Gastroenterology

Question 1

What is the test used for screening and for diagnosing coeliac disease?

Answer 1

Screening: IgA-tTg

Diagnosing: biopsy taken by endoscopy that shows the presence of villous atrophy and crypt hyperplasia

Question 2

What does the blood smear shows in megaloblastic anaemias?

Answer 2

Hypersegmented neutrophils

Question 3

What should you suspect in a patient with intractable peptic ulcerations?

Answer 3

Gastrinoma.

Neuroendocrine tumor found in the pancreas or duodenum, that secrete gastrin, which stimulates parietal cells of the stomach to secrete hydrochloric acid into the stomach.

Diagnosis is made by measurement of fasting gastrin levels or secretin stimulation test.

Question 4

What are the four main organisms associated with travelers diarrhea?

Answer 4

Bloody diarrhea: Campylobacter or Salmonella (Tt: ciprofloxacin)

Watery diarrhea:
Europe = Giardia
Africa = E. coli

Question 5

What is the hystological change associated with Barret’s oesophagus?

Answer 5

Stratifies squamous epithelium is replaced by columnar epithelium, which is called “columnar metaplasia”.

Question 6

What are the key features of Crohn’s disease?

Answer 6

• can affect any part of the GI tract from mouth to anus
• bleeding is less common compared to ulcerative colitis but can still be present
• abdominal mass palpable in right iliac fossa
• increased goblet cells on histology
• granulomas/ granulomatos inflammation seen on histology
• weight loss more proeminent
• transmural, skip lesions, cobble stone appearance on endoscopy
• fistulas seen on colonoscopy and perianal fistulas

Question 7

What are the key features of Ulcerative colitis?

Answer 7

• affects the mucous membrane starting from rectum
• bloddy diarrhoea more common compared to Crohn’s
• abdominal pain in left lower quadrant
• decreased goblet cell on histology
• granulomas are infrequent on histology
• primary sclerosing cholangitis more common
• loss of haustration (haustral markings), drain pipe colon seen on barium enema

Question 8

What is faecal elastase used for?

Answer 8

Investigate chronic pancreatitis

Question 9

What is the most common electrolyte imbalance associated with villous adenoma?

Answer 9

Hypokalaemia and hypoproteinaemia, since the villous adenoma secretes a mucous rich in protein and potassium

Question 10

What is the Charcot’s triad and what does it represent?

Answer 10

Fever, RUQ pain and jaundice.

Represents ascending cholangitis.

Question 11

Which disease is related to antimitochondrial antibodies (AMA), and what is the M rule?

Answer 11

AMA are the hallmark for primary biliary cirrhosis.

M rule:
- IgM
- anti-mitochondrial antibodies
- middle aged females

Question 12

What is faecal calprotectin used for?

Answer 12

To discriminate between inflammatory bowel disease (high) and irritable bowel disease (low)

Question 13

What is deranged LFTs ad secondary amenorrhoea in a young female suggestive of?

Answer 13

Autoimmune hepatitis

Question 14

What are the classic signs of alcoholic liver disease?

Answer 14

History of alcohol excess
raised AST
AST higher than ALT (70%)
raised GGT

end-stage alcoholic liver disease - GI bleed (oesophageal varices due to portal hypertension)

Mnemonic: when you drink you ToAST “to AST”

Question 15

Why is spironolactone the most useful diuretic in cirrhosis?

Answer 15

Because cirrhosis patients have intravascular volume depletion, which results in a high aldosterone state, and spironolactone is an aldosterone antagonist.

Other common spironolactone indications
- ascites: patients with cirrhosis develop secondary hyperaldosteronism
- hypertension: used as one of the last treatment options (step 4)
- heart failure
- nephrotic syndrome

Question 16

What test is used to ensure eradication of H pylori after treatment?

Answer 16

C13 urea breath test

Question 17

What are the Light’s criteria?

Answer 17

TRANSUDATE
- pleural/serum protein ratio < 0.5
- pleural/serum LDH ratio < 0.6
examples: heart failure, hypoalbuminaemia, nephrotic syndrome, cirrhosis, malnutrition

EXUDATE
- pleural/serum protein ratio > 0.5
- pleural/serum LDH > 0.6
- pleural LDH > 200
examples: infection, autoimmune, neoplasm, hemothroax, lymphatic, pancreatitis

Question 18

What are clinchers for pancreatic cancer?

Answer 18

• new-onset jaundice > 40 years old
• painless biliary obstruction (can be painful as the tumor progresses)
• gall bladder may be palpable (Courvoisier’s sign)

indicate urgent admission if
- fever
- abdominal pain
- abnormal inflammatory markers that represent an acute infection

Amylase is performed when acute pancreatitis is suspected rather than patients with suspected pancreatic cancer

Question 19

What should be suspected in a patient with chest pain who has recently had an endoscopy?

Answer 19

Mediastinitis.

It can occur after oesphageal perforation, as the air along the subcutaneous planes or into the mediastinum can cause chest pain, dyspnea, and fever. As the condition progresses, patients would experience increasing chest pain, respiratory distress and odynophagia.

A chest X-ray may show a widened mediastinum or air in the mediastinum. Water-soluble contrast can be added if needed. If there is diagnostic uncertainty, a directo visualisation using endoscopy can confirm the diagnosis.

Management includes repairing the defect and treatment with antibiotics.

Question 20

What to suspect in a child with abdominal pain and episodic headaches withou abnormal findings on examination and investigations?

Answer 20

Abdominal migraine, which are a type of functional pain. It’s usually characterised by
- paroxysmal episodes of intense, acute periumbilical pain lasting hours
- pain is dull
- pain interferes with normal activities (child may miss school)
- pain may be associated with nausea and vomiting
- not attributed to another disorder

Reassurance is all that is needed.

Question 21

What to suspect in a tender, reddish blue swelling in the anal verge?

Answer 21

Perianal haematoma, which is actually a clotted venous saccule.

It can be evacuated under local anaesthesia or left to resolve spontaneously.

Question 22

What are the features of toxic megacolon?

Answer 22

Most common cause is ulcerative colitis.
In the X-ray, the transverse colon is extremely dilated will loss of the normal haustral folds, called lead-pipe colon.

Clinical features: fever, abdominal pain, tachycardia, shortness of breath if septic

Treatment: intravenous corticosteroids and intravenous fluid replacement

Question 23

What should be suspected in a patient with dysphagia, glossitis and iron deficiency anaemia?

Answer 23

Plummer Vinson syndrome.

A condition where iron deficiency is associated with postcricoid oesophageal web. It most affects middle-aged women.

Presents with painless, intermittent dysphagia (due to oesophageal webs), and symptoms of anaemia.

Management is done with iron supplements and dilation of the webs.

Question 24

What are the risk factors for cholecystitis?

Answer 24

Mnemonic 5 F’s
- female
- forties
- fair
- fertile
- fat

Question 25

Which infecting organism should be suspected in a patient that presents with coeliac symptoms (diarrhoea, bloating, gresy stools) with a travel history?

Answer 25

Giardiasis