Gastrointestinal

Question 1

Intestinal obstruction

Answer 1

Intraluminal - Tumours (colorectal), lymphomas, gallstones
Wall - Crohn’s disease (inflammation), diverticular disease, tumours, Hirschsprung’s disease (dilated loops of bowel)
Extraluminal - Adhesions (previous surgery), volvulus (sigmoid colon twisted on itself), peritoneal tumour

Question 2

Crohn’s disease

Answer 2

Anywhere from mouth to anus 
Inflammatory 
Fibrosis 
Cobblestone mucosa
Chronic

Question 3

Diverticular disease

Answer 3

Sigmoid colon
Inflammation
Diverticulitis can lead to peritonitis
Associated with low fibre diet

Question 4

Hirschsprung’s disease

Answer 4

Dilated colon 
Aganglionic segments (lack of ganglion cells)

Question 5

Volvulus

Answer 5

Sigmoid colon twisted on itself

Question 6

Intestinal obstruction

Answer 6

Mechanical

Paralytic

Question 7

Small bowel obstruction - Pathophysiology of proximal dilation

Answer 7

Increased secretions
More dilation 
Increased pressure 
Signs - Loss of appetite, N/V
Untreated leads to - Ischaemia, necrosis, perforation

Question 8

Large bowel obstruction - Pathophysiology

Answer 8

Similar to small bowel obstruction
Competent iliocaecal valve - Caecum usual site of perforation
Incompetent iliocaecal valve - Vomiting
Colonic vulvulus

Question 9

Intestinal obstruction - Symptoms

Answer 9

Anorexia 
N/V
Distension 
Abdo pain 
Altered bowel habits - Constipation, obstipation

Question 10

Bowel obstruction

Answer 10

Small bowel ob more common than large bowel ob

Question 11

SBO in children - Causes

Answer 11

Appendicitis most common

Question 12

SBO in adults - Causes

Answer 12

Malignancy
Crohn’s
Hernia
Surgery adhesions

Question 13

SBO - Uncommon causes

Answer 13

Diverticulitis

Appendicitis

Question 14

LBO - Causes

Answer 14

Colorectal malignancy, volvulus most common

Question 15

Tumours of the lower gastrointestinal tract

Answer 15

Colorectal adenocarcinoma is most common

Question 16

Colorectal adenocarcinoma - Causes

Answer 16

Familial adenomatous polyposis

Hereditary non-polyposis colorectal cancer (HNPCC)

Question 17

Colorectal cancer - Staging

Answer 17

Resection - R0-R2
Spread - Lymph nodes, liver (portal vein drainage - 1st point of drainage from colon)
Dukes - A-D
pTispN0 (-pT1-3pN1-2)

Question 18

Colorectal adenoma treatment

Answer 18

Adenoma - Endoscopic resection
Colorectal adenocarcinoma Surgical resection
Metastatic CAC - Pallitaive chemo

Question 19

Diarrhoea - Bristol stool chart

Answer 19

Type 1-7
Type 1 is hard lumps
Type 4 is smooth and soft
Type 7 is watery

Question 20

Diarrhoea - Causes

Answer 20

Non infective - Neoplasm, inflammatory, irritable bowel, hormonal, anatomical, radiation, chemical
Infective - Bloody (dystentry), non-bloody

Question 21

Types of transmission

Answer 21

Direct - STIs, scabies, viral gastroenteritis (faeco-oral)
Indirect (vector-borne) - Malaria, dengue
Indirect - HepB
Airborne - TB, legionella

Question 22

Diarrhoea - Causative organisms

Answer 22

Vibrio cholerae 
Escherichia coli 
Norovirus 
Shigella (bloody stools)
Clostrdium difficile 
Campylobacter
Salmonella 
Cryptosporidium

Question 23

Norovirus

Answer 23

Main cause of winter vomitting
Lasts 1-3 days
Causes diarrhoea along with nausea, cramps, headache, fever, chills, myalgia

Question 24

Clostridium difficile

Answer 24

Distributed in soil and digestive tract
Spores resistant to heat, drying and chemicals
Associated with antibiotic use (mostly broad-spec ab)
In hospitalised patients causes diarrhoea and colitis
Spreads by faeco-oral route or through spores in environment
Most symptomatic cases occur in elderly
Cause of most antibiotic-associated diarrhoea

Question 25

C difficile - Prevention

Answer 25

Alcohol hand rubs will not destroy the spores as they are highly resistant to chemicals Hand washing using soap and water will remove the microorganisms (spores) from the hands

Question 26

C difficile - SIGHT

Answer 26

``` S-uspect C diff as cause of diarrhoea I-solate the case G-loves and aprons H-and washing with soap and water T-est stool for toxin ```

Question 27

C difficile - Management

Answer 27

``` Control antibiotic usage Infection control procedures Surveillance Metronidazole /vancomycin Fluids to prevent dehydration Zinc Vaccination ```

Question 28

C difficile - Investigation

Answer 28

Stool sample - Toxins | Culture - test stool sample for strain

Question 29

Diarrhoeal disease in children

Answer 29

Frequent loose/watery stools More than 3 times per day If fluid loss not replaced can lead to death Causatives - Rotavirus, E.coli, shigella, campylobacter, salmonella, cryptosporidium

Question 30

Coeliac disease

Answer 30

Gluten-sensitive enteropathy Chronic autoimmune enteropathy triggered by ingested gluten in genetically susceptible individuals V common condition in europe mostly adults

Question 31

Coeliac disease - Investigations

Answer 31

Endoscopy (Upper GI) and duodenal biopsy Serology - IgA tTG Histology - Villous atrophy Test while on a gluten diet otherwise false results!

Question 32

Coeliac disease - Environment+genetics

Answer 32

Environment - Gluten | Individual - HLA DQ2/DQ8 molecules expressed, tissue transglutaminase

Question 33

Coeliac disease - Pathophysiology

Answer 33

Gluten peptides enter gut lumen IL15 cytokine promotes lymphocyte growth Tissue transglutaminase - Gluten peptides have a high affinity to bind to HLA molecules Tissue transglutaminase then activates CD4 molecules which triggers an immune response

Question 34

Coeliac disease - Presentation

Answer 34

``` Diarrhoea Wt loss Steatorrhoea IBS Dermatitis herpetiformis (blistering of the skin can be watery) ```

Question 35

Dermatitis herpetiformis

Answer 35

Chronic autoimmune blistering skin condition Usually on elbows and knees, also buttocks and scalp Cutaneous manifestation of Coeliac Granular IgA on skin biopsy

Question 36

Coeliac disease - Management

Answer 36

Gluten-free diet - Dietitian review | DEXA scan - Osteoporotic risk

Question 37

Gluten

Answer 37

Protein found in wheat, barley, oats, rye | Used in bread, cake, cereals, wheat flour

Question 38

Coeliac disease - Complications

Answer 38

Osteoporosis | Malignancy

Question 39

Peritoneum - Disease functions

Answer 39

Inflammatory and immune responses Fibrinolytic activity Pain perception

Question 40

Peritonitis

Answer 40

Inflammation of peritoneum

Question 41

Peritonitis - Causes

Answer 41

Bacterial - GI Chemical - bile Trauma - operative Ischeamia - strangulated bowel, vascular occlusion

Question 42

Peritoneal infection

Answer 42

``` GI perforation (ulcer, appendix, diverticulum) Transmural translocation (pancreatitis, ischaemic bowel, primary bacterial peritonitis) Exogenous contamination (drains, open surgery, trauma, peritoneal dialysis) Female genital tract infection - (Inflammatory pelvic disease) Haematogenous spread (septicaemia) ```

Question 43

Localised peritonitis - Presentation

Answer 43

``` Pain N/V Fever Tachy Localised guarding Rebound tenderness ```

Question 44

Generalised peritonitis - Presentation

Answer 44

``` Abdo pain Tenderness Guarding Fever Tachy Distension Absent bowel sounds (due to paralytic ileus) ```

Question 45

Peritonitis - Investigations

Answer 45

Urine dipstick - UTI Bloods - UEs, FBC (WCC), serum amylase Aspirate peritoneal fluid CXR

Question 46

Peritonitis - Management

Answer 46

``` Fluids Urinary catheterisation GI compression Antibiotics Analgesia Excision of perforated organ with/without drainage ```

Question 47

Peritonitis - Special forms

Answer 47

``` Bile peritonitis Spontaneous bacterial peritonitis Primary pneumococcal peritonitis Tuberculosis peritonitis Familial mediterranean fever (periodic peritonitis) ```

Question 48

Ascites

Answer 48

Accumulation of excess serous fluid within the peritoneal cavity Healthy men - no fluid Women - up to 20ml Stage 1-4 (4=large and tense)

Question 49

Ascites - Causes

Answer 49

Cirrhosis Malignancy Pancreatitis Cardiac failure

Question 50

Ascites - Presentation

Answer 50

``` Abdo distension Nausea Loss of appetite Constipation Pain If cause is liver - Jaunice Shifting dullness ```

Question 51

Ascites - Investigation

Answer 51

Underlying cause - LFTs, cardiac function CT Abdo Ascitic aspiration - fluid for microscopy, culture and protein content (amylase)

Question 52

Ascites - Treatment

Answer 52

Diuretics - Spironaloctone | Drainage - Paracentesis

Question 53

Aspirin

Answer 53

``` Enteric coated Inhibits COX2 (prostaglandin synthetase) ```

Question 54

Malabsorption

Answer 54

``` Insufficient intake Defective intraluminal digestion Insufficient absorptive area Lack of digestive enzymes Defective epithelial transport Lymphatic obstruction ```

Question 55

Defective intraluminal digestion

Answer 55

Pancreatic insufficiency - pancreatitis, CF Defective bile secretion (lack of fat solubilisation) - Biliary obstruction Bacterial overgrowth

Question 56

Coeliac disease - histological key features

Answer 56

Villous atrophy | Crypt hyperplasia

Question 57

Lack of digestive enzymes

Answer 57

Lactose intolerance - Disaccharidase deficiency | Bacterial overgrowth - Brush border damage

Question 58

Small intestinal bypass/resection

Answer 58

Crohn's disease | Infarcted small bowel

Question 59

Lymphatic obstruction

Answer 59

Lymphoma | TB

Question 60

Gastritis and gastroduodenal ulcer - Treatment

Answer 60

Aspirin | H2 blocker - Cimetidine