis herpetiformis (an itchy blistering skin rash typically on the abdomen)
type of anaemia seen in coeliac?
anaemia secondary to iron, B12 or folate deficiency
could be either micro or macrocytic
Crohn’s (crows NESTS) mnemonic:
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas, gallstones, increased goblet cells
Ulcerative Colitis (remember U – C – CLOSEUP):
C – Continuous inflammation L – Limited to colon and rectum (rectum commonest) O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis
what is a useful investigation for IBD?
faecal calprotectin (90% cases)
diagnostic test for IBD?
endoscopy + biopsy
what type of condition is proctitis?
type of ulcerative collitis
should you start someone on suspected UC on anti-diarrhoea drugs?
no - can precipitate life threatening cx toxic megacolon
what cardiac cx of carcinoid syndrome ca?
pulmonary stenosis and tricuspid insufficiency
affects right side of heart
ix carcinoid syndrome?
urinary 5-HIAA
tx carcinoid syndrome?
somatostatin analogue - octreotide - sx relief
diarrhoea - cryptoheptadine
mild normocytic anaemia and raised urea on U&Es indicates:
GI bleed - especially in context of long term NSAID use with no PPI prescription
If ? GI bleed - ix?
endoscopy within 24 hours
tx for c diff 1st line?
oral metronidazole 10-14/7
2nd is PO vanc alone
c diff - what should happen to pt other than abx treatmetn?
isolated for 48 hours and barrier nursed
other than abx, main risk factor drug for c diff?
PPI
difference between toxin and antigen tests in c diff?
toxin in stool during current infection - stool sample
antigen just indicates exposure, not necessarily current infection - only tx if active infection
severe/resistant to 1st line c diff tx?
oral vancomycin
biologic tx c diff?
bezlotoxumab
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies???
chronic current Hep B infection
anti-HBS positive, all else negative ->
had a vaccine
HBcAb +
HBsAg negative
__>
previous Hep B infection >6/12 ago, not a carrier
HBcAb +
HBsAg + ->
previous infection, now a carrier
4 months post- cholecystectomy - floating diarrhoea stools tx??
cholestryramine
what type of cancer does barret’s oesophagus and GORD increase risk of ?
adenocarcinoma of oesophagus
what type of cancer does achalasia increase the risk of?
squamous cell carcinoma of the oesophagus
which cancers affect which regions of the oesophagus?
upper 2/3 - squamous cell
lower 1/3 - adenocarcinoma
mx of severe alcoholic hepatitis?
prednisolone
gamma-GT is characteristically elevated
the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute ______________?
alcoholic hepatitis
what formula is used in the acute setting to decide which alcoholic hepatitis patients would benefit from tx?
Maddrey’s discriminant function (DF)
prothrombin time and bilirubin concentration
78-year-old man is brought into the emergency department with severe haematemesis. He is brought for urgent endoscopy, which shows oesophageal varices. first line during endoscopy to stop the bleeding?
band ligation
Sengstaken-Blakemore tube
TIPSS if ligation fails
Prophylaxis of variceal haemorrhage:
Propranolol
EVL
raised bili
bigger raise in ALP and GGT than ALT - dx?
obstructive jaundice
cardinal sign of pancreatic ca?
painless jaundice
what does a ‘double-duct’ sign indicate?
pancreatic ca on CT
simultaneous dilatation of the common bile and pancreatic ducts
increased echogenicity of the liver. The patient is 1.8m in height and weighs 120kg. Their abdomen is distended. The patient is currently on no medications, drinks no more than 2 pints of cider a week and is a non-smoker. best advice to give?
lose weight - first line for NAFLD
advice on alcohol intake units:
they advise ‘if you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more’
commonest manifestation of crohn’s disease in children?
abdo pain
Positive antimitochondrial antibodies are commonly associated with which condition?
Primary billiary cholangitis
what should AI hepatitis show on LFTs?
predominantly raised ALT, AST compared with ALP (also raised, but not by as much)
which 2 vessels does a transjugular intrahepatic portosystemic shunt (TIPS) procedure connect??
hepatic vein and portal vein
PBC - the M rule:
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
what disease presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly?
Budd-Chiari syndrome
USS is ix of choice with doppler flow
what is a saag used for??
to determine whether if the ascites has been caused by portal hypertension or not. A raised SAAG (>11g/L) indicates that it is portal hypertension that has caused the ascites
what is the pathology of budd-chiari syndrome?
hepatic vein thrombosis
what is the single strongest risk factor for the development of Barrett’s oesophagus?
GORD
then male, smoking, obesity
The Mackler triad for Boerhaave syndrome:
vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse
Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics is which syndrome??
Mallory-Weiss syndrome
Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia which syndrome?
Plummer-Vinson syndrome
tx: iron supplementation and dilation of the webs
in macrocytic anaemia picture - which antibodies test for?
Intrinsic factor abs
more specific than anti gastric parietal cell abs
odynophagia indicates???
oesophageal cancer
2ww
LFTs in paracetamol OD:
hepatocellular picture:
high ALT, normal ALP, ALT/ALP ratio high
PT a better marker - v increased
which drugs can cause a cholestatic picture on LFTs?
COCP
abx
steroids
sulfonylureas
72-year-old man presents to the GP with trouble swallowing. On further questioning, he explains that some of the food is coming back up and his breath smells much worse than normal.
Given the most likely diagnosis, what is the most appropriate management?
likely dx - Pharyngeal pouch requires surgical treatment
tx for oesophageal spasm?
CCB
treatment for myasthenia gravis:
acetylcholinesterase inhibitors
classical ‘bird’s beak’ appearance of the lower oesophagus that is seen in::
achalasia
dysphagia of BOTH liquids and solids indicates a dx of:
achalasia
lack of lower oesophageal sphincter relaxing during swallowing
lead pipe colon on barium enema?
UC
tenesmus is a symptom seen in ?
UC
ix a woman with microcytic anaemia picked up during an infective AECOPD. which blood tests should you add?
iron studies including TRANSFERRIN, TIBC
ferritin is unreliable during acute infection
A severe flare of ulcerative colitis should be treated in hospital with???????
IV hydrocortisone
which drug can be used to induce remission in a mild-moderate flare of ulcerative colitis, but is not suitable for induction of remission in severe cases.?
oral mesalazine
which UC drug particularly efficacious in distal proctitis but it is not suitable for acute SEVERE exacerbations.?
rectal mesalazine
which drug is most useful to maintain remission after exacerbations of UC (usually 2 in 1 year) which have required steroids.??
azathioprine PO
or PO mercaptopurine
2nd line in inducing remission of UC tx?
PO steroid
combination of liver and neurological disease points towards ______?
wilsons disease
copper
what is the treatment of choice for small bowel bacterial overgrowth syndrome?
rifaximin
risk factors for SIBO?
neonates
DM
scleroderma
50-F gastrointestinal clinic with jaundice. eyes were yellow over the past 2 weeks. fatigue and general itch over the past 3 months before her clinic appointment today. emollients have been trialled - no success. no abdominal tenderness. Excoriation was noted across her hands and feet. IgM. M2. raised alp, raised bili, ggt
dx?
primary biliary cholangitis
which tx slows progression of primary biliary cholangitis
ursodeoxycholic acid
2nd line Obeticholic acid
mx ascitis?
reduce dietary na, fluid restrict if na<125
spiro
drain if tense
Fetor hepaticus, sweet and fecal breath, is a sign of ?
acute liver failure
68M with T2DM is admitted to hospital unwell. has features of septic shock and RUQ tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder.
dx?
acalculous cholecystitis
43F known gallstones is admitted with a high fever and jaundice. looks extremely unwell. Her abdomen is generally soft although there is some mild tenderness in the RUQ.
dx?
cholangitis
34F is admitted with a 3/7 hx of colicky RUQ pain which radiates to her back. now more constant. On examination she is not jaundiced, but has a temperature of 38.5oC. She has localised peritonism in the RUQ.
dx?
acute cholecystitis
what generally used to induce remission of Crohn’s disease?
glucocorticoids only po,top,iv - any diet changes 2nd line sulfasalazine 3rd line azathioprine 4th infliximab
maintaining crohns remission?
azathioprine or mercaptopurine 1st line
stop smoking
2. MTX
mesalazine if had previous surgery
dypepsia + weight loss needs?
urgent referral
tx of variceal haemorrhage?
terlipressin
what is used in the management of upper GI bleeds which are not caused by variceal bleeding?
IV omeprazole
which drugs are strongly linked to Clostridium difficile?
clindamycin and cephalosporins
what is pseudomembranous colitis caused by ?
c.diff
XR: lead pipe appearance of the colon (red arrows). Ankylosis of the left sacroiliac joint and partial ankylosis on the right (yellow arrow), reinforcing the link with sacroilitis. dx?
UC
barium enema for UC:
3
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
which 2 drugs are used for the secondary prophylaxis of hepatic encephalopathy?
lactulose and rifaximin
Intestinal metaplasia with a villiform pattern noted. Multiple intermediate mucous cells and goblet cells noted. No dyplasia noted.
this oesophaageal biopsy report confirms:
barrets oesophagous
mx barrets oesophagus?
high dose PPI and endoscopic surveillance
In life-threatening Clostridium difficile infection treatment is with? (this can present as toxic megacolon)
PO vanc and IV metronidazole
abdominal radiograph shows large bowel distension (diameter > 5.5cm). in?
toxic megacolon
alcohol units equation =
volume (mls) x ABV (%) / 1000
Jaundice following abdominal pain and pruritus during pregnancy think
acute fatty liver of pregnancy
triad of CVD, high lactate and soft but tender abdomen:
mesenteric ischemia (aka intestinal angina) metabolic acidosis
Vitamin B12 deficiency is typically managed?
IM B12 injection replacement, loading regimen then 2-3 monthly injections
A cachectic 32-year-old man with severe perineal Crohns disease is receiving treatment with intravenous antibiotics. Over the past 72 hours he has complained of intermittent dysphagia and odynophagia.
cause of dysphagia?
oesophageal candidiasis
barium swallow -> narrowing irregularity
A 78-year-old lady presents 6 years following a successfully treated squamous cell carcinoma of the oesophagus. She has a long history of dysphagia but it is not progressive.
cause dysphagia?
post-radiation fibrosis
A 32-year-old lady presents with dysphagia. She has a 10 year history of anaemia secondary to menorrhagia and has been strongly resistant to treatment.
cause dysphaagia?
plummer-vinson syndrome
oesophageal web
which condition develops in around 10% of primary sclerosing cholangitis patients?
cholangiocarcinoma
jaundice, weight loss, pruritus and persistent biliary symptoms. this indicates?
cholangiocarcinoma
A 64-year-old woman who is reviewed due to multiple non-healing leg ulcers. She reports feeling generally unwell for many months. Examination findings include a blood pressure of 138/72 mmHg, pulse 90 bpm, pale conjunctivae and poor dentition associated with bleeding gums. What is the most likely underlying diagnosis?
vit C deficiency
scurvy
Abdominal pain with blood and leucocytes on dipstick should prompt you to look for?
stones
non contrast CT abdo and renal tract
raised ALT >1000 following MI think?
ischemic hepatitis
What is the main benefit of prescribing albumin when treating large volume ascites’?
this reduces paracentesis-induced circulatory dysfunction and mortality
which GI drugs can cause hyponatraemia?
PPI
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture:
Ecoli
then klebsiella
anaemia and low ferritin/folate levels, all characteristic of?
coeliac disease
Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in ________ which causes deranged LFTs?
ischemic hepatitis
Liver enzymes are a poor way to look at liver function - they are usually low in end-stage cirrhosis whereas _________ are better measures
coag and albumin
what is the characteristic iron study profile in haemochromatosis?
Raised transferrin saturation and ferritin, with low TIBC
hereditary haemochromatosis genetics?
autosomal recessive
first and second line haemochromatosis tx?
first line: venesection
second line: desferrioxamine
xerostomia: define
dry mouth
primary biliary cholangitis AKA:
primary biliary cirrhosis
differentiating between Primary biliary cholangitis and sjogrens?
ALP raised in PBC
sjogrens seen in 80% of PBC patients
what do patients who have had an episode of spontaneous bacterial peritonitis require in future?
abx prophylaxis - ciprofloxacin
if saag<15
60M 2-year history of diarrhoea and occasional abdominal cramps. Several kilograms of weight loss. Episodes where he becomes very flushed. These episodes began 4 months ago and last for approximately 30 minutes. No triggers. Episodic palpitations.
Dry, flushed skin and the liver edge is palpable 2cm below the costal margin. dx?
carcinoid syndrome
with a gut cancer - bad prog as liver mets present
HBsAg negative, anti-HBs positive, IgG anti-HBc positive -
previous infection
immune due to natural infection
not a carrier
HBsAg positive, anti-HBs negative, IgM anti-HBc positive -
acute infection
71F worsening RUQ pain
all LFTs raised
CT shows abscess
what abscess and what tx?
pyogenic abscess
IV Abx and image-guided percutaneous drainage
You are the GP trainee doing your morning clinic. You see a 30-year-old woman with coeliac disease. what does she need as part of her treatment? (vax)
5-yearly booster of pneumococcal vaccine
coeliacs could develop overwhelming pneumococcal sepsis due to hyposplenism
42M jaundice, pruritus and abdominal pain. PMH: ulcerative colitis, biliary colic and diabetes mellitus. raised ALP and a positive p-ANCA titre.
What is the most likely diagnosis?
Primary sclerosing cholangitis
PSC ix:
MRCP/ERCP
78M sudden onset, severe, diffuse abdominal pain at 7:30pm after meal. It is intermittent and severe in nature. Abdo soft on examination. 1 episode of non-bloody emesis. Initial imaging does not yield any diagnosis. BG: GORD, hernia repair, hypertension, myocardial infarction and atrial fibrillation. What is the most likely diagnosis?
ischemic colitis
‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage in which condition?
ischemic colitis
mesenteric ischemia tx?
surgery urgently
19M past six months his family have noted increasing behavioural and speech problems. He himself has noticed that he is more clumsy than normal and reports excessive salivation. His older brother died of liver disease. Given the likely underlying condition what is the most appropriate therapy?
wilsons disease
penicillamine
54M 5-hour history of vomiting and abdominal pains. BG alcohol-related liver cirrhosis. Urinalysis positive for ketones only. ABG: metabolic acidosis random glucose: 4.5 (N) dx and first line tx?
alcoholic ketoacidosis
IV thiamine and 0.9% saline
Iron defiency anaemia vs. anaemia of chronic disease: how to distinguish?
TIBC is high in IDA vs normal/low in ACID
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of??
Type 1 autoimmune hepatitis
what is characterized by anti-liver/kidney microsomal type 1 antibodies (LKM1) and affects children only?
Type 2 autoimmune hepatitis
mx Autoimmune hepatitis?
steroids
azathioprine
h pylori triple therapy?
amoxicillin, clarithromycin, and omeprazole.
which gastro drug if taken long term can cause hypomagnesia -> muscle aches?
PPI
what is a complication of wilsons disease?
psychosis
what should be stopped 2 weeks before an upper GI endoscopy?
PPI
64-F ED severe upper abdominal pain of sudden onset.
HR 112/min BP 146/86 mmHg. Her abdomen is rigid and particularly tender in the epigastrium. DRE: some soft stools in the rectum.
PMH: OA, previously peptic ulcer disease. She is known to be poorly compliant with her medications.
What is the most appropriate initial management step?
dx: perforated ulcer
ix: erect CXR
34F hx of ETOH is admitted with abdominal swelling to AMU. A diagnosis of ascites secondary to liver cirrhosis is made and paracentesis is performed. creatinine on admission is 95. Ten days after admission urine output decreases significantly and blood tests reveal: creat 221. hyponatraemia, high urea. albumin given. further mx (and dx)?
terlipressin
hepatorenal syndrome
2nd line (TIPS)
gallstone first line mx:
observation
surgery if complications (stones in CBD)
gallstone ix:
MRCP
woman with longstanding UC known to extend to the ascending colon (extending past the left side of the colon) presents to her GP during an acute flare. 4 motions/day, mild bleeding and mildly raised temperature of 37.4ºC. It is thus classed as a mild to moderate flare according to Truelove and Witt’s criteria.
She has been prescribed daily rectal aminosalicylates by the GP but symptoms remain.
What is the most appropriate addition to current therapy?
PO aminosalicylates
what are recommended for acute moderate to severe flares of ulcerative colitis?
steroids
inpatient tx of flares of UC: (severe)
IV steroids first line
IV ciclosporin (if CI to steroids or if no response to IV steroids after 72h)
surgery if no response
how many stools per day in mild-mod-sev UC?
<4 mild
4-6 mod
>6 sev (bloody)
general maintaining remission in UC:
aminosalicylates (top/po)
woman comes in wanting testing for coeliac disease. has been gluten free for 6 weeks so far. what should you tell her?
come back after eating gluten for 6 weeks
paired tissue transglutaminase (TTG) and IgA
cause of itch in gallstone-disease?
hyperbilirubinaemia
T2DM with abnormal LFTs - ?
NAFLD
do ELF tests
27-M gastroenterology clinic due to a 4 month history of diarrhoea. He is now passing around 6 loose non-bloody stools per day. weight loss of 5 kg. He suffers from colicky abdominal pains, particularly after eating.
A barium study: terminal ileum in a ‘string like’ configuration in keeping with a long stricture segment. Termed ‘Kantor’s string sign’. dx?
crohn’s
23-year-old female with a history of diarrhoea and weight loss has a colonoscopy to investigate her symptoms. biopsy:
Pigment laden macrophages suggestive of melanosis coli. dx?
laxative abuse
loperamide MODA:
reduces gastric motility through stimulation of u-opioid receptors
(no systemic fx as not absorbed through the gut)
28M->ED 4 days of watery diarrhoea and fever. He states he has had diarrhoea for the past 6 months but had put it down to the stress and poor diet. Lost 10 kilograms in weight. His abdomen is very tender and distended. Bowel sounds are present. A colonoscopy shows diffuse erythema with deep ulcers in a patchy distribution. Samples are taken for pathology. Considering the likely diagnosis what treatment should be initiated immediately?
IV Hydrocortisone
likely crohns
if tried this for 5 days and no improvement - infliximab
A 24-year-old smoker presents with intermittent diarrhoea for the past 6 months. She feels bloated, especially around her periods. Bloods tests are normal.
dx?
IBS
loperamide 1st line in IBS
2nd sertraline, amitryptiline
A 23-year-old student is admitted due to a two-week history of bloody diarrhoea. He is normally fit and well and has not been abroad recently. His CRP is raised at 56 on admission.
dx?
UC
A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her temperature is 37.8ºC. She has a past history of constipation.
dx?
diverticulitis
which test is the only test recommended for H. pylori post-eradication therapy?
urea breath test
do not use if abx or PPI used in last 4/52
clostridium difficile ix (active infection):
stool toxin test
stool ag if exposure rather than active infection
PO mesalazine for UC increases risk of ?
pancreatitis (acute)
more so than sulfasalazine
also agranulocytosis
Surgical treatment of achalasia -
heller cardiomyotomy
pneumatic (balloon) dilation first line usually
In an acute upper GI bleed, the Blatchford score 0 indicates:
low risk pt - dischargee and f/u in clinic
which part of the bowel is the most likely area to be affected by ischaemic colitis?
splenic flexure
65-year-old man with a history of ischaemic heart disease and hypertension presents to the emergency department with abdominal pain accompanied by some rectal bleeding. He has had associated diarrhoea. This has happened several times before, and tends to be mostly after eating a large meal. dx?
ischemic colitis
worse after meal as increased blood requirement of the gut to digest
triad of encephalopathy, jaundice and coagulopathy:
acute liver failure
46M-> GP as he is concerned about reduced libido and erectile dysfunction. His wife also reports that he has ‘no energy’ and comments that he has a ‘permanent suntan’. During the review of systems he also complains of pains in both hands. Which one of the following investigations is most likely to reveal the diagnosis?
ferritin
haemochromatosis
29-M known UC admitted to hospital with a flare-up. 3/7 hx passing five bloody stools per day. Over the past 24 hours he has also developed abdominal pain and a low grade pyrexia. Bloods show increased inflammatory markers. dx, ix?
toxic megacolon Abdo XR (transverse colon >6cm diameter)
which blood marker checked for HCC recurrence?
AFP
also in dx
causes for decompensation in liver patients:
infection, electrolyte imbalances, dehydration, upper GI bleeds or increased alcohol intake
constipation
Helicobacter pylori infection is associated with which conditions?
duodenal ulcer / gastric ulcer
gastric adenocarcinoma
MALT
atrophic gastritis
55-M -> ED 24h of dark urine, pale stools and right upper quadrant pain. He mentions he is a part-time teacher and smokes 10 cigarettes a day. Sclera appear yellow and his BMI is 29 kg/m².
Which ix will be the most valuable?
USS abdo
progressive nature of symptoms (first solids and now liquids) suggests dysphagia caused by?
oesophageal malignancy
growing obstruction
cause of raised ferritin with no raise in transferrin saturation?
alcohol excess
what is a key differential for abdominal pain and fever in patients with cirrhosis and portal hypertension?
SBP
child-pugh classification for liver failure takes into account 5 things for SEVERITY: (cirrhosis)
bili albumin PT encephalopathy ascites
UK MELD score considers 3 things for MORTALITY:
bilirubin, creatinine, and INR
autoimmune condition that causes inflammation and sclerosis of the hepatic bile ducts. This has a strong association with ulcerative colitis. Anti-smooth muscle and anti-nuclear antibodies tend to be positive. dx?
PSC
macrocytic anaemia, raised GGT and the ratio of AST/ALT being greater than 2:1 along with a mildly raised amylase point towards this being a case of
alcoholic hepatitis
29-F RIF pain. PMH: ectopic 8 months previously with right sided salpingectomy. USS 3 days previously which demonstrated a viable intrauterine pregnancy. Clinically she is Rovsing sign positive with raised inflammatory markers. What is the most likely diagnosis?
appendicitis
The most common type of inherited colorectal cancer:
hereditary non-polyposis coorectal cancer
Raised transaminases in an obese individual who does not have a history of excessive alcohol consumption should raise the suspicion of ?
nafld
59-M 3/12 hx of dyspepsia and weight-loss. He denies any vomiting, change in bowel habit or abdominal pain. He is not known to have gord
What is the most appropriate first step in management?
Upper GI endoscopy (OGD as part of 2ww)
>55 + wt loss
flushing, diarrhoea, bronchospasm, hypotension, and weight loss. =
carcinoid syndrome
increasingly confused 54-M with alcoholic liver disease who presented 5 days ago feeling generally unwell. He is being treated for SBP with IV antibiotics and seemed well on the morning ward round. Blood pressure is 112/76 mmHg and heart rate is 91 beats per minute. The nurses inform you that he last opened his bowels 2 days ago. What is the most likely underlying cause for the patient’s confusion?
ammonia concentration in systemic circulation
main RF for HCC?
liver cirrhosis secondary to hep C> B, alcohol, haemochromatosis and primary biliary cirrhosis.
what is a characteristic biochemical sign in patients at risk of refeeding syndrome?
hypophosphataemia
hypomg, hypokalaemia, thiamine deficient
Courvoisier’s sign states that:
in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.
gilbert’s syndrome:
benign mild raise in bili - reassurance - no tx
dark rings around the iris of both eyes.
???
Kayser-Fleischer rings are seen in the eyes of patients with Wilson’s disease
what weight loss is diagnostic of malnutrition?
> 10% weight loss in past 3-6 months unintentional
A 57-year-old woman with a history of gallstones presents with progressive right upper quadrant pain, rigors and jaundice.
dx?
ascending cholangitis
A 62-year-old presents with upper abdominal pain. She has recently been discharged from hospital where she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination she is apyrexial and has a pulse of 96 / min. dx?
pancreatitis
A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned over the past few days. On examination her abdomen is distended. dx?
gallstone ileus
which drugs should be held during c diff infection?
opioids
A 55-year-old woman presents with swallowing difficulties for the past 5 weeks. She has also noticed some double vision. dx?
myasthenia gravis
Hereditary non-polyposis colorectal cancer (HNPCC) is associated with an increased risk of which other ca?
pancreatic
also endometrial
MSH2 gene. autosomal dominant
diagnostic investigation of choice for pancreatic cancer???
high resolution CT scan
what is done prior to appendicectomy?
IV prophylactic abx
how to differentiate type 1 v type 2 hepatorenal syndrome?
speed of onset - t1 < 2wks
the investigation of choice to detect liver cirrhosis?
transient elastography
Dyspepsia is a very common side effect of ?
bisphosphonates
When treating dyspepsia, if either a PPI or ‘test and treat’ approach has failed then?
try the other approach
other than SCLC, which other tumours can also secrete pituitary hormones, such as ACTH?
carcinoid tumour
Hypotension + melaena →?
bleeding peptic ulcer
what LFTs in pancreatic ca?
cholestatic picture
plain abdominal film classically shows small bowel obstruction and air in the biliary tree (pneumobilia)
dx?
gallstone ileus
dilated transverse colon. The abdomen demonstrates a markedly dilated transverse colon (9 cm) with an impression of slight dilatation of the descending colon with some ‘thumb printing’ in the wall. No free subphrenic gas is seen. dx?
toxic megacolon secondary to UC
74-M abdominal pain consistent with mesenteric ischaemia and he is taken to theatre for an emergency laparotomy. The segment of bowel found to be ischaemic is from the splenic flexure of the colon through to the rectum. At what vertebral level does the blocked artery branch from the aorta?
L3
inferior mesenteric artery supplies the hindgut
distal third of the colon and the rectum superior to the pectinate line
A 23-year-old student who has recently returned from a trip to North Africa presents with anorexia, nausea, mild right upper quadrant pain and lethargy. Blood tests show a marked elevation of his alanine aminotransferase level.
dx?
viral hepatitis
A 72-year-old man who is known to have heart failure and type 2 diabetes mellitus presents with a persistent dull ache in his right upper quadrant. Blood tests show a mild elevation of the alanine aminotransferase level.
dx?
congestive hepatomegaly secondary to HF
which drugs are are major risk factors for duodenal ulcers?
SSRIs - sertraline
Ulcerative colitis + cholestatis (e.g. jaundice, raised ALP) → ?
PSC
15M admitted with colicky abdominal pain of 6 hours duration. Soft abdomen, brownish spots around his mouth, feet and hands. His mother intussusception, aged 12, and has similar lesions. dx?
peutz-jeghers syndrome
AD - numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles
22M crampy abdominal pain diarrhoea and bloating. Returned from Egypt. Swimming in the local pool three weeks ago. Opening his bowels 5 times a day. The stool floats in the toilet water, but there is no blood. What is the most likely cause?
giardia lamblia
- fat malabsorption, therefore greasy stool can occur. It is resistant to chlorination, hence risk of transfer in swimming pools.
45F GP difficulty swallowing. PMH: RA, hypertension and anxiety. Smooth, glossy tongue and conjunctival pallor. Cheilitis is also noted on the corners of her mouth. dx?
IDA
- severe can cause dysphagia - post-cricoid webs (part of Plummer-Vinson syndrome)
2 causes glossitis (smooth glossy tongue)?
IDA
B12 deficiency
In a mild-moderate flare of ulcerative colitis extending past the left-sided colon - mx?
oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
Metoclopramide can cause extrapyramidal side effects, the earliest of which is mainly??
acute dystonia
can’t move eyes
2 Upper GI risk assessment tools and when to use them?
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
Dysphagia, aspiration pneumonia, halitosis → ?
pharyngeal pouch
You wish to screen a patient for hepatitis B infection. Which one of the following is the most suitable test to perform?
HBsAg
A 54-year-old man presents with a 3 month history of ‘heartburn’. He has noticed that swallowing is painful, particularly when he eats meat or bread. After eating and at night he has an ‘unpleasant’ retrosternal sensation. Clinical examination is unremarkable - dx?
oesophagitis
A 67-year-old woman presents with a 5-week history of food getting stuck. She is currently treated for COPD and was recently noted to have a macrocytosis and raised gamma-glutamyl transferase on routine bloods. On a number of occasions, she has vomited during the meal and says she has no taste for food anymore. dx?
oesophageal cancer
A 43-year-old woman with a history of anxiety complains of problems swallowing. On examination she is noted to have a number of small white lumps on her hands and telangiectasia on her face dx?
systemic sclerosis
A 55-year-old man with treatment-resistant gastro-oesophageal reflux disease (GORD) has been referred to the surgeons for fundoplication. Investigation will be required by the surgeon’s before the surgery is performed?
oesophageal pH and manometry studies
endoscopy, barium swallow
An overweight 47-year-old woman presents with recurrent episodes of pain in the right upper quadrant which is brought on by eating fatty food.??
biliary colic
A 56-year-old woman who is known to have gallstones presents with severe epigastric pain and vomiting. On examination she is apyrexial and tender in the epigastrium. dx?
acute pancreatitis
GP bloods for Wilson’s?
reduced serum copper
reduced caeruloplasmin
what should be assessed before offering azathioprine or mercaptopurine therapy in Crohn’s disease?
Thiopurine Methyltransferase (TPMT) activity if absent/low - severe sfx
TB drug leads to peripheral neuropathy and why?
Isoniazid - b6 deficiency
52F - GP progressive dyspepsia, dysphagia and fatigue. Long history of dark brown stools, but no fresh blood is present. She has not had any unexpected weight loss. She had surgery for a peptic ulcer 10 years ago. H pylori positive. mx?
2ww endoscopy to r/o upper GI cancer
describes meleana
bloating, tenesmus, urgency, mucus with stool passage all features of?
IBS
Dysplasia on biopsy in Barrett’s oesophagus> mx?
endoscopic mucosal resection
most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease??
thrombocytopaenia
pt with known polycythaemia rubra vera comes in sudden onset worsening abdominal pain, ruq tenderness, hepatomegaly ->
Budd-chiari syndrome
seafood -> hepatitis?
A
A 37-year-old woman presents with a three week history of diarrhoea and crampy abdominal pains. On examination she is noted to have a number of perianal skin tags. dx?
crohn’s
man with RIF pain but what do you also have to rule out?
testicular causes
A 48-year-old female presents to the GP complaining of a ‘lump in my throat’. She can swallow foods and liquids normally if she tries, although she has noticed the discomfort is worse on swallowing saliva. She does not have any pain on swallowing, chest pain or heartburn. Her appetite is normal. dx?
globus pharyngis
children with tracheo-oesophageal fistulas will commonly develop?
benign oesophageal strictures
deranged LFTs combined with secondary amenorrhoea in young female =
AI hepatitis
ddx duodenal and gastric ulcers:
gastric worse after eating
duod better then worse 3h later
skin changes with pernicious anaemia?
lemon tinge
also neuropathy
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit -
chronic mesenteric ischaemia
vitamin teratogenic in high doses?
A
firm, smooth, tender and pulsatile liver edge??
right heart failure
49F gastro clinic 3/12 epigastric pain and diarrhoea. Her GP initially prescribed lansoprazole 30mg od but this didn’t alleviate her symptoms. PMH hyperparathyroidism. Endoscopy revealed multiple duodenal ulcerations. dx?
Zollinger-Ellison syndrome (MEN-1)
epigastric pain and diarrhoea
what can TIPS exacerbate (eg confused pt)
alcoholic encephalopathy
Dermatitis, diarrhoea, dementia/delusions, leading to death
pellagra
B3 def
signet ring cells in?
gastric adenocarcinoma
coma is only a feature of which grade hep encephalopathy?
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