Gastroenterology Flashcards

Question 1

Q

List the daily requirements of fat, protein, carbohydrate utilised by the body.

Know how to calculate daily requirements for protein, carbs and calories, based on weight and stress levels.

Answer

A

Fat: < 70g (9 kcal/g) (30%)

Protein: 50g (4 kcal/g²) (13%¹)

Carbohydrate: at least 260g (4 kcal/g) (57%)

Calculations:

Basic energy requirements (BER) can be calculated as 1.3kcal/kg/hr

Protein: BER x 0.13¹ = x

x / 4² = grams

1: Percentage of dietary allowance for the macronutrient
2: Calories per gram for the macronutrient

Question 2

Q

List anthropomorphic measurements and objective parameters for assessment of nutritonal state

Answer

A

Anthropomorphic:

Height, weight
Mid-upper arm circumference
Skin fold thickness

Objective:

BMI
Hip:waist ratio
Waist circumference
DEXA

Question 3

Q

UPPER GASTROINTESTINAL TRACT: List the anatomical and physiological factors predisposing to gastro-oesophageal reflux disease

Answer

A

Anatomical:

Hernia: Hiatus hernia

Physiological:

Increased IAP: Obesity, pregnancy
H. Pylori infection
Smoking
Diet:
- Spicy foods, fatty foods, high caffeine intake
Late night meals
Iatrogenic: Medications

Question 4

Q

UPPER GASTROINTESTINAL TRACT: Define hiatus hernia with regard to anatomical type

Answer

A

Sliding (A): The gastro-oesophageal junction (GOJ), abdominal part of the oesophagus and sometimes the cardia of the stomach slide upwards through the diaphragmatic hiatus into the thorax

Rolling (B): Gastric fundus is seen above the diaphragm, creating a ‘bubble’ of stomach in the thorax. This is a true hernia, with a peritoneal sac.

Question 5

Q

UPPER GASTROINTESTINAL TRACT: Name 3 typical symptoms of GORD

Answer

A

‘Heartburn’/dyspepsia
Early satiety and bloating
Water brash
Odynophagia
Nocturnal cough/wheeze
Worsened by intake of certain foods/caffeine
Worsened by the supine position

Question 6

Q

UPPER GASTROINTESTINAL TRACT: Describe the investigations used to confirm a diagnosis of GORD

Answer

A

Hx: Symptoms, no red flags (ALARMS55)

Examination:

Investigations:

H. Pylori test
OGD
Barium swallow (if hiatus hernia is suspected)

Question 7

Q

UPPER GASTROINTESTINAL TRACT: Discuss general measures, medical therapy and surgical treatment for GORD.

Answer

A

General measures:

Avoid spicy, high fat and citrus foods
Reduce caffeine and alcohol intake
Weight loss
Avoid large meals, especially before bed

Medical therapy

PPI and H₂antagonist
Alginates
Triple therapy for H. Pylori: PPI, metronidazole and clarithromycin

Question 8

Q

UPPER GASTROINTESTINAL TRACT: Outline the possible long-term complications of GORD

Answer

A

Metaplasia of the oesophagus with increased risk of malignant transformation
- Barrett’s oesophagus or oesophageal adenocarcinoma
Oesophaheal ulceration, haemorrhage or perforation
Benign strictures
Nutritional deficit due to odynophagia

Question 9

Q

UPPER GASTROINTESTINAL TRACT: Understand the presenting features, investigation and management of Barrett’s oesophagus

Answer

A

Presenting features:

May be asymptomatic
Symptoms of GORD
- Regurgitation
Dysphagia/odynophagia (may indicate a stricture)
?Globus sensation
?Haemoptysis

Investigation:

OGD with biopsy
- Violaceous epithelium proximal to the GOJ. ‘Salmon-coloured’ mucosa
Barium oesophagram

Management:

Non-dysplastic Barrett’s:
- Reduce symptoms of gastric reflux:
  - PPI
- Nissen fundoplication
Dysplasrtic Barrett’s
- Endoscopic eradication therapies
- Endoscopic mucosal resection (EMR)

Risk factors: GORD, increased age, male, white, smoking, obesity

Question 10

Q

DYSPHAGIA: List the common causes and discuss investigations of dysphagia

Answer

A

Common causes:

*OROPHARYNGEAL¹ VS OESOPHAGEAL² DYSPHAGIA (see below)

Stroke
Oesophageal motility disorders
- Achalasia
- Scleroderma
Malignancy
GORD
- Strictures
Congenital abnormalities
- Plummer-Vinson syndrome
Psychological
Infection: Pharyngitis, candidiasis, epiglottitis, tonsillitis, quinsy
Endocrine: Goitre
Neuromuscular disorders

Investigations:

24-hour pH monitoring
OGD with biopsy
Barium swallow
CXR, CT

Oropharyngeal dysphagia: Difficulty initiating swallowing +/- choking and aspiration Most common neuromuscular in origin

Oesophageal dysphagia: Food sticks after swallowing

Question 11

Q

DYSPHAGIA: List the symptoms suggestive of oesophageal malignancy

Answer

A

Progressive oesophageal dysphagia
- Starting with solids and then progressing to liquids
- Short Hx of dysphagia
Constitutional symptoms: Weight loss, cachexia, night sweats, ALARMS55 criteria

Question 12

Q

DYSPHAGIA: Describe the pathology and natural history of oesophageal malignancy

Answer

A

Pathology:

Most occur in the lower third of the oesophagus and are adenocarcinomas
The remaining 2/3rds are SCCs

Question 13

Q

DYSPHAGIA: List the treatment options for an oesophageal maligancy.

Discuss staging and assessment of fitness for operation for oesophageal malignancy

Answer

A

Radiotherapy
Chemotherapy
Surgery - oesophagectomy, +/- pre-operative chemotherapy

Staging

Staging and grading¹ via OGD + biopsy, CT CAP, PET to assess for metastatic disease
TNM

Assessment of fitness

Age and co-morbidities
Anaesthesetic risks

1: Grading looks at the level of cellular differentiation

Question 14

Q

DYSPHAGIA: Outline the pathology, presentation and management of achalasia

Answer

A

Pathology:

An oesophageal motility disorder with loss of oesophageal peristalsis (aperistalsis) and failure of the lower oesophageal sphincter to relax upon swallowing.

Presentation:

Slowly/non-progressive dysphagia
Tends to present in younger patients
Regurgitation
Retrosternal pain
‘Mega-oesophagus’ (due to dilation) and tapering below (bird beak sign)

Management:

Symptomatic to reduce dysphagia
Lifestyle modifications: Eat sitting upright, chew food well, take plenty of water with meals
Surgical:
- Pneumatic dilation of the lower oesophageal sphincter
- Surgical cardiomyotomy: Incision into the muscle fibres across the lower oesophageal sphincter
Pharmacological:
- Calcium channel blockers or nitrares to lower oesophageal sphincter pressure
Poor surgical candidates:
- Endoscopic injection of botulinum toxin

Question 15

Q

PEPTIC ULCER DISEASE: List the main causes, symptoms and investigations of peptic ulcer disease

Answer

A

Main causes:

Iatrogenic: Gastric irritants, e.g. NSAID/aspirin/corticosteroids, use without gastric protection
H. Pylori infection
Zollinger-Ellison syndrome¹
Risk factors: Smoking, increasing age, personal/FHx of peptic ulcer disease

Symptoms:

Epigastric pain, related to eating
Haematemesis and/or melaena
Symptoms of anaemia
Symptoms of gastric reflux: Dyspepsia, bloating/early satiety
Peritonitis if rupture occurs
CHECK for ALARMS55 symptoms

Investigations:

Bloods: FBC²
H. Pylori test
OGD

1: Zollinger-Ellison syndrome - a syndrome of gastric acid hypersecretion caused by a gastrin secreting neuro-endocrine tumour
2: Checking for anaemia, due to blood loss from the ulcer

Question 16

Q

PEPTIC ULCER DISEASE: Discuss the differences between gastric and duodenal ulcers

Question 17

Q

PEPTIC ULCER DISEASE: Discuss the relationship between H. Pylori, smoking, NSAIDs and peptic ulcer disease; including the mechanisms by which they cause peptic ulceration

Question 18

Q

PEPTIC ULCER DISEASE: Be aware of other therapies which may increase GI bleed risk

Answer

A

Anti-coagulants
Anti-platelets

Question 19

Q

PEPTIC ULCER DISEASE: List the complications of peptic ulcer disease and describe subsequent treatment

Answer

A

Complication and associated treatment:

Upper GI bleeding
- Acute: Endoscope, surgical
- Chronic: Causing anaemia. Iron supplementation
Gastric outlet obstruction¹
Perforation
- Surgical treatment

1: Gastric outlet obstruction may occur due to scarring and oedema. PC is often nausea, vomiting and weight loss.

Question 20

Q

GASTROINTESTINAL HAEMORRHAGE: Specify the symptoms and common causes of acute upper GI bleeding

Answer

A

Symptoms:

Shock
- Hypotension, tachycardia
Melaena and/or haematemesis
- Particularly ‘coffee-ground’ emesis
Return of blood through a nasogastric tube

Common causes of acute GI bleeding:

Ruptured oesophageal varices
Peptic ulcer disease
Mallory-Weiss tear
Malignancy
Oesophagitis
Iatrogenic

Question 21

Q

GASTROINTESTINAL HAEMORRHAGE: List the common causes of acute lower gastrointestinal bleeding

Answer

A

Diverticulitis/diverticular disease
Angiodysplasia
IBD: Crohn’s, UC
Intestinal perforation, secondary to GI obstruction
Ischaemic colitis¹
Haemorrhoids
Malignancy
Anal fissure

1: Ischaemic colitis occurs when there is acute, transient interruption to GI perfusion such that the metabolic demands of the bowel cannot be met

Question 22

Q

GASTROINTESTINAL HAEMORRHAGE: List the commonest presentations of chronic GI blood loss

Answer

A

Iron deficiency anaemia

Question 23

Q

GASTROINTESTINAL HAEMORRHAGE: Discuss the initial management of a patient with gastrointestinal haemorrhage

Answer

A

A-E approach

2 large bore cannulas (grey/brown)
- Bloods from one for baseline biochemistry
- IV fluids/blood components into the other
Insert a urinary catheter and monitor hourly urine output
Organise CXR, ECG and ABG
Alert a senior and the surgical team
- +/- resus team
Arrange an urgent endoscopy
- Immediately following resuscitation for unstable patients
- Within 24 hours of admission for all other patients
- Diagnostic and therapeutic¹

The Rockall score is used to assess the risk of rebleeding and mortality.

The Glasgow-Blatchford bleeding score may be used to assess the need for admission in patients with upper GI bleeds. ?May also be used for inpatients

1: Therapeutic uses include adrenaline injection or diathermy for ulcers and banding for varices

Question 24

Q

GASTROINTESTINAL HAEMORRHAGE: List the criteria for endoscopic, surgical and radiological intervention

Answer

A

Surgical or radiological intervention is required if endoscopic intervention is unsuccessful i.e. bleeding reoccurs or is persistent despite treatment.

Endoscopic intervention includes administration of adrenaline, diathermy and banding.

Radiological intervention:

CT angiography to locate the exact site of the bleed
Embolisation through the introduction of an embolic agent into the bleeding vessel

Question 25

Q

GASTRIC NEOPLASMS: List risk factors for, the symptoms suggestive of and investigations for gastric cancers

Answer

A

Risk factors:

Pernicious anaemia¹
H. Pylori infection
Increasing age
Smoking
Obesity and poor diet

Suggestive symptoms:

Weight loss
Epigastric pain/discomfort
Early satiety/bloating
Dyspepsia (refractory to treatment)
ALARMS55
Melaena
Constitutional symptoms: Weight loss, night sweats

Investigations:

Bloods
OGD with biopsy
CT CAP
PET scan to check for lymph node invasion

1: Pernicious anaemia arises due to autoimmune mediated destruction of intrinsic factor producing parietal cells, preventing absorption of Vitamin B12

Question 26

Q

GASTRIC NEOPLASMS: Describe the epidemiology, classification, morphology and natural history of gastric cancers

Answer

A

Epidemiology:

Men > women
More common with increasing age

Classification:

Adenocarcinoma *most common*
- Occur in the antrum
- ‘Leather bottle stomach’ due to fibrous reaction
- ‘Krukenberg’ tumours are the result of metastatic spread to the ovaries
Leiomyomas and leiomyosarcomas
- Usually slower growing and benign

Question 27

Q

GASTRIC NEOPLASMS: Outline the general principles of curative and palliative surgical procedures for gastric cancers and discuss the role of adjuvant and palliative therapy

Answer

A

Surgical procedures for gastric cancers

Gastrectomy
- For all patients with T2 or higher and any N, perioperative treatment should be given
- Post-operative chemoradiation may be indicated
- May be offered to palliative patients to improve symptoms such as bleeding and obstruction
Endoscopic musosal resection (EMR) is appropriate for patients with adenocarcinoma confined to the mucosa

Question 28

Q

GASTRIC NEOPLASMS: Quantify the prognosis for gastric cancer

Answer

A

Overall, the 5 year survival rate is < 10%

Question 29

Q

THE ACUTE ABDOMEN: Define the acute abdomen

Answer

A

‘The rapid onset of acute symptoms that may indicate severe and life-threatening intra-abdominal pathology that requires urgent surgical intervention.’

Abdominal pain is usually a feature although pain-free acute abdomen can occur

Question 30

Q

THE ACUTE ABDOMEN: Identify the symptoms and signs of the acute abdomen

Answer

A

Symptoms:

Abdominal pain
Vomiting
Peritonitis
Fever
Constipation
Melaena

Signs:

Rebound tenderness
Pain on palpation
Abdominal distension
Jaundice
Signs of dehydration

Question 31

Q

THE ACUTE ABDOMEN: Discuss differential diagnosis, relating these to the pathology of the conditions

Question 32

Q

THE ACUTE ABDOMEN: Select appropriate investigations to avoid diagnosis and interpret these

Answer

A

Investigations to consider:

LFTs
U&Es
ESR/CRP/WCC
FBC
Imaging: USS, X-ray, CT
Pregnancy test/serum hCG
ABG
- ?DKA

Question 33

Q

THE ACUTE ABDOMEN: Outline initial management and identify the patient needing urgent resuscitation and operative intervention on the basis of their clinical presentation

Answer

A

Initial management:

A-E approach

Airway: Check patency

Breathing: RR, auscultate, percuss, pulse oximetry, ABG, oxygen

Circulation: Pulse, BP, auscultate, ECG, fluids following insertion of 2 large bore cannulae, urinary catheter

Disability: AVPU, glucose,

Exposure

Patients requiring urgent intervention:

Signs/symptoms of shock with a known or suspected haemoperitoneum
Unstable
Patients with AAA
Patients with suspected ectopic pregnancy
Abdominal pain disproportionate to physical signs, consider mesenteric ischaemia

Question 34

Q

SMALL INTESTINE AND APPENDIX: List the common pathologens that may cause acute diarrhoea in the community and in travellers to tropical and sub-tropical countries

Answer

A

Causative pathogens:

Community

Viral: Norovirus, rotavirus
Bacterial: Campylobacter, E. coli, salmonella, shigella

Tropical countries

Viral: Rotavirus, norovirus
Bacterial: E.coli, shigella, campylobacter
Parasitic¹: Giardia, entamoeba, cryptosporidium

Subtropical countries

1: Persistent diarrhoea (>14 days) may be of parasitic origin

Question 35

Q

SMALL INTESTINE AND APPENDIX: Outline the management of this problem

Answer

A

Community diarrhoea:

ASK if acute (< 2 weeks) or chronic, as if persisting for longer periods an underlying condition must be considered as a cause

Travellers diarrhoea:

Careful selection of food and beverages
Anti-motility agent e.g. loperamide
Oral rehydration therapy
Antibiotic therapy may be consider for severe diarrhoea¹

1: Severe diarrhoea is incapacitating or completely prevents planned activities. Dysentry (mucus and blood in stools) and febrile diarrhoea are also considered severe)

Question 36

Q

SMALL INTESTINE AND APPENDIX: Indicate the risk factors associated with C.difficile infection and discuss its prevention and treatment

Answer

A

Risk factors associated with C.difficile infection:

Recent antibiotic use, causing disruption to the normal GI flora
- Particularly ampicillin, cephalosporins, clindamycin, carbapenems and fluoroquinolones
Advanced age
Hospitalisation or residence in a nursing home
Hx of C.difficile-associated disease

Prevention:

Cautious use of antibiotics and discontinuing as soon as possible.

Probiotics for primary prevention.

Infection control and hand washing to prevent patient to patient spread.

Treatment:

PO vancomycin or fidaxomicin
Discontinuation of the causative agent
Supportive care
Infection control measures

Symptoms: Diarrhoea with systemic upset, abdominal pain, leukocytosis, fever, abdominal tenderness and distension.

Causes colitis, which may progress to toxic megacolon and multi-organ failure.

Question 37

Q

ACUTE APPENDICITIS: List the symptoms and signs of acute appendicitis

Answer

A

Symptoms:

Epigastric pain which then localises to the RIF, at McBurney’s point¹
Fever
Nausea/vomitng
Anorexia
Constipation/diarrhoea

Signs:

Rebound and percussion tenderness
Rosving’s sign: RIF pain > LIF pain
Guarding
Positive psoas sign²
Positive obturator sign³
Vital signs: Tachycardia, mild fever

1: McBurney’s point is found 1/3 of the way between the ASIS and the umbilicus
2: Pain on hip extension. Seen when the appendix is positioned retoperitoneal retrocaecal (most common)
3: Pain on internal hip rotation. Seen when the appendix is positioned pelvically

Question 38

Q

ACUTE APPENDICITIS: Formulate a differential diagnosis and outline appropriate investigations

Answer

A

Ddx:

GI:
- Acute mesenteric adenitis, gastroenteritis, intussusception, IBD,
Renal:
- Nephrolithiasis
Biliary:
- Cholecystitis
- Cholelithasis
Genito-urinary:
- UTI
- PID
- Mittelschmerz
- Ectopic pregnancy
- Ovarian torsion

Investigations to rule-in/out differentials:

Bloods: FBC¹, CRP, group and save, ?amylase
Imaging
- Abdominal USS and/or CT
Urinalysis²
Pregnancy test

1: An elevated WBC and CRP is expected in acute appendicitis. If normal then a watch-and-wait approach may be adopted
2: If positive for red cells, white cells or nitrites then renal colic or UTI should be considered as possible causes

Question 39

Q

ACUTE APPENDICITIS: List the common situations in which appendicitis is difficult to diagnose or manage

Answer

A

Infants with D&V
Children with vague abdominal pain
Confused elderly pts
Females presenting with gynaecological issues

Question 40

Q

ACUTE APPENDICITIS: List the complications of a perforated appendix

Answer

A

Haemorrhage → shock
Peritonitis → sepsis
Appendix abscess
Appendix mass
- Inflamed appendix becomes covered in omentum
Adhesions
Infertility: Due to tubal obstruction following pelvic inflammation (PID)

Question 41

Q

ACUTE APPENDICITIS: List and discuss the common complications following appendicetomy and how each can be prevented

Answer

A

Common complications:

Infection
Bleeding
Adhesions

Question 42

Q

ACUTE APPENDICITIS: List the causes of a mass in the RIF and outline assessment, investigation and management

Question 43

Q

MECKEL’S DIVERTICULUM: Describe the nature of a Meckel’s diverticulum and its possible pathological effects.

Answer

A

Meckel’s diverticulum:

A congenital malformation of the small bowel. Arises due to failure of the embryonic vitelline duct to obliterate, leaving an outpouching on the small intestine.

The outpouching (formed from the vitelline duct remnant) contains cells capable to producing gastric acid, parietal cells.

Possible pathological effects:

Most commonly presents before the ago of 2 with PR bleeding (haematochezia) or obstruction
Inflammation, adhesions, perforations, ulceration - caused by damage to local tissues by gastric acid release

Question 44

Q

MECKEL’S DIVERTICULUM: Describe the variable clinical presentations of a patient with a Meckel’s diverticulum

Answer

A

Usually are asymptomatic
Usually present before 2 years of age with lower GI bleeding or obstruction
Caecal volvulus: The outpouching can be tethered to the umbilicus, acting as a central point for the intestines to twist around to form a volvulus.
Intussusception
Appendicitis: Inflammation of the diverticulum presents in an identical fashion to appendicitis
Peptic ulceration: Due to ulceration caused by the gastric acid secreting epithelium
A sinus tract may be seen between the umbilicus and the diverticulum, known as a patent vitellointestinal duct

Investigations:

Technetium-99m pertechnetate scan: Pertechnetate is preferentially taken up by the mucus-secreting cells of the ectopic gastric tissue in the diverticulum. Ectopic focus or ‘hot spot’ seen on the scan.

Question 45

Q

INTESTINAL OBSTRUCTION: Describe the symptoms and signs in a patient with intestinal obstruction

Answer

A

Symptoms:

Abdominal pain
Vomiting/nausea
Anorexia
(Absolute) constipation: No flatus or faeces is characteristic of absolute constipation
Change in bowel habit

Signs:

Abdominal distention (the more distal the obstruction the greater the degree of distention)
Tingling bowel sounds (may be absent in the later stages of obstruction)
Tympanic abdomen
Palpable abdominal or rectal mass

Question 46

Q

INTESTINAL OBSTRUCTION: List the common causes and the associated pathology of intestinal obstruction

Question 47

Q

INTESTINAL OBSTRUCTION: Discuss the complications of small bowel obstruction and their recognition

Answer

A

Intestinal necrosis¹: Onset of peritonitis, leukocytosis, dehydration and pre-renal AKI are all signs of intestinal necrosis
Intestinal perforation
Sepsis
Multi-organ failure
Short bowel syndrome following surgical resection of the affected section of bowel

Sequelae of intestinal obstruction: Intestinal necrosis → intestinal perforation → sepsis and multi-organ failure

1: As the obstruction progresses, intestinal perfusion decreases with ischaemic change and necrosis following

Question 48

Q

INTESTINAL OBSTRUCTION: List the appropriate laboratory and imaging tests to be employed in a patient with suspected small intestinal obstruction

Answer

A

Laboratory tests:

FBC: Hb, WCC
CRP
U&Es: Checking for signs of shock or organ failure. Elevated urine and creatinine may indicate dehydration.
Urea:creatinine ratio
ABG: Elevated lactate indicates poor tissue perfusion. Check glucose, ketones and pH for signs of DKA.
Serum lipase/amylase: To rule out pancreatitis as a cause of abdominal pain

Imaging:

CT with oral and IV contrast according to local guidelines
- PO Gastrografin, in combination with barium sulphate, may be given prior to CT
- Allows the level and cause of obstruction to be identified
AXR
Erect CXR *to check for pneumoperitoneum*

Question 49

Q

INTESTINAL OBSTRUCTION: Differentiate between mechanical small bowel obstruction and paralytic ileus

Answer

A

Paralytic ileus describes a functional cause of bowel obstruction in which bowel motility is reduced.

Paralytic ileus: Adynamic bowel due to loss of the peristaltic movement of the bowel.

Question 50

Q

INTESTINAL OBSTRUCTION: List the signs and symptoms suggestive of strangulation

Answer

A

Symptoms:

Increasing pain (colicky → constant) and tenderness
Systemic upset

Signs:

Leukocytosis
Peritonism
Absent bowel sounds

Strangulation describes ischaemia and necrosis of the bowel, as vessels are stretched causing blood supply to the tissue to be compromised.

Question 51

Q

INTESTINAL OBSTRUCTION: Compare and contrast a large bowel obstruction and small bowel obstruction

Question 52

Q

INTESTINAL OBSTRUCTION: Outline a plan of treatment in a patient with small bowel obstruction including consideration of fluid and electrolyte therapy, antibiotic therapy, intestinal intubation and operative therapy

Answer

A

3 main elements: Fluid resuscitation, bowel decompression and analgesia

A-E assessment of the patient
Gain IV access and provide fluids¹
Monitor urine output through a urinary catheter
Nasogastric decompression³: Insert a NG tube to allow drainage of gastric contents. Declare the patient nil by mouth - remember to calculate MUST score.
Provide analgesia, and an anti-emetic if indicated
Ongoing monitoring using the NEWS score
Surgical treatment²

2: Indications for surgery include closed loop/complete obstruction, strangulation and peritonitis arising due to any cause of bowel obstruction. Also, in those who do not respond to non-operative treatment after 72 hours. CT evidence of a non-adhesional cause (tumour, hernia, volvulus or gallstone) or evidence of bowel ischaemia is an indication for surgery.

In complete bowel obstruction peritonitis will develop in time if not already present (abdominal tenderness, guarding, rebound tenderness).

1: In bowel obstruction peristalsis increases in an attempt to overcome the blockage. This causes increased secretion of fluid into the bowel. Not only does this cause distention but also dehydration, electrolyte imbalance, volume depletion and AKI.
3: Acts to prevent aspiration of vomit

Question 53

Q

MALABSORPTION AND COELIAC DISEASE: Describe the clinical presentation of malabsorption and outline appropriate investigations

Answer

A

Clinical presentation:

Diarrhoea
Faltering growth/weight loss
Steatorrhoea
Bloating
Lethargy

Investigations:

Bloods: FBC, lipid profile, Fe, B₁₂, calcium
Coeliac disease tests: IgA-tTG (EMA if not available), IgG DGP
Sudan stain for fat globules
Faecal elastase¹
Endoscopy and biopsy

^{1: Reduced when exocrine function of the pancreas is disrupted, e.g. chronic pancreatitis, CF, pancreatic tumour, cholelithasis or T1DM}

Question 54

Q

MALABSORPTION AND COELIAC DISEASE: List causes of malabsorption

Answer

A

Most common causes in the UK are coeliac disease, Crohn’s disease and chronic pancreatitis

Short bowel syndrome (iatrogenic)
Coeliac disease
Lactose intolereance, CMP allergy
IBD: Crohn’s, UC
Infection: Giardiasis, TB,
Malignancy
Congenital abnormalities e.g. Hirschsprung’s, atresia, Meckel’s, cystic fibrosis
Endocrine: Thyroid disease, DM, Addison’s disease, parathyroid disease

Question 55

Q

MALABSORPTION AND COELIAC DISEASE: Outline the pathology of malabsorption of key nutrients and consequent presentation and management for each.

Question 56

Q

MALABSORPTION AND COELIAC DISEASE: Describe the pathology underlying coeliac disease and list clinical conditions that may be associated with it.

Answer

A

Underlying pathology:

Autoimmune destruction of villi, leading to blunting
Gluten derived peptides trigger an immune reaction, leading to local inflammation and subsequent destruction

Associated clinical conditions:

Malabsorption: Leading to anaemia etc.
Osteoporosis/osteopenia
Dermatitis herpetiforms (look at images)
Malignancy
Idiopathic recurrent acute pancreatitis/chronic pancreatitis

Question 57

Q

MALABSORPTION AND COELIAC DISEASE: Outline the investigations undertaken to diagnose coeliac disease.

Answer

A

FBC and blood smear¹
IgA-tTG
- EMA is an alternative to IgA-tTG
Skin biopsy²
IgG DPD or IgA/IgG DPD
- Should be used for pts with IgA deficiency
Small bowel histology
- Essential and the gold-standard for diagnosis

1: Iron deficiency anaemia is the most common presenting feature of coeliac disease
2: For patients with evidence of dermatitis herpetiformis

Question 58

Q

IRRITABLE BOWEL SYNDROME: Describe symptoms that may suggest a diagnosis of IBS.

Answer

A

Alternating diarrhoea and constipation
Abdominal pain and bloating that is associated with changes in stool form or frequency
Symptoms may be relieved by defaecation
Stress related symptoms
Age < 50 *chnage in bowel habit over this age should prompt consideration of malignancy*
Normal abdominal examination

Question 59

Q

IRRITABLE BOWEL SYNDROME: Outline current theories regarding the pathophysiology of IBS

Answer

A

Believed to have multiple contributing causes
A disorder of altered gastrointestinal mobility

Question 60

Q

IRRITABLE BOWEL SYNDROME: Discuss possible investigations and outline therapeutic approaches.

Answer

A

Possible investigations:

Ascertain whether there is a causal relationship between certain foods/drink and symptoms
Test for coeliac disease, lactose intolerance, IBD
Test for endocrine causes of changes in bowel habit: Thyroid function, Hba1c, parathyroid hormone
General tests for wellbeing: FBC, U&Es, thyroid function,

Therapeutic approaches:

Lifestyle and dietary changes

FODMAP diet
Avoid precipitating foods e.g. caffeine

Managing change in bowel habits

Anti-diarrhoeal: Loperamide
Laxative: Ispaghula

Managing bowel spasms/cramps - antispasmodic

Dicycloverine
Peppermint oil

Optional treatments

TCA or SSRI

Question 61

Q

INFLAMMATORY BOWEL DISEASE: Describe the morphology and pathological consequences of Crohn’s disease and ulcerative colitis.

Answer

A

Crohn’s:

‘Mouth to anus’ distribution
Full thickness/transmural inflammation
‘Skip lesions’
Can lead to adhesions between bowel and other pelvic organs
Cobblestoning
Non-caseating granulomatous tissue throughout all layers

UC:

Begins at the rectum and ascends
Continuous inflammation
Crypt abscess, granulomatous inflammation, paneth cell metaplasia

Question 62

Q

INFLAMMATORY BOWEL DISEASE: Describe common presenting symptoms (including extraintestinal manifestations)

Answer

A

Diagnosis is most frequently seen between the age of 15 and 35

Crohn’s disease:

Change in bowel habit: Diarrhoea
Cramping/abdominal pain
Weight loss
Systemic symptoms such as fatigue, malaise and anorexia
Perianal abscess/fistulae/skin tags
Extra-articular manifestations: Joint, eyes, dermatological (erythema nodosum), clubbing

Ulcerative Colitis:

Change in bowel habit: Diarrhoea +/- blood and mucus
Abdominal cramps
Bowel frequency relates to severity
Systemic symptoms: Weight loss, malaise, anorexia, fever
Nutritional deficit
Extraintestinal signs: Clubbing, oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, iritis, large joint arthritis, AS, PSC

Question 63

Q

INFLAMMATORY BOWEL DISEASE: Discuss the investigation of a patient with suspected inflammatory bowel disease.

Question 64

Q

INFLAMMATORY BOWEL DISEASE: Describe the medical therapy available, including the management of acute flares of colitis and the use of immunosuppressives and biological treatments.

Answer 56

A

Complications of Crohn’s disease:

Adhesion and subsequent fistulae
- Entero-enteric
- Colovesical
- Colovaginal
- Perianal
Abscess formation
Perianal disease
Small bowel obstruction
Colon cancer
PSC

Complication of Ulcerative Colitis:

Toxic dilatation of the colon (→ perforation)
VTE
Colonic cancer

Surgery in IBD:

Crohns:

Needed in 50-80% of pts but NOT curative
Indications include failure of medical treatment, obstruction due to strictures, abscess and fistulae formation

Ulcerative Colitis:

Required in ~ 20% of pts
Indicated for failure of medical treatment or due to toxic dilatation
May be completion procectomy (permanent stoma) or ileo-anal pouch (option of stoma reversal and the possibilty of long term continence)

Answer 57

A

Increased risk

Risk of colon cancer in UC:

Risk is proportional to the extent and activity of the disease

Answer 58

A

Diverticulosis: Herniation of the mucosa and submucosa of the gut wall, due to smooth muscle over-activity

Aetiology/Risk factors:

Low dietary fibre intake
Obesity
Tobacco smoking
Excessive alcohol and caffeine intake
Steroids
NSAIDs
Connective tissue disorders e.g. Ehlers-Danlos syndrome,

Answer 59

A

Morphology:

Out-pouching of the gut

Pathological consequences:

Diverticular disease - any clinical symptoms arising as a consequence of diverticulosis
Diverticulitis - Inflammation. May be caused by infection.
GI bleeds
Fistulas
Perforation
Obstruction
Abscess
Neoplasm

Answer 60

A

Clinical features:

Symptoms:

Altered bowel habit
Left sided colic relieved by defecation, nausea and flatulence
Systemic symptoms: Pyrexia, fever, fatigue, anorexia
Melaena

Signs:

Localised or generalised peritonitis
Elevated WCC, ESR/CRP

Answer 61

A

Perforation: Ileus, peritonitis and shock
Haemorrhage
Fistulae
Abscess: Swinging fever, leucocytosis
Post-infective strictures

Answer 62

A

Conservative management

Asymptomatic diverticulosis, discovered incidentally, generally requires no treatment
Antispasmodic e.g. mebeverine
Some evidence to suggest that increasing dietary fibre may help

Surgical management

Occasionally resorted to

Answer 63

A

Elective

Fistula formation
?Stricture

Emergency

Haemorrhage

Answer 64

A

Aetiology:

Familial polyps (FAP, Lynch syndrome)
Increased age
Obesity
Diet: Low fibre, high in processed meats
Smoking
IBD
FHx

Morphology

The vast majority are adenocarcinomas
- ‘Signet ring cells’ on histology
The vast majority occur in the recto-sigmoid region of the colon, with 45% in the rectum

Pathology

*

Answer 65

A

Dukes’ classification:

A: limited to the bowel wall

B: through the bowel wall

C: regional lymph nodes metastasis.

TNM:

Once TNM categories have been determined the information is combined to provide the stage of the tumour.

Answer 66

A

* Most commonly seen in the recto-sigmoid region of the colon*

Answer 67

A

Anal cancer

Mainly SCC
RFs: Anoreceptive sex, syphilis infection, HPV infection, immunosuppression,

Colorectal cancer

Mainly adenocarcinomas

Answer 68

A

Consider a 2WW referral for colorectal cancer, when:

Occult blood in faeces (FIT)
Rectal or abdominal mass
40 years or > with unexplained weight loss and abdominal pain
50 years or > with unexplained rectal bleeding and any of the following - abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia
60 years or > with iron-deficiency anaemia (with no identifiable cause) or changes in bowel habit
For anal cancer, unexplained anal mass or anal ulceration
ALARMS55

Answer 69

A

Laboratory tests

FBC: ?anaemia, WCC
LFT: ?derangement due to mets
Tumour markers:
- CEA (should only be measured after confirmation of diagnosis) - can be used to monitor disease
- AFP
U&Es
Faecal calprotectin: ?raised due to inflammation
CRP/ESR: ?inflammation

Radiological studies

CT CAP
Double-contrast barium enema¹
CT colonography
PET scan

Endoscopic investigations

Colonoscopy with biopsy

1: Characteristic ‘apple core’ lesion

Answer 70

A

Laparoscopic resection
- Right/left hemicolectomy according to the site of the mass
Endoscopic stenting in palliation
Radiotherapy is usually used in palliation or pre-op in rectal cancer
Adjuvant chemotherapy for stage 3 disease

Answer 71

A

Management of anal carcinoma

Chemotherapy (5-FU or mitomycin) plus radiotherapy
75% retain normal anal function

In contract, colorectal cancer management mainly involves resection of the mass and local tissue.

NOTE: Squamous cell anal carcinoma is the most common (below the pectinate line). Adenocarcinomas (above the pectinate line) should be treated as rectal cancer.

Answer 72

A

All pts undergoing surgery require colonoscopy before or soon after to look for additional lesions/metachronous tumours¹
Stage II/III disease: CEA every 3/12 and colonoscopy every 3 years

NHS bowel cancer screening programme sees FIT every 2 years for pts aged 60 - 74.

1: Metachronous tumours - Primary CRC developing 6 months after previous colorectal surgery for CRC

Answer 73

A

Insert a NG tube for gastric decompression and analgesia
Provide IV fluids
Use AXR and erect CXR to confirm diagnosis and to look for signs of perforation (pneumoperitoneum)
CT to determine the level of obstruction
Surgery for resolution or endoscopic stenting if palliative

Answer 74

A

Symptoms

Absolute constipation
Abdominal distension and pain

Signs

Absent bowl sounds
Resonance to percussion
Palpable mass
No abdominal tenderness *unless strangulated*

THINK is there a functional (ileus) or mechanical obstruction?

Answer 75

A

AXR and CXR
CT to identify the level of the obstruction
Oral Gastrografin may be given prior to CT to help identify the level of obstruction and may have mild therapeutic effect on the obstruction

Answer 76

A

NEC -AXR
Volvulus - AXR, barium CT
Intussusception
Malrotation
Strictures
Secondary to Meckel’s diverticulum
Hirschsprung disease - biopsy

Answer 77

A

Severe constipation can cause faecal impaction.

General factors: Poor diet, dehydration, lack of exercise, IBS, old age, pain

Anorectal disease: Fissure, stricture, rectal prolapse

Metabolic/endocrine: Hypercalcaemia, hypothyroid, hypokalaemia

Drugs: Opiates, anticholinergics, iron, aluminium based antacids, diuretics

Neuromuscular: Diabetic neuropathy, spinal/pelvic nerve injury, Hirschprung’s disease

Investigations:

FBC, ESR, U&Es, calcium, TFTs

Answer 78

A

Haemorrhoids: Disrupted and dilated anal cushions.

Anal cushions contribute to anal closure. There are 3 anal cushions can be seen at 3, 7 and 11 o’clock in the lithotomy position.

Haemorrhoids may be internal (origin above the dentate line), external (origin below the dentate line) or mixed.

Answer 79

A

Internal anal sphincter:

Under involuntary control, surrounding the upper 2/3 of the anal canal
Smooth muscle

External anal sphincter:

Under voluntary control (inferior rectal nerve, S4), surrounds the lower 2/3 of the anal canal
Striated muscle

Answer 80

A

Straining (chronic constipation or diarrhoea)
Increased IAP (obesity, pregnancy)
Pelvis masses which reduce vascular return, resulting in anal vascular engorgement
Increased anal tone (stress)

Answer 81

A

Symptoms:

PR bleeding: fresh, associated with wiping
Pain (if thrombosis occurs)
Pruritis ani
Prolapse of haemorrhoids (piles)

Complications:

Anaemia
Thrombosis: If prolapsing vessels become compressed by the anal sphincter (strangulation) the cessation of venous return can lead to thrombosis. Treatment is conservative, as they often resolve spontaneously. Cold compress, opioids and rest are advised.

Answer 82

A

Haemorrhoids
IBD
Malignancy
Anal fissure
Trauma
GI bleed e.g. diverticulitis, ulceration
Gastroenteritis
Perianal haematoma

Answer 83

A

Inspection

Visibly protruding haemorrhoids (piles)
PR bleeding
Exocoriations

Abdominal examination

Check for palpable masses (as pelvic masses may reduce vascular return) and hepatomegaly

Proctoscope

Piles can be visualised
Assess for any lesions higher within the anus and rectum which may have caused bleeding

Colonoscopy/flexible sigmoidoscopy - if a more sinister pathology is suspected

Answer 84

A

Investigations

Examination: Abdo examination, proctoscopy, ?colonoscopy - if sinister cause suspected

Management

1st line: Dietary and lifestyle modification - increased fibre and ensure adequate fluids. Avoid excessive straining.
- Adjunct: Short course of topical corticosteroid to reduce pruritis

For prolapsing internal haemorrhoids

Rubber band ligation or sclerotherapy or infrared photocoagulation or haemorrhoid arterial ligation

For grade 4 internal/external/mixed internal or external haemorrhoids

Surgical haemorrhoidectomy

Ddx

Malignancy
Anal fissure
Perianal haematoma
Abscess

Answer 85

A

Caused by rupture of a vein beneath the anal skin, with onset after a heavy effort (lifting/coughing/sneezing/straining at stool). It is not related at all to haemorrhoids.

Signs:

Tense, smooth, dark blue/black lump close to the anal verge

Symptoms:

Acute onset pain

Management:

If treatment is sought within a few hours of onset then incision and drainage can be performed.
Generally the perianal haematoma resolves within a few days. Oral analgesia and hot baths can be advised.

Answer 86

A

Anal crypts act to release mucous when compressed by faeces, aiding evacuation of the anal canal
The crypts are the most common site of infection

Answer 87

A

Pain, tenderness and swelling around the anus
Perianal infection can leads to the formation of a perianal abscess
- Visibly red, exquisitely tender swelling next to the anus
Perianal cellulitis may also be seen: Erythema, swelling, hot

Answer 88

A

Perianal cellulitis
Perianal abscess
Pilonidal sinus
Perianal warts

Answer 89

A

Inspect

Scars
Visible signs of infection, swelling, lumps
Anal skin tags/fissures/ulcers

Proctoscopy

PR examination

Any discharging area near the anus should be assumed to communicate with the anorectum, until proven otherwise. MRI or operative exploration may be used to investigate.

Answer 90

A

A tract communicates between the skin and the anal canal/rectum.

Blockage of deep IM gland ducts is thought to predispose to the formation of abscesses, which then discharge to form a fistula.

Other RFs: IBD, diabetes, TB, HIV, history of anal trauma

Clinical features:

Recurrent perianal abscess
Intermittent/continuous discharge onto the perineum (mucus, blood, pus or faeces)

Goodsall Rule

Can be used to predict the trafectory of a fistula tract, through looking at the location of the exteral opening.

External opening posterior to the transverse anal line - fistula follows a curved course to the posterior midline

External opening anterior to the transverse anal line - fistula tract will follow a straight radial course to the dentate line

Answer 91

A

Management of fistula in ano

*** Dependent upon the cause and site of the fistula

No symptoms → conservative approach
Symptoms →
- Fistulotomy: Laying the tract open and allowing healign through secondary intention
- Placement of a seton through the fistula to allow the tract to drain, encouraging healing

Answer 92

A

A painful tear in the squamous lining of the lower anal canal/split in the skin of the distal anal canal.

If the tear is chronic it my be associated with a ‘sentinal pile’ or mucosal tag at the external aspect.

Answer 93

A

Risk factors: Hard stools, pregnancy, opiate analgesia

Symptoms

Pain on defecation - ‘like passing broken glass’
- May continue for 1-2 hours after defecation and can be burning in nature
PR bleeding - fresh blood on stool/paper
Tearing sensation when passing stool
Anal spasm

Physical examination

Fissure visible on retraction of the buttock
Associated sentinel pile or mucosal tag
Proctoscopy *may not be possible due to pain*
Colonoscopy should be performed to rule out more sinister causes/ other anorectal conditions

Answer 94

A

Current theories of aetiology:

Hard stools
Pregnancy
Opiate use

Management

On 1st presentation:

Conservative treatment: High fibre diet, topical analgesia, sitz baths, stool softeners to make defecation more comfortable
Adjunct: Topical GTN (causes relaxation of the anal sphincter but may not be tolerated by patients due to the occurence of headaches with use)

Recurrent fissures:

Botulinum toxin: Relaxes the anal sphincter (inhibits pre-synaptic ACh release)
Surgical sphincterotomy

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