Gastrointestinal Flashcards
1
Q
Define intestinal obstruction
A
Blockage to the lumen of the gut - often refers to blockage of the intra-abdominal part of the intestine
2
Q
How do we classify bowel obstructions
A
- According to site
- Large/Small bowel/Gastric - Extent of luminal obstruction
- Partial/complete - According to mechanism
- Mechanical
- Paralytic - According to pathology
- Simple
- Closed loop
- Strangulation
- Intussusception
3
Q
What percentage of intestinal obstruction occurs in the small bowel
A
60-75%
4
Q
Describe the pathophysiology of small bowel disease
A
Bowel obstruction leads to bowel distension with increased secretion of fluid into the distended bowel leading to proximal dilation above the block
Increased secretion, swallowed air and bacterial fermentation lead to more dilation
5
Q
What are the three results of untreated obstruction in the small bowel
A
Ischaemia
Necrosis
Perforation
6
Q
What percentage of bowel obstructions is due to large bowel obstruction
A
25%
7
Q
What is the pathophysiology of large bowel obstruction
A
Colon proximal to obstruction dilates and increased colonic pressure leads to decreased mesenteric blood flow resulting in mucosal oedema
This causes the arterial blood supply to become compromised leading to necrosis and perforation
8
Q
What happens if the ileocaecal valve is competent in bowel obstruction
A
Caecum dilates and patient won’t feel unwell but will have massive distension
9
Q
What happens if the ileocaecal valve is incompetent in bowel obstruction
A
Faeculent vomiting
10
Q
What are the three different types of bowel obstruction
A
Intaluminal - something in the bowel
Intramural = something in the wall of the bowel
Extraluminal = something outside the bowel
11
Q
What are the causes of intraluminal obstruction
A
Tumour
- Carcinoma and lymphoma
Diaphragm disease
- Fibrous fold in lumen
Meconium Ileus
- Content of neonate bowel becomes sticky
Gallstone Ileus
- Stone gets stuck in small bowel by eroding through gall bladder
12
Q
Diaphragm disease is associated with what
A
NSAIDs
13
Q
What are the causes of intramural obstruction
A
- Inflammatory disease
- Crohn’s/diverticulitis/ulcerative colitis - Tumours in bowel wall
- Hirschsprung’s disease
14
Q
What is Crohn’s disease
A
Fibrosis of the bowel wall producing a cobblestone mucosa and granulomas
15
Q
What is the pathophysiology of diverticular disease
A
Inflammation an fibrosis in the sigmoid colon - In low fibre diet mucosa is pushed through gaps in the muscular wall of the bowel due to increased pressure resulting in diverticulae
These act as cul de sacs where faeces can remain and become inflamed and rupture causing faecal peritonitis
16
Q
What is Hirschsprung’s disease
A
Aganglionic segment of the bowel where there is no nerves meaning the bowel doesn’t contract leading to distal distension
17
Q
What are the causes of extraluminal obstruction
A
Adhesions
Volvus
Intussusception
Peritoneal tumour
18
Q
What is an adhesion
A
Fibrous band that sticks two bits of bowel together and the bowel is pulled and distorted
Normally seen post abdominal surgery
19
Q
What is Volvulus
A
Bowel twisting around each other which cuts off blood supply = closed loop obstruction
20
Q
What is intussusception
A
One part of intestine telescopes inside another
21
Q
Where does a peritoneal tumour normally originate from
A
Ovarian cancer which spreads onto the peritoneum
22
Q
What ares of the bowel of most likely to be affected with Volvos
A
Areas of the bowel with a mesentery ie. sigmoid colon
23
Q
What are the causes of small bowel obstruction in adults
A
- Adhesions
- Hernia
- Crohns
- Malignancy
24
Q
What are the causes of small bowel obstruction in children
A
Appendicitis Intesussception Volvus Atresia Hypertrophic pyloric stenosis
25
What are the two types of intesussuption
Idiopathic
| Enteroenteral Intersussception
26
What is enteroenteral intersussception associated with
Cystic fibrosis
27
What are the uncommon causes of a small bowel obstruction
```
Radiation
Gallstones
Diverticulitis and Appendicitis
Sealed small perforation
Foreign bodies (Bezoars)
```
28
What are the symptoms of small bowel obstruction
1. Early feculent projectile vomit
2. Diffuse colicky pain
3. Late constipation
4. Distension
5. Tenderness
29
What investigations might you do in someone who you suspect to have a small bowel obstruction?
Take a good history - ask about previous surgery (adhesions)!
2. FBC, U+E, lactate.
3. X-ray.
4. CT, ultrasound, MRI.
30
What is the management/treatment for small bowel obstruction?
1. Fluid resuscitation.
2. Bowel decompression.
3. Analgesia and anti-emetics.
4. Antibiotics.
5. Surgery e.g. laparotomy, bypass segment, resection
31
What are the causes of large bowel obstruction
1. Age and race dependent
- Colorectal malignancy
- Volvulus
- Ischaemic structures
- hernia
2. Paediatric
- Imperforate anus
- Hirschsprung disease
32
What are the symptoms of large bowel obstruction
```
Abdominal discomfort
Fullness
Bloating
Distension
Late vomiting
Colicky pain
Obstipation
Volvulus
Sudden pain
Localised tenderness
```
33
What investigations might you do in someone who you suspect to have a large bowel obstruction?
1. Digital rectal examination.
2. Sigmoidoscopy.
3. Plain X-ray.
4. CT scan.
34
Describe the management for a large bowel obstruction.
1. Fast the patient.
2. Supplement O2.
3. IV fluids to replace losses and correct electrolyte imbalance.
4. Urinary catheterisation to monitor urine output.
35
Describe the progression from normal epithelium to colorectal cancer.
1. Normal epithelium.
2. Adenoma.
3. Colorectal adenocarcinoma.
4. Metastatic colorectal adenocarcinoma.
36
Define adenocarcinoma
A malignant tumour of glandular epithelium.
37
What is familial adenomatous polyposis?
Familial adenomatous polyposis is a genetic condition where you develop thousands of polyps in your teens.
38
Describe the pathophysiology of familial adenomatous polyposis.
There is a mutation in apc protein and so the apc/GSK complex isn't formed -> beta catenin cannot be broken down so levels increase -> up-regulation of adenomatous epithelium gene transcription --> Adenoma forms
39
Describe the pathophysiology of Hereditary Non-Polyposis Colorectal Cancer.
There are no DNA repair proteins meaning there is a risk of colon cancer and endometrial cancers.
40
What are the implications of hereditary non-polyposis colorectal cancer
Cant use DNA damaging chemo as lack of DNA repair gene means DNA damage cant be recognised so apoptosis not activated
41
Where is the most common location for colorectal cancer
Sigmoid colon/rectum
42
How can adenoma formation be prevented?
NSAIDS are believed to prevent adenoma formation
43
What is the treatment for adenoma?
Endoscopic resection.
44
What is the treatment for colorectal adenocarcinoma?
Surgical resection can be done when there is no spread. Remember to balance risks v benefits. The patient has a pre-op assessment.
45
What is the treatment for metastatic colorectal adenocarcinoma?
Chemotherapy and palliative care
46
Give 3 reasons why bowel cancer survival has increased over recent years.
1. Introduction of the bowel cancer screening programme.
2. Colonoscopic techniques.
3. Improvements in treatment options.
47
Give 5 risk factors for colorectal cancer.
1. Low fibre diet.
2. Diet high in red meat.
3. Alcohol.
4. Smoking.
5. A PMH of adenoma or ulcerative colitis.
6. A family history of colorectal cancer; FAP or HNPCC
48
What are the symptoms of a left sided sigmoid cancer
rectal bleeding, altered bowel habit/obstruction, colicky pain
49
What are the symptoms of a right sided sigmoid cancer
iron deficiency anaemia, R iliac fossa mass, weight loss
50
What investigations might you do in someone who you suspect might have colorectal cancer?
Colonoscopy = gold standard!
It permits biopsy and removal of small polyps.
- Tumour markers are good for monitoring progress.
- Faecal occult blood is used in screening but not diagnosis.
51
Describe the coding system for resection of tumours
```
R0 = tumour completely excised locally
R1 = Microscopic involvement of margin by tumour
R2 = Macroscopic involvement of margin by tumour
```
52
Describe the staging system for cancer
* T – T1 (invades submucosa) -> T2 (muscularis propria) -> T3 (bowel wall) -> T4 (peritoneum)
* N – N1 (spread to lymph nodes) -> N2 (spread to lymph nodes above diaphragm)
* M – M1 = surrounding structure involvement (liver)
53
What are the non-infectious causes of diarrhoea
```
hormonal
Radiation
Chemical
Anatomical
Irritable bowel
Inflammatory
Neoplasm
```
54
Name some causative agents of diarrhoea
```
Rotavirus
Shigella
E.coli
Salmonella type
Salmonella paratyphoid
Hepatitis A
Hepatitis E
Vibrio cholerae
```
55
Define gastroenteritis
Diarrhoea +/- vomiting due to an enteric infection
56
Define acute diarrhoea
3+ episodes of partially formed watery stools for <14 days
57
Define dysentery
Infectious diarrhoea and blood
58
Define travellers diarrhoea
Gastroenteritis occurring under 2 weeks after entering a new country
59
What is the pathogenesis of norovirus
Single strand RNA
60
What are the symptoms of norovirus
Vomiting
Watery diarrhoea
Cramps
Nausea
61
What is the treatment for norovirus
Self limiting disease
| Supportive with loperamide
62
What Id the pathophysiology of rotavirus
Double stranded DNA
63
What are the symptoms of rotavirus
2-day incubation --> 3-8 day symptoms
Watery diarrhoea
Vomiting
fever
Abdominal pain
64
What is the management of rotavirus
Prevention through vaccination
65
ETEC is the most common cause of what
Traveller's Diarrhoea
66
What is the pathophysiology of ETEC
Gram -ve bacillus anaerobe that is heat stable toxin
67
What are the symptoms of ETEC
1-3 day incubation with 3-4 days symptoms
| Watery diarrhoea and cramps
68
What is the management of ETEC
Rehydration
| Anti-motility agents (Loperamide)
69
What is the pathophysiology of clostridium perfringens
Gram +ve anaerobe which produces enterotoxins
Spores survive cooking and multiply in unrefrigerated storage
70
What are the symptoms of clostridium perfringens
sudden onset diarrhoea and cramps normally for 24hr
71
What is the management of clostridium perfringens
Supportive
72
What is the pathophysiology of vibrio cholerae
Gram -ve flagellated aerobe vibrio transmitted by faecally contaminated water
Servers 01 and 0139 are pathogenic
73
What are the symptoms of vibrio cholerae
```
2-5 days incubation
Rice water stools
Vomiting
Dehydration
Circulatory collapse = death
```
74
What is the management of vibrio cholerae
Prevention through clean water and vaccination
Treatment with oral rehydration salts/IV rehydration and antibiotics
75
What is the pathophysiology of shigella
Gram -ve
76
What are the symptoms of shigella
```
1-2 days incubation and 5-7 day symptoms
Watery/bloody diarrhoea
Pain
Cramping rectal pain
Fever
```
77
What is the management of shigella
Supportive
Zinc for children
Antibiotics (Ciprofloxacin and azithromycin)
78
What is the pathophysiology of campylobacter jejuni
Gram -ve bacillus - very common in meat and milk
79
What are the symptoms of campylobacter jejuni
```
2-5 day incubation
Bloody diarrhoea
Pain
Fever
Headache
```
80
What is the management of campylobacter jejuni
Supportive - antibiotics if invasive (Macrolide and doxycycline)
81
What is the pathophysiology of salmonella enterocolitis
gram -ve anaerobic bacilli
82
What are the symptoms of salmonella enterocolitis
```
12-36hr exposure
Bloody diarrhoea
Crampls
Fever
Invasive infection = sepsis, meningitis, osteomyelitis
```
83
What is the management of salmonella enterocolitis
Supportive - antibiotics for invasive infection (Quinolone and macrolide)
84
What is the pathophysiology of clostridium difficile
Gram +ve aerobic bacilli that produces enterotoxin A and B
Antibiotic use destroys the competing flora so there is less inhibition of C.diff
Spread by the faeco-oral route
85
Symptoms of clostridium difficile
Watery diarrhoea
| Fulminant colitis
86
How would you investigate someone thought to have C.diff
Test stool samples for toxins
| Tissue samples obtained at sigmoidoscopy
87
What antibiotics can cause C.diff
Clindamycin
Ciprofloxacin
Co-amoxiclav
Cephalosporins
88
What is the treatment for C.diff
Metronidazole
| Vancomycin
89
Name some other causes of gastroenteritis
Protozoa (Giardia, cryptosporidium)
Helminths (Schistosome, strongyloide)
90
How can we prevent diarrhoea
1. Rotavirus and measles vaccination
2. Promote early breastfeeding
3. Promote hand washing with soap
4. Improve water supply quantity and quality
5. Community wide sanitation promotion
91
What groups are most at risk of diarrhoea
1. Persons of doubtful hygiene or unsatisfactory hygiene at home, work or school
2. Children who attend pre-school or nursery
3. People who work in preparing or serving unwrapped/uncooked food
4. Health care workers or social care staff working with vulnerable people
92
What is a notifiable disease
Diseases, infections and conditions specifically listed as notifiable under public health
93
Name some examples of notifiable diseases
```
Anthrax
Cholera
Plague
Rabies
SARS
Smallpox
Yellow fever
Leprosy
Malaria
Botulism
```
94
Name some examples of vaccine preventable diseases
```
Diptheria
Measles
Mumps
Rubella
Tetanus
Whooping cough
Acute meningitis
Meningococcal septicaemia
```
95
What diseases need specific control measures
```
Acute infectious hepatitis
Foodborne
- food poisoning
- botulism
- Enteric fever
- infectious blood diarrhoea
Scarlet fever
Tuberculosis
```
96
What are some diseases notifiable
Very dangerous
Vaccine preventable
Diseases that need specific control measures
97
What is the role of surveillance in notifiable diseases
Detection of any changes in disease
- Outbreak detection
- Early warning
- Forecasting
Track changes in disease
- Extent and severity of disease
- Risk factors
98
How do you protect a community from notifiable disease
Investigate - control tracing, partner notification, lookback exercises
Identify and protect vulnerable people
(Chemoprophylaxis, immunisation and isolation)
Exclude high risk persons from high risk settings
Educate, inform, raise awarnesss and promote health
Coordinate multi-agency responses
99
What are the steps that must be taken when notifying about a disease
1. Notification
- all suspected cases without delay
2. Contact tracing
- Any person with close contact in past 7 days
3. Prophylaxis
- Advice (warn about symptoms and glass spot tests)
- Antibiotics chemoprophylaxis (Close contacts, ciprofloxacin and rifampicin)
- Immunisation (If available serogroup)
100
What are the two forms of active immunity
Cell mediated immunity
| Antibody mediated immunity
101
What is passive immunity
Protection provided from the transfer of antibodies from immune individuals
102
What is the most common form of passive immunity
Cross placental transfer of antibodies from mother to child or via transfusion of blood or blood products
Protection is temporary
103
Describe passive immunisation through the use of human normal immunoglobulin
Increases the persons antibody level to that specific infection providing protection
From plasma donors and contains antibodies to infectious disease currently prevalent
104
When is human normal immunoglobulin used
```
Immunocompromised children
Tetanus
Hepatitis B
Rabies
Varicella Zoster
```
105
What is an active immunisation
Vaccination stimulates immune response and memory to a specific antigen/infection
106
What are vaccines made from
inactivated (Killed) (Pertussis, inactivated polio)
Attenuated live organisms (yellow fever, MMR, polio and BCG)
Secreted products (Tetanus, diphtheria toxoids)
Constituents of cell walls (HepB) or recombinant components (Experimental)
107
Define vaccine failure
Small proportion of individuals get infected despite vaccination
108
Define primary vaccine failure
Persons doesn't develop immunity from vaccine
109
Define secondary vaccine failure
Initially responds but protection wanes overtimes
110
What are the two presentations of meningococcal infection
Meningitis
| Septicaemia
111
Meningococcal infection is caused by what
Neisseria meningitidis
| Serogroups B, C, A, Y and W135
112
How is meningococcal infection spread
Person to person by inhaling respiratory secretions from mouth and throat or by direct contact (kissing)
113
What can meningococcal infection cause
```
Brain abscess
Brain damage
Seizure disorder
Hearing impairment
Focal neurological disorders
Organ failure
Gangrene
Auto-amputation
Death
```
114
What is the management of meningococcal infection
Antibiotic therapy: Cefotaxime and ceftriaxone
| Supportive therapy
115
What are the routine childhood immunisations
Meningitis C vaccine
meningitis B vaccine
Quadrivalent (A, C, W135, Y)
116
What immunisations are given the eight week baby check
Diptheria, tetanus, pertussis, polio, heaemophilus influenza type B
Pneumococcal
Meningococcal group B
Rotavirus gastroenteritis
117
What can helicobacter pylori infection cause?
H.pylori produces urease -> ammonia -> damage to gastric mucosa -> neutrophil recruitment and inflammation. This can cause gastritis; peptic ulcer disease and gastric cancer.
118
Describe h.pylori.
A gram negative bacilli with a flagellum.
119
Describe the treatment for H.pylori infection.
Triple therapy: 2 antibiotics and 1 PPI e.g. omeprazole, clarithromyocin and amoxicillin.
120
Define hernia
Abnormal protrusion of an organ into a body cavity
121
Give 2 symptoms of a hernia
Pain
| Palpable lump
122
Define irritable bowel syndrome
Disorders of enhanced visceral perception - bowel symptoms for which no organic cause can be found
123
What are the causes of IBS
```
Unknown
Stress
Food
Gastroenteritis or menstruation
Depression/Anxiety
Psychosocial stress and trauma
GI infection
Sexual, physical or verbal abuse
```
124
Describe the multi-factorial pathophysiology of IBS.
The following factors can all contribute to IBS:
- Psychological morbidity e.g. trauma in early life.
- Abnormal gut motility.
- Genetics.
- Altered gut signalling (visceral hypersensitivity).
125
Describe the epidemology of IBS
More common in women
| Age of onset <40
126
When should you consider IBS as a diagnosis (Think ABC)
If patients reports
1. Abdominal pain or discomfort
2. Bloating
3. Change in bowel habit
127
Give 3 symptoms of IBS.
1. ABDOMINAL PAIN!
2. Pain is relieved on defecation.
3. Bloating.
4. Change in bowel habit.
5. Mucus.
6. Fatigue.
128
What is the diagnostic criteria for IBS
ROME criteria
Abdominal discomfort/pain for > 12 weeks which has 2 of the following
- Relieved by defecation
- Change in stool frequency
- Change in stool form (Pellets, mucus)
+ 2 of
- Urgency
- Incomplete evacuation
- Abdominal bloating/distension
- Mucous pro rectum
- Worsening symptoms after food
129
What are the exclusion criteria for IBS
```
>40yrs
Bloody stool
Anorexia
Wt loss
Diarrhoea at night
```
130
Give an example of a differential diagnosis for IBS.
1. Coeliac disease.
2. Lactose intolerance.
3. Bile acid malabsorption.
4. IBD.
5. Colorectal cancer.
131
What investigations might you do in someone with IBS
1. Bloods - FBC, U+E and LFT
2. Coeliac serology
3. CRP
4. Colonoscopy if >60 years
132
What are the treatments for mild IBS
```
Education
Reassurance
Dietary modification
- Decreased processed food
- Low FODMAP diet
- Regular small meals
- Plenty of fluids
- Avoid caffeine, alcohol + fizzy drinks
```
133
What are the pharmacotherapy options for IBS
Laxatives (Mavicol) for constipation
Loperamide (Anti-motility) for diarrhoea
Antispasmodics (Mebeverine/buscopan) for colic/bloating
CBT and amitriptyline
134
What are the treatment options for severe IBS
MDT approach and amitriptyline
135
What are the non-intestinal symptoms of IBS
Painful period
Urinary frequency
Back pain
Fatigue
136
Define dyspepsia
An inexact term used to describe a number of abdominal symptoms
137
What is the criteria for dyspepsia
>1 of the following
- Post prandial fullness
- Early satiation
- Epigastric pain/burning
138
What are the symptoms of dyspepsia
```
Epigastric pain
Bloating
Heartburn
Acidity
Nocturnal cough
Hoarse voice
Fullness
```
139
Give 5 causes of dyspepsia
```
GORD
Gastritis
Peptic ulcer disease
Excess acid
Prolonged NSAIDs
Large volume meals
Obesity
Smoking/alcohol
Pregnancy
Oesophageal or stomach cancer
non ulcer dyspepsia
```
140
Give 5 red flag symptoms that you might detect when taking a history from someone with dyspepsia.
```
Anaemia
Loss of wt
Anorexia
Recent onset progressive symptoms
Melaena or haematemesis
Swallowing difficulty
```
141
What investigations might you do in someone with dyspepsia
Endoscopy
Gastroscopy
Barium swallow
Capsule endoscopy
142
What is the management for dyspepsia if the red flag criteria has been met?
1. Suspend NSAID use and review medication.
2. Endoscopy.
3. Refer malignancy to specialist.
143
What is the management for dyspepsia without red flag symptoms?
1. Review medication.
2. Lifestyle advice.
3. Full dose PPI for 1 month.
4. Test and treat h.pylori infection.
144
What kind of lifestyle advice might you give to someone with dyspepsia?
1. Lose weight.
2. Stop smoking.
3. Cut down alcohol.
4. Dietary modification.
5. Stop NSAIDs
6. Avoid hot drinks
145
Define GORD
Exists when reflux of stomach contents causes troublesome symptoms - 2 or more heartburn episodes a week with or without complications
146
What is the pathophysiology of GORD
Lower oesophageal sphincter dysfunction leads to reflux of gastric contents and oesophagitis --> Prolonged exposure leads to Barret's oesophagus
147
What are the causes of GORD
1. Reduced lower oesophageal sphincter tone
2. Hiatus hernia
3. increased mucosal sensitivity to gastric acid and reduced oesophageal acid clearance
4. Gastric acid hypersecretion
5. Alcohol
6. Delayed gastric emptying an prolonged post prandial
148
What are the risk factors of GORD
```
Hiatus hernia
Smoking
EtOH
Obesity
Pregnancy
Drugs
Large meals
```
149
What are the oesophageal symptoms of GORD
Heartburn
- Related to meals
- Worse lying down/stooping
- Relieved by antacids
- Worse with hot drinks and alcohol
```
Belching
Acid regurgitation (Acid brash)
Increased salivation (Water brash)
Odonophagia (Pain swallowing)
```
150
What are the extra-oesophageal symptoms of GORD
Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis
151
What are the complications of GORD
```
Oesophagitis = heartburn
Ulceration - haematemesis
Benign stricture = dysphagia
Barrett's oesophagus
Oesophageal adenocarcinoma
```
152
What Is the pathophysiology of Barrett's oesophagus
Intestinal metaplasia of squamous epithelium to columnar epithelium leading to dysplasia and adenocarcinoma
153
What is the differential diagnosis of GORD
```
Oesophagitis
PUD
Oesophageal cancer
NSAIDs
Herpes
```
154
What are the investigations for someone with GORD
Endoscopy if
- >55yrs
- symptoms >4 weeks
- Dysphagia
- Wt loss
Bloods - FBC
CXR - may show hiatus hernia
Barium swallow
155
What are the conservative measures for treatment of GORD
```
Lose Wt
Small regular meals
Avoid eating within 3 hours of bed
Stop smoking
Decrease alcohol
Avoid hot drinks and spicy food
Stop drug (NSAIDs, Steroids
```
156
What is the medical management of GORD
Antacids (gaviscon)
1. Full dose proton pump inhibitor (Lansoprazole)
2. No response then double lansoprazole dose
3. No response then add a H2 receptor antagonist such as Ranitidine
4. Surgery - Nissen Fundoplication
157
When is the Nissen fundoplication procedure indicated in the treatment of GORD
All three of
Severe symptoms
Refractory t medical therapy
Confirmed reflux
158
What is the aim of the Nissen fundoplication procedure
Aims to laparoscopically increase resting lower oesophageal sphincter pressure to prevent reflux
159
What are the 2 types of hiatus hernia
Sliding (80%)
| Rolling (15%)
160
What is a sliding hiatus hernia
When the gastro-oesophageal junction slides up into the chest to lie above the diaphragm
161
What is a rolling hiatus hernia
Gastro-oesophageal junction remains in abdomen but a bulge of stomach rolls into chest alongside the oesophagus
162
What investigations would you carry out in someone with suspected hiatus hernia
CXR - gas bubble and fluid level in chest
Ba swallow
OGD
163
What is the treatment for hiatus hernia
Lose Wt
Treat the reflux
Surgery
164
Smoking is protective in ulcerative colitis or Crohns
Ulcerative colitis
165
Smoking is damaging in ulcerative colitis or Crohns
Crohns
166
What age does ulcerative colitis present
30's
167
What age does crohn's disease present
20's
168
Where is ulcerative colitis found
In the rectum up to the colon but no further
169
Where is crohn's disease found
From the mouth to the anus and especially in the terminal ileum
170
Describe the distribution of ulcerative colitis
Continguous
171
Describe the distribution of crohns
Skip lesions
172
Do you get strictures in ulcerative colitis
No
173
Do you get skip lesions in crohn;s disease
Yes
174
Where dies the inflammation occur in ulcerative colitis
Mucosal - mainly in crypts leading to abscesses
175
Where does the inflammation occur in crohn's
Transmural
176
Describe the ulcers found in ulcerative colitis
Shallow and broad
177
Describe the ulcers found in Crohn's disease
Deep, thin producing a cobblestone mucosa
178
Are there granulomas in ulcerative colitis
No
179
Are there granulomas in crohns
yes
180
Do you get fistulas in ulcerative colitis
No
181
Do you gt fistulas in crohns
Yes
182
What are the systemic symptoms of ulcerative colitis and crohns
Fever
Malaise
Anorexia
Weight loss
183
What are the abdominal symptoms in ulcerative colitis
diarrhoea
Blood and mucus
Abdominal discomfort
Faecal urgency
184
What are the abdominal symptoms in Crohn's
Diarrhoea (Not bloody)
abdominal pain
Weight losss
Failure to thrive
185
What are the extra-abdominal symptoms of ulcerative colitis and Crohns
Skin
- Clubbing
- erythema nodosum
- Pyoderma gangrene
Eyes
- Iritis
- Conjunctivitis
- Uveitis
Joints
- Arthritis
- Ankylosing Spondylitis
HPB
- PSC nd cholangiocarcinoma
- Gallstones
- Fatty liver
Other
- Amyloidosis
186
What are the complications of ulcerative colitis
Toxic megacolon leading to blood loss, colorectal cancer, cholangiocarcinoma and toxic dilatation
187
What are the complications of crohns disease
```
Fistulae
Strictures leading to obstruction
Abscesses
Malabsorption
Toxic Megacolon
```
188
What are the risk factors for ulcerative colitis
Family history
NSAIDs
Chronic stress and depression
189
What investigations would you carry out in someone with ulcerative colitis
Bloods
- FBC shows low HBC and Increased WCC
- Increased CPR/ESR
- Blood cultures
Stools
- Exclude campy, shigella and salmonella
Imaging
- AXA - megacolon
- CXR - perforation
- CT
- Ba enema
190
What is the management of ulcerative colitis
1st line = aminosalicylitate acid (Mesalazine/sulfalazine)
2nd line = Prednisolone
Additional therapies are steroid sparring (Azathioprine and mercaptopurine)
Infliximab and adalimumab
Surgery
191
What is the management for maintaining remission in ulcerative colitis
1st line = 5-ASA's
2nd line = Azathioprine and 6-mercaptourine
3rd line = Infliximab
192
What is the pneumonic for ulcerative colitis (CLOSEUP)
```
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicyates
Primary sclerosing cholangitis
```
193
What is the surgical management of ulcerative colitis and when is it indicated
Surgery indicated when there is toxic megacolon, perforation and haemorrhage or failure to respond to medicine
- Total/subtotal colectomy
194
What are the risk factors for Crohn's
```
Genetic association with mutations in NOD2 gene on chromosome 16
Smoking
NSAIDs exacerbate
Family history
Chronic stresss
```
195
What is the oral therapy for crohns
1. Illeocaecal = budesonide
2. prednisolone
3. Methotrexate
4. Infliximab
196
What is the supportive therapy for Crohns
High fibre diet
Vitamin supplementation
Smoking cessation
197
What is the management for maintaining remission of Crohns
1st Azathioprine
2nd methotrexate
3rd Infliximab
198
What is the pneumonic for Crhons
NESTs
```
No blood/mucus
Entire GIT
Skip lesions on endoscopy
Terminal ileum most affected and transmural
Smoking is a risk factor
```
199
Give 5 broad causes of malabsorption.
1. Defective intra-luminal digestion.
2. Insufficient absorptive area.
3. Lack of digestive enzymes.
4. Defective epithelial transport.
5. Lymphatic obstruction.
200
What are the causes of defective intraluminal digestion
1. Pancreatic insufficiency due to pancreatitis or CF. There is a lack of digestive enzymes.
2. Defective bile secretion due to biliary obstruction (gallstone) or ileal resection.
3. Bacterial overgrowth.
201
Why can pancreatitis cause malabsorption?
Pancreatitis results in pancreatic insufficiency and so a lack of pancreatic digestive enzymes. There is defective intra-luminal digestion which leads to malabsorption.
202
What can cause insufficient absorptive area
1. Coeliac (Villous atrophy and crypt hyperplasia)
2. Crohn's - inflammatory damage = cobblestone mucosa
3. Extensive surface parasitation = Giardia lambda which coat villli so no absorbing
4. Small intestinal resection or bypass = procedure for morbid obesity/crohns and infarcted small bowel
203
What can cause a lack of digesitive enzymes
Lactose intolerance - undigested lactose passes to the colon where it is eaten by bacteria and Co2 is released as wind and diarrhoea
Bacterial overgrowth
204
What can cause defective epithelial transport
Abetalipoproteinaemia - deficient lipoprotein transporter
Primary bile acid malabsorption - mutations in bile acid transporter protein
205
What can cause lymphatic obstruction
Lymphoma
| TB
206
Define malabsorption
Failure to fully absorb nutrients because of epithelial destruction due to problem in the lumen meaning food cannot be digested
207
What is the presentation of malabsorption
Diarrhoea/Steatorrhea
Wt loss despite normal calorie intake
lethargy
Anaemia despite normal diet
208
What investigations would you carry out in someone with malabsorption
Coeliac tests
Stool microscopy
MRI/CT
Small bowel endoscopy
209
Define coeliac disease
Common autoimmune condition characterised by heightened immunological response to ingested gluten
210
What is the epidemiology of coeliac
Bimodal from infancy to 50-60 years
F>M
increased in Ireland and N.africa
211
Describe the pathophysiology of coeliac disease
1. Gliadin from gluten deaminated by tissue transglutaminase leading to increased immunogenicity
2. Gliadin recognised by HLA-DQ2 receptor on antigen presenting cells = inflammatory response
3. Plasma cells produce anti-gliadin leading to T cell cytokine activation
4. Consequences = villous atrophy an crypt hyperplasia = malabsorption
212
What is the presentation of coeliac disease
```
Fatigue and weakness
Carbs
- Nausea, vomiting, diarehoea
- Abdo distension + colic
- Flatus
- Wt loss
FAT
- Steatorrhoea
- Hyperoxaluria
Protein
- Protein losing enteropathy
Haematinics
- Loss of folate and Fe = anaemia
Lymphoma and carcinoma
Dermatitis Hepetiformis
```
213
What are the dermatological presentations of coeliac
Dermatitis herpetiformis - symmetrical vesicles especially on the elbows which are very itchy
214
What investigations would you carry out in someone with coeliac
```
FBC, LFTs, INR
Antibodies
Anti TTG IgA
Anti Endomysial IgA
Anti gliardin IgG
Stools - exclude giardia
OGD and duodenal biopsy
- Crypt hyperplasia
- villous atrophy
intra-epithelial lymphocytes
```
215
What antibodies would you see in someone with coeliac
Anti-endomysial IgA
Anti tissue transglutaminase IgA
Anti-gliadin IgG
216
What would a duodenal biopsy show n coeliac disease
Subtotal villous atrophy
Crypt hyperplasia
Intra-epithelial lymphocytes
217
What is the management of coeliac disease
Life long gluten free diet and Dapsone for the dermatitis herpetiformis
218
What are the complications of coeliac disease
Osteoporosis
| Increased risk of gastrointestinal tumour
219
Describe the pathophysiology of appendicitis
Inflammation of the vermiform appendix secondary to a faecolith obstruction with bacterial overgrowth
if the appendix ruptures then infected faecal matter will enter the peritoneum and resulting in peritonitis
220
What are the causes appendicitis
Faecolith
Lymphoid hyperplasia
Worms
221
What is the epidemiology of appendicitis
10-20 years old
222
What are the symptoms of appendicitis
Umbilical pain that moves to the right iliac fossa, nausea, constipation and anorexia
223
What are the signs of appendicitis
Tenderness with guarding and rebound
Percussion tenderness
Tachycardia
224
What are the investigations in someone with appendicitis
Inflammatory markers (ESR, CRP, WCC)
CT is diagnostic
225
What is the management of appendicitis
Surgical appendectomy
| Antibiotics
226
What are the complications of appendicitis
Ruptured appendix - faecal matter in the peritoneal cavity leading to peritonitis
227
Define gastritis
Inflammation of the gastric mucosa
228
What are the 5 things that ca break down the mucin layer in the stomach and cause gastritis
1. mucosal Ischaemia due to atherosclerosis
2. Increased stomach acid (Stress)
3. Bile reflux
4. Alcohol
5. Aspirin and NSAIDs
6. Helicobacter pylori
229
Why is helicobacter pylori irritant to the gastric mucosa
Secrete urease which splits urea into CO2 and ammonia
Ammonia combines to H+ to form ammonium which is toxic to the gastric mucosa resulting in reduced mucus production
230
What are the symptoms of gastritis
```
Can be asymptomatic
Epigastric pain and vomiting
Anorexia
Weight loss
Indigestion
Abdominal bloating
```
231
What are the red flag symptoms for gastric cancer
```
Unexplained weight loss
anaemia
Evidence of GI bleed or haematemesis
Dysphagia
Upper abdominal mass
Persistent vomiting
```
232
What are the investigations for gastritis
Endoscopy, biopsy and blood tests
233
What are the investigations for someone with H.pylori
Serology - Detect IgG antibodies
C-urea breath test - measures CO2 in breath after ingestion of C-urea
Stool antigen test - immunoassay using monoclonal antibodies for detection of H.pylori
234
What is the management of gastritis
Decrease alcohol and smoking and irritating foods
Stop NSAIDs
Ant-acids (Magnesium carbonate) or PPI (Omeprazole or H2 receptor blocker (Nizatidine)
235
What is the anti-h.pylori treatment
Triple therapy of 2 antibiotics and a proton pump inhibitor
Amoxicillin, omeprazole and clarithomycin
236
Wha are the complications of gastritis
Peptic/duodenal ulcer
237
Define oesophago-gastric varices
Varices are a dilated vein which risk ruptures resulting in haemorrhage which can result in a GI bleed (occurs when pressure exceeds 12mmHg)
238
What are the causes of oesophagi-gastric varices
Alcoholism and viral cirrhosis
Portal hypertension
1. Pre-hepatic
- Thrombosis in portal or splenic vein
2. Intra-hepatic
- Cirrhosis
- Schistosomiasis
- Sarcoid
- Congenital hepatic fibrosis
3. Post hepatic
- Budd chiari (Hepatic vein obstruction by tumour or thrombosis)
- Right heart failure
- Constrictive pericarditis
239
What is the clinical presentation of oesophagi-gastric varices
If ruptured
- haematemesis
- Abdominal pain
- Shock
- Fresh rectal bleeding
- Pallor
240
What is the treatment of oesophago-gastric varices
IV terlipressen to cause vasoconstriction
Variceal banding
Balloon tamponade
241
What disorders might be associated with coeliac disease
```
Other autoimmune disorders:
1. T1 diabetes.
2. Thyroxoicosis.
3. Hypothyroidism.
4. Addisons disease.
Osteoporosis is also commonly seen in people with coeliac disease.
```
242
What cells normally line the oesophagus?
Stratified squamous non-keratinising cells.
243
What is Barrett's oesophagus?
When squamous cells undergo metaplastic changes and become columnar cells.
244
What can cause Barrett's oesophagus?
1. GORD.
2. Obesity.
3. Hiatus hernia
4. Smoking
245
Give a potential consequence of Barrett's oesophagus.
Adenocarcinoma.
| Squamous cell carcinoma
246
Describe how Barrett's oesophagus can lead to oesophageal adenocarcinoma.
1. GORD damages normal oesophageal squamous cells.
2. Glandular columnar epithelial cells replace squamous cells (metaplasia).
3. Continuing reflux leads to dysplastic oesophageal glandular epithelium.
4. Continuing reflux leads to neoplastic oesophageal glandular epithelium - adenocarcinoma.
247
What are the causes of squamous cell carcinoma int the oesophagus
Smoking
Alcohol
Nitrous amines
248
Give 5 symptoms of oesophageal carcinoma.
1. Dysphagia.
2. Odynophagia (painful swallowing).
People often present very late.
3. Vomiting.
4. Weight loss.
5. Anaemia.
6. GI bleed
7. Reflux
249
Give 3 causes of gastric cancer.
1. Smoked foods.
2. Pickles.
3. H.pylori infection.
4. Pernicious anaemia.
250
Describe how gastric cancer can develop from normal gastric mucosa.
Smoked/pickled food diet leads to intestinal metaplasia of the normal gastric mucosa. Several genetic changes lead to dysplasia and then eventually intra-mucosal and invasive carcinoma.
251
What investigations might you do in someone who you suspect to have oesophageal carcinoma?
. Barium swallow.
2. Endoscopy.
CT/MRI for staging
252
Describe the 2 treatment options for oesophageal cancer.
1. Medically fit and no metastases = operate. The oesophagus is replaced with stomach or sometimes the colon. The patient often has 2/3 rounds of chemo before surgery.
2. Medically unfit and metastases = palliative care. Stents can help with dysphagia.
253
Give 3 signs of gastric cancer.
1. Weight loss.
2. Anaemia.
3. Vomiting blood.
4. Melaena.
5. Dyspepsia.
254
A mutation in what gene can cause familial diffuse gastric cancer?
CDH1 - 80% chance of gastric cancer.
| Prophylactic gastrectomy is done in these patients.
255
What investigations might you do in someone who you suspect has gastric cancer?
1. Endoscopy.
2. CT.
3. Laparoscopy.
256
What is the advantage of doing a laparoscopy in someone with gastric cancer?
It can detect metastatic disease that may not be detected on ultrasound/endoscopy.
257
What is the treatment for proximal gastric cancers that have no spread?
3 cycles of chemo and then a full gastrectomy. Lymph node removal too.
258
What is the treatment for distal gastric cancers that have no spread?
3 cycles of chemo and then a partial gastrectomy if the tumour is causing stenosis or bleeding. Lymph node removal too.
259
What vitamin supplement will a patient need following gastrectomy?
They will be deficient in intrinsic factor and so will need vitamin B12 supplements to prevent pernicious anaemia.
260
What is the dukes classification for tumour invasion
Dukes' A: Invasion into but not through the bowel wall
Dukes' B: Invasion through the bowel wall penetrating the muscle layer but not involving lymph nodes
Dukes' C: Involvement of lymph nodes
Dukes' D: Widespread metastases[7]
261
Which one of the following is FALSE regarding colorectal cancer?
a. Bowel cancer screening is offered to people aged 55 or over
b. The majority of cancers occur in the proximal colon
c. FAP and HNPCC are two inherited causes of colon cancer
d. Proximal cancers usually have a worse prognosis
e. Patients with PSC and UC have an increased risk of developing colon cancer
b. The majority of cancers occur in the proximal colon
Majority of cancers occur in the distal colon but proximal cancers have worse prognosis
262
A 50 year old man presents with dysphagia. Which one of the following suggests a benign nature of his disease?
a. Weight loss
b. Dysphagia to solids initially then both solids and liquids
c. Dysphagia to solids and liquids occurring from the start
d. Anaemia
e. Recent onset of symptom
c. Dysphagia to solids and liquids occurring from the start
If solids then liquids it suggests the lumen is slightly narrowed
263
A 32 year old lady complains of a 6 month history of bloating and diarrhoea. What is the most likely diagnosis based on the small bowel histology?
a. Crohn’s disease
b. Ulcerative colitis
c. Microscopic colitis
d. Coeliac disease
e. Irritable bowel syndrome
d. Coeliac disease
264
A 19 year old girl presents with abdominal pain and loose stool. Which of the features suggest that she has irritable bowel syndrome?
a. Anaemia
b. Nocturnal diarrhoea
c. Weight loss
d. Blood in stool
e. Abdominal pain relieved by defaecation
e. Abdominal pain relieved by defaecation
265
6. Which statement is true regarding Helicobacter pylori?
a. It is a gram-positive bacteria
b. HP prevalence is similar in developing and developed countries
c. 15% of patients with a duodenal ulcer are infected with H. Pylori
d. PPIs should be stopped 1 week before a H. Pylori stool antigen test
e. It is associated with an increased risk of gastric cancer
e. It is associated with an increased risk of gastric cancer
Increased risk of gastric adenocarcinoma, peptic ulcer disease and mucosa associated lymphoid tissue (MALT)
266
A 56 year old man presents with abdominal distension and shortness of breath. Examination revealed fever of 38C, a tense distended abdomen with shifting dullness. He also has dullness to percussion in the right lung base. Several spider naevi are seen on his chest. Which is the most important test in the management of this patient?
a. CXR
b. Ultrasound abdomen
c. Echocardiogram
d. Ascitic tap
Ascitic tap
267
8. Which of the following features best distinguishes Ulcerative colitis from Crohn’s disease?
a. Ileal involvement
b. Continuous colonic involvement on endoscopy
c. Non-caseating granuloma
d. Transmural inflammation
e. Perianal disease
b. Continuous colonic involvement on endoscopy
268
A 68 year old lady presents with abdominal pain and distention. She last opened her bowels 5 days ago. She has a poor appetite and has lost some weight recently. Her PMH includes an abdominal hysterectomy and diverticulosis. She drinks 20 units of alcohol a week and smokes 5 a day. Examination reveals a distended abdomen with tympanic percussion throughout. There is a small left groin lump with a cough impulse. Which one of the following is NOT likely to be the cause of her abdominal pain and distention?
a. Colon cancer
b. Adhesions
c. Ascites
d. Diverticulitis
e. Strangulated hernia
Ascites
269
10. A patient drinks 4 pints (568ml=1 pint) of beer (4%) a day, and 2 standard (175ml) glasses of red wine (13%) on Saturday and Sunday additionally. How many units of alcohol is he drinking per week? (round up to nearest whole number)
a. 73 units
b. 62 units
c. 94 units
d. 57 units
e. 49 units
73 units
% x ml / 1000
270
11. A 71 year old man was admitted to hospital with pneumonia after he returned from a cruise holiday in the Mediterranean Sea. He was treated with a week of augmentin (co-amoxiclav) for his pneumonia. On day 7 of his admission, he started having diarrhoea 10 times a day without any blood. He feels unwell and dehydrated. He had a flexible sigmoidoscopy which showed this. What is the likely organism responsible for his diarrhoea?
a. Norovirus
b. Escherichia coli
c. Giardia lamblia
d. Clostridium difficile
e. Salmonella enteritidis
Clostridium difficile
271
12. A 52 year old lady presents with fatigue and itching. She noticed pale stool and dark urine. She suffers from hypercholesterolaemia and rheumatoid arthritis. She takes simvastatin and cocodamol. Examination revealed jaundice, xanthelasma, spider naevi, and hepatomegaly. Her bloods showed Bili 150, ALP 988, ALT 80, positive AMA and a raised IgM. What is the most likely diagnosis?
a. Simvastatin induced liver injury
b. Primary biliary cirrhosis
c. Gall stones
d. Autoimmune hepatitis
e. Primary sclerosing cholangitis
b. Primary biliary cirrhosis
272
1. A 16 year old girl is admitted with vomiting and abdominal pain. She reports taking 20 paracetamol tablets after her boyfriend split up with her. Which one of the following test results would you NOT expect to see?
a. Metabolic acidosis
b. A prolonged prothrombin time
c. A raised creatinine
d. Hyperglycaemia
e. ALT 1000
Hyperglycaemia
Should be hypo because there is an inhibition of gluconeogenesus
Raised creatinine because of renal failure
273
13. A 68 year old unkempt and malnourished homeless man was brought to the hospital with haematemesis. Endoscopy found bleeding varices. Subsequent USS showed a coarse shrunken liver. On day 2 admission he was found to be ataxic, confused with nystagmus. What is the most likely cause of his neurological presentation?
a. Alcohol toxicity
b. Alcohol withdrawal
c. Delirium tremens
d. Wernicke’s encephalopathy
e. Korsakoff syndrome
Wernickes Encephalopathy
274
What are the symptoms of alcohol withdrawal
occurs 6-24 after last drink, lasts up to a week
| • - tremor, insomnia, N+V, agitation, seizures
275
What are the symptoms of delirium tremens
most severe form of alcohol withdrawal (5-20%)
• - usually occurs 24 to 72 hours after alcohol cessation
• - hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness, and visual and auditory hallucinations.
276
What are the symptoms of wernickes encephalopathy
due to exhaustion of thiamine reserves (malnutrition, alcoholism)
• - triad of : ataxia, nystagmus/ophthalmoplegia, confusion (but only 10% patients have all 3)
• - acute onset, reversible with IV thiamine
277
What are the symptoms of Korsakoff syndrome
85% untreated WE leads to Korsakoff syndrome
• - memory impairment, confabulation
• - chronic and irreversible
278
14. A 23 year old man was brought in at 2am with RIF pain and was diagnosed with acute appendicitis. He was stable and was scheduled for appendicectomy in the morning. During the ward round, he acutely deteriorated. He was immediately brought to theatre for a perforated appendix. What clinical signs would you NOT expect to see?
a. Fever
b. Bowel sounds
c. Tachycardia
d. Rebound tenderness
e. Guarding
Bowel sounds
279
Anti-DsDNA antibody is associated with what condition
SLE
280
The anti-phospholipid antibody is associated with what condition
Anti-phospholipid syndrome
281
ANCA antibodies are associated with what condition
Small cell vasculitis
282
Alpha gliadin antibody is associated with what condition
Coeliac
283
RF antibody is associated with what condition
Rheumatoid arthritis
284
Ferrous Sulphate is what sort of drug
Iron supplement
285
Loperamide is what sort of drug
anti-diarrhoea
286
methotrexate is what sort of drug
DMARD
287
Metronidazole is what sort of drug
Antibiotic
288
3. South African patient with Left iliac abdominal region pain and not able to pass stool with no previous surgery, non-smoker and his transglutamase results are negative – what’s the diagnosis
a. Coeliac disease
b. Colorectal cancer
c. Large bowel obstruction – volvus
d. Small bowel obstruction – adhesion
e. Strangulation hernia
Large bowel obstruction – volvus
289
4. Which of the following is not a feature of Crohn’s?
a. Mouth ulcers
b. Mucosal inflammation
c. Granulomatous skip lesions
d. Raised CRP
e. Smoking decreases level of risk
Smoking decreases level of risk
| This is true in ulcerative colitis but in Crohn's smoking increases the risk of disease
290
5. Symptoms of IBD rather than IBS
a. Smelly stools
b. DXA scan revealing decreased bone mineral density
c. Nocturnal diarrhoea
d. Abdominal cramps
e. Feeling fatigued
c. Nocturnal diarrhoea
291
Which of the following two statements about ascending cholangitis are false
a. Caused by bacterial infection of biliary tree
b. Patients experience epigastric pain
c. Patients present with a temperature
d. Patients present with yellowing of the skin and sclera
e. Murphy’s sign is negative
b. Patients experience epigastric pain
- Should be RUQ pain as ascending cholangitis symptoms are charcots triad
e. Murphy’s sign is negative
292
7. Gallbladder is supplied by the cystic artery which is a branch of what
a. Coeliac trunk
b. Gastroduodenal
c. Left gastric epiploic
d. Right hepatic
e. Splenic
Right hepatic
293
8. Which form of hepatitis is a DNA virus
a. Hep A – Faeco/oral
b. Hep B - blood and bodily fluids
c. Hep C - blood and bodily fluids
d. Hep D – Blood and bodily fluids
e. Hep E - Faeco-oral
Hep B is DNA, all the others are RNA
294
9. Haemochromatosis is metabolic liver disease caused by uncontrolled intestinal absorption of what ion
a. Ca2+
b. Cu2+
c. Fe2+
d. Li+
e. K+
Fe2+
295
10. Which antibiotics are given alongside PPI for h.pylori and peptic ulcer
a. Amoxicillin and clarithromycin
b. Doxycyclin and metronidazole
c. Ethambutol and trimethoprim
d. Lithium and clarithromycin
e. Rifampicin and amoxicillin
Amoxicillin and clarithomycin
