Gastro I

Question 1

Symptoms of Achalasia

Answer 1

Heartburn, regurgitation particularly at night, chest pain- cramping

Question 2

Achalasia- Shown on CXR

Answer 2

Air fluid level in in upper chest

Absence of normal gastric air bubble

Question 3

Barium Swallow shows

Answer 3

Dilated oesophagus which smoothly tapers down to the sphincter

Question 4

Manometry shows

Answer 4

Absence of peristalsis in the smooth muscle portion of the oesophagus and >45mmhg

Question 5

What is Acute Cholangitis

Answer 5

infection of the bile duct

Question 6

causes of Acute Cholangitis

Answer 6

Tumours pancreatic/cholangiocarcinoma , bile duct strictures or stenosis, obstruction of gall bladder or bile duct due to stones, parasitic infection ascariasis, ercp

Question 7

Uncommon presentation in acute cholangitis

Answer 7

peritonitis

Question 8

Bloods of acute cholangitis

Answer 8

increased WBC
CRP/ESR POSSIBLE 
LFT - pattern of obstructive jaundice increased ALP and GGT
UandE signs of renal dysfunction
Blood cultures check for sepsis
Amylase may be raised

Question 9

Why might the Amylase be raised

Answer 9

Due to involvement of lower part of common bile duct

Question 10

What to look for in imaging

Answer 10

Stones and enlarged bile duct

Question 11

overall management

Answer 11

Antibiotics Cefuroxime and metronidazole

Endoscopic biliary drainage

Question 12

Management for different stages

What might indicate a severe stage

Answer 12

Mild-antimicrobial therapy, percutaneous, endoscopic or operative intervention

Moderate-early percutaneous/endoscopic biliary drainage

Severe- sepsis, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC

• Treatment of organ failure e.g vasopressors
• Urgent percutaneous or endoscopic drainage

Question 13

Alcoholic hepatitis- histopathological features

Answer 13

Centrilobular ballooning, degeneration and necrosis of hepatocytes, steatosis, neutrophilic inflammation, cholestasis, mallory hyaline inclusions-eosinophilic intracytomplasmic aggregates of cytokeratin intermediate filaments, giant mitochondria

Question 14

Presenting symptoms: mild, more severe

Answer 14

Mild:Epigastric pain, nausea, malaise, low grade fever

More severe: Swollen ankles, GI bleeding

Question 15

Signs of alcohol excess

Answer 15

Testicular atrophy, gynaecomastia, parotid enlargment

Question 16

Signs of severe alcoholic hepatitis

Answer 16

Febrile, tachycardia, splenomegaly

Question 17

Bloods for alcoholic hepatitis

Clotting

Answer 17

Low hb, high mcv, high wcc, low platelets, high LFT, high bilirubin low albumin

Prolonged pt

Question 18

U and e for alcoholic hep

Answer 18

low K+, LOW urea

Question 19

Imaging

Answer 19

Ultrasound for possible malignancy, Upper GI endoscopy for varices, liver biopsy possible malignancy, EEC for encephalitis

Question 20

Management

Answer 20

Pabrinex- vitamin c and others
Monitor and correct Mg 2+, k+ glucose
Urine output
Treat encephalopathy with lactulose or phosphate enemas
Ascites- diuretics spironolactone/ frusemide
Glypressin and N-acetylcyesteine for hepatorenal syndrome
vit b parenterally then orally
Steroid therapy

Question 21

Management nutrition

Answer 21

oral/ng feeding

protein restriction avoided unless patient is encephalopathic

Question 22

Hepatorenal sydrome

Answer 22

Renal failure.Abnormalities in blood vessel tone in kidneys. Blood vessels constrict because of dilation of blood vessels in splanchic circulation.
Leads to reduced effective volume of blood detected by juxtaglomerular apparatus, leads to activation of RAS and vasoconstriction of vessels in kidney.

Question 23

Anal fissure second cause

Answer 23

Anal sphincter spasm can constrict the inferior renal artery causing ischaemia and impairing healing process

Question 24

Tears on which lining

Answer 24

Squamous lining

Question 25

Medication | Surgery

Answer 25

Diltiazem, lidocaine, GTN, Botox | Lateral sphincterotomy- relax anal sphincter

Question 26

Appendicitis aetiology

Answer 26

Gut organisms invade the appendix wall after lumen obstruction e.g by lymphoid hyperplasia, faecolith, filarial worms Leads to oedema, ischaemic necrossis and perforation

Question 27

Symptoms of appendicitis

Answer 27

Anorexia, Constipation, Diarrhoea

Question 28

Signs of appendicitis

Answer 28

Tachycardia, fever, furred tongue, foetus, shallow breaths, guarding

Question 29

3 signs of appendicitis

Answer 29

Rovsings- Palpaton of left iliac fossa Psoas-Pain on extending the hip Cope- Flexion and internal rotation of the hip

Question 30

Bloods

Answer 30

wcc- neutrophils and CRP

Question 31

Imaging for appendicitis

Answer 31

CT and US may help

Question 32

Medication

Answer 32

Cefuroxime and metronidazole

Question 33

Complications of appendicitis

Answer 33

Perforation Appendix mass -- covered with momentum Appendix abscess = may occur if appendix mass fails to resolve

Question 34

Autoimmune hepatitis is

Answer 34

Chronic hep with hyperglobulinaemia | May lead to hepatocyte expression of HLA antigens-- focus of T cell mediated

Question 35

2 types of autoimmune hepatitis Type 1 Type 2

Answer 35

``` Type 1 ANA ASMA Anti Actin Antibodies Anti SLA ``` Type 2 Antibodies to liver/kidney microsomes = ALKM-1 Antibodies to liver cytosol antigen ALC-1

Question 36

Presentation of autoimmune hepatitis insiduous Acute hepatitis

Answer 36

Malaise, fatigue, anorexia, weight loss, nausea, amenorrhoea, epistaxis Fever, anorexia, nausea/diarrhoea, serum sickness- arthralgia polyarthritis, maculopapular

Question 37

Signs of autoimmune hepatitis on physical examination

Answer 37

>chronic liver disease stigmata e.g spider naevi >Ascites, oedema and hepatic encephalopathy are late features > Cushingoid features may be present even before steroids are given

Question 38

Investigations results

Answer 38

bloods: high LFTs and bilirubin, low albumin clotting- PT increased FBC low Hb, platelets and WCC Hyper gamma globulinaemia ANA, ASMA and Anti LKM

Question 39

To rule out other liver conditions

Answer 39

Biopsy: hep vs cirrhosis ``` Viral serology Urinary copper/caeruloplasmin fERRITIN AND TRANSFERRIN SATURIATION a1 antitrypsin anti mitochondrial antibodies ```