Gastrointestinal

Question 1

Alcoholic liver disease

Answer 1

Damage to the liver due to years of excessive drinking. Begins as steatosis (fatty liver) which can progress to alcoholic hepatitis and eventually cirrhosis.
C: Alcohol changed into acetaldehyde in hepatocytes, increasing NADH levels (increasing fatty acids), as well as ROS which damage the cells, and binding causing inflammation.
S: Nausea and vomiting, weight loss, loss of appetite, jaundice, oedema in legs and abdo, confusion, mood swings, vomiting blood or passing blood in the stools.
D: FBC, LFTs (AST level is two times higher than your ALT), abdominal ultrasound, liver biopsy, CT scan.
T: Stop drinking, Alcoholic rehabilitation program, multivitamins (A and B), liver transplant (cirrhosis).

Question 2

Non-alcoholic fatty liver disease

Answer 2

Results from fat deposition in the liver unrelated to alcohol or viral causes, typically affects people with metabolic syndrome (obesity, HT, DM, hypertriglyceridemia, hyperlipidaemia).
C: Insulin receptors become less responsive to insulin, leading to increased uptake of fatty acids, filling hepatocytes with fat. Radicals can damage cells and cause inflammation. Can lead to fibrosis and cirrhosis.
S: May be asymptomatic, fatigue, malaise, pain in RUQ, weight loss, weakness, hepatomegaly, jaundice, ascites.
D: LFTs (increased ALT, AST), ultrasound/fibroscan, MRI/CT, liver biopsy.
T: Lifestyle changes, medication to treat DM, HT, high cholesterol, liver transplant (if cirrhosis).

Question 3

Cholestatic liver disease

Answer 3

Occurs when the flow of bile from the liver is reduced or blocked, can cause a build up of bilirubin.
C: Intrahepatic (viral/bacterial infection, genetic disorders, liver and pancreatic cancer, autoimmune disorders like primary biliary cirrhosis, medication) or Extrahepatic (physical blockage due to gallstones, cysts, tumours).
S: Jaundice, dark urine, light-coloured stool, abdominal pain, fatigue, nausea, excessive itching.
D: FBC, LFTs, ultrasound, MRI, liver biopsy.
T: Treat underlying cause - review medication, surgery to remove obstruction.

Question 4

Cholelithiasis

Answer 4

The presence of one or more calculi (gallstones) in the gallbladder.
C: Excessive cholesterol (yellow), excessive bilirubin (black/brown), dysfunctional gallbladder (doesn’t empty enough).
Increased risk if fat, fertile, 40 and female.
S: Biliary colic - severe upper abdominal pain (lasting 1-5 hours) which resolves spontaneously (right or centre of abdomen), fever, tachycardia, jaundice, nausea and vomting.
D: Murphys test, bloods and LFTs, abdominal ultrasound, MRI, cholangiography, CT, endoscopic retrograde cholangiopancreatography.
T: No need for treatment if asymptomatic. Lifestyle advice, analgesia, ursodeoxycholic acid (to dissolve stones) ERCP (can remove at the same time), Cholecystectomy (removal of gallbladder).

Question 5

Cirrhosis

Answer 5

When the liver is exposed to long-term hepatocyte destruction and inflammation, the liver can be chronically scarred and damaged, to the point where it is no longer reversible.
C: Alcohol, virus, NAFLD
S: Compensated liver - asymptomatic or non-specific symptoms e.g. weight loss, weakness, fatigue
Decompensated liver - jaundice, pruritis, ascites, hepatic encephalopathy, easy bruising due to low coagulation factors. May also lead to gynecomastia, spider angiomata and palmar erythema, hypoalbuminemia.
D: Liver biopsy, LFTs (elevated bilirubin, AST (more so), ALT (less so), ALP, GGT), FBC (thrombocytopenia)
T: Irreversible. Prevent further damage (antiviral treatment, stop drinking). Liver transplant.

Question 6

Portal Hypertension

Answer 6

Increased blood pressure in the hepatic portal system (above 12mmHg) due to obstruction which prevents blood flowing from portal vein to the IVC, causing a portosystemic shunt where blood backs up into systemic veins.
C: Pre-hepatic (thrombi), Intra-hepatic (cirrhosis, schistosomiasis, sarcoidosis), Post-hepatic (right-sided HF and constrictive pericarditis, Budd-Chiari syndrome)
S: Ascites, Caput Medusae, GI bleeding (haematemesis, melena, haematochezia), jaundice, asterixis, altered consciousness, lethargy, seizure, coma.
D: Hepatic venous pressure gradient measurement , ultrasound, FBC, liver enzymes, serology, endoscopy, CT/MRI scan.
T: Beta-blockers e.g. propranolol, Ascites - diuretics and sodium restriction, Bleeding oesophageal varices - octreotide medication, balloon tamponade, sclerotherapy, variceal ligation, Transjugular intrahepatic portosystemic shunt (TIPS) - a tube is inserted via a catheter to allow communication between the portal vein and hepatic vein.

Question 7

Peritonitis

Answer 7

Inflammation of the serosa membrane lining abdominal cavity and organs.
C: Spontaneous bacterial peritonitis (E.coli, Klebsiella, Pseudomonas, Proteus, Gram-negatives), Leakage of GI contents through a perforated viscera, Foreign material - blood, bile, contrast medium, Endometriosis, Peritoneal dialysis.
S: Fever, tachycardia, ascites, abdominal distention, abdominal rigidity, spider angiomata, jaundice, nausea and vomiting, diarrhoea, lack of bowel sounds, abdominal pain (worsening).
D: Abdominal X-ray, FBC, ABG, serum ascites albumin gradient (SAAG): >1.1 in spontaneous bacterial peritonitis.
T: Systemic antibiotics - third generation cephalosporins/quinolones

Question 8

Primary Biliary Cholangitis/Cirrhosis

Answer 8

Inflammation of the bile duct that can become cirrhotic due to infiltration of bile and the autoimmune attack.
C: Unknown. Genetic predisposition and environmental factors. Associated with autoimmune hepatitis and Sjogren’s syndrome.
S: Bone/joint aches, fatigue, itchy skin, dry eyes and mouth, problems sleeping, RUQ pain, postural hypotension. Cirrhosis can lead to jaundice, oedema, ascites, xanthelasmata, pale stools, dark urine.
D: FBC, LFTs, AMA, liver biopsy, ultrasound, X-ray of bile duct, CT/MRI scan.
T: Ursodeoxycholic acid - reduces the body’s absorption of cholesterol
Cholestyramine - binds to cholesterol and allows it to be more easily excreted
Liver transplant - if damage is severe
Artificial tears and saliva for dry eyes and mouth.
Antihistamines for itching.

Question 9

Primary Sclerosing Cholangitis

Answer 9

Inflammation and fibrosis of intra and extra hepatic ducts, causing a pattern of tightening and dilation.
C: Unknown. Related to UC and CD, genetic predisposition for those with specific human leukocyte antigens, increased IgM and p-ANCA.
S: Fatigue, itching, RUQ pain, fever, night sweats, enlarged liver and spleen, weight loss, jaundice.
D: LFTs, MRI or X-ray of bile ducts, liver biopsy.
T: No immunosuppressant and anti-inflammatory medications have proven to slow PSC
Liver transplant

Question 10

Haemochromatosis

Answer 10

Metabolic disorder where the body absorbs too much iron from the food you eat. Leads to elevated iron in the blood which can poison the liver, pancreas, heart, pituitary gland, joints and skin.
C: Primary (gene mutation in HFE gene), Secondary (frequent blood transfusion).
S: Weakness, lethargy, weight loss, joint pain, abdominal pain, erectile dysfunction, abnormal/irregular periods, darkening of skin, jaundice, chest pain, SOB.
D: FBC, transferrin saturation %, total iron binding capacity, liver biopsy
T: Phlebotomy - bloodletting until ferritin, % saturation and iron load are decreased
Deferoxamine - binds to free Fe in the blood and causes it to be excreted in the urine, decreasing the iron load

Question 11

Hepatocellular carcinoma

Answer 11

Severe cancer of the liver. Can be primary (goes to lungs) or secondary (comes from colon, pancreas, lung, breast).
C: Alcoholic hepatitis, Haemochromatosis, Primary biliary cirrhosis, a1- antitrypsin deficiency, Hepatitis B and C viruses
S: Asymptomatic, abdominal pain, fever, ascites and hepatosplenomegaly, weight loss, fatigue, nausea and vomiting, jaundiced skin and eyes.
D: LFTs (increased ALP and GTT), erythropoietin, insulin-like growth factor 1, parathyroid hormone-related protein, alpha-fetoprotein (increased), ultrasound, CT scan, angiography.
T: Surgery, radiotherapy, chemotherapy, liver transplant.

Question 12

Budd-Chiari syndrome

Answer 12

A rare disorder caused by hepatic venous outflow obstruction.
C: Haematological conditions, reduced blood flow due to right HF or peritonitis, pregnancy, COC, HRT, chronic infections, chronic inflammatory disease, tumours, trauma, surgery, idiopathic, alpha 1-antitrypsin deficiency.
S: RUQ abdominal pain, jaundice, ascites, hepatomegaly, AKI, dilated veins on the abdominal wall.
D: LFTs, Prothrombin time, Ascitic fluid, MRI/CT scan, Doppler ultrasound, Caval venography, Liver biopsy
T: Treat underlying conditions
Anticoagulation
Ascites - diuretics, fluid and salt retention
Endovascular treatment to restore vessel patency (angioplasty, stenting, and local thrombolysis)
Placement of transjugular portosystemic shunt (TIPS)
Orthotopic liver transplantation

Question 13

Acute Diarrhoea

Answer 13

3 or more liquid stools in 24 hours. Acute (less than 2 weeks), Persistent (2-4 weeks), Chronic (more than 4 weeks).
C: Pathogens: viruses, bacteria, parasites, protozoa which spread through faecal-oral transmission. Most commonly caused Salmonella, Shigella, Yersina, Campylobacter, Enteroinvasice E.coli.
Non-infectious causes - stress, medication, toxic ingestion
S: Stools contain blood and mucous, abdominal pain, fever.
D: Abdo examination, FBC, electrolytes, creatinine and urea, blood cultures, stool cultures, testing for common viruses and C. Diff
T: Oral rehydration solutions - orally or NG tube
Dietary adjustments - liquids and simple foods like soups, juices, breads and crackers
Antibiotic treatment is given to those who are severely ill or who have risk factors for complications
e.g. Azithromycin or Fluroquinolones
Antimotility medications e.g. Loperamide should reduce the frequency of stools

Question 14

Chronic Diarrhoea

Answer 14

3 or more liquid stools in 24 hours. Acute (less than 2 weeks), Persistent (2-4 weeks), Chronic (more than 4 weeks).
C: Infectious organisms, inflammatory bowel disease, and malabsorption syndromes like coeliac disease and lactose intolerance, tumours.
S: Coeliac - fat in stool, abdominal pain, weight loss, skin rashes. Lactose intolerance - watery diarrhoea, abdominal pain. Inflammatory bowel disease - inflammatory diarrhoea, bloody stools, fever, weight loss.
D: FBC, CRP, ESR, protein and albumin, Stool occult blood and antibody test for HIV, stool calprotectin (IBS), IgA and tTG (CD)
T: Each specific cause of diarrhoea have a specific treatment
Fluid retention
Dietary adjustment
Loperamide - decrease frequency of stools

Question 15

Cholera

Answer 15

Contagious infection caused by the bacteria Vibrio Cholerae which in turn can cause severe gastroenteritis and watery diarrhoea.
C: Consuming untreated sewage water or anything that comes in contact with it (raw or undercooked fish).
Improper hygiene.
S: Vomiting, increasing diarrhoea, severe dehydration leading to disorientation, dry mouth, swollen tongue, sunken eyes, cold and clammy skin, shrivelled/dry hands and feet, electrolyte disturbances, hypovolemic shock, hypotension.
D: Stool sample, growing V.Cholerae on thiosulfate-citrate-bile salts-sucrose agar.
T: Replace lost water and electrolytes either orally or intravenously.
More extreme cases - antibiotics (stool culture will identify which antibiotics are most effective).
May include tetracyclines, ciprofloxacin, ofloxacin, furazolidone or trimethoprim-sulfamethoxazole.

Question 16

Bowel obstruction

Answer 16

Normal flow of contents through the intestines is interrupted.
C: Mechanical (post-op adhesions, hernia in small bowel)(volvulus in large bowel)(IBS, foreign body, intussusception in both). Functional (Post-operative ileus, infection or inflammation like in appenditicis/peritonitis, hypothyroidism, electrolyte abnormalities).
S: Abdominal pain (intermittent bouts in SB, less frequent but longer bouts in LB), constipation, vomiting, abdominal distension, respiratory distress (SOB, cyanosis, tachypnoea).
D: Auscultation (high-pitched tinkling sounds), abdominal X-ray, abdominal CT scan with contrast, abdominal ultrasonography.
T: Most obstructions resolve on their own
Relieve symptoms with IV fluids or NG suction
If symptoms don’t improve or there is perforation surgery may be needed.

Question 17

Gallstone Ileus

Answer 17

Gallstone become lodged in the small bowel through cholecystoenteric fistula, commonly at the terminal ileum at the ileocecal valve, causing mechanical obstruction.
C: Repeated bouts of cholecystitis. Increased risk if female, old, pregnant or obese.
S: Abdominal distension, nausea and vomiting, RUQ pain, dehydration.
D: Abdominal X-ray, FBC, U&E and creatinine, and LFTs, Group and save, CT scan.
T: Managing the symptoms e.g. dehydration with intravenous fluids
Nasogastric suction - removing fluid and air
Emergency surgery - enterolithotomy alone, in conjunction with simultaneous cholecystectomy and fistula closure, or a two-stage procedure.

Question 18

Crohn’s disease

Answer 18

Inflammatory bowel disease that causes transmural granulomatous inflammation anywhere along the GI tract. Can occur with skip lesions.
C: Triggered by a foreign pathogen like mycobacterium paratuberculosis, pseudomonas, listeria. Causes a large and uncontrolled immune response which leads to destruction of cells in the GI tract. Genetic predisposition.
S: Pain commonly in the RLQ, diarrhoea with blood in the stool, malabsorption issues, fatigue, reduced appetite, fever, painful joints, sore mouth.
D: FBC, CRP, U&Es, LFTs, stool culture and microscopy,, Faecal calprotectin, ileocolonoscopy and biopsies from the terminal ileum, CT/MRI scan.
T: Monotherapy with a conventional glucocorticosteroid (prednisolone, methylprednisolone or intravenous hydrocortisone). Consider adding azathioprine or mercaptopurine. Infliximab or adalimumab fo severe Crohn’s that is not responding. Surgery for those with Crohn’s only in the distal ileum. Antibiotics, antidiarrhoeals, antispasmodics may also be given.

Question 19

Diverticular disease

Answer 19

Diverticula are pouches that form along the walls of large and small bowel, their presence is known as diverticulosis. When they are inflamed it is known as diverticulitis. Commonly in the sigmoid.
C: Exaggerated or unequalled smooth muscle contractions that cause high pressure. Low fibre and fatty foods. Associated with Marfan’s syndrome and Ehlers-Danlos syndrome.
Inflammation caused by faecal material lodged in the diverticula or erosion of the diverticula wall.
S: Vague stomach pain and occasionally bleeding (diverticulosis). LLQ pain, fever, tachycardia, nausea, vomiting. Air or stool in the urine if a colovesicular fistula has occured.
D: FBC, urea and electrolytes, CRP, colonoscopy, contrast CT scan.
T: Diverticulosis - high fibre diet, adequate fluid intake, bulk-forming laxatives, analgesia.
Diverticulitis - May not need antibiotics, if they do use co-amoxiclav for a week. Analgesia. Liquids at first then reintroduce solids. IV co-amoxiclav, hydration, analgesia if admitted. May need surgery if complicated.

Question 20

Colorectal cancer

Answer 20

Malignant or cancerous cell in the large intestines, which includes the colon and rectum. Mostly adenocarcinomas.
C: Sporadic mutations, inherited APC gene, mutations in DNA repair genes.
S: Ascending colon (vague abdominal pain, weight loss, can be asymptomatic for a while, can ulcerate and bleed), descending colon (bowel obstruction, colic abdominal pain, haematochezia).
D: Colonoscopy, Faecal occult blood testing, tumour marker CEA, Barium enema with X-ray.
T: Early cancers - surgically resection
Cancers spread to the lymph nodes - chemotherapy
Metastatic cancers - typically incurable

Question 21

Gastritis

Answer 21

Inflammation of the lining of the stomach, may occur as an acute episode or of long duration (chronic).
C: ACUTE: NSAIDs, corticosteroids, alcohol, H pylori infection, smoking, caffeine, extreme physiological stress (e.g. shock, sepsis, burns).
CHRONIC: H pylori infection, inherited autoimmunity against intrinsic factor.
S: Asymptomatic, epigastric pain, nausea, vomiting, mucosal ulcers, Haemorrhage, haematemesis, melena. For Autoimmune atrophic gastritis - iron deficiency anaemia, symmetrical neuropathy.
D: Biopsy, H pylori testing using serology, stool antigen test, urease breath test. For autoimmune atrophic gastritis, anti-IF antibodies, anti-parietal cell antibodies, increased serum gastrin, decreased serum pepsinogen, lymphocytosis.
T: Remove offending agents. Eradicate H pylori - triple therapy (PPI, clarithromycin, amoxicillin) or quadruple therapy (PPI, bismuth, metronidazole, tetracycline)
Correct vitamin deficiencies for autoimmune atrophic gastritis

Question 22

Peptic ulcer disease

Answer 22

One or more sores in the stomach (gastric ulcers) or in the duodenum (duodenal ulcers).
C: H pylori infection, NSAIDs, Gastrinoma (neuroendocrine tumour)
S: Epigastric burning pain, bloating, belching, vomiting.
Gastric (pain increases whilst eating, weight loss). Duodenal (pain decreases whilst eating, weight gain).
D: Upper endoscopy into the stomach and upper duodenum. Biopsy is taken to look for malignancy of evidence of H pylori.
T: Dependant on underlying cause
H.pylori infection - antibiotics and acid-lowering medications like PPIs
Stop the use of NSAIDs, alcohol, caffeine

Question 23

Ulcerative colitis

Answer 23

Inflammation of the colon and rectum with circumferential and continuous ulcers of the lumen (the membrane has been eroded away, leaving behind open sores).
C: Unknown. Thought to be a mix of environmental stimuli and genetic predisposition. Autoimmune - pANCA cross react with the body’s own neutrophils.
S: LLQ pain, severe and frequent bouts of diarrhoea (with or without blood), painful and swollen joints, mouth ulcers, red, painful, swollen skin.
D: Colonoscopy - see ulcers and take a biopsy
CT scan, MRI, Barium enema, X-ray to look for abnormalities
T: Anti-inflammatory medications - sulfasalazine or mesalamine
Immunosuppressors - corticosteroids, azathioprine, cyclosporin
Biologics - infliximab, adalimumab, golimumab
Colectomy - removal of the colon

Question 24

Coeliac disease

Answer 24

Autoimmune disorder whereby gliadin in gluten triggers destruction of the intestinal cells (mostly dudodenum).
C: Genetic factors, infant feeding practices, gut bacteria. Can be triggered by surgery, pregnancy, childbirth, viral infection or severe emotional stress.
S: Diarrhoea, fatigue, weight loss, bloating and gas, abdominal pain, nausea and vomiting, constipation, anaemia, osteoporosis, itchy, blistery skin rash.
D: Anti-gliadin, Anti-transglutaminase, Anti-endomysia tests, biopsy via endoscopy, DEXA scan.
T: Remove the gluten from the diet, for life. Support groups. Extra vaccinations and supplements. Dapsone can be used to treat dermatitis herpetiformis.

Question 25

Barrett’s Oesophagus

Answer 25

Metaplasia of cells lining the lower oesophagus - normal stratified squamous epithelium becomes simple columnar epithelium with goblet cells (which is usually native to the lower gastrointestinal tract). Increased risk of Oesophageal adenocarcinoma.
C: Chronic acid exposure causes reflux oesophagitis, Bile acids leading to intestinal differentiation. Associated with bulimia, obesity, smoking, hiatal hernia
S: Asymptomatic, similar to reflux, frequent prolonged heartburn, dysphagia, haematemesis, epigastric pain, weight loss (due to painful eating)
D: OGD, biopsy to look for goblet cells, Screening for males >60 years old, Oesophageal pH studies to test action of PPIs
T: Proton pump inhibitors e.g. Omeprazole, Chemoprevention in a low-grade lesion - Aspirin, NSAIDs, Surgery - endoscopic mucosal resection, surgical removal of the oesophagus, radiation therapy, systemic chemotherapy. Avoid/reduce intake of foods known to worsen reflux: chocolate, coffee, tea, peppermint, alcohol, fatty/spicy/acidic foods
For dysplastic lesions: radiofrequency ablation, spray cryotherapy, photodynamic therapy.

Question 26

Pancreatitis

Answer 26

Inflammation of pancreas and peripancreatic tissues. Can be acute or chronic leading to irreversible loss of function.
C: Excessive alcohol consumption, gallstones, medications, pancreatitic cancer, abdominal surgery, infections, cystic fibrosis, trauma.
S: Pain that wraps around the body in a band like pattern, indigestion, nausea, vomiting, abdominal tenderness, weight loss, distended abdomen, hiccups, fever.
D: Bloods (liver function, amylase, lipase), Biopsy, Secretin stimulation test, faecal fat test, ultrasound, MRI, and CT scans.
T: Acute- analgesics, treat gallstones, fluids, oxygen, drain cysts, remove necrotic tissue
Chronic- supportive- pancreatic enzyme replacement therapy, antibiotics, analgesics, screen for diabetes (autoimmune can have steroids), pancreatomy/surgery last resort.

Question 27

Acute cholecystitis

Answer 27

Inflammation of the gall bladder.
C: Gallstones present in the gallbladder, one of them to become lodged in the cystic duct, preventing the flow of bile. This causes the gallbladder mucosa to secrete mucous and enzymes, resulting in inflammation, distension and pressure build-up. Bacterial growth and peritonitis can occur.
S: Mid-epigastric pain which can shift to RUQ and radiate to right scapula and shoulder, nausea and vomiting, neutrophilic leucocytosis and fever. Jaundice when bile leaks into the bloodstream.
D: LFTs (increased ALP), Murphy’s sign, ultrasound, cholescintigraphy (radiolabelled marker), ERCP, MRCP
T: Supportive - IV fluids, pain management, antibiotics
Surgical removal using a cholecystectomy

Question 28

Pancreatic cancer

Answer 28

Malignant cells form in the pancreas, usually in the exocrine tissue in the head or neck of the pancreas.
C: Usually caused by genetic mutations - may activate oncogenes or inactive tumour suppressor genes. Family history - BRCA2 and PALB2.
S: Nausea, vomiting, fatigue, weight loss, steatorrhea, epigastric pain that radiates to the back (worse on lying down), Trousseau sign of malignancy - blood clots that can be felt as small lumps under the skin, Courvoisier’s sign - gallbladder is enlarged and palpable, but not tender to touch.
If it’s in the head, it can block the CBD - obstructive jaundice, loss of appetite, darker urine, paler stools, pruritis.
D: Serum amylase, serum lipase, CA19-9 antigen, CEA (elevated), LFTs, ultrasound, CT/MRI, biopsy.
T: Chemotherapy - neoadjuvant therapy used to shrink the tumour before surgery or as an adjuvant therapy after surgery, or for those who can’t have surgery at all.
Whipple procedure - removal of head of the pancreas, gallbladder, duodenum and parts of the jejunum and stomach.

Question 29

Intestinal colic

Answer 29

Cramp like pain in the small and large intestines.
C: Primarily due to blockages in passing food or liquid through the intestine. May be due to IBS, divertilitis, post-surgical adhesions, tumours in the bowel.
S: Dull colicky abdominal pain/cramps, inability to pass stools, vomiting, loss of appetite, abdominal distension, pain may be worsened after eating.
D: Abdominal exam, X-ray, CT scan for bowel obstruction, colonoscopy.
T: Treat underlying cause. Antispasmodics can relieve muscle spasm and analgesics such as paracetamol to relieve pain.

Question 30

Irritable bowel syndrome

Answer 30

A chronic disorder that is characterised by a group of symptoms that come and go, and can last for days, weeks, months.
C: Unknown. May be due to oversensitive colon or immune system, stress, previous bacterial infection in the GI system, certain foods.
S: Abdominal pain, bloating, diarrhoea, constipation, symptoms are worse after eating and improve after defecation.
D: FBC, ESR, CRP, antibody testing for coeliac disease (endomysia antibodies EMA or tissue transglutaminase TTG).
T: Healthy diet, lifestyle advice, Loperamide for diarrhoea, Laxatives for constipation. Avoid lactuloseas it can cause bloating. Linaclotide is used if not responding to first line laxatives. Mebeverine and peppermint oil.

Question 31

Eosinophilic Oesophagitis

Answer 31

Characterised by oesophageal symptoms and infiltration of eosinophils in the oesophageal epithelium.
C: Immune hypersensitivity responses to particular foods or allergens in some affected individuals. Familial inheritance.
S: Children - failure to thrive and refusal of food.
Adolescents - chest pain, epigastric pain, vomiting.
Adults - dysphagia, food bolus obstruction, heart burn, chest pain.
D: Endoscopy with biopsy - more than 15 eosinophils per high-power field on microscopy of an oesophageal biopsy.
T: Amino acid mixture for 6 weeks
Exclusion of the 6 food groups
Exclusion of food based on allergen tests
Fluticasone metered dose inhaler - dry swallowed
Budesonide oral solution mixed with sucralose, chocolate syrup or honey
Hydrostatic balloon dilatation or guided wire bougie dilatation
Anti-IgE therapy

Question 32

GORD

Answer 32

A chronic condition where there is reflux of gastric contents (particularly acid, bile, and pepsin) back into into the oesophagus, causing inflammation.
C: The ring of muscle at the bottom of the oesophagus becomes weakened. May be due to increased intra-abdominal pressure, anatomical reasons, smoking, alcohol, coffee, pregnancy, obesity, tight clothes, big meals, surgery in achalasia of the cardia, systemic sclerosis, hiatus hernia, drugs, including tricyclic antidepressants, anticholinergics, nitrates and calcium-channel blockers.
S: Burning feeling rising from the stomach towards the neck, regurgitation of acid or bile, excessive saliva, odynophagia, chronic hoarseness, chronic cough, wheezing, SOB.
D: FBC, endoscopy, Barium swallow, Oesophageal pH monitoring using a Naso-oesophageal pH catheter (24-hour study).
T: Lifestyle changes. Avoid hot drinks, alcohol and eating during the three hours before going to bed.. Avoid drugs which affect oesophageal motility (nitrates, anticholinergics, tricyclic antidepressants) or damage the mucosa (NSAIDs, potassium salts, alendronate). PPIs for one month, and then low-dose maintaince. Laparoscopic insertion of a magnetic bead band.

Question 33

Constipation

Answer 33

Unsatisfactory defecation because of infrequent stools (<3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.
C: Low fibre, low fluid intake, IBS, elderly, post-surgery, anal fissure, anal stricture, rectal prolapse, strictures, cancer, diverticulosis, hypothyroidism, hypercalcaemia, hypokalaemia, porphyria, opioid analgesia, anticholinergics, iron, spinal or pelvic nerve injury, diabetic neuropathy, idiopathic megacolon.
D: FBC, U&E, Ca2+, TFTs, Sigmoidoscopy and biopsy of abnormal and normal mucosa, barium enema.
T: Treat the cause. Mobilise the patient
Increase fluid intake; increase intake of high-fibre foods (including fruits, vegetables, whole wheat and bran). If using medication, try to use for a short period of time.

Question 34

Haemorrhoids

Answer 34

Abnormally enlarged vascular mucosal cushions in the anal canal. Above the dentate line (internal haemorrhoids - usually painless) or below the dentate line (external haemorrhoids - can become painful and itchy)
C: Constipation, prolonged straining and time on the toilet, increased abdominal pressure as in ascites or during pregnancy and childbirth, heavy lifting, chronic cough, ageing and hereditary factors.
S: Asymptomatic, bright-red, painless rectal bleeding with defecation (not mixed in), anal itching and irritation, rectal fullness, discomfort or of incomplete evacuation, impaired continence.
D: Proctoscopy, Flexible sigmoidoscopy and possible colonoscopy, Anorectal physiological studies and anorectal ultrasound, FBC.
T: Simple analgesia, topical anaesthetics or corticosteroids, good perianal hygiene. Surgery - rubber band ligation, infrared coagulation/photocoagulation, injection sclerotherapy, bipolar diathermy, haemorrhoidectomy, circular stapled haemorrhoidectomy, haemorrhoidal artery ligation.

Question 35

Dyspepsia

Answer 35

Pain or discomfort in the upper abdomen. Dysphagia is a ‘red flag’ warning sign that should be referred urgently for investigation.
C: Peptic ulcer disease, GORD, functional dyspepsia.
S: Epigastric discomfort, fullness or bloating, excessive wind, nausea, fatty food intolerance.
RED FLAG: weight loss, recurrent vomiting, dysphagia, GI bleeding.
D: FBC, H Pylori test, barium meal, OGD.
T: For people with GORD, offer a full-dose PPI, for four to eight weeks. Where there is no initial response to a PPI (and recent endoscopy has shown GORD), offer H2-receptor antagonist (H2RA).
Review medications
Lifestyle advice
Antacids for relief of occasional symptoms

Question 36

Gastroenteritis

Answer 36

Inflammation of the gastrointestinal tract.
C: Viral (norovirus, rotavirus and adenovirus), bacterial (Campylobacter spp., E.coli, Salmonella spp., Shigella spp., or toxins from Staphylococcus aureus, Bacillus cereus or Clostridium perfringens) and parasitic pathogens (Cryptosporidium spp., Entamoeba histolytica (amoebiasis) or Giardia lamblia.
S: Nausea, vomiting, diarrhoea, abdominal pain, fever.
D: Obs, abdominal exam, assess for dehydration, stool investigations - microscopy, culture and sensitivity, blood tests, imaging if there is bowel distension.
T: Prevent the spread of infection
Avoid work for at least 48 hours after the person is free from diarrhoea and vomiting
Loperamide (anti-motility drug) may be used
Antibiotics for gastroenteritis is due to a known bacterial or protozoal cause

Question 37

Acute poisioning

Answer 37

The adverse effects of a substance that result either from a single exposure or from multiple exposures in a short period of time.
C: Can be deliberate (self-harm, suicide, child abuse, attempted homicide, terrorist) or accidental - dosage error, recreational, environmental (plants, insects, venomous stings/bites), industrial exposure)
S: Nausea, vomiting, diarrhoea, pain, loss of appetite, fever, breathing difficulties, rash, confusion, irritability, burns, double vision, coma.
D: Cardiovascular, respiratory, abdominal and neurological examination, Breath - ketones (diabetic/alcoholic ketoacidosis), ‘bitter almonds’ (cyanide), ‘garlic-like’ (organophosphates, arsenic), ‘rotten eggs’ (hydrogen sulphide), organic solvents
Mouth - perioral acneiform lesions (solvent abuse), dry mouth (anticholinergics), hypersalivation (parasympathomimetics), ECG, ABG, FBC, U&Es, LFTs, clotting, glucose, toxicology screens, CXR, CT scan.
T: Obtain info from Toxbase, decontamination if posssible, single-dose activated charcoal, whole bowel irrigation, specific antidotes and antagonists.

Question 38

Mallory-Weiss tear

Answer 38

Characterised by upper gastrointestinal bleeding from mucosal lacerations in the upper gastrointestinal tract, usually at the gastro-oesophageal junction or gastric cardia.
C: Prolonged or forceful bout of retching, vomiting, coughing, straining or even hiccupping. May also occur with other events which cause a sudden rise in intragastric pressure or gastric prolapse into the oesophagus.
S: Haematemesis following a bout of retching or vomiting. Melaena, light-headedness, dizziness, or syncope.
D: Rockall score, endoscopy, FBC, clotting, U&Es, group and save, electrocardiogram.
T: Resuscitation - maintain airway, provide high-flow oxygen, place two wide-bore cannulae, IV fluids and potentially blood transfusion.
Endoscopy asap- banding and clipping, or injection with adrenaline.
Angiography with vasopressin injection or embolisation is occasionally used.

Question 39

Oesophageal strictures, webs and rings

Answer 39

Narrowing of the oesophagus can be due either to strictures (benign or malignant), webs (mucosa and submucosa only), and rings (mucosa, submucosa and muscle), or from external compression from other structures in the neck or mediastinum.
C: Benign strictures are usually caused by severe GORD, post-operative complications or drugs. Malignant strictures usually result from carcinoma of the oesophagus or stomach. Webs are associated with iron-deficiency, koilonychia (spoon nails), cheilosis and glossitis. Unknown causes of rings.
S: Heartburn, dysphagia, impaction of food, weight loss, persistent cough and wheeze due to the aspiration of food and acid.
D: FBC, ferritin, LFTs, CXR, endoscopy, barium swallow, CT scan, endoscopic ultrasound.
T: Benign strictures or rings are managed with dilatation during endoscopy.
Long-term use of PPIs should reduce the need for frequent dilatations.
Malignant strictures require surgical excision (oesophagectomy) or palliative management with an oesophageal stent.

Question 40

Oesophageal varices

Answer 40

Variceal haemorrhage occurs from dilated veins (varices) at the junction between the portal and systemic venous systems. Varices tend to be in the distal oesophagus and/or the proximal stomach but isolated varices may be found in the distal stomach, large and small intestine.
C: Pre-hepatic - portal vein thrombosis, portal vein obstruction, increased portal flow, increased splenic flow
Intrahepatic - cirrhosis due to acute or chronic hepatitis, idiopathic portal hypertension, schistosomiasis, congenital hepatic fibrosis
Post hepatic - compression from tumour, Budd-Chiari syndrome, constrictive pericarditis
S: Haematemesis, meleana, abdominal pain, dysphagia/odynophagia, peripherally shut down, pallor, hypotension and tachycardia, reduced urine output, reduced GCS, signs of sepsis.
D: FBC, clotting, INR, U&Es, LFTs, group and save, CXR.
T: Resuscitation and blood transfusion if necessary, urgent endoscopy, vasoactive drugs like Terlipressin, prophylactic antibiotics, band ligation, stent insertion, endoscopic injection of a glue like substance, oesophageal transection and gastric devascularisation.

Question 41

Stomach cancer

Answer 41

Cancer cells form in the inner lining of your stomach and grow into a tumour, can be present on any part of the stomach.
C: Mutations. Associated with increased age, male, long-term H Pylori infection, severe GORD, gastritis, pernicious anaemia, family history.
S: Dyspepsia, weight loss, vomiting, dysphagia, anaemia, abdominal pain, epigastric mass, hepatomegaly, jaundice, ascites.
D: FBC and LFTs, rapid-access flexible endoscopy with biopsy, endoscopic ultrasound, CT/MRI scan for metastasis.
T: Symptom control - pain, nausea, constipation, depression and mouth care. Corticosteroids or megestrol acetate for anorexia. Surgery is the treatment of choice - Distal tumours should be treated by subtotal gastrectomy and proximal tumours by total gastrectomy. Perioperative combination chemotherapy (5-fluorouracil) has become the standard of care for localised gastric cancer. Palliative chemotherapy.

Question 42

Appenticitis

Answer 42

Sudden inflammation of the appendix, usually initiated by obstruction of the lumen. This results in invasion of the appendix wall by gut flora, and it becomes inflamed and infected.
C: Unknown. May be related to blockage of the opening inside the appendix, enlarged tissue in the wall of your appendix, infection GI tract or elsewhere in your body, IBD, stool, parasites, or growths that can clog your appendiceal lumen, abdominal trauma.
S: Pain that begins as periumbilical and then becomes RIF (worse on movement and coughing), nausea, vomiting, anorexia, pyrexia, tenderness, guarding and rebound tenderness, Rosving’s sign may be positive: palpation of the left lower quadrant increases the pain felt in the right lower quadrant.
D: Urinalysis, pregnancy test, FBC, CRP, ultrasound, CT scan.
T: Admission to hospital for laparoscopic appendicectomy, antibiotics, intravenous fluids and opiate analgesia.

Question 43

Intussusception

Answer 43

Part of the GI tract invaginates or telescopes into another neighbouring portion.
There is usually a ‘lead point’ which is the cause of the invagination.
C: Malignancy, Meckel’s diverticulum, abnormal peristalsis, heterotopic pancreatic tissue, endometriosis, IBD, adhesions, enterovirus infection, diabetic ketoacidosis.
S: Recurrent non-specific abdominal pain, nausea and vomiting, change in bowel habit, abdominal distension, palpable mass, decreased or absent bowel sounds.
D: Barium enema, abdominal ultrasonography, CT scan, colonoscopy.
T: All intussusceptions involving the large bowel should be resected, as there is an almost 60% risk of malignancy, whereas small bowel intussusceptions should be managed by reduction initially, as the risk of a neoplastic lesion is much less.

Question 44

Acute mesenteric ischaemia

Answer 44

Includes acute mesenteric arterial embolus and thrombus, mesenteric venous thrombus and non-occlusive mesenteric ischaemia.
C: Arterial emboli (mitral stenosis, AF, valvular endocarditis), arterial thrombosis (atherosclerosis, aortic aneurysm, arteritis, MI, dehydration), hypotension, vasopressive drugs, ergotamines, cocaine, digitalis, hypercoagulability disorders, infection, tumour, venous trauma.
S: Moderate-to-severe colicky or constant and poorly localised pain, guarding and tenderness (peritonism), palpable mass.
D: Blood tests, CT angiography, ultrasound, MRI, electrocardiography, echocardiogram.
T: Initial resuscitation with IV fluids and oxygen, NG tube, broad-spectrum antibiotics, IV unfractionated heparin, prompt laparotomy should be done for patients with overt peritonitis.

Question 45

Chronic mesenteric ischaemia

Answer 45

Chronic atherosclerotic disease of the vessels supplying the intestine, usually involves all three mesenteric arteries.
C: Atherosclerosis -smoking, hypertension, diabetes mellitus and hyperlipidaemia.
S: Moderate-to-severe colicky or constant and poorly localised pain, weight loss, postprandial pain, nausea, vomiting, bowel irregularity, abdominal bruit.
D: FBC, LFTs and U&E, CXR, Arteriography, Mesenteric duplex ultrasonography
T: Conservatively - smoking cessation and antiplatelet therapy. Open or endovascular revascularisation. Total parenteral nutrition may be necessary both pre- and postoperatively.

Question 46

Ischaemic colic

Answer 46

A compromise of the blood circulation supplying the colon.
C: Thrombosis, emboli, arrythmias, shock, trauma, strangulated hernia or volvulus, medication, surgery, vasculitis, coagulation disorders, colonoscopy, barium enema.
S: Acute-onset abdominal pain, usually in the left iliac fossa, nausea and vomiting, loose stools containing blood, symptoms worsen with systemic instability.
D: Blood tests, ABG, colonoscopy, CXR, barium enema, CT/MRI scan, angiography.
T: Bowel rest and supportive care. Broad-spectrum antibiotics. If continues, and becomes more severe, may need require urgent laparotomy and removal of the necrotic part of the colon.

Question 47

Toxic megacolon

Answer 47

Megacolon is a general term that means the abnormal dilation of the colon. Toxic megacolon is a term used to express the seriousness of the condition.
C: IBD causing expansion, dilation and distension. If it ruptured it’s life-threatning. Infections such as Clostridium difficile colitis.
S: Abdominal pain, distension, fever, tachycardia, shock, bloody diarrhoea, painful bowel movements.
D: FBC, electrolytes, CXR, CT scan.
T: IV fluids to treat shock
Surgery - colectomy
Antibiotics to prevent sepsis

Question 48

Anal fissure

Answer 48

A tear in the mucosa of the anal canal, just inside the anal margin. Can be acute or chronic (more than 6 weeks).
C: Primary (no apparent cause), Secondary (constipation, IBD, STI, rectal malignancy)
S: Anal pain on defecation, bright red blood when passing stools, change to bowel habits, abdominal pain, weight loss, rectal discharge.
D: Bloods, abdominal exam, external examination, lexible sigmoidoscopy.
T: Increased dietary fibre, fluids, warm baths, topical ointments and botulinum toxin injections. Analgesia - paracetamol/ibuprofen, GTN ointment, 1-2 ml of lidocaine. Topical diltiazem 2%. Nifedipine. Surgery - usually lateral internal sphincterotomy.

Question 49

Anal fistula

Answer 49

A small tunnel that develops between the end of the bowel and the skin near the anus.
C: Anal abcess (glands around the anal can become blocked and infected, and if they become large enough), Crohn’s, diverticulitis, radiotherapy to the bowel/anus, anorectal cancer, TB, HIV, AIDS.
S: Skin irritation around the anus, constant throbbing pain, smelly discharge, passing pus or blood during defecation, bowel incontinence.
D: PR exam, proctoscopy, ultrasound, CT/MRI scan, STI screen.
T: Antibiotics. Seton procedure - surgical thread used to form a continuous ring and aid healing
Fistulotomy - cutting whole length of the fistula so it heals into a flat scar
Fibrin glue - injected into the fistula
Fistula plug - blocks the internal opening of the fistula
Endorectal advancement flat - healthy bowel wall used to cover the internal opening of the fistula
Ligation of the intersphincteric fistula track (LIFT) - fistula is cut, tied and divided

Question 50

Anal abcess

Answer 50

A collection of pus in the anal or rectal region.
C: Infection of an anal fissure, sexually transmitted infections or blocked anal glands.
S: Painful, hardened tissue in the perianal area, pus discharge, tenderness, fever, constant throbbing pain, constipation.
D: PR exam, Proctosigmoidoscopy, STI screen, Proctosigmoidoscopy, MRI scan, Transperineal ultrasound.
T: Prompt surgical drain, analgesia, antibiotics, fistulotomy or fistulectomy for associated fistulae.

Question 51

Pilonidal disease

Answer 51

A type of skin infection which typically occurs as a cyst between the cheeks of the buttocks.
C: Ingrown hair, excessive sitting, congenital pilonidal dimple, excessive sweating.
S: Asymptomatic, intermittent pain, yellow or bloody discharge, unexpected moisture, discomfort sitting, doing sit-ups, riding a bike.
D: Clinical symptoms and examination.
T: Incision and drainage
Surgical excision of the pilonidal sinus complex (+/- reconstructive flap technique)
Fibrin glue

Question 52

Bowel polyps

Answer 52

Small growths on the inner lining of the large intestine or rectum. Abnormal to have more than 5. Can be hyperplastic (small and common) or adenoma (more commonly become malignant).
C: Unknown. Family predisposition - polyposis syndromes e.g. FAP, HNPCC
S: Asymptomatic. Rectal bleeding, diarrhoea, constipation.
D: Faecal Occult blood test, Colonoscopy (+/- biopsy), Barium enema, Sigmoidoscopy
T: Removed during colonoscopy
Removal of part of the bowel (if you have a polyposis syndrome)

Question 53

Abdominal hernias

Answer 53

The protrusion of a viscis or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
Can be inguinal, femoral, epigastric, umbilical, incisional, spigelian, lumbar, sciatic.
C: Cogenitial, aging, damage from injury/surgery, chronic coughing, strenuous exercise, pregnancy, constipation, obesity, ascites.
S: Small lump, swelling, ache (not usually painful)
D: Physical examination, abdominal ultrasound, CT/MRI scan, Gastrografin or barium X-ray, endoscopy
T: Surgery for hernias depends on the size and type and can be performed under local or general anaesthetic.
Inguinal hernia: laparoscopic surgery, a mesh is glued or stitched over the hole of the hernia
Femoral hernia: with a mesh or open repair
Umbilical or paraumbilical: smaller ones repaired with stitches, larger ones repaired with a mesh

Question 54

GI perforation

Answer 54

Occurs when a hole forms all the way through, anywhere from the upper oesophagus to the anorectal junction.
C: Peptic ulcer disease, foreign body, diverticulitis, cholecystitis, Meckel’s diverticulum, mesenteric ischaemia, obstructing lesions like cancer or faeces, toxic megacolon, surgery, trauma, excessive vomiting.
S: Rapid onset and sharp pain, systemically unwell, features of sepsis, rigid abdomen and features of peritonism, pleural effusion.
D: Bloods, urinaylsis, CXR, abdominal X-ray, CT scan.
T: Broad spectrum antibiotics, NG insertion, IV fluids and analgesia. Surgical intervention to repair the perforation and thorough wash out.

Question 55

Upper GI haemorrhage

Answer 55

Any bleeding proximal to the suspensory ligament of the duodenum that marks the duodenojejunal junction.
C: Peptic ulcer disease, liver disease, Mallory-Weiss tear, malignancy, oesophagitis, varices.
S: Haematemesis, meleana, syncope, dizziness, fresh PR bleeding, hypotension, tachycardia.
D: FBC, U&Es, VBG, Coag, LFTs, group and save, CXR, ECG, Glasgow-Blatchford Bleeding Score, Rockall score
T: PPIs, such as omeprazole or pantoprazole, Somatostatins (Octreotide) and vasopressins (Terlipressin) for a variceal haemorrhage
Endoscopic intervention and repair
Balloon tamponade

Question 56

Lower GI haemorrhage

Answer 56

Bleeding distal to the suspensory ligament of the duodenum that marks the duodenojejunal junction, i.e. some of the small bowel, the colon and the rectum.
C: Diverticular disease, colitis, haemorrhoids, colorectal cancer, angiodysplasia, following the removal of a colonic polyp, IBD, rectal varices.
S: Passing bright red blood per rectum, dyspnoea, tachycardia, postural hypotension, abdominal tenderness.
D: FBC, U&Es, Coag, LFTs, group and save, ECG, CXR, PR examination, VBG/ABG.
T: Colonoscopy with coagulation (usually thermal contact or epinephrine injection, can use haemoclips and band ligation)
Angiography
Review medication
Surgery if massive bleed

Question 57

Pyloric stenosis

Answer 57

Pyloric stenosis means a narrowed outlet of the stomach. It occurs in some newborn babies (2-4 weeks old) and can lead to serious illness.
C: The muscle in the pylorus is abnormally thick, causing it to become narrowed. Unknown cause.
S: Vomiting after feeding, passing little to no faeces, not gaining weight, dehydration.
D: Abdominal examination (bulge next to the stomach), ultrasound.
T: Pyloromyotomy - A small cut is made in the skin over the pylorus under general anasthetic

Question 58

Intrabdominal abcess

Answer 58

Localised collections of infected fluid and can be simple or complex. The most common areas are subhepatic, pelvic and paracolic gutters.
C: malignancy, trauma, peptic ulcer perforation, iatrogenic (in Upper GI), ischaemic bowel, diverticulitis, hernia, obstruction, IBD, appendicitis, trauma (in Lower GI), cholecystitis. malignancy, pancreatitis, endocarditis, pelvic inflammatory disease.
S: Swinging fever, abdominal pain, ileus, diarrhoea, can cause chest/shoulder pain/flank pain, palpable abdominal inflammatory mass or a hot tender mass on rectal examination.
D: FBC, U&Es and creatinine, LFTs, amylase, lipase, blood cultures, peritoneal fluid culture, urinalysis, CXR, AXR, CT/MRI.
T: Antibiotics - based on results of blood or abscess culture material. Percutaneous drainage under CT or ultrasound guidance.

Question 59

Acute viral hepatitis

Answer 59

Inflammation of the liver.
C: Commonly caused by a virus. A (contaminated water or food), E (contaminated water or food, usually uncooked shellfish), C (via blood), B (via blood), D (only if HBV is present). Also EBV.
S: Fever, malaise, nausea, hepatomegaly, RUQ pain, jaundice, dark urine.
Fulminant - jaundice, very unwell, deteriorating mental function, abnormal prothrombin time and INR.
D: Increase ALT and AST in the blood (ALT more so), elevated levels of atypical lymphocytes, viral antibodies.
T: Supportive care to manage symptoms - NSAIDs and paracetamol, metoclopramide, chlorphenamine.
Abstain from alcohol.
Notify the Health Protection Unit.
Avoid work, school, or nursery, until they are no longer infectious (7 days after symptoms).
Minimize transmission.
Admission if severely unwell or dehydrated.

Question 60

Chronic hepatitis

Answer 60

Inflammatory disease of the liver lasting for more than six months.
C: Hep B, hep C, EBV, cytomegalovirus, NAFLD, haemochromatosis, alpha-1-antitrypsin deficiency, autoimmune hepatitis, alcoholic liver disease, primary biliary cirrhosis, primary sclerosing cholangitis, sarcoidosis.
S: Fatigue, anorexia, muscle pains, weight loss, RUQ pain, ascites, ankle swelling, confusion and drowsiness, jaundice, spider naevi, palmar erythema, clubbing, xanthomas.
D: Urinalysis: bilirubin and urobilinogen, FBC, LFTs, renal function, electrolytes, serum albumin, prothrombin time, Immunoglobulins, autoantibodies, serology, ultrasound, CT/MRI, biopsy.
T: Hep B - peginterferon alfa 2-a (injection once a week for 48 weeks). If this doesn’t work, antivirals. This will usually be either tenofovir or entecavir.
Hep C - combination of highly active antiviral agents known as direct-acting antivirals (DAAs). May need to be taken for 8-24 weeks.

Question 61

Enteric fever

Answer 61

Bacterial infection that can spread throughout the body.
C: Typhoid fever (Salmonella typhi), paratyphoid fever (Salmonella enterica A, B, C).
S: Fever, dry cough, malaise, headache, abdominal pain, diarrhoea, constipation, hepatosplenomegaly, confusion, weight loss, abdo distension.
D: Stool culture, blood cultures, bone marrow aspiration, Widal’s test (test for antibodies)
T: A soft, easily digestible diet, rest, rehydration, correction of electrolytes, antipyretic therapy, avoid transmission.
5 day course of antibiotics - usually Azithromycin
Multiple-resistant - fluoroquinolone (5-7 days), or cefixime (7-14 days).
Quinolone-resistant - azithromycin (7 days) or ceftriaxone (10-14 days).

Question 62

Colonic volvulus

Answer 62

Twisting of a loop of intestine around its mesenteric attachment, resulting in a closed loop bowel obstruction and sometimes ischaemia. Usually sigmoid or can be caecum.
C: Age, neuropsychiatric disorders, chronic constipation or laxative use, male, previous abdominal operations.
Caecum - intestinal malformation or excessive exercise, chronic constipation, distal obstruction, or dementia.
S: Colicky pain, abdominal distension, constipation, vomiting, abdomen is often very tympanic to percussion.
D: Routine bloods should be taken, including electrolytes, Ca2+, and TFTs, CT scan abdomen-pelvis with contrast, abdominal XR.
T: Admitted to hospital - examined for any signs of ischaemia and given fluid resuscitation.
Treated conservatively initially with decompression by sigmoidoscope and insertion of a flatus tube.
Surgery - laparotomy for a Hartmann’s procedure if ischemia, necrosis, perforation or failed decompression.