Gastroenterology

Question 1

Sx of constipation

Answer 1

1. Less than 3 stools a week
2. Hard stools that are difficult to pass
3. Rabbit dropping stools
4. Straining and painful passages of stools
5. Abdominal pain
6. Holding an abnormal posture, referred to as retentive posturing
7. Rectal bleeding associated with hard stools

Question 2

Causes of constipation

Answer 2

1. MC - idiopathic
2. Diet - low fibre, low water, dairy products
3. Medications - opioids, antidepressants, iron supplements
4. Obstruction - small/large bowel
5. Haemorrhoids
6. Anal fissures
7. Psychosocial - i.e. Parkinson’s

Question 3

Tx of constipation

Answer 3

Correct any reversible contributing factors, recommend a high fibre diet and good hydration

Start laxatives

Question 4

What are haemorrhoids?

Answer 4

Enlarged anal vascular cushions.

Question 5

What are anal cushions?

Answer 5

Specialised submucosal tissue that contain connections between the arteries and veins - very vascular.

They help to control anal continence, along with the internal and external sphincters.

Question 6

RF for haemorrhoids

Answer 6

pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing).

Question 7

Describe classification of haemorrhoids

Answer 7

1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
4th degree: prolapsed permanently

Question 8

Sx of haemorrhoids

Answer 8

1. Constipation and straining.
2. Painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels - NO BLOOD mixed with stool
3. Sore / itchy anus
4. Feeling a lump around or inside the anus

Question 9

Ddx of rectal bleeding

Answer 9

Anal fissures
Diverticulosis
IBD
Colorectal cancer

Question 10

Tx of haemorrhoids

Answer 10

Topical tx - i.e. anusol
Prevention + tx of constipation

Question 11

What is an anal fissure?

Answer 11

Small tear in the anal mucosa caused defaecation or tight anal sphincter

Question 12

Sx of anal fissure

Answer 12

1. Rectal bleeding - bright red
2. Perianal pain - feels like razor blade coming out
3. Pruritis
4. They DONT have faecal incontinence

Question 13

Tx of anal fissure

Answer 13

Dietary changes - inc fibre
Laxatives - SOFTEN stools!!
Topical steroids

Question 14

Difference between haemorrhoids and anal fissures

Answer 14

Haemorrhoid = painless
Anal fissure = painful

Question 15

Define the following:
1. Diverticulum
2. Diverticulosis
3. Diverticular disease
4. Diverticulitis

Answer 15

1. a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.
2. presence of diverticulum, without inflammation or infection.
3. when patients experience symptoms.
4. inflammation and infection of diverticula.

Question 16

RF for diverticular disease

Answer 16

Low fibre diet
Ageing
Smoking
Obesity
NSAIDs

Question 17

Sx of:
1. Diverticular disease
2. Diverticulitis

Answer 17

1. Triad:
   LLQ pain - typically occurs in sigmoid colon
   Constipation
   Fresh rectal bleeding
2. LLQ pain
   Rectal bleeding
   Fever
   N&V
   Diarrhoea

Question 18

Ix for diverticular disease

Answer 18

Colonoscopy
Abdo CT w/contrast

Question 19

Tx for:
1. Diverticular disease
2. Diverticulitis

Answer 19

1. Inc fibre in diet
   Bulk-forming laxatives (AVOID stimulant laxatives)
   Surgery
2. Oral co-amoxiclav
   Paracetamol
   Liquid food (avoid solid food)

Question 20

What is Murphy’s sign and how is it elicited?

Answer 20

If pain occurs when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.

Murphy’s sign is elicited in patients by asking them to take in and hold a deep breath while palpating the right subcostal area

Question 21

What is Cullen’s sign?

Answer 21

Superficial oedema with bruising around the peri-umbilical region (below belly button)

Question 22

What is Grey Turner’s sign?

Answer 22

Bruising of the flanks

Question 23

RF of IBS

Answer 23

Anxiety
Depression
Stress
Sleep disturbance
Illness
Medications
Certain foods
Caffeine
Alcohol

Question 24

Ddx for IBS (3)

Answer 24

Bowel cancer
Inflammatory bowel disease
Coeliac disease
Ovarian cancer
Pancreatic cancer

Question 25

Sx of IBS

Answer 25

Abdominal pain Diarrhoea Constipation Fluctuating bowel habit Bloating Worse after eating Improved by opening bowels Passing mucus

Question 26

Ix for IBS

Answer 26

Faecal calprotectin - detects inflammation in intestines Tests to rule out Ddx: FBC - anaemia Inflammatory markers - CRP, ESR Coeliac serology - anti-TTG antibodies CA125 - ovarian cancer

Question 27

Tx of IBS

Answer 27

Lifestyle: fluids, regular small meals, adjust fibre, limit caffeine, alcohol and fatty foods Meds (Tx Sx) Loperamide - diarrhoea Bulk-forming laxatives - constipation Amitriptyline - severe IBS

Question 28

What is the epithelial lining of: Oesophagus Stomach

Answer 28

Oesophagus: squamous epithelial lining - more sensitive to the effects of stomach acid. Stomach: columnar epithelial lining - more protected against stomach acid.

Question 29

Describe GORD

Answer 29

Acid from stomach flows through the lower oesophageal sphincter and into the oesophagus, where it irritates the lining.

Question 30

RF for GORD (5)

Answer 30

Greasy and spicy foods Coffee and tea Alcohol NSAIDs Stress Smoking Obesity Hiatus hernia

Question 31

Sx of GORD + red flag Sx

Answer 31

Heartburn (dyspepsia) + acid regurgitation - worse after meal or when lying down Epigastric pain Bloating Nocturnal cough Red flag sx (can indicate cancer): *** Dysphagia - difficulty swallowing Haematemesis N+V Wgt loss Upper abdo mass

Question 32

Ix for GORD

Answer 32

GS: oesophago-gastro-duodenoscopy (OGD)

Question 33

Tx for GORD

Answer 33

Lifestyle: diet change, NSAIDs, elevate head at night, no late night meals Antacids: e.g. Gaviscon, Pepto-Bismol PPI: e.g. lansoprazole or omeprazole H2 receptor antagonists: e.g. famotidine Surgery: laparoscopic fundoplication - (tightening fundus of stomach to narrow lower oesophageal sphincter)

Question 34

What are the two main complications for GORD and briefly describe each?

Answer 34

1. Oesophageal stricture: abnormal tightening or narrowing of oesophagus 2. Barret's oesophagus - metaplasia of lower oesophageal epithelium from squamous to columnar epithelium caused by chronic acid reflux. It's a pre-malignant condition - for oesophageal adenocarcinoma.

Question 35

What is hiatus hernia?

Answer 35

Herniation of the stomach up through the diaphragm. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm, and the contents of the stomach can reflux into the oesophagus.

Question 36

What are the different types of hiatus hernia?

Answer 36

Type 1: Sliding - stomach slides up through the diaphragm Type 2: Rolling - separate portion of the stomach (i.e., the fundus), folds around and enters through the diaphragm opening Type 3: Combination of sliding and rolling Type 4: Large opening with additional abdominal organs entering the thorax

Question 37

Ix for hiatus hernia

Answer 37

Chest x-ray CT scan Endoscopy Barium swallow