Gastrointestinal Flashcards
Most likely cause of duodenal peptic ulcer in someone taking aspirin once weekly and drinking 2 cheeky wines/day
H. pylori
NSAID use
Alcohol duodenitis
Idiopathic
H pylori
especially Maori
Lady (about 24 or close to it) with malabsorption, how best to diagnose the cause of the malabsorption?
Stool sample
Small bowel Biopsy
3 hour faecal fat estimate
D-xylose absorption test
Small bowel Biopsy
Guy with epigastric pain on lying flat, food regurg when he bends forwards. Previously relieved by antacids, now getting worse. Whats the most appropriate intervention
More antacids
No treatment
Omeprazole
Endoscopy
Omeprazole
Boring pain. History of GORD. Wakes him at 1am. Relief with milk. Worse with stress. Radiating to the back. Diagnosis?
Gastric ulcer
Duodenal ulcer +6
GORD
Functional dyspepsia
Duodenal ulcers are two to three times more common than gastric ulcers
The pain associated with duodenal ulcers improves after meals, while the pain associated with gastric ulcers generally intensifies after meals.
60-ish year old smoker with dry cough for the last 6 months, worse at night and sometimes after meals. Sometimes gets retrosternal discomfort which lasts around 10-20 mins at rest. He also drinks alcohol. 25 cigs a day. He was also on losartan 50mg
GORD
Smokers cough
Chronic bronchitis
Paroxysmal HF
Drug induced cough
GORD
36 year old man with 6 months of abdominal bloating and discomfort. Blood results showed anti-transglutaminase antibodies. What do you recommend?
· colonoscopy
· Gluten free diet
· Heaps of other investigations
Gluten free diet
Guy with stress at work, presents with abdo pain and nausea post eating only, no heart burn, no malaena, no vomiting, no concerning features
· Functional dyspepsia
· GORD
· Ulcer
Peptic ulcer
Functional dyspepsia
recurring upset stomach without cause/chronic indigestiony thing
Lady not opened bowels in three days, N+V, and not passing flatus. PMHx of Parkinsons. Best investigation? (repeat q)
a. Abdo XR
b. CT oral contrast
c. Gastrografin enema
d. Triple phase CT
Abdo XRay
Complete obstruction
Pacific pastor with epigastric pain and nausea sometimes after eating, happening for 6 months. No red flags and no heartburn. What is it?
a. Functional dyspepsia
b. GORD
c. Peptic ulcer
d. Biliary colic
Functional dyspepsia
Old lady given Abx for URTI, has loose stools, abdo pain 7 days later, why?
Antibiotic associated diarrhoea
clostridium difficile
viral gastro
ischaemic gastro
clostridium difficile 5-10 days after abx
Smoker with 10 years of GORD assoc w weight gain, dysphagia for few weeks
CT chest,
omeprazole,
lose weight and stop smoking, gastroscopy
GASTROSCOPY!!!
I am concerned about dysphagia. Gastroscopy would be good.
From health pathways
Oesophageal cancer - red flag
Dysphagia (new onset and/or progressive)
However, endoscopy is the investigation with the highest specificity for oesophagitis caused by GORD as it is able to differentiate between mucosal lesions caused by infective oesophagitis, peptic ulcer disease, malignancy and other abnormalities of the gut
Hematemesis. Patient had hx of H.pylori infection, tobacco use, older age
Gastric cancer
PR bleeding, mucous present, colonoscopy normal in left colon
Colonic carcinoma
Person regurgitating food, losing weight, radiograph showing birds beak sign
insufficient relaxation of the lower oesophageal sphincter (LOS) and a reduction in or absence of oesophageal peristalsis
Bird beak sign = refer to the tapering of the inferior esophagus in achalasia
Woman with pain after eating. Weight loss. No problem with swallowing.
Gastric cancer
Man with indigestion. CLO test negative. Gastric juices have pH of < 1. What is
the cause?
Zollinger-ellison syndrome –> increases gastrin secretion
Note CLO = H pylori test, rapid urease
Path report, hiatus hernia on gastroscopy. Treatment?
Starts omeprazole (PPI)
Man comes to GP for a health check, he has a BMI of 38. LFT’s same as they were 5 years ago. Picture of fatty liver. What process is most likely disturbed?
a) Insulin resistance
b) Coagulation
c) UDP transferase
d) Portal vein problems
e) Active transport with pump
f) Decreased clotting factors synthesis
g) Decreased albumin synthesis
Fatty liver as blue = fibrosis, extending through around hepatocytes too.
Insulin resistance!!
High BMI –> metabolic syndrome (insulin resistance) –> fatty liver (NAFLD)
60 year old with non-productive cough for the last 6 months, worse at night and sometimes after meals. Sometimes gets retrosternal discomfort which lasts around 10-20 mins at rest. He also drinks alcohol. BMI 32. Smokes 25 cigs a day. Takes losartan for HTN. Dx?
a) GORD
b) Smokers cough
c) Chronic bronchitis
d) Paroxysmal HF
e) Drug induced cough
GORD
Asymptomatic guy, bilirubin 40 on screen for his VISA. All other things normal. Likely diagnosis?
a) Gilbert Syndrome
b) Wilson’s disease
c) Alcoholism
d) Fatty liver disease
e) Hepatitis
Isolated high bilirubin - Gilbert syndrome
Literally just a benign disorder which makes it hard to process bilirubin –> mild intermittment jaundice.
55 year old NZ European man with 8 weeks of altered bowel habit. 5 days of loose bowels with dark red blood and mucous. Had lost 2kg of weight in 1 month. Brother has UC. DRE and sigmoidoscopy up to 16cm normal. Bloods showed microcytic anaemia with low ferritin. Likely diagnosis?
a) Caecal angiodysplasia
b) Haemorrhoids
c) UC
d) Crohn’s
e) Colonic carcinoma
Its giving cancer fr
So left colon is normal –> very unlikely to be UC which has continuous lesions spreading up from rectum.
= Colonic carcinoma
Intestinal biopsy showing fissures and transmural involvement. Diagnosis?
a) Crohn’s disease
b) Ulcerative colitis
c) Diverticulitis
Crohn’s disease
Granulomas, All layers, Skip Lesions
25yo lady with bouts of mucousy diarrhoea. Pulse 100. 5kg of weight loss in last 6 months. Dx? a) IBS
b) Salpingitis c) Giardiasis d) IBD
IBD
Most likely to be…. CD as not bloody like in UC.
Crohn’s disease with pustule on leg and purple necrotic edge. What is this?
a) Necrobiosis lipoidica
b) Pyoderma gangrenosum
Pyoderma gangrenosum = rapidly enlarging painful ulcer associated with autoimmune disorders
Truck driver/pastor presents with mild epigastric pain and nausea post eating for 6 months. No heart burn, no melaena, no vomiting, no concerning features. Worse with stress. Dx?
a) Functional dyspepsia
b) GORD
c) Ulcer
d) Peptic ulcer
e) Biliary colic
f) Barret’s oesophagus
g) Gastric cancer
Woman with RUQ pain, BP 80/60, urine output 15ml in last hour with catheter in situ. Also had a central line with a 2cm water pressure (~JVP). What do you give her?
a) Furosemide
b) Isotonic saline bolus
c) Dexamethasone
d) Adrenaline
e) Dopamine
f) Dextrose 5% solution over 4 hours
Saline bolus
36 year old man with 6 months of abdominal bloating and discomfort. Blood results showed mild iron deficiency anaemia and positive anti-transglutaminase and anti-endomysial antibodies. What do you recommend?
a) Colonoscopy
b) Gluten free diet
Gold standard dx of coeliacs disease= +ve serology + histo changes on duodenal biopsy while patient consumes gluten – biopsy not always necessary
79 year old lady presents with jaundice and weight loss. Has a painless mass in the RUQ, dark urine, pale stools. Has had abdo USS show dilated bile duct and gallbladder. Bloods show obstructive jaundice. What investigation would you do next?
a) Abdo CT
b) Abdo XR
c) ERCP
d) MRCP
Its giving cancer.
Prob ERCP
Jaundice with palpable gallbladder. Most likely cause?
a) Pancreatic tumour (head of pancreas)
b) Gall stones (choledocholithiasis)
c) Cholangiocarcinoma (bile duct cancer)
pancreatic tumour
What from the history makes you think this is cancer of the head of the pancreas?
a) Palpable gallbladder
b) Weight loss
Palpable gallbladder/obstructive cholestasis
Alcoholic with epigastric pain radiating to back, fever, vomiting, tenderness and guarding. Diagnosis?
a) Acute Pancreatitis
b) Chronic pancreatitis
c) Peptic ulcer
d) Diverticulitis
e) Acute appendicitis
Acute pancreatitis (alcohol)
Guy with diarrhoea and PR bleeding that didn’t go away with over the counter diarrhoea treatments or antibiotics. Sigmoidoscopy showed red raw mucosa and pseudopolyps. Diagnosis?
a) Salmonella
b) E. coli
c) Crohn’s
d) Pseudomembranous colitis
e) Clostridium perfringens
f) Ulcerative colitis
Just the mucosa, anal involvement… + BLOODY.
This is therefore… UC.
Man with history of GORD. Boring epigastric pain radiating to back wakes him at 1am. Getting worse – now has fatigue and weight loss. Relief with glass of milk. Worse with stress. Diagnosis?
a) Gastric ulcer
b) Duodenal ulcer
c) GORD
d) Functional dyspepsia
Gastric ulcer = pain exacerbated by meal, assoc w/ vomiting + heartburn
Duodenal ulcer = more common, pain relieved by meal, felt 2-3 hours after meal, wake at night, assoc w/ melaena
DUODENAL, takes longer to feel (several hours after meal), bleeding out lower GI
Guy with ulcer in duodenal cap that is bleeding. Had hypotension but was given saline infusion and responded well. Endoscopy shows bleeding at the edges of ulcer. Management?
a) Endoscopic adrenaline injection
b) Laparotomy and oversew bleeding edges
c) Omeprazole
d) Triple therapy
e) Vagotomy And pyeloplasty
Endoscopic adrenaline injection
Lady with breast cancer, bone mets and liver mets. Started on morphine for pain 2 weeks ago. Was charted lactulose but only took it 3 times. Presents with distention and abdominal pain, has had a few episodes of nocturnal faecal incontinence with liquid foul poos. What investigation?
a) Digital rectal exam
b) Microbiology culture
c) Prescribe codeine as an anti-diarrheal
d) Referral to surg
e) Ask about diet
Difficult. Id prefer imaging. DRE i guess.
This is overflow diarrhoea secondary to colon mets.
Dude with UC on sulfasalazine develops jaundice and pruritis. What process does it disrupt?
a) Bile canaliculi transport
b) Decreased portal vein flow
c) Cytochrome p450 pathways
PRIMARY SCLEROSING CHOLANGITIS =
Dude with UC on sulfasalazine develops jaundice and pruritis. What process does it disrupt?
a) Bile canaliculi transport
b) Decreased portal vein flow
c) Cytochrome p450 pathways
Bile canaliculi transport
Fibrosis basically
20 year old guy with a difficult laparoscopic appendectomy - large amount of pus was removed from abdominal cavity. Had a thorough washout at the time. 24hrs with a urinary catheter, 3/7 of IV Abx. Sent home with oral Abx (5/7 script). Now day 6 post surgery and has diarrhoea and a generally tender rectum. Likely diagnosis?
a) Pelvic abscess
b) Appendix stump leaking
c) Clostridium difficile infection
C diff
70-year-old man with Parkinson’s taking L-dopa. Distended tummy and constipated. Previously had appendicectomy aged 20. On DRE hard faeces. XR: dilated loop of small bowel (central location, taeniae coli). High pitched bowel sounds. Dx?
a) Drug induced pseudo-obstruction
b) Fecal impaction
c) Sigmoid volvulus
d) Obstruction secondary to adhesions
e) Cancer
Previous surgery –> adhesions.
Old Lady with colicky abdo pain that became continuous for 6h and localised to the left, previous appendicectomy. Diagnosis?
a) Mesenteric ischaemia
b) Adhesive obstruction
c) Diverticulitis
Adhesive obstruction
Most likely cause of duodenal peptic ulcer in someone taking aspirin once weekly and drinking 2 G&T’s a day?
a) H. pylori
b) NSAIDs
c) Alcohol duodenitis d) Idiopathic
H. pylori
Guy with 3 year history of loose bowels, with crampy abdo pain, episodes of diarrhoea
and moderate anaemia. Now he thinks about it hasn’t been able to put on weight even in his 20’s. Diagnosis?
a) Coeliac disease
b) Ulcerative colitis
c) Crohn’s disease
d) IBS
Coeliac disease
Lady with IBS Sx. Diarrhoea and mild abdo discomfort. Hasn’t tried anything else. All investigations normal. Treatment?
a) Cut out gluten
b) Cut out dairy
c) Encourage general dietary changes - decrease caffeine and increase fibre
d) TCA
e) SSRI
Encourage general dietary changes - decrease caffeine and increase fibre
Patient has positive endomysial antibody. What is this associated with?
a) Coeliac disease
b) Systemic lupus erythematosus
c) Inflammatory bowel disease
Coeliac antibodies = tTG (more sensitive) + endomysial (more specific)
Path report states: villous atrophy of small intestine. Dx?
a) Coeliac disease
b) Systemic lupus erythematosus
c) Inflammatory bowel disease
Coeliac disease
72 year old woman with 4-6 weeks of heartburn and epigastric discomfort. No dysphagia or problems swallowing. Food coming back up undigested, feeling of fullness with meals and early satiety. Has had 6kg weight loss in the last month. Diagnosis?
Gastric cancer
What raised blood lipid is good prognosis? a) HDL
b) LDL
c) Chylomicron d) VLDL
HDL is good
Endoscopy showed gastric cancer. What other pathology is associated?
a) Atrophic gastritis
b) Barrett’s oesophagus
c) Gastric ulcer
H pylori –> chronic inflam –> atrophic gastritis
Ulcers very rare to form cancer.
Patient with cirrhosis develops ascites. Treatment?
a) Spironolactone
b) Furosemide
c) Fluid restriction
spironolactone
Hiatus hernia on gastroscopy. Treatment? a) Start omeprazole
b) Surgery
Sliding hernia tx = sx relief w/ lifestyle + meds (e.g. omeprazole for GORD)
surgery only if unresponsive
Man presenting with abdo pain, jaundice, ataxia and orange-brown ring around iris. Investigation?
a) Copper ceruloplasmin
b) Liver biopsy
Copper ceruloplasmin for Wilson’s disease
Wilson’s disease = genetic disorder – copper accumulation in liver + other tissues (cornea)
Patient with IBD develops abdo pain and distension and severe bloody diarrhea. Abdo CT shows colon diameter increased (>6cm). Management?
a) Urgent laparotomy for colectomy
b) IV glucocorticoid
IV glucocorticoid
This is toxic megacolon caused by weak muscle around the inflammed colon.
Tx: IV glucocorticoid for 3/7 –> infliximab or cyclosporine for 3/7 –> surgery (subtotal colectomy)
Diarrhea. Patient looks emaciated. Dx? a) Laxative abuse
b) Gastroenteritis
Laxative abuse
