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UKMLA Prep > Gastrointestinal including liver > Flashcards

Gastrointestinal including liver Flashcards

Conditions and presentation

1
Q

Acute pancreatitis symptoms

A
  • stabbing-like, epigastric pain radiating to the back.
  • foetal position is usally taken
  • associated with vomiting
  • assoicated with alcohol consumption
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2
Q

Clinical signs of pancreatitis

A
  • hypovolaemia
  • fever
  • Non-specific guarding
  • Grey-Turner’s sign (bruising along the flanks)
  • Cullen’s sign, characterized by bruising around the peri-umbilical area
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3
Q

Pancreatitis investigations

A
  • FBC,urea and electrolytes
  • LFTs
  • Lipase and amylase
  • US
  • MRCP
  • ERCP
  • CT pancreas
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4
Q

Pancrease Mnemonic

A

PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L

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5
Q

Managment of pancreatitis

A
  • Aggressive fluid resuscitation with crystalloids to maintain urine output > 30 mL/hour.
  • Catheterisation.
  • Analgesia: Strong opioids are often necessary.
  • Anti-emetics.
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6
Q

complications of pancreatitis

A
  • Peripancreatic Fluid Collection
  • Pdeudocyst
  • pancreatic abcess
  • pancreatic necrosis
  • haemorrhage
  • ARDS
  • Hypovolemic
  • DM
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7
Q

Porphyria

A

pectrum of disorders arising from abnormalities in the haem synthesis pathway, which result from either structural or functional alterations in the enzymes involved.

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8
Q

Porphyria symptoms

A

Abdominal pain
Nausea
Confusion
Hypertension
Seizures

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9
Q

Signs and symptoms of Porphyria

A
  • Urine may appear red/purple
  • Urinary porphobilinogen levels (keep away from light)
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10
Q

Managment of Porphyria

A

supportive

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11
Q

6-12 hours after withdrawal symptoms of alcohol

A
  • Insomnia
  • Tremors
  • Anxiety
  • Agitation
  • Nausea and vomiting
  • Sweating
  • Palpitations
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12
Q

12-24 hours post-drink

A

hallucinations

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13
Q

72-hours post drink

A

Delusions
Confusion
Seizures
Tachycardia
Hypertension
Hyperthermia

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14
Q

alcohol withdrawal investigations

A
  • AUDIT and SADQ questionnaires to assess the severity of alcohol misuse.
  • Blood tests to assess liver function and electrolyte balance.
  • Neuroimaging may be considered in cases of persistent confusion or seizures.
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15
Q

INDICATIONS FOR INPATIENT WITHDRAWAL TREATMENT

A
  • Patients drinking >30 units per day
  • Scoring over 30 on the SADQ score
  • High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
  • Concurrent withdrawal from benzodiazepines
  • Significant medical or psychiatric comorbidity
  • Vulnerable patients
  • Patients under 18
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16
Q

Managment of alcohol withdrawal

A
  • chlordiazepoxide
  • Pabrinex
  • intravenous lorazepam or oral lorazepam
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17
Q

Cyclizine

A
  • H1 receptor antagonist
  • Vestibular disturbances
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18
Q

Domperidone, metoclopramide

A
  • D2 receptor antagonist
  • Post-operative nausea, motion sickness
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19
Q

Ondansetron

A
  • 5HT3 receptor antagonist
  • Acute gastroenteritis, post-operative nausea, radiotherapy- or chemotherapy-induced
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20
Q

Hyoscine hydrobromide

A
  • Anti-muscarinics
  • Vestibular disturbances, palliative care
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21
Q

When to avoid Metoclopramide

A
  • bowel obstruction
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22
Q

When to avoid Haloperidol

A

Parkinson’s disease and prolonged QT interval.

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23
Q

Prochlorperazine and clorpromazine avoid using when

A
  • Parkinson’s disease symptoms
  • young women as causes dystonia
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24
Q

Cyclizine avoidance when?

A

acute porphyurias

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25
Q

Zollinger Ellison syndrome

A
  • Tumour that sits in the pancreas or the duodenum.
  • Uncontrolled release of gastrin from a gastrinoma,
  • development of multiple ulcerations in the stomach and duodenum.
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26
Q

Zollinger Ellison signs and syptoms

A
  • Abdominal pain, particularly in the epigastric region
  • Diarrhoea
  • Ulceration of the duodenum, which can often lead to gastrointestinal bleeding
  • Non-responsiveness to simple Proton Pump Inhibitors (PPIs)
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27
Q

Zollinger Ellison investigations

A
  • screening for elevated gastrin levels.
  • secretin stimulation test
  • Somatostatin receptor scintigraphy is the preferred imaging modality, as conventional
  • CT scans may often miss the tumour.
    Endoscopy is also performed to identify duodenal ulcers.
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28
Q

Zollinger Ellison syndrome managment

A
  • surgical resection
  • PPIs
  • chemotherapy and somatostatin analogues may be considered.
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29
Q

Ascites

A

abnormal accumulation of fluid within the peritoneal cavity.

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30
Q

Symptoms of ascities

A
  • Abdominal distension
  • Abdominal discomfort or pain
  • Dyspnea
  • Reduced mobility
  • Anorexia and early satiety due to pressure on the stomach
  • Tense abdomen
  • Shifting dullness
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31
Q

What is the term for the position of a structure relative to the front of the body?

A

Anterior relations

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32
Q

What is the term for the position of a structure relative to the back of the body?

A

Posterior relations

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33
Q

What is the vertebral level of T12?

A

12th thoracic vertebra

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34
Q

What is the vertebral level of L4?

A

4th lumbar vertebra

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35
Q

List the vertebral bodies from L1 to L4

A
  • L1
  • L2
  • L3
  • L4
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36
Q

What structure connects the stomach to the liver?

A

Lesser omentum

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37
Q

Which organ is primarily responsible for detoxification and metabolism?

A

Liver

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38
Q

What vein drains the left kidney?

A

Left renal vein

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39
Q

What vein drains the gastrointestinal tract and connects to the superior mesenteric vein?

A

Inferior mesenteric vein

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40
Q

Which part of the duodenum is referred to as the third part?

A

Third part of duodenum

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41
Q

Which organ is located behind the stomach and is involved in digestion?

A

Pancreas

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42
Q

What layer of the abdominal cavity lines the abdominal wall?

A

Parietal peritoneum

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43
Q

What is the term for the space within the abdomen that contains the intestines, liver, and other organs?

A

Peritoneal cavity

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44
Q

What is the name of the right portion of the diaphragm?

A

Right crus of the diaphragm

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45
Q

What is the name of the lymphatic structure that collects lymph from the lower body?

A

Cisterna chyli

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46
Q

What vein is responsible for draining blood from the thoracic wall into the superior vena cava?

A

Azygos vein

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47
Q

What does IVC stand for in the context of venous drainage?

A

Inferior vena cava

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48
Q

What is the fourth part of the duodenum called?

A

4th part of duodenum

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49
Q

What is the term for the bend between the duodenum and jejunum?

A

Duodenal-jejunal flexure

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50
Q

What structure is part of the sympathetic nervous system located on the left side of the vertebral column?

A

Left sympathetic trunk

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51
Q

What are the right lateral relations of a structure?

A

Right lateral relations

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52
Q

What are the left lateral relations of a structure?

A

Left lateral relations

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53
Q

What are the branches of the abdominal aorta?

A

Inferior phrenic, Coeliac, Superior mesenteric, Middle suprarenal, Renal, Gonadal, Lumbar, Inferior mesenteric, Median sacral, Common iliac

These branches supply various organs and structures in the abdominal region.

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54
Q

At what level does the abdominal aorta primarily branch?

A

T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4

The levels indicate the vertebral locations where the branches emerge.

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55
Q

Which abdominal aortic branches are paired?

A

Renal, Gonadal, Lumbar, Common iliac

Paired branches typically supply symmetrical structures on either side of the body.

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56
Q

Which abdominal aortic branches are unpaired?

A

Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral

Unpaired branches usually supply midline structures in the abdomen.

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57
Q

What type of branches are the Inferior phrenic and Lumbar?

A

Parietal

Parietal branches supply the body wall.

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58
Q

What type of branches are the Coeliac and Superior mesenteric?

A

Visceral

Visceral branches supply the organs within the abdominal cavity.

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59
Q

Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.

A

Inferior phrenic

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60
Q

True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.

A

False

The Middle suprarenal branch is unpaired.

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61
Q

Which branches of the abdominal aorta are classified as terminal?

A

Common iliac

Terminal branches are the final branches of the abdominal aorta before it bifurcates.

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62
Q

What are the branches of the abdominal aorta?

A

Inferior phrenic, Coeliac, Superior mesenteric, Middle suprarenal, Renal, Gonadal, Lumbar, Inferior mesenteric, Median sacral, Common iliac

These branches supply various organs and structures in the abdominal region.

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63
Q

At what level does the abdominal aorta primarily branch?

A

T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4

The levels indicate the vertebral locations where the branches emerge.

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64
Q

Which abdominal aortic branches are paired?

A

Renal, Gonadal, Lumbar, Common iliac

Paired branches typically supply symmetrical structures on either side of the body.

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65
Q

Which abdominal aortic branches are unpaired?

A

Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral

Unpaired branches usually supply midline structures in the abdomen.

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66
Q

What type of branches are the Inferior phrenic and Lumbar?

A

Parietal

Parietal branches supply the body wall.

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67
Q

What type of branches are the Coeliac and Superior mesenteric?

A

Visceral

Visceral branches supply the organs within the abdominal cavity.

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68
Q

Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.

A

Inferior phrenic

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69
Q

True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.

A

False

The Middle suprarenal branch is unpaired.

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70
Q

Which branches of the abdominal aorta are classified as terminal?

A

Common iliac

Terminal branches are the final branches of the abdominal aorta before it bifurcates.

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71
Q

What is the location of the appendix?

A

Base of caecum

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72
Q

How long can the appendix be?

A

Up to 10cm long

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73
Q

What type of tissue mainly composes the appendix?

A

Lymphoid tissue

This is significant because mesenteric adenitis may mimic appendicitis.

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74
Q

What anatomical feature helps in identifying the appendix during surgery?

A

Convergence of caecal taenia coli at base of appendix

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75
Q

What is the arterial supply to the appendix?

A

Appendicular artery (branch of the ileocolic)

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76
Q

Is the appendix intra or retroperitoneal?

A

Intra peritoneal

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77
Q

Where is McBurney’s point located?

A

1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus

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78
Q

What percentage of appendices are found in the retrocaecal position?

A

74%

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79
Q

What percentage of appendices are found in the pelvic position?

A

21%

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80
Q

List the six positions of the appendix.

A
  • Retrocaecal
  • Pelvic
  • Postileal
  • Subcaecal
  • Paracaecal
  • Preileal
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81
Q

Where is the caecum located?

A

Proximal right colon below the ileocaecal valve

The caecum is intraperitoneal.

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82
Q

What are the posterior relations of the caecum?

A
  • Psoas
  • Iliacus
  • Femoral nerve
  • Genitofemoral nerve
  • Gonadal vessels

These structures are located behind the caecum.

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83
Q

What are the anterior relations of the caecum?

A

Greater omentum

The greater omentum is a fold of peritoneum that hangs down from the stomach.

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84
Q

What is the arterial supply of the caecum?

A

Ileocolic artery

The ileocolic artery branches from the superior mesenteric artery.

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85
Q

What accompanies the venous drainage of the caecum?

A

Mesenteric nodes

Lymphatic drainage is important for immune function and fluid balance.

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86
Q

What is the most distensible part of the colon?

A

Caecum

This characteristic makes it vulnerable in cases of bowel obstruction.

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87
Q

In complete large bowel obstruction, where is the most likely site of eventual perforation?

A

Caecum

This occurs specifically with a competent ileocaecal valve.

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88
Q

What is the length of the ureter?

A

25-35 cm long

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89
Q

What type of epithelium lines the ureter?

A

Transitional epithelium

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90
Q

What surrounds the ureter?

A

Thick muscular coat

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91
Q

How many muscular layers does the ureter have as it crosses the bony pelvis?

A

3 muscular layers

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92
Q

Where is the ureter located in relation to the transverse processes?

A

Retroperitoneal structure overlying transverse processes L2-L5

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93
Q

What lies anterior to the bifurcation of the iliac vessels?

A

Ureter

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94
Q

What is the blood supply to the ureter?

A

Segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac

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95
Q

Where does the ureter lie in relation to the uterine artery?

A

Beneath the uterine artery

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96
Q

What is the diaphragm?

A

A muscle that separates the thoracic cavity from the abdominal cavity and is the primary muscle involved in respiration.

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97
Q

What are diaphragm apertures?

A

Openings within the diaphragm that allow specific structures to pass from the thoracic cavity to the abdominal cavity.

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98
Q

List the three main diaphragm apertures and their vertebral levels.

A
  • Aortic hiatus - T12
  • Oesophageal hiatus - T10
  • Vena cava foramen - T8
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99
Q

How can the vertebral levels of diaphragm apertures be remembered?

A

By counting the total number of letters in the spellings of ‘vena cava’ (8), ‘oesophagus’ (10), and ‘aortic hiatus’ (12).

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100
Q

What are lesser diaphragmatic apertures?

A

Smaller openings in the diaphragm that allow much smaller structures to pass through.

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101
Q

Name some examples of lesser diaphragmatic apertures.

A
  • Left phrenic nerve
  • Small veins
  • Superior epigastric artery
  • Intercostal nerves & vessels
  • Subcostal nerves & vessels
  • Splanchnic nerves
  • Sympathetic trunk
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102
Q

What is Klinefelter’s syndrome associated with?

A

Karyotype 47, XXY

Klinefelter’s syndrome is a genetic condition resulting from the presence of an extra X chromosome.

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103
Q

List some features of Klinefelter’s syndrome.

A
  • Often taller than average
  • Lack of secondary sexual characteristics
  • Small, firm testes
  • Infertile
  • Gynaecomastia
  • Increased incidence of breast cancer
  • Elevated gonadotrophin levels but low testosterone

These features contribute to the diagnosis and understanding of the syndrome’s impact on individuals.

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104
Q

How is Klinefelter’s syndrome diagnosed?

A

By karyotype (chromosomal analysis)

Karyotyping helps to confirm the presence of the extra chromosome associated with the syndrome.

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105
Q

True or False: Individuals with Klinefelter’s syndrome are typically fertile.

A

False

Infertility is a common feature of Klinefelter’s syndrome due to testicular dysfunction.

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106
Q

Fill in the blank: Klinefelter’s syndrome results in _______ levels of testosterone.

A

Low

The low testosterone levels are due to testicular dysgenesis associated with the syndrome.

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107
Q

Acute Cholangitis

A

Definition: Infection of the biliary tree due to obstruction (often gallstones).
Key Features: Fever, jaundice, RUQ pain (Charcot’s triad); can progress to hypotension and confusion (Reynolds’ pentad).
Diagnosis: Elevated ALP, GGT, bilirubin; imaging (US, MRCP).
Management: IV antibiotics, ERCP for decompression.

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108
Q

Acute Pancreatitis

A

Definition: Inflammation of the pancreas, often caused by gallstones or alcohol.
Key Features: Epigastric pain radiating to the back, nausea, vomiting.
Diagnosis: Serum lipase/amylase >3x normal, CT if severe.
Management: Supportive care (IV fluids, analgesia), treat underlying cause.

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109
Q

Alcoholic Hepatitis

A

Definition: Liver inflammation caused by excessive alcohol consumption.
Key Features: Jaundice, hepatomegaly, RUQ pain, fever.
Diagnosis: AST > ALT (usually 2:1), elevated bilirubin, INR.
Management: Abstinence, nutritional support, corticosteroids in severe cases

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110
Q

Anaemia

A

Definition: Low hemoglobin levels; multiple types (iron deficiency, B12/folate deficiency, etc.).
Key Features: Fatigue, pallor, breathlessness, tachycardia.
Diagnosis: FBC, iron studies, B12/folate levels, peripheral blood smear.
Management: Treat underlying cause (iron supplements, B12 injections).

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111
Q

Anal fissure

A

Definition: Tear in the anal mucosa, usually posterior midline.
Key Features: Pain during defecation, bright red rectal bleeding.
Diagnosis: Clinical examination.
Management: High-fiber diet, topical anesthetics, GTN cream; surgery if chronic.

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112
Q

Appendicitis

A

Definition: Inflammation of the appendix.
Key Features: Periumbilical pain migrating to RLQ, fever, nausea, vomiting.
Diagnosis: Clinical exam, elevated WBCs, imaging (US, CT).
Management: Appendectomy (laparoscopic preferred).

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113
Q

Ascites

A

efinition: Accumulation of fluid in the peritoneal cavity, often due to cirrhosis.
Key Features: Abdominal distension, shifting dullness.
Diagnosis: Abdominal US, paracentesis (for SAAG).
Management: Salt restriction, diuretics, paracentesis if large-volume.

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114
Q

Cholecystitis

A

Definition: Inflammation of the gallbladder, often secondary to gallstones.
Key Features: RUQ pain, Murphy’s sign, fever, nausea.
Diagnosis: US (thickened gallbladder wall, stones), WBCs.
Management: IV fluids, antibiotics, cholecystectomy.

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115
Q

Coeliac’s disease

A

Definition: Autoimmune reaction to gluten, causing villous atrophy in the small intestine.
Key Features: Diarrhea, weight loss, bloating, iron deficiency anemia.
Diagnosis: Anti-tTG antibodies, duodenal biopsy.
Management: Gluten-free diet.

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116
Q

Diverticular disease

A

Definition: Outpouchings of the colonic wall (diverticula), which can become inflamed (diverticulitis).
Key Features: LLQ pain, fever, constipation/diarrhea, rectal bleeding.
Diagnosis: CT abdomen with contrast; avoid colonoscopy during acute inflammation.
Management: High-fiber diet (diverticulosis), antibiotics, and bowel rest for diverticulitis. Surgery if complications (e.g., perforation).

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117
Q

Gall stones and Billary colic

A

Definition: Stones in the gallbladder (cholelithiasis) causing intermittent biliary obstruction.
Key Features: RUQ pain (post-fatty meal), radiating to the back or shoulder, no fever/jaundice.
Diagnosis: Abdominal ultrasound.
Management: Pain relief, elective cholecystectomy if symptomatic.

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118
Q

GI perforation

A

Definition: A hole in the wall of the GI tract, leading to peritonitis.
Key Features: Severe abdominal pain, guarding, rigidity, fever, hypotension.
Diagnosis: Upright chest X-ray (free air under diaphragm), CT abdomen.
Management: Emergency surgery, antibiotics, and fluid resuscitation.

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119
Q

GERD

A

Definition: Reflux of gastric contents into the esophagus due to lower esophageal sphincter dysfunction.
Key Features: Heartburn, regurgitation, dysphagia, chronic cough.
Diagnosis: Clinical, endoscopy if red flags.
Management: Lifestyle modifications, PPI (e.g., omeprazole), and antacids.

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120
Q

Haemochromatosis

A

Definition: Autosomal recessive condition causing iron overload and tissue damage.
Key Features: Fatigue, arthralgia, bronzed skin, hepatomegaly, diabetes.
Diagnosis: Elevated ferritin, transferrin saturation, genetic testing (HFE mutation).
Management: Regular venesection, iron chelation if needed.

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121
Q

Hepatits

A

Definition: Inflammation of the liver (causes: viral, autoimmune, alcohol, drugs).
Key Features: Jaundice, fatigue, RUQ pain, hepatomegaly.
Diagnosis: Liver function tests, viral serology, imaging.
Management: Depends on cause (e.g., antivirals for viral hepatitis, abstinence for alcoholic hepatitis).

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122
Q
A
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123
Q

What is the commonest approach to the abdomen?

A

Midline incision

Structures divided include linea alba, transversalis fascia, extraperitoneal fat, and peritoneum, while avoiding the falciform ligament above the umbilicus.

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124
Q

Which incision allows for access to the bladder via an extraperitoneal approach?

A

Midline incision

Access is achieved through the space of Retzius.

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125
Q

What is a paramedian incision?

A

An incision parallel to the midline (about 3-4cm)

Structures divided/retracted include anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, and peritoneum.

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126
Q

What structures are divided or retracted in a paramedian incision?

A
  • Anterior rectus sheath
  • Rectus (retracted)
  • Posterior rectus sheath
  • Transversalis fascia
  • Extraperitoneal fat
  • Peritoneum

The incision is closed in layers.

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127
Q

What is the Battle incision?

A

Similar location to paramedian but rectus displaced medially

This incision is now seldom used.

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128
Q

Describe Kocher’s incision.

A

Incision under right subcostal margin

Commonly used for cholecystectomy (open).

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129
Q

What is the purpose of the Lanz incision?

A

Incision in right iliac fossa

Typically used for appendicectomy.

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130
Q

What is the Gridiron incision used for?

A

Oblique incision centered over McBurney’s point

Usually performed for appendicectomy and is less cosmetically acceptable than Lanz.

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131
Q

What type of incision is Pfannenstiel’s incision?

A

Transverse supra pubic incision

Primarily used to access pelvic organs.

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132
Q

What is McEvedy’s incision used for?

A

Groin incision

Used for emergency repair of strangulated femoral hernia.

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133
Q

What is the Rutherford Morrison incision known for?

A

Extraperitoneal approach to left or right lower quadrants

Provides excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

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134
Q

What is a characteristic feature of duodenal ulcers?

A

Epigastric pain relieved by eating

Duodenal ulcers are more common than gastric ulcers.

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135
Q

What symptom is associated with gastric ulcers?

A

Epigastric pain worsened by eating

Features of upper gastrointestinal hemorrhage may be seen.

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136
Q

What is the typical initial pain location in appendicitis?

A

Central abdomen

Pain later localizes to the right iliac fossa.

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137
Q

What are common symptoms of appendicitis?

A
  • Anorexia
  • Tachycardia
  • Low-grade pyrexia
  • Tenderness in RIF
  • Rovsing’s sign

Rovsing’s sign indicates more pain in the RIF than LIF when palpating the LIF.

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138
Q

What is the most common cause of acute pancreatitis?

A

Alcohol or gallstones

Severe epigastric pain and vomiting are common.

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139
Q

What are Cullen’s sign and Grey-Turner’s sign associated with?

A

Periumbilical and flank discoloration, respectively

These signs are described in acute pancreatitis but are rare.

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140
Q

What is a characteristic feature of biliary colic?

A

RUQ pain radiating to the back and interscapular region

Pain may follow a fatty meal and can persist for hours.

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141
Q

What may obstructive jaundice cause in terms of stool and urine color?

A
  • Pale stools
  • Dark urine

These changes are due to bile duct obstruction.

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142
Q

What are classic symptoms of acute cholecystitis?

A
  • Continuous RUQ pain
  • Fever
  • Raised inflammatory markers
  • Positive Murphy’s sign

Murphy’s sign involves arrest of inspiration on palpation of the RUQ.

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143
Q

What is the typical presentation of diverticulitis?

A

Colicky pain in the LLQ

Fever and raised inflammatory markers are also common.

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144
Q

What type of pain is associated with an abdominal aortic aneurysm?

A

Severe central abdominal pain radiating to the back

Presentation may be catastrophic or sub-acute.

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145
Q

What are common symptoms of intestinal obstruction?

A
  • History of malignancy/previous operations
  • Vomiting
  • Not opened bowels recently
  • ‘Tinkling’ bowel sounds

These symptoms indicate a possible blockage in the intestines.

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146
Q

What is the significance of pain in the RIF?

A

It is a sign associated with appendicitis

RIF stands for Right Iliac Fossa, where appendicitis pain is typically localized.

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147
Q

What are common symptoms of appendicitis?

A

Pain on extending the hip and raised inflammatory markers

Inflammatory markers indicate an immune response, which is common in appendicitis.

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148
Q

What demographic is more likely to experience appendicitis?

A

Thin, male patients

This demographic has a higher likelihood of presenting with appendicitis.

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149
Q

What is the typical percentage likelihood of appendicitis in certain cases?

A

55%

This statistic may refer to specific clinical scenarios involving appendicitis.

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150
Q

Appendicitis is often indicated by which combination of factors?

A

Raised inflammatory markers and compatible history

A compatible history includes symptoms and clinical findings consistent with appendicitis.

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151
Q

Fill in the blank: Pain in the RIF is now considered a sign of _______.

A

appendicitis

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152
Q

True or False: Pain on extending the hip is not associated with appendicitis.

A

False

This type of pain is indeed a sign of appendicitis.

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153
Q

What does RIF stand for in the context of appendicitis?

A

Right Iliac Fossa

It is the anatomical location where appendicitis pain is typically felt.

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154
Q

What is Whipple’s disease?

A

A rare multi-system disorder caused by Tropheryma whippelii infection

More common in those who are HLA-B27 positive and in middle-aged men.

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155
Q

List the common features of Whipple’s disease.

A
  • Malabsorption: diarrhoea, weight loss
  • Large-joint arthralgia
  • Lymphadenopathy
  • Skin: hyperpigmentation and photosensitivity
  • Pleurisy, pericarditis
  • Neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
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156
Q

What does jejunal biopsy reveal in Whipple’s disease?

A

Deposition of macrophages containing Periodic acid-Schiff (PAS) granules

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157
Q

What is the first-line management for Whipple’s disease?

A

Oral co-trimoxazole for a year, sometimes preceded by a course of IV penicillin

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158
Q

True or False: Whipple’s disease is more common in women than men.

A

False

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159
Q

Fill in the blank: Whipple’s disease is associated with _______ positive individuals.

A

HLA-B27

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160
Q

What are the neurological symptoms associated with Whipple’s disease?

A
  • Ophthalmoplegia
  • Dementia
  • Seizures
  • Ataxia
  • Myoclonus
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161
Q

What are some gastrointestinal symptoms of Whipple’s disease?

A
  • Diarrhoea
  • Weight loss
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162
Q

What are the skin manifestations of Whipple’s disease?

A
  • Hyperpigmentation
  • Photosensitivity
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163
Q

What is the significance of HLA-B27 in Whipple’s disease?

A

Its presence indicates a higher risk of developing the disease

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164
Q

What is Wilson’s disease primarily associated with?

A

Copper accumulation in the body

Wilson’s disease leads to excessive copper deposition, particularly affecting the liver and brain.

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165
Q

Which part of the brain is primarily affected by copper deposition in Wilson’s disease?

A

Basal ganglia, particularly the putamen and globus pallidus

These regions are crucial for motor control and may lead to neurological symptoms.

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166
Q

What are common neurological manifestations of Wilson’s disease?

A
  • Asterixis
  • Chorea
  • Dementia
  • Behavioral problems

These symptoms arise from copper accumulation affecting brain function.

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167
Q

What characteristic eye finding is associated with Wilson’s disease?

A

Green-brown rings in the periphery of the iris

This is due to copper accumulation in the Descemet membrane and is present in many patients.

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168
Q

In which percentage of patients with isolated hepatic Wilson’s disease are Kayser-Fleischer rings present?

A

Around 50%

Kayser-Fleischer rings are a key diagnostic feature of Wilson’s disease.

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169
Q

What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson’s disease?

A

Up to 90%

This high prevalence indicates significant copper accumulation affecting neurological function.

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170
Q

What renal condition is associated with Wilson’s disease?

A

Renal tubular acidosis

This condition can manifest as part of the systemic effects of copper overload.

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171
Q

What is a potential new treatment agent currently under investigation for Wilson’s disease?

A

Tetrathiomolybdate

This agent aims to enhance copper excretion and reduce its toxic effects.

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172
Q

What is a physical sign that may indicate Wilson’s disease?

A

Blue nails

This is a less common manifestation but can be associated with copper dysregulation.

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173
Q

What is Wilson’s disease primarily associated with?

A

Copper accumulation in the body

Wilson’s disease leads to excessive copper deposition, particularly affecting the liver and brain.

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174
Q

Which part of the brain is primarily affected by copper deposition in Wilson’s disease?

A

Basal ganglia, particularly the putamen and globus pallidus

These regions are crucial for motor control and may lead to neurological symptoms.

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175
Q

What are common neurological manifestations of Wilson’s disease?

A
  • Asterixis
  • Chorea
  • Dementia
  • Behavioral problems

These symptoms arise from copper accumulation affecting brain function.

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176
Q

What characteristic eye finding is associated with Wilson’s disease?

A

Green-brown rings in the periphery of the iris

This is due to copper accumulation in the Descemet membrane and is present in many patients.

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177
Q

In which percentage of patients with isolated hepatic Wilson’s disease are Kayser-Fleischer rings present?

A

Around 50%

Kayser-Fleischer rings are a key diagnostic feature of Wilson’s disease.

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178
Q

What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson’s disease?

A

Up to 90%

This high prevalence indicates significant copper accumulation affecting neurological function.

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179
Q

What renal condition is associated with Wilson’s disease?

A

Renal tubular acidosis

This condition can manifest as part of the systemic effects of copper overload.

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180
Q

What is a potential new treatment agent currently under investigation for Wilson’s disease?

A

Tetrathiomolybdate

This agent aims to enhance copper excretion and reduce its toxic effects.

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181
Q

What is a physical sign that may indicate Wilson’s disease?

A

Blue nails

This is a less common manifestation but can be associated with copper dysregulation.

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182
Q

What is Zollinger-Ellison syndrome?

A

A condition characterised by excessive levels of gastrin secondary to a gastrin-secreting tumour

The majority of these tumours are found in the first part of the duodenum, with the pancreas being the second most common location.

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183
Q

Where are the majority of gastrin-secreting tumours found in Zollinger-Ellison syndrome?

A

First part of the duodenum

The pancreas is the second most common location for these tumours.

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184
Q

What percentage of gastrinomas occur as part of MEN type I syndrome?

A

Around 30%

MEN stands for Multiple Endocrine Neoplasia.

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185
Q

List three features of Zollinger-Ellison syndrome.

A
  • Multiple gastroduodenal ulcers
  • Diarrhoea
  • Malabsorption
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186
Q

What is the single best screening test for Zollinger-Ellison syndrome?

A

Fasting gastrin levels

This test is used to measure the amount of gastrin hormone in the blood.

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187
Q

What test is used to further evaluate Zollinger-Ellison syndrome after initial screening?

A

Secretin stimulation test

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188
Q

What is the scientific name for threadworms?

A

Enterobius vermicularis

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189
Q

In which population is threadworm infestation particularly common?

A

Children in the UK

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190
Q

How does threadworm infestation occur?

A

After swallowing eggs that are present in the environment

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191
Q

What percentage of threadworm infestations are asymptomatic?

A

90%

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192
Q

What are possible features of threadworm infestation?

A
  • Perianal itching, particularly at night
  • Vulval symptoms in girls
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193
Q

What diagnostic method can be used for threadworm infestation?

A

Applying Sellotape to the perianal area and sending it for microscopy

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194
Q

What is the recommended management approach for threadworm infestation?

A
  • Combination of anthelmintic with hygiene measures for all household members
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195
Q

What is the first-line treatment for threadworm infestation in children over 6 months old?

A

Mebendazole

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196
Q

How is mebendazole administered for threadworm infestation?

A

A single dose is given unless infestation persists

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197
Q

True or False: Most patients with threadworm infestation are treated empirically.

A

True

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198
Q

What guidelines support the empirical treatment of threadworm infestation?

A

CKS guidelines

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199
Q

What are desmoid tumours?

A

Fibrous neoplasms arising from musculoaponeurotic structures containing clonal proliferations of myofibroblasts

Desmoid tumours are not classified as malignant but can be aggressive in behavior, infiltrating surrounding tissues.

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200
Q

What is the typical appearance of desmoid tumours?

A

Firm overgrowths of tissue with a propensity to local infiltration

These characteristics make desmoid tumours challenging to treat and manage.

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201
Q

In what percentage of patients with familial adenomatous polyposis coli do desmoid tumours occur?

A

Up to 15%

Familial adenomatous polyposis coli is a genetic condition that increases the risk for colorectal cancer.

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202
Q

What genetic mutations are typically seen in desmoid tumours?

A

Bi allelic APC mutations

APC gene mutations are commonly associated with familial adenomatous polyposis and are critical in tumorigenesis.

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203
Q

In which demographic do desmoid tumours most commonly occur?

A

Women after childbirth in the rectus abdominis muscle

This demographic factor may relate to hormonal changes and physical stress during and after pregnancy.

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204
Q

What is the primary treatment for desmoid tumours?

A

Radical surgical resection

Surgical intervention is preferred due to the high tendency for local recurrence.

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205
Q

What are the alternative treatments for desmoid tumours, if surgery is not an option?

A

Radiotherapy and chemotherapy may be considered

However, the results of non-surgical therapy are generally inferior to surgical resection.

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206
Q

What is the prognosis for abdominal desmoid tumours?

A

Some may spontaneously regress

In selected cases, a period of observation may be preferred, particularly if the tumours are not causing significant symptoms.

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207
Q

True or False: Desmoid tumours have a low tendency to local recurrence.

A

False

Desmoid tumours are known for their high tendency to recur locally after treatment.

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208
Q

Fill in the blank: Desmoids consist of sheets of differentiated _______.

A

fibroblasts

This cellular composition is significant in understanding their pathological behavior.

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209
Q

What type of bacteria is Helicobacter pylori?

A

Gram-negative bacteria

Associated with various gastrointestinal problems, particularly peptic ulcer disease.

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210
Q

What are the two main mechanisms Helicobacter pylori uses to survive in acidic gastric environments?

A
  • Chemotaxis away from low pH areas using flagella
  • Secretes urease to convert urea to NH, alkalinizing the environment

These mechanisms increase bacterial survival in the stomach.

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211
Q

What type of cytotoxins does Helicobacter pylori release?

A

Bacterial cytotoxins (e.g., CagA toxin)

These toxins disrupt the gastric mucosa.

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212
Q

What gastrointestinal conditions are associated with Helicobacter pylori?

A
  • Peptic ulcer disease
  • 95% of duodenal ulcers
  • 75% of gastric ulcers
  • Gastric cancer
  • B cell lymphoma of MALT tissue
  • Atrophic gastritis

Eradication of H pylori can lead to regression of B cell lymphoma in 80% of patients.

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213
Q

Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?

A

No, there is currently no role for eradication in GORD

The relationship between H pylori and GORD is unclear.

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214
Q

What is the standard management for Helicobacter pylori infection?

A

A 7-day course of:
* Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole)

If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.

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215
Q

What type of bacteria is Helicobacter pylori?

A

Gram-negative bacteria

Associated with various gastrointestinal problems, particularly peptic ulcer disease.

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216
Q

What are the two main mechanisms Helicobacter pylori uses to survive in acidic gastric environments?

A
  • Chemotaxis away from low pH areas using flagella
  • Secretes urease to convert urea to NH, alkalinizing the environment

These mechanisms increase bacterial survival in the stomach.

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217
Q

What type of cytotoxins does Helicobacter pylori release?

A

Bacterial cytotoxins (e.g., CagA toxin)

These toxins disrupt the gastric mucosa.

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218
Q

What gastrointestinal conditions are associated with Helicobacter pylori?

A
  • Peptic ulcer disease
  • 95% of duodenal ulcers
  • 75% of gastric ulcers
  • Gastric cancer
  • B cell lymphoma of MALT tissue
  • Atrophic gastritis

Eradication of H pylori can lead to regression of B cell lymphoma in 80% of patients.

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219
Q

Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?

A

No, there is currently no role for eradication in GORD

The relationship between H pylori and GORD is unclear.

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220
Q

What is the standard management for Helicobacter pylori infection?

A

A 7-day course of:
* Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole)

If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.

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221
Q

What is coeliac disease?

A

An autoimmune condition caused by sensitivity to the protein gluten

It affects around 1% of the UK population.

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222
Q

What happens with repeated exposure to gluten in coeliac disease?

A

Leads to villous atrophy, causing malabsorption

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223
Q

What skin condition is associated with coeliac disease?

A

Dermatitis herpetiformis (a vesicular, pruritic skin eruption)

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224
Q

What autoimmune disorders are associated with coeliac disease?

A
  • Type 1 diabetes mellitus
  • Autoimmune hepatitis
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225
Q

What HLA types are strongly associated with coeliac disease?

A
  • HLA-DQ2 (95% of patients)
  • HLA-DQ8 (80%)
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226
Q

According to NICE guidelines, which patients should be screened for coeliac disease?

A

Patients with specific signs and symptoms

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227
Q

Name two signs or symptoms of coeliac disease.

A
  • Chronic or intermittent diarrhoea
  • Failure to thrive or faltering growth in children
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228
Q

What is a common gastrointestinal symptom of coeliac disease?

A

Persistent or unexplained gastrointestinal symptoms, including nausea and vomiting

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229
Q

What are some complications of coeliac disease?

A
  • Iron deficiency anemia
  • Folate deficiency
  • Vitamin B12 deficiency
  • Osteoporosis
  • Osteomalacia
  • Enteropathy-associated T-cell lymphoma of the small intestine
  • Unfavorable pregnancy outcomes
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230
Q

True or False: Folate deficiency is more common than vitamin B12 deficiency in coeliac disease.

A

True

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231
Q

What are rare complications associated with coeliac disease?

A
  • Oesophageal cancer
  • Other malignancies
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232
Q

Fill in the blank: Coeliac disease is associated with _______ thyroid disease.

A

Autoimmune

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233
Q

What is a common gastrointestinal condition that may be confused with coeliac disease?

A

Irritable bowel syndrome

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234
Q

Who are considered first-degree relatives in relation to coeliac disease?

A
  • Parents
  • Siblings
  • Children
235
Q

What is Coeliac disease caused by?

A

Sensitivity to the protein gluten

236
Q

What is the consequence of repeated exposure to gluten in Coeliac disease?

A

Villous atrophy leading to malabsorption

237
Q

At what age do children typically present with Coeliac disease?

A

Before the age of 3 years

238
Q

What genetic markers are strongly associated with Coeliac disease?

A

HLA-DQ2 and HLA-DQ8

239
Q

What is the incidence of Coeliac disease?

A

Around 1:100

240
Q

What symptoms may coincide with the introduction of cereals in children with Coeliac disease?

A
  • Failure to thrive
  • Diarrhoea
  • Abdominal distension
  • Anaemia in older children
241
Q

What is a common issue regarding the diagnosis of Coeliac disease?

A

Many cases are not diagnosed until adulthood

242
Q

What findings are seen in a jejunal biopsy for Coeliac disease?

A

Subtotal villous atrophy

243
Q

What are useful screening tests for Coeliac disease?

A
  • Anti-endomysial antibodies
  • Anti-gliadin antibodies
244
Q

What causes coeliac disease?

A

Coeliac disease is caused by sensitivity to the protein gluten.

245
Q

What leads to malabsorption in coeliac disease?

A

Repeated exposure to gluten leads to villous atrophy, which in turn causes malabsorption.

246
Q

What are conditions associated with coeliac disease?

A

Conditions include dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis.

247
Q

How is coeliac disease diagnosed?

A

Diagnosis is made by a combination of serology and endoscopic intestinal biopsy.

248
Q

What happens to villous atrophy and immunology on a gluten-free diet?

A

Villous atrophy and immunology normally reverses on a gluten-free diet.

249
Q

What did NICE issue in 2009 regarding coeliac disease?

A

NICE issued guidelines on the investigation of coeliac disease.

250
Q

What should patients do if they are already on a gluten-free diet before testing?

A

They should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.

251
Q

What is the first-choice serology test according to NICE?

A

Tissue transglutaminase (TTG) antibodies (IgA) are the first-choice test.

252
Q

What is needed to look for selective IgA deficiency?

A

Endomyseal antibody (IgA) is needed to look for selective IgA deficiency.

253
Q

Are anti-gliadin antibody tests recommended by NICE?

A

No, anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE.

254
Q

What is the ‘gold standard’ for diagnosing coeliac disease?

A

Endoscopic intestinal biopsy is the ‘gold standard’ for diagnosis.

255
Q

Where is the endoscopic intestinal biopsy traditionally performed?

A

Traditionally done in the duodenum, but jejunal biopsies are also sometimes performed.

256
Q

What are findings supportive of coeliac disease?

A

Findings include villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes.

257
Q

Is rectal gluten challenge widely used?

A

No, rectal gluten challenge has been described but is not widely used.

258
Q

What happens to clotting factors in liver failure?

A

All clotting factors are low, except for factor VIII which is paradoxically supra-normal.

Factor VIII is synthesized in endothelial cells throughout the body, unlike other clotting factors synthesized in hepatic endothelial cells.

259
Q

Why is factor VIII levels increased in liver failure?

A

Factor VIII is synthesized in endothelial cells throughout the body and requires good hepatic function for clearance.

This leads to increased circulating levels despite liver dysfunction.

260
Q

What do conventional coagulation studies indicate in chronic liver disease?

A

Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk.

However, patients are paradoxically at an increased risk of thrombosis.

261
Q

What paradoxical condition occurs in patients with chronic liver disease?

A

Patients are at an increased risk of thrombosis despite bleeding risk suggested by coagulation studies.

This is due to various factors including reduced synthesis of anticoagulants.

262
Q

Which natural anticoagulants are reduced in chronic liver disease?

A

Reduction in protein C, protein S (vitamin K dependent), and anti-thrombin (non-vitamin K dependent).

These reductions lead to an imbalance favoring thrombosis.

263
Q

True or False: Patients with chronic liver disease are only at risk for bleeding.

A

False.

They are also at an increased risk for thrombosis.

264
Q

Fill in the blank: In liver failure, factor VIII is _______.

A

supra-normal

265
Q

What leads to the paradoxical increase in factor VIII during liver failure?

A

Good hepatic function is required for the clearance of activated factor VIII.

Impaired hepatic function leads to decreased clearance and increased levels.

266
Q

What happens to clotting factors in liver failure?

A

All clotting factors are low, except for factor VIII which is paradoxically supra-normal.

Factor VIII is synthesized in endothelial cells throughout the body, unlike other clotting factors synthesized in hepatic endothelial cells.

267
Q

Why is factor VIII levels increased in liver failure?

A

Factor VIII is synthesized in endothelial cells throughout the body and requires good hepatic function for clearance.

This leads to increased circulating levels despite liver dysfunction.

268
Q

What do conventional coagulation studies indicate in chronic liver disease?

A

Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk.

However, patients are paradoxically at an increased risk of thrombosis.

269
Q

What paradoxical condition occurs in patients with chronic liver disease?

A

Patients are at an increased risk of thrombosis despite bleeding risk suggested by coagulation studies.

This is due to various factors including reduced synthesis of anticoagulants.

270
Q

Which natural anticoagulants are reduced in chronic liver disease?

A

Reduction in protein C, protein S (vitamin K dependent), and anti-thrombin (non-vitamin K dependent).

These reductions lead to an imbalance favoring thrombosis.

271
Q

True or False: Patients with chronic liver disease are only at risk for bleeding.

A

False.

They are also at an increased risk for thrombosis.

272
Q

Fill in the blank: In liver failure, factor VIII is _______.

A

supra-normal

273
Q

What leads to the paradoxical increase in factor VIII during liver failure?

A

Good hepatic function is required for the clearance of activated factor VIII.

Impaired hepatic function leads to decreased clearance and increased levels.

274
Q

What does acute liver failure describe?

A

The rapid onset of hepatocellular dysfunction leading to various systemic complications

Acute liver failure can be life-threatening and requires immediate medical attention.

275
Q

List three common causes of acute liver failure.

A
  • Paracetamol overdose
  • Alcohol
  • Viral hepatitis (usually A or B)

Other causes include acute fatty liver of pregnancy.

276
Q

What are the main features of acute liver failure?

A
  • Jaundice
  • Coagulopathy: raised prothrombin time
  • Hypoalbuminaemia
  • Hepatic encephalopathy
  • Renal failure (hepatorenal syndrome)

These features indicate severe liver dysfunction.

277
Q

True or False: Liver function tests always accurately reflect the synthetic function of the liver.

A

False

Liver function tests may not provide a complete picture; prothrombin time and albumin levels are better indicators.

278
Q

What is the best way to assess the synthetic function of the liver?

A

By looking at the prothrombin time and albumin level

These parameters provide insight into the liver’s ability to synthesize proteins.

279
Q

Fill in the blank: Renal failure is common in acute liver failure and is referred to as _______.

A

hepatorenal syndrome

This condition results from the interplay between liver failure and kidney function.

280
Q

What is acute mesenteric ischaemia typically caused by?

A

An embolism resulting in occlusion of an artery supplying the small bowel

Commonly the superior mesenteric artery is involved.

281
Q

What medical history is classically associated with acute mesenteric ischaemia?

A

Atrial fibrillation

This condition can lead to the formation of emboli.

282
Q

Describe the nature of abdominal pain in acute mesenteric ischaemia.

A

Severe, of sudden onset, and out-of-keeping with physical exam findings

This discrepancy often raises suspicion for the condition.

283
Q

What is the typical management for acute mesenteric ischaemia?

A

Immediate laparotomy

Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.

284
Q

What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?

A

Poor prognosis

Timely intervention is critical for better outcomes.

285
Q

What is acute mesenteric ischaemia typically caused by?

A

An embolism resulting in occlusion of an artery supplying the small bowel

Commonly the superior mesenteric artery is involved.

286
Q

What medical history is classically associated with acute mesenteric ischaemia?

A

Atrial fibrillation

This condition can lead to the formation of emboli.

287
Q

Describe the nature of abdominal pain in acute mesenteric ischaemia.

A

Severe, of sudden onset, and out-of-keeping with physical exam findings

This discrepancy often raises suspicion for the condition.

288
Q

What is the typical management for acute mesenteric ischaemia?

A

Immediate laparotomy

Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.

289
Q

What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?

A

Poor prognosis

Timely intervention is critical for better outcomes.

290
Q

GET SMASHED

A
  • Gall stones
  • Ethanol
  • Trauma
  • Scoropion bites
  • M umps
  • Autoimmune
  • Steroids
  • Hypercalmeia orhypertriglycerdemia
  • ERCP
  • Drugs (NSAIDs, Azithromycin)
291
Q
A
292
Q

What is the most common cause of acute pancreatitis?

A

Alcohol or gallstones

293
Q

What is the pathophysiological mechanism of acute pancreatitis?

A

Antedigestion of pancreatic tissue by pancreatic enzymes

294
Q

What are common physical examination findings in acute pancreatitis?

A

Epigastric tenderness, ileus, and low-grade fever

295
Q

What are Cullen’s sign and Grey-Turner’s sign associated with?

A

Acute pancreatitis (rarely seen)

296
Q

What rare complication can occur due to pancreatitis?

A

Blindness due to retinopathy

297
Q

What laboratory test is typically raised in 75% of acute pancreatitis cases?

A

Serum amylase

298
Q

What does a serum amylase level > 3 times the upper limit of normal indicate?

A

Possible acute pancreatitis

299
Q

What is the specificity of serum amylase for pancreatitis?

A

Around 90%

300
Q

What other conditions can cause raised serum amylase levels?

A
  • Pancreatic pseudocyst
  • Mesenteric infarct
  • Perforated viscus
  • Acute cholecystitis
  • Diabetic ketoacidosis
301
Q

Which enzyme is more sensitive and specific than serum amylase in diagnosing pancreatitis?

A

Serum lipase

302
Q

What is a unique characteristic of serum lipase compared to serum amylase?

A

Longer half-life

303
Q

When might serum lipase be particularly useful?

A

In late presentations (> 44 hours)

304
Q

Can acute pancreatitis be diagnosed without imaging?

A

Yes, with characteristic pain + amylase/lipase > 3 times normal

305
Q

What imaging is important for diagnosing gallstones or biliary obstruction in pancreatitis?

A

Early ultrasound imaging

306
Q

What imaging technique can also be used for diagnosing acute pancreatitis?

A

Contrast-enhanced CT

307
Q

Is the actual amylase level of prognostic value in acute pancreatitis?

A

No

308
Q

What percentage of acute pancreatitis cases experience Erinacetis fluid collections?

A

25%

Erinacetis fluid collections are located in or near the pancreas and lack a wall of granulation or fibrous tissue.

309
Q

What may happen to Erinacetis fluid collections in acute pancreatitis?

A

They may resolve or develop into pseudocysts or abscesses

Aspiration and drainage are best avoided as they may precipitate infection.

310
Q

What characterizes pseudocysts in acute pancreatitis?

A

Result from organization of peripancreatic fluid collection

They may or may not communicate with the ductal system.

311
Q

What is the typical occurrence time for pseudocysts after an attack of acute pancreatitis?

A

4 weeks or more

The collection is walled by fibrous or granulation tissue.

312
Q

What proportion of symptomatic pseudocysts may resolve within 12 weeks?

A

Up to 50%

Treatment options include endoscopic or surgical interventions.

313
Q

What does pancreatic necrosis involve?

A

Both the pancreatic parenchyma and surrounding fat

Complications are directly linked to the extent of necrosis.

314
Q

What is associated with a high mortality rate in pancreatic necrosis?

A

Extent of parenchymal necrosis

Some centers perform fine-needle aspiration sampling of necrotic tissue if infection is suspected.

315
Q

What is a pancreatic abscess?

A

A localized collection of pus associated with the pancreas

This occurs in the absence of hemorrhage.

316
Q

What may infected necrosis involve that can lead to hemorrhage?

A

Vascular structures

Hemorrhage may occur de novo or post-surgery.

317
Q

What systemic complication is associated with a high mortality rate of around 20%?

A

Acute respiratory distress syndrome

This condition is a significant concern in cases of acute pancreatitis.

318
Q

What is necrotising enterocolitis?

A

One of the leading causes of death among premature infants.

319
Q

What are initial symptoms of necrotising enterocolitis?

A
  • Feeding intolerance
  • Abdominal distension
  • Bloody stools
320
Q

What imaging findings can be seen in necrotising enterocolitis?

A
  • Dilated bowel loops
  • Bowel wall oedema
  • Pneumatosis intestinalis
  • Portal venous gas
  • Pneumoperitoneum
  • Rigler sign
  • Football sign
321
Q

What is the most common type of oesophageal cancer?

A

Adenocarcinoma

322
Q

Which condition is associated with an increased risk of adenocarcinoma of the oesophagus?

A

Gastro-oesophageal reflux disease (GORD) or Barrett’s oesophagus.

323
Q

Where are adenocarcinomas typically located in the oesophagus?

A

Near the gastroesophageal junction.

324
Q

What is the most common presenting symptom of oesophageal cancer?

A

Dysphagia

325
Q

What is the preferred method for locoregional staging of oesophageal cancer?

A

Endoscopic ultrasound

326
Q

What is the most common procedure for operable oesophageal cancer?

A

Ivor-Lewis type oesophagectomy

327
Q

What is the typical presentation of pancreatic cancer?

A

Classically painless jaundice.

328
Q

What are some common associations with pancreatic cancer?

A
  • Increasing age
  • Smoking
  • Diabetes
  • Chronic pancreatitis
  • Hereditary non-polyposis colorectal carcinoma
  • Multiple endocrine neoplasia
  • BRCA2 gene
  • KRAS gene mutation
329
Q

What is Courvoisier’s law?

A

In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones.

330
Q

What imaging technique is the investigation of choice for suspected pancreatic cancer?

A

High-resolution CT scanning.

331
Q

What is the treatment for resectable lesions in the head of the pancreas?

A

Whipple’s resection (pancreaticoduodenectomy).

332
Q

What is a perianal abscess?

A

A collection of pus within the subcutaneous tissue of the anus.

333
Q

What are common features of a perianal abscess?

A
  • Pain around the anus
  • Hardened tissue in the anal region
  • Pus-like discharge
  • Features of systemic infection if longstanding
334
Q

What is the gold standard imaging for anorectal abscesses?

A

MRI

335
Q

What is secondary peritonitis?

A

An inflammatory condition of the peritoneum from spillage of gastrointestinal or biliary contents.

336
Q

What are common causes of secondary peritonitis?

A
  • Perforated peptic ulcer
  • Ruptured appendicitis
  • Diverticulitis
  • Trauma or neoplasia
337
Q

What are the clinical features of secondary peritonitis?

A
  • Acute abdominal pain
  • Fever
  • Tachycardia
  • Rebound tenderness
  • Guarding
338
Q

What is the cornerstone of management for secondary peritonitis?

A

Surgical intervention and broad-spectrum antibiotic therapy.

339
Q

What is spontaneous bacterial peritonitis (SBP)?

A

A form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.

340
Q

What is the most common organism found in ascitic fluid culture for SBP?

A

E. coli

341
Q

What is primary biliary cholangitis?

A

A chronic liver disorder typically seen in middle-aged females.

342
Q

What are common associations with primary biliary cholangitis?

A
  • Sjogren’s syndrome
  • Rheumatoid arthritis
  • Systemic sclerosis
  • Thyroid disease
343
Q

What is the first-line treatment for primary biliary cholangitis?

A

Ursodeoxycholic acid.

344
Q

What is the incubation period for Hepatitis A?

A

2-4 weeks.

345
Q

What is a significant complication of Hepatitis B infection?

A

Chronic hepatitis.

346
Q

Which groups should be vaccinated against Hepatitis B?

A
  • Healthcare workers
  • Intravenous drug users
  • Sex workers
  • Close family contacts of individuals with Hepatitis B
  • Chronic kidney disease patients
347
Q

What percentage of adults fail to respond or respond poorly to 3 doses of the hepatitis B vaccine?

A

5-10%

Risk factors include age over 40 years, obesity, smoking, alcohol excess, and immunosuppression.

348
Q

Who is recommended to be tested for anti-HBs?

A

Individuals at risk of occupational exposure and patients with chronic kidney disease

Anti-HBs levels should be checked 1-4 months after primary immunization.

349
Q

What does an anti-HBs level of > 100 mIU/ml indicate?

A

Adequate response, no further testing required, booster at 5 years

This indicates strong immunity.

350
Q

What is indicated by an anti-HBs level of 10 - 100 mIU/ml?

A

Suboptimal response - one additional vaccine dose should be given

If immunocompetent, no further testing is required.

351
Q

What should be done if anti-HBs is < 10 mIU/ml?

A

Test for current or past infection; give further vaccine course with testing following

If still fails to respond, HBIG would be required for protection if exposed to the virus.

352
Q

What was the only treatment available for hepatitis B before newer antivirals?

A

Pegylated interferon-alpha

It reduces viral replication in up to 30% of chronic carriers.

353
Q

What factors predict a better response to pegylated interferon treatment?

A

Being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy

354
Q

What are some antiviral medications used to treat hepatitis B?

A

Tenofovir, entecavir, telbivudine

These aim to suppress viral replication.

355
Q

What screening is offered to all pregnant women regarding hepatitis B?

A

Screening for hepatitis B

Babies born to infected mothers should receive complete vaccination + hepatitis B immunoglobulin.

356
Q

What is the vertical transmission rate of hepatitis B from mother to child?

A

6%

The risk is higher if there is coexistent HIV.

357
Q

True or False: Hepatitis B can be transmitted via breastfeeding.

A

False

Unlike HIV, hepatitis B cannot be transmitted through breastfeeding.

358
Q

What does HBsAg indicate in hepatitis B serology?

A

Ongoing infection, either acute or chronic if present > 6 months

HBsAg is the first marker to appear.

359
Q

What does the presence of anti-HBs imply?

A

Immunity (either exposure or immunization)

It is negative in chronic disease.

360
Q

What does anti-HBc indicate?

A

Previous or current infection

IgM anti-HBc appears during acute infection and is present for about 6 months.

361
Q

What is the chronic hepatitis C defined as?

A

Persistence of HCV RNA in the blood for 6 months

362
Q

List some potential complications of chronic hepatitis C.

A
  • Rheumatological problems: arthralgia, arthritis
  • Eye problems: Sjogren’s syndrome
  • Cirrhosis
  • Hepatocellular cancer
  • Cryoglobulinaemia
  • Porphyria cutanea tarda
  • Membranoproliferative glomerulonephritis
363
Q

What is the goal of hepatitis C treatment?

A

Sustained virological response (SVR)

Defined as undetectable serum HCV RNA six months after the end of therapy.

364
Q

What are common side effects of ribavirin?

A
  • Haemolytic anaemia
  • Cough

Women should avoid pregnancy within 6 months of stopping ribavirin as it is teratogenic.

365
Q

What are the side effects of interferon alpha?

A
  • Flu-like symptoms
  • Depression
  • Fatigue
  • Leukopenia
  • Thrombocytopenia
366
Q

What is the estimated number of people chronically infected with hepatitis C in the UK?

A

Around 200,000 people.

This number indicates a significant public health concern.

367
Q

What is the incubation period for hepatitis C?

A

6-9 weeks.

368
Q

What is the vertical transmission rate of hepatitis C from mother to child?

A

About 6%.

369
Q

True or False: Breastfeeding is contraindicated in mothers with hepatitis C.

A

False.

370
Q

What is the risk of transmission of hepatitis C during a needle stick injury?

A

About 2%.

371
Q

What percentage of patients will develop chronic hepatitis C after an acute infection?

A

55-85%.

372
Q

What defines chronic hepatitis C?

A

Persistence of HCV RNA in the blood for 6 months.

373
Q

List potential complications of chronic hepatitis C.

A
  • Rheumatological problems (arthralgia, arthritis)
  • Eye problems (Sjogren’s syndrome)
  • Cirrhosis (5-20% of cases)
  • Hepatocellular cancer
  • Cryoglobulinaemia (type II)
  • Porphyria cutanea tarda
  • Membranoproliferative glomerulonephritis.
374
Q

What is the aim of treatment for chronic hepatitis C?

A

Sustained virological response (SVR), defined as undetectable serum HCV RNA six months after therapy.

375
Q

What are the first-line treatments for chronic hepatitis C?

A

Combination of protease inhibitors (e.g., daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin.

376
Q

What are common side effects of ribavirin?

A

Haemolytic anaemia, cough.

377
Q

What is the risk associated with interferon alpha treatment?

A

Flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia.

378
Q

Fill in the blank: Hepatitis D is an incomplete RNA virus that requires _______ for replication.

A

Hepatitis B surface antigen.

379
Q

What is the term used for simultaneous Hepatitis B and Hepatitis D infections?

A

Co-infection.

380
Q

What is the major risk associated with Hepatitis D superinfection?

A

High risk of fulminant hepatitis, chronic hepatitis status, and cirrhosis.

381
Q

How is Hepatitis D diagnosed?

A

Reverse polymerase chain reaction of hepatitis D RNA.

382
Q

What is the incubation period for Hepatitis E?

A

3-8 weeks.

383
Q

List the common symptoms of irritable bowel syndrome (IBS).

A
  • Abdominal pain
  • Bloating
  • Change in bowel habit.
384
Q

What are ‘red flag’ features that should be investigated in IBS?

A
  • Rectal bleeding
  • Unexplained/unintentional weight loss
  • Family history of bowel or ovarian cancer
  • Onset after 60 years of age.
385
Q

What is the first-line pharmacological treatment for pain in IBS?

A

Antispasmodic agents.

386
Q

What dietary advice is recommended for managing IBS?

A
  • Have regular meals and take time to eat
  • Drink at least 8 cups of fluid per day
  • Avoid missing meals
  • Limit fresh fruit to 3 portions per day.
387
Q

What is a hiatus hernia?

A

Herniation of part of the stomach above the diaphragm.

388
Q

What are the two types of hiatus hernias?

A
  • Sliding
  • Rolling (paraoesophageal).
389
Q

What is the most sensitive test for investigating hiatus hernias?

A

Barium swallow.

390
Q

What is diverticular disease?

A

Herniation of colonic mucosa through the muscular wall of the colon.

391
Q

List the complications of diverticular disease.

A
  • Diverticulitis
  • Haemorrhage
  • Development of fistula
  • Perforation and faecal peritonitis
  • Development of diverticular phlegmon.
392
Q

What is the traditional mnemonic for the risk factors of biliary colic?

A

The ‘4 F’s’: Fat, Female, Fertile, Forty.

393
Q

What is the primary management for biliary colic?

A

Elective laparoscopic cholecystectomy.

394
Q

What are the features of anal fissures?

A
  • Painful, bright red rectal bleeding
  • 90% occur on the posterior midline.
395
Q

What is the first-line treatment for chronic anal fissures?

A

Topical glyceryl trinitrate (GTN).

396
Q

What are the risk factors for alcoholic liver disease?

A

N/A

397
Q

What should be tried if lactulose is not tolerated?

A

Lubricants such as petroleum jelly

Lubricants may be used to ease defecation.

398
Q

What is the first-line treatment for a chronic anal fissure?

A

Topical glyceryl trinitrate (GTN)

GTN is often applied to promote healing.

399
Q

What conditions are covered under alcoholic liver disease?

A
  • Alcoholic fatty liver disease
  • Alcoholic hepatitis
  • Cirrhosis

These conditions represent a spectrum of liver disease due to alcohol consumption.

400
Q

What is characteristically elevated in alcoholic liver disease?

A

Gamma-GT

This enzyme is commonly used as a marker for liver disease.

401
Q

What is the typical AST:ALT ratio in alcoholic hepatitis?

A

> 2

A ratio of > 3 is strongly suggestive of acute alcoholic hepatitis.

402
Q

Which glucocorticoid is often used during acute episodes of alcoholic hepatitis?

A

Prednisolone

Glucocorticoids help manage inflammation during acute episodes.

403
Q

What formula is used in Maddrey’s discriminant function (DF)?

A

Prothrombin time and bilirubin concentration

This formula helps determine the need for glucocorticoid therapy.

404
Q

What did the STOPAH study compare?

A

Pentoxyphylline and prednisolone

The study found that prednisolone improved survival at 28 days.

405
Q

What is the most common acute abdominal condition requiring surgery?

A

Acute appendicitis

It is most common in young people aged 10-20 years.

406
Q

What is the pathogenesis of acute appendicitis?

A
  • Lymphoid hyperplasia or a faecolith
  • Obstruction of appendiceal lumen
  • Gut organisms invading the appendix wall
  • Oedema, ischaemia +/- perforation

This sequence leads to inflammation and potential perforation of the appendix.

407
Q

What type of abdominal pain is typically seen in appendicitis?

A

Peri-umbilical abdominal pain radiating to the right iliac fossa (RIF)

This pain migration is a strong indicator of appendicitis.

408
Q

What are common symptoms of acute appendicitis?

A
  • Vomiting
  • Mild pyrexia
  • Anorexia
  • Localised right lower quadrant pain

Anorexia and peri-umbilical pain are often present alongside nausea.

409
Q

What examination findings suggest perforation in appendicitis?

A
  • Generalised peritonitis
  • Localised peritonism
  • Rebound tenderness
  • Guarding and rigidity

These signs indicate potential complications from appendicitis.

410
Q

What laboratory finding is seen in 80-90% of appendicitis cases?

A

Neutrophil-predominant leucocytosis

This is a common marker of infection.

411
Q

What is the first-line investigation for acute cholecystitis?

A

Ultrasound

This imaging modality is preferred for assessing gallbladder inflammation.

412
Q

What are the typical features of acute cholecystitis?

A
  • Right upper quadrant pain
  • Fever
  • Murphy’s sign

Murphy’s sign is positive if there is inspiratory arrest upon palpation.

413
Q

What is the recommended treatment for acute cholecystitis?

A
  • Intravenous antibiotics
  • Cholecystectomy

Early laparoscopic cholecystectomy is now recommended.

414
Q

What percentage of children are affected by cow’s milk protein intolerance/allergy (CMPI/CMPA)?

A

3-6%

CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.

415
Q

What are the two types of reactions associated with cow’s milk protein allergy/intolerance?

A

Immediate (IgE mediated) and delayed (non-IgE mediated)

CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.

416
Q

List some symptoms of cow’s milk protein intolerance/allergy.

A
  • Regurgitation and vomiting
  • Diarrhea
  • Urticaria
  • Atopic eczema
  • ‘Colic’ symptoms (irritability, crying)
  • Wheeze
  • Chronic cough
  • Rarely angioedema and anaphylaxis
417
Q

What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?

A

Extensive hydrolysed formula (eHF)

Amino acid-based formula (AAF) is used in infants with severe CMPA.

418
Q

What should breastfeeding mothers do if their infant has cow’s milk protein intolerance?

A

Eliminate cow’s milk protein from their diet

Consider prescribing calcium supplements to prevent deficiency.

419
Q

What is the prognosis for children with cow’s milk protein intolerance?

A

Usually resolves in most children

55% of children with IgE mediated intolerance will be milk tolerant by age 5.

420
Q

What are the common locations for hemorrhoids?

A

3, 7, 11 o’clock position

Hemorrhoids can be internal or external.

421
Q

What are the typical features of an anal fissure?

A

Painful rectal bleeding and typically midline location (6 & 12 o’clock position)

Chronic fissures present with a triad of ulcer, sentinel pile, and enlarged anal papillae.

422
Q

What are common causes of proctitis?

A
  • Crohn’s
  • Ulcerative colitis
  • Clostridioides difficile
423
Q

What is a perianal abscess?

A

A collection of pus within the subcutaneous tissue of the anus

It has tracked from the tissue surrounding the anal sphincter.

424
Q

What is the most common form of anorectal abscess?

A

Perianal abscess

They make up around 60% of cases.

425
Q

What is the average age of patients with perianal abscess?

A

Around 40 years

426
Q

What is the first-line treatment for perianal abscess?

A

Incision and drainage

Usually performed under local anaesthetic.

427
Q

Identify two imaging techniques useful for diagnosing anorectal abscesses.

A
  • MRI
  • Transperineal ultrasound
428
Q

What are common symptoms of threadworm infestation?

A
  • Perianal itching, particularly at night
  • Vulval symptoms in girls
429
Q

What is the first-line treatment for threadworm infestation in children over 6 months old?

A

Mebendazole

A single dose is given unless infestation persists.

430
Q

True or False: Most patients with threadworm infestation are asymptomatic.

A

True

431
Q

What percentage of children are affected by cow’s milk protein intolerance/allergy (CMPI/CMPA)?

A

3-6%

CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.

432
Q

What are the two types of reactions associated with cow’s milk protein allergy/intolerance?

A

Immediate (IgE mediated) and delayed (non-IgE mediated)

CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.

433
Q

List some symptoms of cow’s milk protein intolerance/allergy.

A
  • Regurgitation and vomiting
  • Diarrhea
  • Urticaria
  • Atopic eczema
  • ‘Colic’ symptoms (irritability, crying)
  • Wheeze
  • Chronic cough
  • Rarely angioedema and anaphylaxis
434
Q

What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?

A

Extensive hydrolysed formula (eHF)

Amino acid-based formula (AAF) is used in infants with severe CMPA.

435
Q

What should breastfeeding mothers do if their infant has cow’s milk protein intolerance?

A

Eliminate cow’s milk protein from their diet

Consider prescribing calcium supplements to prevent deficiency.

436
Q

What is the prognosis for children with cow’s milk protein intolerance?

A

Usually resolves in most children

55% of children with IgE mediated intolerance will be milk tolerant by age 5.

437
Q

What are the common locations for hemorrhoids?

A

3, 7, 11 o’clock position

Hemorrhoids can be internal or external.

438
Q

What are the typical features of an anal fissure?

A

Painful rectal bleeding and typically midline location (6 & 12 o’clock position)

Chronic fissures present with a triad of ulcer, sentinel pile, and enlarged anal papillae.

439
Q

What are common causes of proctitis?

A
  • Crohn’s
  • Ulcerative colitis
  • Clostridioides difficile
440
Q

What is a perianal abscess?

A

A collection of pus within the subcutaneous tissue of the anus

It has tracked from the tissue surrounding the anal sphincter.

441
Q

What is the most common form of anorectal abscess?

A

Perianal abscess

They make up around 60% of cases.

442
Q

What is the average age of patients with perianal abscess?

A

Around 40 years

443
Q

What is the first-line treatment for perianal abscess?

A

Incision and drainage

Usually performed under local anaesthetic.

444
Q

Identify two imaging techniques useful for diagnosing anorectal abscesses.

A
  • MRI
  • Transperineal ultrasound
445
Q

What are common symptoms of threadworm infestation?

A
  • Perianal itching, particularly at night
  • Vulval symptoms in girls
446
Q

What is the first-line treatment for threadworm infestation in children over 6 months old?

A

Mebendazole

A single dose is given unless infestation persists.

447
Q

True or False: Most patients with threadworm infestation are asymptomatic.

A

True

448
Q

What is the commonest bacterial cause of infectious intestinal disease in the UK?

A

Campylobacter jejuni

Campylobacter is primarily spread by the faecal-oral route.

449
Q

What are the common features of Campylobacter jejuni infection?

A
  • Prodrome: headache, malaise
  • Diarrhoea: often bloody
  • Abdominal pain: may mimic appendicitis
450
Q

What is the incubation period for Campylobacter jejuni?

A

1-6 days

451
Q

What is the first-line antibiotic for severe Campylobacter jejuni infections?

A

Clarithromycin

452
Q

True or False: Ciprofloxacin is frequently indicated for treating Campylobacter jejuni infections.

A

False

Strains with decreased sensitivity to ciprofloxacin are commonly isolated.

453
Q

What complications may follow Campylobacter jejuni infections?

A
  • Guillain-Barre syndrome
  • Reactive arthritis
  • Septicaemia
  • Endocarditis
  • Arthritis
454
Q

What is Clostridioides difficile commonly associated with?

A

Pseudomembranous colitis

455
Q

What type of bacteria is Clostridioides difficile?

A

Gram-positive rod

456
Q

What are the two exotoxins released by Clostridioides difficile?

A
  • Toxin A
  • Toxin B
457
Q

What are common risk factors for Clostridioides difficile infection?

A
  • Broad-spectrum antibiotics
  • Proton pump inhibitors
458
Q

What characterizes the white blood cell count in Clostridioides difficile infection?

A

A raised white blood cell count (WCC) is characteristic

459
Q

What is the first-line therapy for a first episode of C. difficile infection?

A

Oral vancomycin for 10 days

460
Q

What is the recurrence rate of C. difficile infection after the first episode?

A

Around 20%

461
Q

What is a key feature of travellers’ diarrhoea?

A

At least 3 loose to watery stools in 24 hours

462
Q

What is the most common cause of travellers’ diarrhoea?

A

Escherichia coli

463
Q

What pathogens are typically associated with acute food poisoning?

A
  • Staphylococcus aureus
  • Bacillus cereus
  • Clostridium perfringens
464
Q

What type of illness does Bacillus cereus cause when vomiting occurs within 6 hours?

A

Vomiting subtype

465
Q

What is the incubation period for Staphylococcus aureus food poisoning?

A

1-6 hours

466
Q

What are the common features of Salmonella infections?

A
  • Diarrhoea
  • Nausea and vomiting
  • Abdominal cramps
  • Fever
  • Lethargy
467
Q

What are the two types of enteric fevers caused by Salmonella?

A
  • Typhoid
  • Paratyphoid
468
Q

What is the management for Shigella infection?

A

Usually self-limiting; antibiotics indicated for severe disease

469
Q

Fill in the blank: Howell-Jolly bodies are associated with _______.

A

hyposplenism

470
Q

What increases the risk of post-splenectomy sepsis?

A

Loss of spleen’s ability to respond to encapsulated organisms

471
Q

What vaccines should be administered post-splenectomy?

A
  • Pneumococcal
  • Haemophilus type b
  • Meningococcal type C
472
Q

What is a common feature of alcoholic liver disease?

A

Gamma-GT is characteristically elevated

473
Q

What is the typical AST:ALT ratio in alcoholic hepatitis?

A

> 2

474
Q

What is the most common cause of acute pancreatitis?

A

Alcohol or gallstones

475
Q

What scoring systems are used to identify severe pancreatitis?

A
  • Ranson score
  • Glasgow score
  • APACHE II
476
Q

What does the mnemonic GET SMASHED stand for in relation to pancreatitis causes?

A
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hypertriglyceridaemia
  • ERCP
  • Drugs
477
Q

What are common causes of acute pancreatitis?

A

Gallstones, ethanol, trauma, steroids, mumps, autoimmune conditions, Ascaris infection, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, certain drugs

Drugs include azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate.

478
Q

How much more common is pancreatitis in patients taking mesalazine compared to sulfasalazine?

A

7 times more common

479
Q

What is the prognostic value of the actual amylase level in pancreatitis?

A

Not of prognostic value

480
Q

What are peripancreatic fluid collections?

A

Fluid collections occurring in 25% of cases, located in or near the pancreas, lacking a wall of granulation or fibrous tissue

They may resolve or develop into pseudocysts or abscesses.

481
Q

What is a pseudocyst in the context of pancreatitis?

A

A collection of fluid walled by fibrous or granulation tissue, typically occurring 4 weeks or more after an attack of acute pancreatitis

482
Q

What investigations are used for pseudocysts?

A

CT, ERCP, MRI, endoscopic USS

483
Q

What is pancreatic necrosis?

A

Involves both pancreatic parenchyma and surrounding fat, with complications linked to the extent of necrosis

484
Q

What is the management for sterile pancreatic necrosis?

A

Managed conservatively at least initially

485
Q

What are the systemic complications of acute pancreatitis?

A

Acute respiratory distress syndrome, associated with a high-mortality rate of around 20%

486
Q

What are the three classifications of severity for acute pancreatitis?

A
  • Mild: No organ failure, no local complications
  • Moderately severe: No or transient organ failure (<48 hours), possible local complications
  • Severe: Persistent organ failure (>48 hours), possible local complications
487
Q

What are key aspects of care for acute pancreatitis?

A
  • Fluid resuscitation
  • Analgesia
  • Nutrition
  • Role of antibiotics
  • Role of surgery
488
Q

What is the recommended fluid resuscitation for severe acute pancreatitis?

A

3-6 litres of crystalloids to manage third space fluid loss

489
Q

When should enteral nutrition be offered in acute pancreatitis?

A

Within 72 hours of presentation for moderately severe or severe cases

490
Q

What is the role of antibiotics in acute pancreatitis according to NICE?

A

Do not offer prophylactic antimicrobials; potential indications include infected pancreatic necrosis

491
Q

What surgical intervention is recommended for patients with acute pancreatitis due to gallstones?

A

Early cholecystectomy

492
Q

What is chronic pancreatitis?

A

An inflammatory condition affecting both exocrine and endocrine functions of the pancreas, often due to alcohol excess

493
Q

What are common features of chronic pancreatitis?

A
  • Pain worse 15-30 minutes after meals
  • Steatorrhoea
  • Diabetes mellitus development
494
Q

What is the sensitivity and specificity of CT in detecting pancreatic calcification?

A

Sensitivity: 80%, Specificity: 85%

495
Q

What is a key management strategy for chronic pancreatitis?

A

Pancreatic enzyme supplements, analgesia, antioxidants

496
Q

What is the incidence of gastric cancer in the developed world?

A

Accounts for around 2% of all cancer diagnoses

497
Q

What are the risk factors for gastric adenocarcinoma?

A
  • Helicobacter pylori infection
  • Pernicious anaemia
  • Atrophic gastritis
  • Diet (salt, nitrates)
  • Ethnicity (Japan, China)
  • Smoking
  • Blood group A
498
Q

What are the typical symptoms of gastric cancer?

A
  • Abdominal pain
  • Weight loss
  • Nausea and vomiting
  • Dysphagia
499
Q

What is the diagnosis method for gastric cancer?

A

Oesophago-gastro-duodenoscopy with biopsy

500
Q

What is the management approach for ovarian cancer?

A

Combination of surgery and platinum-based chemotherapy

501
Q

What are common clinical features of ovarian cancer?

A
  • Abdominal distension
  • Abdominal pain
  • Urinary symptoms
  • Early satiety
  • Diarrhoea
502
Q

What is the most common symptom of haemorrhoids?

A

Painless rectal bleeding

503
Q

What are the two types of haemorrhoids?

A
  • External: below the dentate line, prone to thrombosis
  • Internal: above the dentate line, generally painless
504
Q

What are the grades of internal haemorrhoids?

A
  • Grade I: Do not prolapse
  • Grade II: Prolapse on defecation, reduce spontaneously
  • Grade III: Manually reducible
  • Grade IV: Cannot be reduced
505
Q

What is the management for acutely thrombosed external haemorrhoids?

A

Referral for excision if presented within 72 hours; otherwise manage with stool softeners, ice packs, and analgesia

506
Q

What is coeliac disease?

A

An autoimmune condition caused by sensitivity to the protein gluten.

507
Q

What percentage of the UK population is thought to be affected by coeliac disease?

A

Around 1%.

508
Q

What is a consequence of repeated exposure to gluten in coeliac disease?

A

Villous atrophy leading to malabsorption.

509
Q

What skin condition is associated with coeliac disease?

A

Dermatitis herpetiformis.

510
Q

What autoimmune disorders are associated with coeliac disease?

A
  • Type 1 diabetes mellitus
  • Autoimmune hepatitis
511
Q

What HLA types are strongly associated with coeliac disease?

A
  • HLA-DQ2 (95% of patients)
  • HLA-DQ8 (80%)
512
Q

List some signs and symptoms that should prompt screening for coeliac disease.

A
  • Chronic or intermittent diarrhoea
  • Failure to thrive or faltering growth (in children)
  • Persistent gastrointestinal symptoms (nausea, vomiting)
  • Prolonged fatigue
  • Recurrent abdominal pain
  • Sudden weight loss
  • Unexplained anaemia
  • Autoimmune thyroid disease
  • Dermatitis herpetiformis
  • Irritable bowel syndrome
  • Type 1 diabetes
  • First-degree relatives with coeliac disease
513
Q

What are common complications of coeliac disease?

A
  • Anaemia (iron, folate, vitamin B12 deficiency)
  • Hyposplenism
  • Osteoporosis, osteomalacia
  • Lactose intolerance
  • Enteropathy-associated T-cell lymphoma
  • Subfertility, unfavourable pregnancy outcomes
  • Rare: oesophageal cancer, other malignancies
514
Q

What are the WHO definitions of diarrhoea?

A
  • Diarrhoea: > 3 loose or watery stools per day
  • Acute diarrhoea: < 14 days
  • Chronic diarrhoea: > 14 days
515
Q

What is the most common cause of acute diarrhoea?

A

Gastroenteritis.

516
Q

What are the typical symptoms of irritable bowel syndrome (IBS)?

A
  • Abdominal pain
  • Bloating
  • Change in bowel habit
517
Q

What features indicate a positive diagnosis of IBS?

A

Abdominal pain relieved by defecation or associated with altered bowel frequency, plus 2 of the following:
* Altered stool passage
* Abdominal bloating
* Symptoms worsened by eating
* Passage of mucus

518
Q

What are red flag features in the context of IBS?

A
  • Rectal bleeding
  • Unexplained weight loss
  • Family history of bowel or ovarian cancer
  • Onset after 60 years
519
Q

What is the significance of the carcinoembryonic antigen (CEA) test in colorectal cancer?

A

It is used for staging colorectal cancer.

520
Q

What is the most common type of colon cancer?

A

Sporadic colon cancer (95%).

521
Q

What is hereditary non-polyposis colorectal carcinoma (HNPCC) also known as?

A

Lynch syndrome.

522
Q

What are the Amsterdam criteria for HNPCC diagnosis?

A
  • At least 3 family members with colon cancer
  • Cases spanning at least two generations
  • At least one case diagnosed before age 50
523
Q

What is familial adenomatous polyposis (FAP)?

A

A rare autosomal dominant condition leading to hundreds of polyps and inevitable carcinoma.

524
Q

What mutation is associated with familial adenomatous polyposis (FAP)?

A

Mutation in the adenomatous polyposis coli gene (APC).

525
Q

What is the typical management for colorectal cancer?

A

Surgery, chemotherapy, radiation therapy, and targeted therapies.

526
Q

What is the role of Faecal Immunochemical Test (FIT) in colorectal cancer screening?

A

Used to guide referral for suspected cancer.

527
Q

What should be done if a FIT test result is positive?

A

Refer the patient on the suspected cancer pathway.

528
Q

What are some symptoms of colorectal cancer?

A
  • Change in bowel habits
  • Rectal bleeding
  • Abdominal pain
  • Unexplained weight loss
  • Anaemia
  • Bowel obstruction
529
Q

What does the TNM staging system stand for?

A

Tumour, Node, Metastasis.

530
Q

What is the common treatment for obstructing colon cancer?

A

Stenting or resection.

531
Q

What is a Hartmann’s procedure?

A

Resection of the sigmoid colon with formation of an end colostomy.

532
Q

What is the age range for the NHS screening program in England?

A

60 to 74 years

Patients aged over 74 years may request screening.

533
Q

What test is used in the NHS screening program to detect human blood in stool samples?

A

Faecal Immunochemical Test (FIT)

FIT tests are sent through the post to eligible patients.

534
Q

What does the Faecal Immunochemical Test (FIT) specifically recognize?

A

Human haemoglobin (Hb)

It is a type of faecal occult blood (FOB) test.

535
Q

What is the main advantage of the FIT test over conventional FOB tests?

A

Only detects human haemoglobin

Conventional tests may detect animal haemoglobin from diet.

536
Q

How many faecal samples are needed for the FIT test?

A

One

Conventional FOB tests typically require 2-3 samples.

537
Q

What happens to patients with abnormal FIT test results?

A

Offered a colonoscopy

This is to further investigate the cause of the abnormal results.

538
Q

What percentage of patients at colonoscopy will have a normal exam?

A

50%

Approximately 5 out of 10 patients will have a normal exam.

539
Q

What is the likelihood of finding polyps during a colonoscopy?

A

40%

Approximately 4 out of 10 patients will be found to have polyps.

540
Q

What is the risk associated with polyps found during colonoscopy?

A

Premalignant potential

Polyps may be removed due to this risk.

541
Q

What percentage of patients undergoing colonoscopy will be found to have cancer?

A

10%

Approximately 1 out of 10 patients will be found to have cancer.

542
Q

When was the one-off flexible sigmoidoscopy trial at age 55 abandoned?

A

2021

This was mainly due to recruitment issues exacerbated by the COVID-19 pandemic.

543
Q

What was the impact of screening for colorectal cancer on mortality?

A

Reduced mortality by 16%

This is based on evidence showing the effectiveness of screening.

544
Q

What are the new symptoms that warrant a FIT test for patients under 60 years?

A

Changes in bowel habit OR iron deficiency anaemia

These symptoms indicate the need for further investigation.

545
Q

True or False: The FIT test reports numerical values to patients.

A

False

Patients are informed if the test is normal or abnormal, but not the numerical value.

546
Q

What is Crohn’s disease?

A

A form of inflammatory bowel disease that can affect any part of the gastrointestinal tract from mouth to anus.

547
Q

Which areas are most commonly affected by Crohn’s disease?

A

Terminal ileum and colon.

548
Q

What is the cause of Crohn’s disease?

A

Unknown, but there is strong genetic susceptibility.

549
Q

What are the common complications of Crohn’s disease?

A

Strictures, fistulas, and adhesions.

550
Q

What percentage of Crohn’s disease patients have small bowel involvement?

A

80%.

551
Q

What is the most prominent symptom of Crohn’s disease in adults?

A

Diarrhoea.

552
Q

What is the most prominent symptom of Crohn’s disease in children?

A

Abdominal pain.

553
Q

What are the common investigations for Crohn’s disease?

A

Raised inflammatory markers, increased faecal calprotectin, anaemia, low vitamin B12 and vitamin D.

554
Q

Name two extra-intestinal features related to disease activity in Crohn’s disease.

A
  • Arthritis (pauciarticular, asymmetric)
  • Erythema nodosum.
555
Q

What is the investigation of choice for Crohn’s disease?

A

Colonoscopy.

556
Q

What histological features are observed in Crohn’s disease?

A
  • Inflammation in all layers from mucosa to serosa
  • Goblet cells
  • Granulomas.
557
Q

What is the first-line treatment for inducing remission in Crohn’s disease?

A

Glucocorticoids.

558
Q

What is azathioprine used for in Crohn’s disease?

A

As an add-on medication to induce remission.

559
Q

What percentage of Crohn’s disease patients will eventually require surgery?

A

Around 80%.

560
Q

What is the standard incidence ratio for small bowel cancer in Crohn’s disease?

A

40.

561
Q

True or False: Ulcerative colitis inflammation always starts at the rectum.

A

True.

562
Q

What are common symptoms of ulcerative colitis?

A

Bloody diarrhoea, urgency, tenesmus, abdominal pain, particularly in the left lower quadrant.

563
Q

What is the typical endoscopic finding in ulcerative colitis?

A

Red, raw mucosa that bleeds easily.

564
Q

What is the management approach for mild ulcerative colitis?

A

Topical (rectal) aminosalicylate.

565
Q

What factors can trigger flares of ulcerative colitis?

A
  • Stress
  • Medications
  • NSAIDs
  • Antibiotics
  • Cessation of smoking.
566
Q

What is the recommended follow-up colonoscopy interval for lower risk ulcerative colitis patients?

A

5 years.

567
Q

What autoimmune condition is caused by sensitivity to gluten?

A

Coeliac disease.

568
Q

What are the associations of coeliac disease?

A
  • Dermatitis herpetiformis
  • Type 1 diabetes mellitus
  • Autoimmune hepatitis.
569
Q

What genetic markers are strongly associated with coeliac disease?

A
  • HLA-DQ2 (95% of patients)
  • HLA-DQ8 (80%).
570
Q

What is the typical presentation of coeliac disease?

A

Villous atrophy leading to malabsorption.

571
Q

What dietary component must be eliminated in patients with coeliac disease?

A

Gluten.

572
Q

What is coeliac disease?

A

An autoimmune condition caused by sensitivity to the protein gluten

It affects around 1% of the UK population and leads to villous atrophy and malabsorption.

573
Q

What are common conditions associated with coeliac disease?

A
  • Dermatitis herpetiformis
  • Type 1 diabetes mellitus
  • Autoimmune hepatitis

Dermatitis herpetiformis presents as a vesicular, pruritic skin eruption.

574
Q

What genetic associations are strongly linked to coeliac disease?

A
  • HLA-DQ2 (95% of patients)
  • HLA-DQ8 (80%)

These genetic markers are critical in understanding susceptibility to the disease.

575
Q

What symptoms should prompt screening for coeliac disease according to NICE guidelines?

A
  • Chronic or intermittent diarrhoea
  • Failure to thrive or faltering growth (in children)
  • Persistent gastrointestinal symptoms
  • Prolonged fatigue
  • Recurrent abdominal pain
  • Sudden weight loss
  • Unexplained iron-deficiency anaemia
  • Autoimmune thyroid disease
  • Dermatitis herpetiformis
  • Irritable bowel syndrome
  • Type 1 diabetes
  • First-degree relatives with coeliac disease

These symptoms indicate a potential need for further investigation.

576
Q

What are some complications of coeliac disease?

A
  • Anaemia (iron, folate, vitamin B12 deficiency)
  • Hyposplenism
  • Osteoporosis, osteomalacia
  • Lactose intolerance
  • Enteropathy-associated T-cell lymphoma
  • Subfertility, unfavourable pregnancy outcomes
  • Rare malignancies (oesophageal cancer)

Complications can significantly impact health and quality of life.

577
Q

At what age do children typically present symptoms of coeliac disease?

A

Before the age of 3 years, following the introduction of cereals into the diet

Symptoms may coincide with the introduction of gluten-containing foods.

578
Q

What is the gold standard for diagnosing coeliac disease?

A

Endoscopic intestinal biopsy

This should be performed in all patients suspected of having coeliac disease.

579
Q

What serological tests are first-choice for coeliac disease diagnosis according to NICE?

A
  • Tissue transglutaminase (TTG) antibodies (IgA)
  • Endomysial antibody (IgA)

These tests help confirm the diagnosis and assess compliance with a gluten-free diet.

580
Q

What dietary management is required for coeliac disease?

A

A gluten-free diet

This includes avoiding gluten-containing cereals such as wheat, barley, rye, and sometimes oats.

581
Q

Which foods are gluten-free?

A
  • Rice
  • Potatoes
  • Corn (maize)

These foods can be safely consumed by patients with coeliac disease.

582
Q

True or False: Whisky is safe for patients with coeliac disease.

A

True

Whisky is made from malted barley, but gluten proteins are removed during distillation.

583
Q

What vaccination is recommended for patients with coeliac disease?

A

Pneumococcal vaccine

Due to functional hyposplenism, vaccination is crucial for preventing infections.

584
Q

Fill in the blank: Anti-gliadin antibody tests are _______ by NICE.

A

not recommended

These tests are not considered reliable for diagnosing coeliac disease.

UKMLA Prep (39 decks)

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