Gastrointestinal

Question 1

ALARMS Symptoms of Dyspepsia

Answer 1

Anaemia
Loss of weight 
Anorexia
Recent onset
Malaena
Swallowing difficulty

Question 2

A 14 year old male being investigated for iron deficiency anaemia is found to have numerous polyps in his jejunem. On examination he is also noted to have pigmented lesions on his palms and soles. What is the likely diagnosis?

(A) Hereditary non-polyposis colorectal carcinoma
(B) Gardner’s Syndrome
(C) Familial Adenomatous Polyposis
(D) Peutz-Jegher’s Syndrome
(E) Hereditary Haemorrhagic Telangiectasia

Answer 2

(D) Peutz-Jegher’s Syndrome

Hereditary haemorrhagic telangiectasia is associated with mucocutaneus Lesions and iron deficiency anaemia but intestinal polyps are not a feature.

Question 3

A 55 year old man with treatment-resistant gastro-oesophageal reflux disease (GORD) has been referred to the surgeons for fundoplication. Which of the following investigations will be required by the surgeons before the surgery is performed?

(A) Manometry Studies
(B) Laryngoscopy
(C) Neck Ultrasound Scan
(D) Erect Abdominal X-Ray
(E) Blood Cultures

Answer 3

(A) Manometry Studies

Patients with GORD being considered fundoplication surgery require oesophageal pH and manometry studies.

This question is asking for the pre-operative work-up for a patient undergoing a Nissan-fundoplication for treatment-resistant GORD. In this case, the only test listed above that is required is oesophageal manometry. This measures the pressure within the lower oesophageal sphincter and helps to confirm the diagnosis of GORD.

Other required investigations include an endoscopy, barium swallow and pH monitoring.

Question 4

A 35 year old female presents with abdominal pain associated with bloating for the past 6 months. Which one of the following symptoms is least associated with a diagnosis of IBS (Irritable Bowel Syndrome)?

(A) Feeling of Incomplete Stool Evacuation
(B) Weight Loss
(C) Back Pain
(D) Lethargy
(E) Nausea

Answer 4

(B) Weight Loss is not a feature of IBS. Underlying malignancy or inflammatory disease needs to be excluded here.

Question 5

A 35 year old man comes to his GP with questions about his family history of colorectal carcinoma. He says his father, paternal grandmother, and two aunts on his fathers side have been diagnosed with colorectal cancer before the age of 50, and is worried that this may be an inherited condition

Which of the following is the most common cause of inherited colorectal cancer?

(A) BRCA1
(B) Familial Adenomatous Polyposis (FAP)
(C) Gardner's Syndrome
(D) Hereditary nonpolyposis colorectal cancer (HNPCC)
(E) Von Hippel-Linda disease

Answer 5

(D) Hereditady nonpolyposis colorectal cancer (HNPCC)

HNPCC is the most common form of inherited colorectal cancer. It accounts for around 5% of all colorectal cancer cases, and is also strongly associated with endometrial cancer.

BRCA1 gene mutation is mainly associated with breast cancer, and to a lesser degree ovarian cancer.

Familial Adenomatous Polyposis (FAP) is the second most common cause of inherited colorectal cancer. Gardner’s Syndrome is a variant of FAP, often with cutaneous signs.

Von Hippel-Linda disease is a rare autosomal dominant disease that is associated with central nervous system cancers and retinal cancer.

Question 6

A 59 year old smoker presents with a 3 month history of dyspepsia and weight-loss. He denies any vomiting, change in bowel habit or abdominal pain. He is not known to have GORD (Gastro-Oesophageal Reflux Disease).

What is the most appropriate first step in management?

(A) Trial Proton Pump Inhibitor and review in four weeks
(B) Trial Helicobacter Pylori eradication therapy and review in 4 weeks
(C) Upper GI endoscopy
(D) Barium Swallow
(E) CT Thorax-Abdomen

Answer 6

(C) Upper GI Endoscopy

Red flag symptoms for gastric cancer include

• New onset dyspepsia in a patient under 55 years
• Unexplained persistent vomiting
• Unexplained weight loss
• Progressively worsening dysphagia
• Odynophagia
• Epigastric pain

Although a CT Scan would be used to help stage a malignancy should this be the case, the diagnostic test would be an upper GI biopsy. This would be performed as an urgent case. In a younger man you may consider a trial of PPI or testing for H-Pylori if this does not resolve his symptoms. A barium swallow would be indicated if you suspected an oesophageal motility disorder.