Gastrointestinal

Question 1

Achalasia

Answer 1

Imaging

• Upper GI Endoscopy
• Barium Swallow (beak sign)
• Oesophageal Manometry (incomplete relax of LOS + aperistalsis oesoph)

Question 2

Anal Fissure

Answer 2

Clinical Diagnosis

Question 3

Anorectal Abscess

Answer 3

Bedside
 - Clinical Diagnosis
 - Swab and Culture
Bloods
 - FBC (WCC raised)
 - Electrolytes in ?Sepsis

Question 4

Appendicitis

Answer 4

Bloods
 - FBC
 - CRP (raised)
 - G+S (surgery)
Imaging (d>6mm)
 - Abdominal USS 
 - Contrast Abdo CT

Question 5

Crohn’s Disease

Answer 5

Bloods
- FBC (anaemia, WCC, thrombocytosis)
- Iron Study (anaemia)
- Serum B12 (malabsorption)
- Serum Folate (malabsorption)
- CMP (hypoalbumin, hypocholesterol, Hypocalcaemia)
- CRP (raised)
- ESR (raised)
Imaging
- Plain AXR (bowel dilation, calcification, sacroiliitis, intra abdo abscess)
- CR/MRI (skip lesions, bowel wall thick, inflam, abscess, fistulae)
Special
- Stool Sample (absence of infection)
- Yersinia Enterocolitica Serology (negative)

Question 6

GORD

Answer 6

PPI Trial 8/52 with symptom improvement

?OGD - oesophagitis, Barrett’s

Question 7

Haemorrhoids

Answer 7

Bedside
- Anoscopic Examination (visual haemorrhoids)
Bloods
- FBC (prolonged bleeding)
Imaging
- Colonoscopy/ Flexi Sigmoidoscopy (exclusion)
Special
- Stool for occult haem if no haemorrhoidal tissue seen (positive)

Question 8

Hiatus Hernia

Answer 8

Imaging

• CXR (intrathoracic retrocardiac gastric bubble or air fluid level)
• Upper GI series (barium meal) intrathoracic stomach

Question 9

Inguinal Hernia

Answer 9

Mainly Clinical Diagnosis

Image if uncertain

• USS of Groin
• CT Scan in obese
• Herniography (contrast into sac)
• MRI groin (abnormal widening of inguinal canal)

Question 10

Malignant Oesophageal Sphincter

Answer 10

Bloods
 - Metabolic Panel (dysphagia --> Hypovolaemia) 
    1. Hypokalaemia
    2. Elevated Creatinine
    3. Elevated urea/nitrogen
Imaging
 - OGD with biopsy

Question 11

Colorectal Cancer

Answer 11

Bloods

• FBC (anaemia)
• LFT (baseline check for chemo)
• U+E (normal)

Imaging

• Colonoscopy + Biopsy (ulcerating exophytic mucosal lesion narrow bowel lumen)
• CT Colonography (ulcerating exophytic lesion narrowing bowel lumen
• Barium Enema (mass lesion in colon and/or ‘apple core’ lesion)
• CT chest, abdomen and pelvis (colonic wall thickening, enlarged lymph nodes, liver mets, lung secondaries)

Question 12

Ruptured Viscus (Perforated Bowel)

Answer 12

Bedside

• Clinical Examination
• Pregnancy Test (ectopic)
• Urinalysis (infection, stones)

Bloods

• FBC (WCC)
• Electrolytes (obstruction = hypochloraemia, hypokalaemia)
• Urea (raised in AAA or Dissection impairing renal arteries)
• Glucose (elevated in pancreatitis if islets affected)

Imaging

• Plain AXR
• Erect CXR (Pneumoperitoneum)
• USS (GB, pelvis, AAA)
• OGD

Special
- Laparoscopy

Question 13

Ascending Cholangitis

Answer 13

Bloods

• FBC (WCC, Platelets raised)
• Blood Culture
• Urea (raised in severe)
• Creatinine (raised in severe)
• ABG (metabolic acidosis with raised lactate)
• LFT (bilirubin, ALT, AST, ALP raised)
• CRP (raised)
• Potassium (low)
• Magnesium (high)
• Coagulation (increase PT))

Imaging

• Abdo USS (if RUQ) - dilated CBD, CBD stones
• ERCP - observe CBD stones or obstruction

Question 14

Acute Pancreatitis

Answer 14

Bedside
- Pulse Oximetry

Bloods

• Lipase and Amylase (>3x upper limit +acute pain)
• FBC (WCC, haematocrit)
• CRP (>200 necrotic)
• Urea/creatinine (dehydration)
• LFT (ALT >3x upper limit = gallstone cause)
• Calcium (hyper is a cause)
• ABG (hypoxaemia, and acid-base disturb)

Imaging

• AUSS (GS, inflammation, calcification, fluid)
• CXR (pleural effusion, basal atelectasis, elevated hemidiaphragm)

Question 15

Alcoholic Liver Disease

Answer 15

Bloods

• AST/ALT ratio >2
• ALP
• Bilirubin
• Albumin
• Gamma-GT
• FBC (Hb, WCC, platelet)
• Electrolytes (hypo)
• U+E (elevated urea + normal creatinine = GI bleed)
• PT, INR

Imaging
- Hepatic USS (megaly, fatty, cirrhosis, mass, ascites)

Special
- Hepatitis Serology

Question 16

Cholecystitis

Answer 16

Bloods

• FBC (WCC)
• CRP
• Bilirubin
• ALP (raised)
• ALT/AST (normal unless liver involve)
• Lipase/Amylase (exclude panc if <3 x upper)
• Blood Culture

Imaging

• Abdo USS
  
  • Pericholecystic Fluid
  • Distended GB
  • Thickened GB Wall >3mm
  • Gallstones
• CT/MRI Abdo
  
  • Irreg thick GB wall
  • Poor contrast enhanced GB wall
  • Increased fatty tissue around GB
  • Gas in GB lumen or wall
  • Peri GB abscess

Question 17

Constipation

Answer 17

Bedside

• Anocutaneous Relfex (ext sphinct tone)
• DRE

Bloods

• FBC (anaemia iron)
• TFT (TSH increased in 1. hypothyroid)
• Electrolytes (Hypokalaemia)
• Calcium (Hypercalcaemia >2.75)
• Magnesium (Hypomagnesemia)
• Glucose (elevated DM)

Imaging

• AXR (impaction, rectal mass)
• Barium Enema (impaction, rectal mass)

Question 18

Ascites

Answer 18

Bedside

• Shifting Dullness
• Fluid Thrill
• Fluid Wave

Bloods

• FBC (thrombocytopenia in portal HTN)
• Metabolic Panel
• Albumin
• Prothrombin time
• Bilirubin
• Hep ABC

Imaging

• Abdo USS (fluid + portal and hepatic vein thrombosis or stenosis)
• CT (malignancy + spleen diameter >12cm or recanalisation of umbilical veins = portal HTN)

Special

• Paracentesis + testing for WCC, culture, serum to ascitic fluid albumin gradient.
• Liver biopsy to rule out or distinguish cause of cirrhosis

Question 19

Biliary Colic

Answer 19

Bedside
- No Fever or Jaundice

Bloods (Exclusion)

• FBC (normal)
• LFT (normal)
• Amylase/Lipase (normal)

Imaging

• USS RUQ detects Gallstones
• ERCP only if suggestion of bile duct stone