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Gastroenterology Flashcards

1
Q

What is Rovsing’s sign and what does it indicate?

A

Palpation of LLQ increases pain in RLQ

Indicates appendicitis

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2
Q

How does Wilson’s disease usually present? (Age + 3 features)?

A

Excessive copper deposition
Presents age 10-25
(Autosomal recessive)

Hepatitis, speech/ behaviour problems, haemolysis, blue nails, asterixis (flapping tremour), chorea (kerky movements)
- Liver + neuro signs = think Wilsons

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3
Q

What triad of features are seen in acute liver failure?

A

Encephalopathy
Jaundice
Coagulopathy

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4
Q

What is an important complication of primary sclerosing cholangitis?

A

Cholangiocarcinoma (jaundice, weight loss and biliary symptoms) - 10% of all those with PSC

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5
Q 
A 25-year-old female currently under investigation for secondary amenorrhoea presents with jaundiced sclera. On examination spider naevi are present along with tender hepatomegaly. Blood tests show:
Hb	11.6 g/dl
Plt	145 * 109/l
WCC	6.4 * 109/l
 Albumin	33 g/l
Bilirubin	78 µmol/l
ALT	245 iu/l
What is the most likely diagnosis?
A

Autoimmune hepatitis

The combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest autoimmune hepatitis

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6
Q

What are the histological findings in coeliac disease?

A

Villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia

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7
Q

What is Gilberts syndrome?

A

Autosomal recessive
Unconjugated hyperbilirubinemia
Reduced glucuronyltransferase

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8
Q

What is Virchow’s node?

A

Swollen LN in left supraclavicular region

- Indicates gastric cancer

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9
Q

You suspect bowel obstruction, what investigations must be done as a minimum?

A

AXR

PR exam

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10
Q

What is primary sclerosing cholangitis?

A

Fibrosis of intra and extrahepatic ducts, possibly autoimmune

  • Associated with UC (80%)
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11
Q

What investigations could be done for suspected PSC? (3)

A

US then MRCP
pANCA may be +ve
LFT’s (obstructive)

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12
Q

What triad is typically seen in mesenteric ischemia?

A

CVD - look for AF
Poorly localised abdo pain (worse than exam would suggest)
Vomiting or diarrhoea

(High lactate)

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13
Q

What advice is given to patients awaiting OGD regarding their PPI’s?

A

Stop 2 weeks before gastroscopy

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14
Q

What antibody is highly specific for primary billiary sclerosis?

A

anti-Mitochondrial antibody

M’s (mitochondrial ab, Middle aged women, IgM)

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15
Q

What are the two hepatitis A antibodies and what do they show?

A

Hep A IgM = Current infection
Hep A IgG = Past infection or vaccination

(think G=gone)

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16
Q

Which blood test can be used to look for current hepatitis B?

A

HBsAg

(HBs antigen = acute disease)
HBeAg is a marker of infectivity

Also anti-HBc MAY be +ve

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17
Q

What are the two main antibodies seen in hepatitis B, what do they each show?

A

Anti-HBs = Immunity (either infection or vaccine)

Anti-HBc = Previous or current infection

C is CORE so will only be infection, not vaccination

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18
Q

A healthcare professional has been vaccinated against Hep B but never had the disease, what will a hep B screen show?

A 
Anti-HBs = +ve 
Anti-HBc= -ve (shows current/ past infection)
HBsAg = -ve (shows current infection)
HBeAg = -ve (shows current infectivity)
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19
Q

A patient has previous had Hep B and is now immune, what will their bloods show? (Assuming no current active disease)

A 
Anti-HBs = +ve
Anti-HBc = +ve 
HBsAg = -ve
HBeAg = -ve
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20
Q

How do you manage Hep A?

A

rest, fluids, anti-emetics
Stop alcohol and paracetamol
Recovery 3-6months

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21
Q

How do you manage Hep B?

A

(as Hep A) +

  • No intercouse til non-infective
  • If HBeAg +ve then give peginterferon alpha for a year

Symptoms resolve in 4-8 weeks (10% become chronic)

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22
Q

How do you manage Hep C?

A

Supportive as A/B

+ Peginterfron alpha and ribavarin
85% become chronic

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23
Q

What serology can be checked for Hep C, what does each indicate?

A

Anti-HCV = Current or recovered infection

HCV RNA = Active infection (the ones to be treated)

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24
Q

Name 5 symptoms of hepatitis?

A 
Malaise 
Weakness
Pruritus
Jaundice (dark urine + pale stools)
Anorexia
Hepatomegaly
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25
Q

How does coeliac disease usually present? (5)

A 
Abdo pain
Bloating 
Diarrhoea 
FTT or weight loss
Fatigue
Frothy or fatty stools

Anaemia/ vit deficiency/ low ferritin all possible

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26
Q

What investigations can be done for coeliac disease?

A

TTG and endomyseal antibody (on gluten for at least 6 weeks prior)

Jejunal biopsy to confirm

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27
Q

How should coeliac be managed (what foods to avoid + any other)?

A

Avoid wheat (bread, pasta, pastry, barley etc)

Vaccines for flu and pneumococcal

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28
Q

Name 2 investigations which could be done for hepatocellular carcinoma?

A

USS
AFP bloods

(these are done to screen all high risk groups)

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29
Q

What three tests can help diagnose Wilsons disease?

A

Reduced serum caeruloplasmin
Reduced serum copper
Increased 24 urinary copper excretion

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30
Q

What is used to manage Wilsons disease?

A

Penicillamine

trientine hydrochloride may become first line soon

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31
Q

What is the most common type of PUD? Name 3 risk factors

A

DU are 4x more common than GU (GU most common only in elderly)

  • H.pylori (95% DU and 80%GU)
  • NSAIDS or steroids
  • Smoking, alcohol, stress
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32
Q

A patient presents with dyspepsia, name 5 red flags which would warrant a 2ww OGD?

A 
A- Anorexia
L- Loss of weight
A- Anaemia 
R- Recent onset <55yrs
M- Melena/ haematemesis
S- Swallowing difficulty
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33
Q

How should new dyspepsia in a 50year old male be managed? (First 3 steps)

A

1) Lifestyle (OTC antacids, avoid NSAIDS, alcohol etc)
+ 4 week course of PPI
+ test for H.Pylori
2) If +ve for h.pylori treat with triple therapy AND test for eradication with urea breath test at 6-8weeks post tx
3) If still present after 8 weeks consider endoscopy

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34
Q

A patient has an ulcer, likely causes by NSAIDS, how long should it take to heal with lanzoprazole and stopping of the NSAID?

A

Around 8 weeks

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35
Q

What is initial tx for a mild-moderate flare up of UC? (4points)

A

1) Oral ASA (Mesalazine)
- Consider adding topical aminosalicylate OR oral steroid depending on patient preferences (or if more moderate)

2) Oral pred if ASA’s not tolerated or CI (add if no improvement within 4 weeks or if syx worsen despite tx)

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36
Q

What is the initial management of a severe flare up of UC?

A

Admit, NBM and IV hydration
+ IV hydrocortisone
+ rectal hydrocortisone

(if improvement in 5 days transfer to oral pred)

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37
Q

What is first, second and third line management to maintain remission in UC?

A

1) 5ASA (mesalazine)
2) Azathioprine
3) Biologics

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38
Q

A patient with UC has a flare up restricted, how do you manage?

A

1) PR Mesalazine

- Can add PR steroid

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39
Q

Name two general measures with regard to Crohns management?

A

1) Smoking cessation key

2) Avoid anti-diarrhoeals in acute episodes (toxic megacolon)

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40
Q

What are the first 3 lines of crohns maintainance management?

A

1) Azathioprine (>2 flare ups per year or relapse on steroid therapy)
2) Mercaptopurine or methotrexate
3) BIologics

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41
Q

How do you manage a mild to moderate flare up of crohns disease?

A

Oral pred (40mg/d for 1wk then taper over 7 weeks)

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42
Q

How do you manage severe flares of Crohns?

A

Admit, NBM and IV hydration
+ IV hydrocortisone
+ rectal hydrocortisone

(if improvement in 5 days transfer to oral pred)

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43
Q

How are flare ups of UC classified? (Truelove and Witt’s)

A

Mild: <4 stools, no systemic disturbance, normal ESR and CRP

Moderate: 4-6 stools/day, minimal systemic disturbance

Severe: >6 stools a day, systemic disturbance

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44
Q

Where does pain tend to occur for each type of IBD?

A 
Crohns = LRQ
UC = LLQ
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45
Q

What histological features characterise each type of IBD?

A

Crohns = Granuloma’s and increased goblet cells

UC = Cryptitis and crypt abscess’

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46
Q

What complications tend to characterise each type of IBD?

A

Crohns = Strictures, fistula’s, perianal disease

UC = Toxic megacolon, colorectal cancer more likely

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47
Q

What diseases are associated with each type of IBD?

A

Crohns = Ank spond, polyarthritis, erythem nodosum

UC = Primary sclerosing cholangitis and uveitis

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48
Q

Name 3 things which are risk factors for both crohns and UC?

A 
FHx
NSAID use
High fat diets
Oral contraceptives
Hygiene hypothesis
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49
Q

What is the peak diagnosis age for both UC and crohns?

A

15-30

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50
Q

You suspect a patient has IBD, what investigations should be performed? (5)

A
  • FBC, CRP, U+E, LFT
  • Iron/ B12/ folate (low more likely crohns)
  • Calprotectin (distinguish IBS/IBD)
  • Stool culture and microscopy (?infective cause)
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51
Q

How is perianal disease managed in Crohns?

A

MRI and exam under GA

Tx: Oral AB’s, immunosuppresion, local surgery +/- seton stitch insertion

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52
Q

What are the criteria for diagnosing IBS?

A

At least 6 months of (abdo pain or bloating or altered bowel habit)
- Relieved by defecation OR be with altered bowel frequency
PLUS 2 of:
- Altered passage
- Bloating, distension or tenderness
- Symptoms worse on eating
- Passage of mucus

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53
Q

What aspect of FHx should always be covered when suspecting IBS?

A

Ensure you always ask about FHx of CRC, as a +ve history of family member <50 should lower the threshold for referral and investigation.

Weight loss IS NOT a feature of IBS

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54
Q

What investigations should be performed for a patient meeting the IBS criteria?

A 
FBC (normal)
ESR and CRP (normal, raised could be IBD)
Coeliac screen
CA-125
Feacal calprotectin
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55
Q

Name 5 management options in IBS

A

Regular meals (avoid long gaps)
Lots of fluids, restrict caffeine, alcohol, fizzy drinks
Limit high fibre food
Limit FODMAP foods (85% report improvement after reducing)
Diarrhoea: Loperamide
Constipation: Senna
Spasm pain: Buscapan/ pepermint oil

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56
Q

How does GORD typically present?

A

Heartburn (burning from stomach to lower chest/ neck), related to meals
Lying down or straining makes symptoms worse
Acid or bitter taste in mouth

  • Possible excessive salvia and odynophagia
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57
Q

What is Barrett’s oesophagus?

A

Chronic acid reflux leads to change from squamous to columnar epithelium

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58
Q

What is the most common cancer following GORD and Barrett’s?

A

Adenocarcinoma

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59
Q

Name 5 indications for endoscopy in a patient presenting with GORD?

A 
New in >55yrs
A- Anaemia
L- Loss of weight
A- Anorexia
R- Recent onset/ progessive (
M- Masses 
S- Swallowing difficulty
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60
Q

Name 3 conservative measures to treat GORD?

A

Weight loss
Smoking cessation
Small regular meals instead of large ones
Avoid hot drinks, alcohol, spicy foods and fizzy drinks
Don’t eat <3hrs before bed

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61
Q

How should GORD be managed medically?

A

Full dose PPI for one month
+ gaviscon

If no resolution (post endoscopy to r/o serious cause)

1) Up PPI dose
2) Add ranitidine

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62
Q

How should Barrett’s Oesophagus be managed?

A 
If no pre-malignant change:
- High dose PPI
- Regular endoscopy (1-3yrs)
If pre-malignant change:
- Oesophageal resection
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63
Q

Name 4 risk factors for oesophageal cancer?

A 
GORD
Diet (nitrosamines)
Alcohol excess
Smoking 
Achalasia
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64
Q

What is a hiatus hernia?

A

Herniation of part of the abdominal viscera (most commonly stomach) through the oesophageal aperture in the diaphragm

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65
Q

How does a hiatus hernia usually present, what’s the best way to investigate it?

A

Presents similar to GORD

Investigate with endoscopy

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66
Q

How should hiatus hernia be managed?

A

As GORD

Emphasis on weight loss
> Can consider surgery in some cases

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67
Q

What is the most common abdominal wall hernia? What groups is it most common in?

A

75% are inguinal hernia’s

95% of hernia’s are in men, meaning males have 25% lifetime risk

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68
Q

Name 5 risk factors for an inguinal hernia?

A

(Increased pressure or weakness of wall)

  • Chronic cough
  • Constipation
  • Heavy lifting
  • Old age
  • Obesity
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69
Q

How do inguinal hernia’s most commonly present?

A

Commonly painless swelling in groin which develops over time
- May come and go, i.e. after heavy lifting or straining

Syx can include:

  • Pain when coughing
  • Change in bowel habit (constipation)
  • Burning sensation
  • Scrotal swelling
70
Q

How are inguinal hernias managed?

A

Surigcal (open or laproscopic)

- To prevent obstruction (bowel contents), strangulated (blood flow) or incarceration (can’t be pushed back)

71
Q

Which hernia’s are most likely to experience strangulation? What group are they most common in?

A

Femoral (as femoral canal is very tight)

More common in females

72
Q

Coeliac disease pre-disoposes to what malignancy?

A

Enteropathy-associated T cell lymphoma (EATL)

73
Q

What is the most common cause of liver disease worldwide?

A

NAFLD

74
Q

What are the stages of NAFLD?

A

Thought to be linked to insulin resistance

  • Steatosis
  • Steatohepatitis
  • Fibrosis and cirrhosis
75
Q

What blood test is used to diagnose NAFLD?

A

ELF (a triple test similar to that for downs)

76
Q

How is NAFLD treated?

A

Weight loss and other lifestyle changes

77
Q

Which antibiotics most commonly caused c.diff?

A 
Clindamycin
Cephalosporins
- Ceftriaxone, cefataxime 
Fluroquinolones
- Ciprofloxacin
Penicillins
78
Q

First two lines of c.diff treatment?

A 
Oral metronidazole (10-14days)
- No improvement give oral vancomycin

If severly unwell IV metronidazole + oral vanc

79
Q

Name 3 differences between a colostomy and an ileostomy on examination?

A

Colostomy in LIF, Ileostomy in RIF

Colostomy usually has solid faeces, ileostomy usually liquid

Colostomies are flush to the skin, ileostomies are spouted

80
Q

How do you distinguish between an ileostomy and a urostomy?

A

Bag contains urine not faeces in a urostomy

Both are in RIF, both are spouted

81
Q

Name 3 presenting features of a pancreatic ca?

A

Painless, progressive, obstructive jaundice (dark urine, pale stools, pruritus).

May have epigastric discomfort of RUQ mass

82
Q

A px had suspect pancreatic ca, what investigations would you perform?

A

Obs
BB - CA19-9 (+FBC, LFT, U+E) - could also do pancreatic enzymes/ glucose (insulin etc)
I- USS followed by staging CT

83
Q

How is pancreatic ca treated?

A

Surgical only

Adj chemo can be used

84
Q

What are the most common causes of pancreatitis?

A

Gallstones
Alcohol
Idiopathic
ERCP

85
Q

How does pancreatitis most commonly present?

A

Severe epigastric/ upper abdominal pain which penetrates through to the back
Prominent vomiting
Dehydration

Tachycardia, jaundice (if alcohol or gallstones cause), mild fever, hypoxia

86
Q

Name two eponymous signs associated with pancreatitis?

A

Grey turners sign - Bilateral flank blue discolouration

Cullens sign- Periumbilical blue discolouration

Both seen in hemorrhagic pancreatitis

87
Q

What investigations would you do if suspecting a patient has pancreatitis?

A

Obs
B- ECG (r/o MI), ABG (hypoxia common)
B- Amylase (3x UL), CRP (WCC, Ca, LFT, Glucose for Glasgow score)
I- Start with USS (gallstones) then do abdo CT
D- MI, obstruction, AAA

88
Q

What scoring systems can be used for pancreatitis?

A

Glasgow Prognostic Score

(acronym is PANCREAS)

(Any score over 3 needs transfer to HDU or ITU)

89
Q

What are your first three management steps for acute pancreatitis?

A 
ABCDE
R- Refer ITU if Glasgow score >3
O- Regular (hourly) obs
C- NBM
M- Fluids, analgesia (morphine), NG tube, catheter to monitor UO
S- ERCP and gallstone removal if needed
If CT shows abscess may need debridement
90
Q

Name 3 indications to do an ERCP?

A 
Gallstones in common bile duct
Acute pancreatitis due to gallstones 
Diagnosis of pancreatic or biliary malignancy 
Stent insertion in chronic pancreatitis
Dilation of benign strictures
91
Q

How is chronic pancreatitis managed?

A

C- Supportive (lifestyle cutting down alcohol etc)
M- Analgesia (paracetamol and NSAID to start)
Pancreatic enzyme supplementation if needed
S- ERCP to dilate strictures

92
Q

What investigations are performed for suspected chronic pancreatitis?

A

Secretin stimulation test
MRCP
Standard bloods etc

93
Q

How is ERCP performed?

A

Sedation but no GA
Endoscope down throat, find ampulla
Dye injected so images can be taken
Now also theraputic (lithotripsy, ballooning etc.)

94
Q

How does diverticular disease present?

A

Lower left abdo pain
Exacerbated by eating, relieved by flatus

Bloating, constipation and rectal bleeding all possible

95
Q

How should suspected diverticular disease be investigated and managed?

A

I: Colonoscopy

M: High fibre diet, bulk forming laxatives, paracetamol for pain

96
Q

A 60yoM patient presents with LLQ pain, fever, tachycardia, localised tenderness and N+V. What is your top differential and what investigations would you like to perform?

A

Diverticulitis
Investigations:
- Obs
- BB (FBC, U+E, LFT)
- I (Upright CXR to exclude pneumoperitoneum), AXR and possible CT with contrast
- D (If red flag symptoms consider endoscopy but not otherwise)

97
Q

How is diverticulitis managed?

A

R- Admit if (Severe pain, can’t hydrate with fluids or oral AB’s not tolerated, frail, bleeding etc)
O- Obs for baseline
C- Hydration
M- Analgesia (paracetamol) and AB’s 7 days (Co-Amoxiclav)

98
Q

Liver cancer or metastasis is commonly associated with what paraneoplastic syndrome? How does it present and what investigation is done?

A

Carcinoid tumours (release serotonin)

Presentation: Flushing, diarrhoea, weight loss

Investigate: 24hr urinary 5-HIAA (metabolite of serotonin)

99
Q

Which eponymous sign is associated with appendicitis?

A

Rosvigs sign

Palpation in LLQ increases pain in RLQ

100
Q

What investigations should be performed for a patient presenting with RLQ pain where you suspect appendicitis?

A

O- Get obs
B-
B- FBC, U+E, LFT, preg test if F
I- All get USS, CT reserved only for diagnostic uncertainty
D- R/o ectopic, ovarian pathology etc (pelvic USS)

101
Q

How is suspected appendicits treated?

A 
R- To surgeons 
O- Regular obs, ABCDE
C- N/A
M- Analgesia, pre-op AB's
S- Appendectomy
102
Q

What is zollinger-ellison syndrome and how does it present?

A

Rare condition cause by a gastrin secreting tumour in either pancreas or duodenal wall

Presentation: Recurrent ulcers
(Do surgical resection of tumour)

103
Q

Where does colorectal cancer commonly metastasize to?

A

Liver

Followed by lungs, brain and bone
- 20% have mets on presentation

104
Q

Name 5 RF’s for CRC?

A

FHx (under 60) or personal hx (incl endometrial, breast/ ovarian)
IBD
FAP
Diet (meat, fat, low fibre)
Lifestyle (obesity, smoking, alcohol)
Hormones (nulliparity, late first preg, early menopause)

105
Q

A 2ww referral for CRC should be done for a 40year old in what circumstances?

A

Rectal bleeding + change in bowel habit for 6 weeks or more

106
Q

What are the main functions of the large and small intestine?

A

Large: Water re-absorption
Small: Absorb nutrients

107
Q

A 2ww referral for CRC should be done for a 60year old in what circumstances?

A

Any rectal bleed for >6weeks
OR
Any change in bowel habit >6 weeks

108
Q

A 2ww referral for CRC should be done for a patient of any age with what symptoms and signs?

A 
RLQ mass
OR
Palpable rectal mass
OR
Men with unexplained Hb <11
Or 
Non-menstruating women with unexplained Hb <10
109
Q

How does gallstones, cholecystitis and ascending cholangitis present?

A

Gallstones: RUQ Pain
Cholecystitis: RUQ + Fever
Ascending cholagnitis: RUQ + Fever + Jaundice (Charcot’s triad)

110
Q

How should you investigate potential gallstones, cholecystitis and cholangitis?

A

Obs
B- N/A
B- FBC, U+E, LFT, clotting (vit K needs fat to absorb)
I- USS
D- R/o MI (ECG), pneumonia (CXR), stones (urine dip)

111
Q

How is gallstones managed?

A

R
O
C- Lifestyle advice around weight, diet etc.
WATCH AND WAIT
M- Simple analgesia
S- Laproscopic cholecystecomy only if severe pain

112
Q

How is cholecystitis managed?

A 
R (generally admit if pain+ fever)
O- Monitor obs
C- N/A
M- PO Morphine and PR Diclofenac 
S- Lap cholecystecomy
113
Q

How is ascending cholangitis managed?

A 
R- Surgeons involved early
O- Regular monitoring 
C- N/A
M- Analgesia (morphione/ diclofenac), IV AB's and fluids 
S- Endoscopic biliary drainage
114
Q

How does liver disease commonly present?

A 
Malaise 
Fatigue 
Jaundice 
Portal hypertension (acities, varicies)
Abnormal bleeding or itching
Anorexia or weight loss
RUQ pain
115
Q

What is Budd-chiari syndrome and how does it present? How should it be investigated?

A

Obstruction of hepatic venous outflow. Normally occurs in patient with hypercoagulable state (antiphospholipid syndrome) but c-an also be because of physical obstruction (tumour)

P: RUQ pain, acscities, aki, jaundice etc
I: Prolonged prothrombin time, high protein in ascitic fluid

116
Q

How should a suspected hepatocellular carcinoma be investigated?

A

US is gold standard

AFP of >400 is almost diagnostic (10-20 is normal)

117
Q

What is primary billiary cirrhosis, how does it present?

A

Autoimmune chronic liver disorder, which may progress over decades, stereotypically affecting middle aged females. It causes inflammation, chronic cholestasis and may progress to cirrhosis.

P: Fatigue, pruritus, RUQ pain. Possible jaudince or sjogrens (dry eyes/ mouth)

118
Q

Give an example medication that could be used to treat itching?

A

Cholestyramine (from biliary causes as removes bile from body)

Ursodeoxycholic acid (breaks down gallstones and can be used for itching, i.e. cholestasis of pregnancy)

119
Q

What scoring system is used to grade the severity of liver cirrhosis?

A

Child-Pugh (gives either grade A, B or C)

120
Q

What is the first line anti-diarrhoea medication for IBS?

A

Loperamide

121
Q

A 35-year-old former intravenous drug user is reviewed in the liver clinic. He has recently been diagnosed with hepatitis C after being found to have abnormal liver function tests. It is decided as part of his work-up that he should be assessed for liver cirrhosis. What is the most appropriate test to perform?

A

Transient elastography (Fibroscan)

122
Q

What is indicated by thumb printing of the small bowel?

A

Thumbprinting is a radiographic sign of bowel wall thickening. It is seen in a variety of conditions causing colitis (Crohn disease, ulcerative colitis, pseudomembranous colitis, ischaemic colitis)

123
Q

Name 3 causes of pre-hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?

A

Pre-hepatic jaundice = unconjugated (not reached liver yet to be conjugated).

1) Gilberts disease (autosomal recessive)
2) Haemolytic anaemia (spherocytosis/ pernicious anaemia)
3) Thalassemia

124
Q

Name 5 causes of hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?

A

Hepatic jaudice = Mixed picture

1) Hepatitis (Viral, alcoholic, autoimmune, drug induced)
2) Cirrhosis (decompensated)
3) Hepatocellular carcinoma
4) Primary billiary cirrhosis
5) Primary sclerosising cholangitis

125
Q

Name 3 causes of post-hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?

A

Post-hepatic = Conjugated

1) Stones (in common bile duct) i.e. ascending cholangitis
2) Pancreatitis
3) Pancreatic cancer/ cholangiocarinoma/ cancer of the gallbladder

126
Q

What advice should patients be given before a gastroscopy?

A

Don’t eat for 4-6 hours before the test
If having sedation will need someone to drive home, otherwise can go home after 30mins
OGD takes around 10 mins to complete

  • Very small risk of bleeding or perforation
127
Q

What advice should patients be given before a colonoscopy?

A

Special diet for a few days before and then bowel prep (make sure you take properly)

  • Procedure takes around 30mins
  • If had sedative need someone to drive you home, otherwise can go after 30 mins
  • Very small risk of bleeding or perforation
128
Q

What are the common features of both small and large bowel obstruction?

A

Not passing flatus or stools (1st in LB)
Vomiting (1st in SB)
Abdominal distension

129
Q

How do you manage a bowel obstruction?

A

NG tube with fluids (drip and suck). Give catheter for fluid balance, often will need many litres
+ Analgesia/ antiemetics
Endoscopy to clear
If severe laparotomy

130
Q

What features of bowel obstruction are seen on AXR? (Small and large)

A

Small:
- <3cm, central location, valvulae conniventes cross whole bowel
Large:
- <6cm, peripheral location, haustra cross only halfway

131
Q

Name two common symptoms of vitamin C deficiency?

A

Scurvy

Gingivitis, bleeding

132
Q

Name a common symptom of vitamin A deficiency?

A

Night blindness (nyctalopia)

133
Q

Name a common manifestation of vitamin B1 deficiency?

A

(B1 = Thiamine)

Polyneuropathies, wenicke-korsakoff syndrome, heart failure

134
Q

Name a common manifestation of vitamin B9 deficiency?

A

B9 = Folic acid

Megaloblastic anaemia, if in pregnancy = NTD

135
Q

How do you manage an acute GI bleed?

A 
ABCDE
R- Get senior help
Obs- Nurse do 15 min obs + 
C
M- (Cannula in, bloods incl crossmatch out)
> Fluids in stat 
> Blood into other arm if hypotension 
> Correct clotting (vit K, FFP, platlets)

If varicies give terlipressiin and broad spectrum AB’s

S- Urgent endoscopy

136
Q

What scoring systems are used for upper GI bleeds?

A

Blatchford Score - Calculates risk when first happens (any score over 1 needs admission and endoscopy)

Rockall score calculates post endoscopy risk of re-bleeding (<3 is low risk and can early discharge)

137
Q

A patient presents with dysphagia, what history questions should you ask in the HPC of the consultaiton?

A

Solids/ liquids (motility vs. obstructive)
Timing (all the time or just sometimes)
Onset
Progressive?

138
Q

Name 6 differentials for dysphagia and some key points which may indicate each?

A

Benign peptic stricture > Progressive, with pain, GORD in Hx
Oesophageal cancer > As above, no pain, other RF’s
Candidasis > Painful with HIV/ steroid RF’s
Achalasia > Solid+Liquid, regurg + cough
Pharangeal pouch > As achalasia + hallitosis + gurgling
Diffuse oesophageal spasm > Intermittent symptoms

139
Q

Name the 4 categories of laxatives and give at least one example in each?

A

Bulk forming - Fybogel (ispaghula husk)
Osmotic - Lactulose or magrogol
Stimulant - Senna, sodium pixosulfate, bisocodyl
Softners - Docusate, glycerol

140
Q

Short term constipation should be treated with…?

A

1) Bulk forming laxative (fybogel)
- If stools remain hard add or switch to an osmotic (lactulose or magrogol)
- If stools are soft add a stimulant (senna) laxative

141
Q

Opioid induced constipation should be treated with?

A

1) Softner + stimulant (Docusate and senna)

Avoid bulk forming (fybogel)

142
Q

How should faecal impaction be treated?

A

Hard stools = Give osmotic (macrogol)
Soft stools = Give stimulant (senna)

If not working add PR bisacodyl (stimulant) if soft or glycerol (softener) if hard

143
Q

How should chronic constipation be treated?

A

1) Bulk former (Fibogel)
- If stools remain hard add or change to macrogol or lactulose

(Aiming for 1-2 soft stools per day)

144
Q

How should children be treated for constipation?

A

First line is an osmotic (magrogol (i.e. Movicol)), if needed add stimulant (bisocodyl)

  • Continue for several weeks after regular movements return
145
Q

Name 5 differentials for epigastric pain?

A 
Cardiac causes
GORD
Gastric/ duodenal ulcer 
Pancreatitis 
Biliary disease (more likely RUQ)
146
Q

Name 5 differentials for RUQ pain?

A 
Hepatic (including PSC or PBC)
Gallbladder (stones/ cholecystitis)
Ascending cholangitis 
Gastric or duodenal ulcer (more common epigastric)
Renal causes (more likely flank) 
Pneumonia
147
Q

Name 5 differentials for RLQ pain?

A 
Appendicitis 
Crohns
Female (Ectopic, ovarian)
Incarcerated hernia
Renal pathologies
148
Q

Name 3 differentials for LUQ pain?

A

Pneumonia
Renal
Ruptured spleen

149
Q

Name 4 differentials for LLQ pain?

A

Diverticulitis
UC
Renal
Ovarian pathology

150
Q

Name 4 differentials for suprapubic pain?

A

Retention
Testicular torsion
Cystitis
Placental abruption

151
Q

What are the common causes of ascities with a high SAAG (Serum ascities albumin gradient)?

A

High SAAG = Portal hypertension (so losing fluid and higher protein concentration)

  • Liver cirrhosis
  • Liver mets
  • Cardiac failure
  • Alcoholic liver disease
  • Budd-chiari syndrome
152
Q

How does hepatic encephalopathy present? (3)

A

New confusion
Altered GCS
Asterix (liver flap)

153
Q

How is hepatic encephalopathy treated?

A

1) Lactulose (thought to increase gut ammonia metabolism)

2) Rifaximin (antibiotic for secondary prophylaxis)

154
Q

What is a volvulus and how does it present?

A

Torsion of colon causing obstruction
(80% sigmoid, 20% caecum)

Presents as obstruction

155
Q

How should a sigmoid volvulus be managed?

A

1) Rigid sigmoidoscopy with rectal tube insertion

If caecal then management is operative, R hemicolectomy often needed

156
Q

What is the difference between hepatic and wernicke’s encephalopathy?

A

Hepatic - Caused by general toxin build up (ammonia etc)
Wernicke’s - Caused by thiamine B1 deficiency

(Wernickes = ataxia, confusion, opthalmaplegia)

157
Q

What is the gold standard test for pancreatitis?

A

MRCP and CT

158
Q

What is Plummer-Vinson Syndrome? How is it treated?

A

This is a triad of dysphagia, glossitis and iron-deficiency anaemia (some definitions additionally include cheilitis in the syndrome).

Tx: Correct IDA, do dilation of the oesophageal webs causing the dysphagia!

159
Q

How do you differentiate between an inguinal or femoral hernia on examination?

A

Starts above + medial to pubic tubercle (next to pubic symphisis) = INGUINAL
Starts below + lateral to pubic tubercle = FEMORAL

  • Note femoral are often smaller and pea sized, but have a higher risk of strangulation
160
Q

How do you distinguish between direct and indirect inguinal hernia?

A

Reduce hernia, press on deep inguinal ring (in mid point between ASIS and pubic symphisis). Ask patient to cough.

If hernia comes back out = Direct
If stays in = Indirect

Note not a very good test, needs surgery to determine true site and doesn’t change management at all.

161
Q

What is the SAAG and what does it indicate?

A

Serum Ascites Albumin Gradient (normal <11g/L)

  • If raised it indicates the ascities is due to portal hypertension
    (Budd-Chiari, cirrhosis, hepatitis, splenomegaly etc)
162
Q

What is the most common cause of inherited CRC?

A

HNPCC
(5% of all CRC cases and strongly associated with endometrial cancer)

(FAP is second most common)

BOTH ARE AUTOSOMAL DOMINANT

163
Q

What is Courvoisiers sign?

A

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.

164
Q

What characterises chronic mesenteric ischemia (also called intestinal angina)?

A

Triad: Severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
- Normally increasing age and CVS risk factors

165
Q

Anti-smooth muscle antibodies are typically associated with?

A

Autoimmune hepatitis

166
Q

One parent of a patient has an autosomal recessive condition, the other parent is not a carrier. What is the chance any offspring will have the condition?

A

0%
(Need two copies of gene if autosomal recessive, one parent is homozygous so they are guaranteed to be a carrier but will not be effected as the gene from the second parent will be normal)

167
Q

Name 5 presenting features of haemochromotosis?

A

Fatigue, erectile dysfunction and arthralgia

  • Bronze skin
  • Diabetes
  • Liver disease
168
Q

How is haemochromotosis inhertied?

A 
Autosomal recessive
(So both parents need to pass on gene to be affected)
169
Q

Which anti-emetic should be avoided in bowel obstruction?

A

Metoclopramide should be avoided as it is a pro-kinetic anti-emetic so could cause a perforation in bowel obstruction.

170
Q

What bug is most commonly responsible for SBP?

A

Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli

  • If transudate (due to cirrhosis etc) on ascitic tap then need long term antibiotics as prophylaxis
171
Q

What are the best tests to assess the function of the liver?

A

Prothrombin time

Albumin

172
Q

Numerous polyps in GI tract/ early diagnosis of CRC + pigmented lesions on lips/ palms/ soles + FHx = ?

A

Peutz-Jeghers syndrome

Autosomal dominant

MCHB full (21 decks)

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