Gastrointestinal including liver Flashcards
Conditions and presentation
Acute pancreatitis symptoms
- stabbing-like, epigastric pain radiating to the back.
- foetal position is usally taken
- associated with vomiting
- assoicated with alcohol consumption
Clinical signs of pancreatitis
- hypovolaemia
- fever
- Non-specific guarding
- Grey-Turner’s sign (bruising along the flanks)
- Cullen’s sign, characterized by bruising around the peri-umbilical area
Pancreatitis investigations
- FBC,urea and electrolytes
- LFTs
- Lipase and amylase
- US
- MRCP
- ERCP
- CT pancreas
Pancrease Mnemonic
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
Managment of pancreatitis
- Aggressive fluid resuscitation with crystalloids to maintain urine output > 30 mL/hour.
- Catheterisation.
- Analgesia: Strong opioids are often necessary.
- Anti-emetics.
complications of pancreatitis
- Peripancreatic Fluid Collection
- Pdeudocyst
- pancreatic abcess
- pancreatic necrosis
- haemorrhage
- ARDS
- Hypovolemic
- DM
Porphyria
pectrum of disorders arising from abnormalities in the haem synthesis pathway, which result from either structural or functional alterations in the enzymes involved.
Porphyria symptoms. (5)
Abdominal pain
Nausea
Confusion
Hypertension
Seizures
Signs and symptoms of Porphyria
- Urine may appear red/purple
- Urinary porphobilinogen levels (keep away from light)
Managment of Porphyria
supportive
6-12 hours after withdrawal symptoms of alcohol
- Insomnia
- Tremors
- Anxiety
- Agitation
- Nausea and vomiting
- Sweating
- Palpitations
12-24 hours post-drink
hallucinations
72-hours post drink
Delusions
Confusion
Seizures
Tachycardia
Hypertension
Hyperthermia
alcohol withdrawal investigations
- 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.
INDICATIONS FOR INPATIENT ALCOHOL WITHDRAWAL TREATMENT
- 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
Managment of alcohol withdrawal
- chlordiazepoxide
- Pabrinex
- intravenous lorazepam or oral lorazepam
Cyclizine
- H1 receptor antagonist
- Vestibular disturbances
Domperidone, metoclopramide
- D2 receptor antagonist
- Post-operative nausea, motion sickness
Ondansetron
- 5HT3 receptor antagonist
- Acute gastroenteritis, post-operative nausea, radiotherapy- or chemotherapy-induced
Hyoscine hydrobromide
- Anti-muscarinics
- Vestibular disturbances, palliative care
When to avoid Metoclopramide
- bowel obstruction
When to avoid Haloperidol
Parkinson’s disease and prolonged QT interval.
Prochlorperazine and clorpromazine avoid using when
- Parkinson’s disease symptoms
- young women as causes dystonia
Cyclizine avoidance when?
acute porphyurias
Zollinger Ellison syndrome
- 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.
Zollinger Ellison signs and syptoms
- 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)
Zollinger Ellison investigations
- 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.
Zollinger Ellison syndrome managment
- surgical resection
- PPIs
- chemotherapy and somatostatin analogues may be considered.
Ascites
abnormal accumulation of fluid within the peritoneal cavity.
Symptoms of ascities
- Abdominal distension
- Abdominal discomfort or pain
- Dyspnea
- Reduced mobility
- Anorexia and early satiety due to pressure on the stomach
- Tense abdomen
- Shifting dullness
What is the term for the position of a structure relative to the front of the body?
Anterior relations
What is the term for the position of a structure relative to the back of the body?
Posterior relations
What is the vertebral level of T12?
12th thoracic vertebra
What is the vertebral level of L4?
4th lumbar vertebra
List the vertebral bodies from L1 to L4
- L1
- L2
- L3
- L4
What structure connects the stomach to the liver?
Lesser omentum
Which organ is primarily responsible for detoxification and metabolism?
Liver
What vein drains the left kidney?
Left renal vein
What vein drains the gastrointestinal tract and connects to the superior mesenteric vein?
Inferior mesenteric vein
Which part of the duodenum is referred to as the third part?
Third part of duodenum
Which organ is located behind the stomach and is involved in digestion?
Pancreas
What layer of the abdominal cavity lines the abdominal wall?
Parietal peritoneum
What is the term for the space within the abdomen that contains the intestines, liver, and other organs?
Peritoneal cavity
What is the name of the right portion of the diaphragm?
Right crus of the diaphragm
What is the name of the lymphatic structure that collects lymph from the lower body?
Cisterna chyli
What vein is responsible for draining blood from the thoracic wall into the superior vena cava?
Azygos vein
What does IVC stand for in the context of venous drainage?
Inferior vena cava
What is the fourth part of the duodenum called?
4th part of duodenum
What is the term for the bend between the duodenum and jejunum?
Duodenal-jejunal flexure
What structure is part of the sympathetic nervous system located on the left side of the vertebral column?
Left sympathetic trunk
What are the right lateral relations of a structure?
Right lateral relations
What are the left lateral relations of a structure?
Left lateral relations
What are the branches of the abdominal aorta? (10)
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.
At what level does the abdominal aorta primarily branch?
T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4
The levels indicate the vertebral locations where the branches emerge.
Which abdominal aortic branches are paired? (4)
Renal, Gonadal, Lumbar, Common iliac
Paired branches typically supply symmetrical structures on either side of the body.
Which abdominal aortic branches are unpaired?
Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral
Unpaired branches usually supply midline structures in the abdomen.
What type of branches are the Inferior phrenic and Lumbar?
Parietal
Parietal branches supply the body wall.
What type of branches are the Coeliac and Superior mesenteric?
Visceral
Visceral branches supply the organs within the abdominal cavity.
Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.
Inferior phrenic
True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.
False
The Middle suprarenal branch is unpaired.
Which branches of the abdominal aorta are classified as terminal?
Common iliac
Terminal branches are the final branches of the abdominal aorta before it bifurcates.
What are the branches of the abdominal aorta? (9)
- 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.
At what level does the abdominal aorta primarily branch?
T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4
The levels indicate the vertebral locations where the branches emerge.
Which abdominal aortic branches are paired?
Renal, Gonadal, Lumbar, Common iliac
Paired branches typically supply symmetrical structures on either side of the body.
Which abdominal aortic branches are unpaired? (4)
Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral
Unpaired branches usually supply midline structures in the abdomen.
What type of branches are the Inferior phrenic and Lumbar?
Parietal
Parietal branches supply the body wall.
What type of branches are the Coeliac and Superior mesenteric?
Visceral
Visceral branches supply the organs within the abdominal cavity.
Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.
Inferior phrenic
True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.
False
The Middle suprarenal branch is unpaired.
Which branches of the abdominal aorta are classified as terminal?
Common iliac
Terminal branches are the final branches of the abdominal aorta before it bifurcates.
What is the location of the appendix?
Base of caecum
How long can the appendix be?
Up to 10cm long
What type of tissue mainly composes the appendix?
Lymphoid tissue
This is significant because mesenteric adenitis may mimic appendicitis.
What anatomical feature helps in identifying the appendix during surgery?
Convergence of caecal taenia coli at base of appendix
What is the arterial supply to the appendix?
Appendicular artery (branch of the ileocolic)
Is the appendix intra or retroperitoneal?
Intra peritoneal
Where is McBurney’s point located?
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus
What percentage of appendices are found in the retrocaecal position?
74%
What percentage of appendices are found in the pelvic position?
21%
List the six positions of the appendix. (6)
- Retrocaecal
- Pelvic
- Postileal
- Subcaecal
- Paracaecal
- Preileal
Where is the caecum located?
Proximal right colon below the ileocaecal valve
The caecum is intraperitoneal.
What are the posterior relations of the caecum?
- Psoas
- Iliacus
- Femoral nerve
- Genitofemoral nerve
- Gonadal vessels
These structures are located behind the caecum.
What are the anterior relations of the caecum?
Greater omentum
The greater omentum is a fold of peritoneum that hangs down from the stomach.
What is the arterial supply of the caecum?
Ileocolic artery
The ileocolic artery branches from the superior mesenteric artery.
What accompanies the venous drainage of the caecum?
Mesenteric nodes
Lymphatic drainage is important for immune function and fluid balance.
What is the most distensible part of the colon?
Caecum
This characteristic makes it vulnerable in cases of bowel obstruction.
In complete large bowel obstruction, where is the most likely site of eventual perforation?
Caecum
This occurs specifically with a competent ileocaecal valve.
What is the length of the ureter?
25-35 cm long
What type of epithelium lines the ureter?
Transitional epithelium
What surrounds the ureter?
Thick muscular coat
How many muscular layers does the ureter have as it crosses the bony pelvis?
3 muscular layers
Where is the ureter located in relation to the transverse processes?
Retroperitoneal structure overlying transverse processes L2-L5
What lies anterior to the bifurcation of the iliac vessels?
Ureter
What is the blood supply to the ureter?
Segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac
Where does the ureter lie in relation to the uterine artery?
Beneath the uterine artery
What is the diaphragm?
A muscle that separates the thoracic cavity from the abdominal cavity and is the primary muscle involved in respiration.
What are diaphragm apertures?
Openings within the diaphragm that allow specific structures to pass from the thoracic cavity to the abdominal cavity.
List the three main diaphragm apertures and their vertebral levels.
- Aortic hiatus - T12
- Oesophageal hiatus - T10
- Vena cava foramen - T8
How can the vertebral levels of diaphragm apertures be remembered?
By counting the total number of letters in the spellings of ‘vena cava’ (8), ‘oesophagus’ (10), and ‘aortic hiatus’ (12).
What are lesser diaphragmatic apertures?
Smaller openings in the diaphragm that allow much smaller structures to pass through.
Name some examples of lesser diaphragmatic apertures.
- Left phrenic nerve
- Small veins
- Superior epigastric artery
- Intercostal nerves & vessels
- Subcostal nerves & vessels
- Splanchnic nerves
- Sympathetic trunk
What is Klinefelter’s syndrome associated with?
Karyotype 47, XXY
Klinefelter’s syndrome is a genetic condition resulting from the presence of an extra X chromosome.
List some features of Klinefelter’s syndrome.
- 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.
How is Klinefelter’s syndrome diagnosed?
By karyotype (chromosomal analysis)
Karyotyping helps to confirm the presence of the extra chromosome associated with the syndrome.
True or False: Individuals with Klinefelter’s syndrome are typically fertile.
False
Infertility is a common feature of Klinefelter’s syndrome due to testicular dysfunction.
Fill in the blank: Klinefelter’s syndrome results in _______ levels of testosterone.
Low
The low testosterone levels are due to testicular dysgenesis associated with the syndrome.
Acute Cholangitis
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.
Alcoholic Hepatitis
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
Anaemia
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).
Anal fissure
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.
Appendicitis
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).
Ascites
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.
Cholecystitis
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.
Coeliac’s disease
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.
Diverticular disease
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).
Gall stones and Billary colic
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.
GI perforation
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.
GERD
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.
Haemochromatosis
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.
Hepatits
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).
What is the commonest approach to the abdomen?
Midline incision
Structures divided include linea alba, transversalis fascia, extraperitoneal fat, and peritoneum, while avoiding the falciform ligament above the umbilicus.
Which incision allows for access to the bladder via an extraperitoneal approach?
Midline incision
Access is achieved through the space of Retzius.
What is a paramedian incision?
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.
What structures are divided or retracted in a paramedian incision?
- Anterior rectus sheath
- Rectus (retracted)
- Posterior rectus sheath
- Transversalis fascia
- Extraperitoneal fat
- Peritoneum
The incision is closed in layers.
What is the Battle incision?
Similar location to paramedian but rectus displaced medially
This incision is now seldom used.
Describe Kocher’s incision.
Incision under right subcostal margin
Commonly used for cholecystectomy (open).
What is the purpose of the Lanz incision?
Incision in right iliac fossa
Typically used for appendicectomy.
What is the Gridiron incision used for?
Oblique incision centered over McBurney’s point
Usually performed for appendicectomy and is less cosmetically acceptable than Lanz.
What type of incision is Pfannenstiel’s incision?
Transverse supra pubic incision
Primarily used to access pelvic organs.
What is McEvedy’s incision used for?
Groin incision
Used for emergency repair of strangulated femoral hernia.
What is the Rutherford Morrison incision known for?
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.
What is a characteristic feature of duodenal ulcers?
Epigastric pain relieved by eating
Duodenal ulcers are more common than gastric ulcers.
What symptom is associated with gastric ulcers?
Epigastric pain worsened by eating
Features of upper gastrointestinal hemorrhage may be seen.
What is the typical initial pain location in appendicitis?
Central abdomen
Pain later localizes to the right iliac fossa.
What are common symptoms of appendicitis?
- 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.
What is the most common cause of acute pancreatitis?
Alcohol or gallstones
Severe epigastric pain and vomiting are common.
What are Cullen’s sign and Grey-Turner’s sign associated with?
Periumbilical and flank discoloration, respectively
These signs are described in acute pancreatitis but are rare.
What is a characteristic feature of biliary colic?
RUQ pain radiating to the back and interscapular region
Pain may follow a fatty meal and can persist for hours.
What may obstructive jaundice cause in terms of stool and urine color?
- Pale stools
- Dark urine
These changes are due to bile duct obstruction.
What are classic symptoms of acute cholecystitis?
- Continuous RUQ pain
- Fever
- Raised inflammatory markers
- Positive Murphy’s sign
Murphy’s sign involves arrest of inspiration on palpation of the RUQ.
What is the typical presentation of diverticulitis?
Colicky pain in the LLQ
Fever and raised inflammatory markers are also common.
What type of pain is associated with an abdominal aortic aneurysm?
Severe central abdominal pain radiating to the back
Presentation may be catastrophic or sub-acute.
What are common symptoms of intestinal obstruction?
- History of malignancy/previous operations
- Vomiting
- Not opened bowels recently
- ‘Tinkling’ bowel sounds
These symptoms indicate a possible blockage in the intestines.
What is the significance of pain in the RIF?
It is a sign associated with appendicitis
RIF stands for Right Iliac Fossa, where appendicitis pain is typically localized.
What are common symptoms of appendicitis?
Pain on extending the hip and raised inflammatory markers
Inflammatory markers indicate an immune response, which is common in appendicitis.
What demographic is more likely to experience appendicitis?
Thin, male patients
This demographic has a higher likelihood of presenting with appendicitis.
What is the typical percentage likelihood of appendicitis in certain cases?
55%
This statistic may refer to specific clinical scenarios involving appendicitis.
Appendicitis is often indicated by which combination of factors?
Raised inflammatory markers and compatible history
A compatible history includes symptoms and clinical findings consistent with appendicitis.
Fill in the blank: Pain in the RIF is now considered a sign of _______.
appendicitis
True or False: Pain on extending the hip is not associated with appendicitis.
False
This type of pain is indeed a sign of appendicitis.
What does RIF stand for in the context of appendicitis?
Right Iliac Fossa
It is the anatomical location where appendicitis pain is typically felt.
What is Whipple’s disease?
A rare multi-system disorder caused by Tropheryma whippelii infection
More common in those who are HLA-B27 positive and in middle-aged men.
List the common features of Whipple’s disease.
- Malabsorption: diarrhoea, weight loss
- Large-joint arthralgia
- Lymphadenopathy
- Skin: hyperpigmentation and photosensitivity
- Pleurisy, pericarditis
- Neurological symptoms (rare): ophthalmoplegia, dementia, seizures, ataxia, myoclonus
What does jejunal biopsy reveal in Whipple’s disease?
Deposition of macrophages containing Periodic acid-Schiff (PAS) granules
What is the first-line management for Whipple’s disease?
Oral co-trimoxazole for a year, sometimes preceded by a course of IV penicillin
True or False: Whipple’s disease is more common in women than men.
False
Fill in the blank: Whipple’s disease is associated with _______ positive individuals.
HLA-B27
What are the neurological symptoms associated with Whipple’s disease?
- Ophthalmoplegia
- Dementia
- Seizures
- Ataxia
- Myoclonus
What are some gastrointestinal symptoms of Whipple’s disease?
- Diarrhoea
- Weight loss
What are the skin manifestations of Whipple’s disease?
- Hyperpigmentation
- Photosensitivity
What is the significance of HLA-B27 in Whipple’s disease?
Its presence indicates a higher risk of developing the disease
What is Wilson’s disease primarily associated with?
Copper accumulation in the body
Wilson’s disease leads to excessive copper deposition, particularly affecting the liver and brain.
Which part of the brain is primarily affected by copper deposition in Wilson’s disease?
Basal ganglia, particularly the putamen and globus pallidus
These regions are crucial for motor control and may lead to neurological symptoms.
What are common neurological manifestations of Wilson’s disease?
- Asterixis
- Chorea
- Dementia
- Behavioral problems
These symptoms arise from copper accumulation affecting brain function.
What characteristic eye finding is associated with Wilson’s disease?
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.
In which percentage of patients with isolated hepatic Wilson’s disease are Kayser-Fleischer rings present?
Around 50%
Kayser-Fleischer rings are a key diagnostic feature of Wilson’s disease.
What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson’s disease?
Up to 90%
This high prevalence indicates significant copper accumulation affecting neurological function.
What renal condition is associated with Wilson’s disease?
Renal tubular acidosis
This condition can manifest as part of the systemic effects of copper overload.
What is a potential new treatment agent currently under investigation for Wilson’s disease?
Tetrathiomolybdate
This agent aims to enhance copper excretion and reduce its toxic effects.
What is a physical sign that may indicate Wilson’s disease?
Blue nails
This is a less common manifestation but can be associated with copper dysregulation.
What is Wilson’s disease primarily associated with?
Copper accumulation in the body
Wilson’s disease leads to excessive copper deposition, particularly affecting the liver and brain.
What are common neurological manifestations of Wilson’s disease?
- Asterixis
- Chorea
- Dementia
- Behavioral problems
These symptoms arise from copper accumulation affecting brain function.
What characteristic eye finding is associated with Wilson’s disease?
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.
In which percentage of patients with isolated hepatic Wilson’s disease are Kayser-Fleischer rings present?
Around 50%
Kayser-Fleischer rings are a key diagnostic feature of Wilson’s disease.
What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson’s disease?
Up to 90%
This high prevalence indicates significant copper accumulation affecting neurological function.
What renal condition is associated with Wilson’s disease?
Renal tubular acidosis
This condition can manifest as part of the systemic effects of copper overload.
What is a potential new treatment agent currently under investigation for Wilson’s disease?
Tetrathiomolybdate
This agent aims to enhance copper excretion and reduce its toxic effects.
What is Zollinger-Ellison syndrome?
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.
Where are the majority of gastrin-secreting tumours found in Zollinger-Ellison syndrome?
First part of the duodenum
The pancreas is the second most common location for these tumours.
What percentage of gastrinomas occur as part of MEN type I syndrome?
Around 30%
MEN stands for Multiple Endocrine Neoplasia.
List three features of Zollinger-Ellison syndrome.
- Multiple gastroduodenal ulcers
- Diarrhoea
- Malabsorption
What is the single best screening test for Zollinger-Ellison syndrome?
Fasting gastrin levels
This test is used to measure the amount of gastrin hormone in the blood.
What test is used to further evaluate Zollinger-Ellison syndrome after initial screening?
Secretin stimulation test
What is the scientific name for threadworms?
Enterobius vermicularis
In which population is threadworm infestation particularly common?
Children in the UK
How does threadworm infestation occur?
After swallowing eggs that are present in the environment
What percentage of threadworm infestations are asymptomatic?
90%
What are possible features of threadworm infestation?
- Perianal itching, particularly at night
- Vulval symptoms in girls
What diagnostic method can be used for threadworm infestation?
Applying Sellotape to the perianal area and sending it for microscopy
What is the recommended management approach for threadworm infestation?
- Combination of anthelmintic with hygiene measures for all household members
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole
How is mebendazole administered for threadworm infestation?
A single dose is given unless infestation persists
True or False: Most patients with threadworm infestation are treated empirically.
True
What are desmoid tumours?
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.
What is the typical appearance of desmoid tumours?
Firm overgrowths of tissue with a propensity to local infiltration
These characteristics make desmoid tumours challenging to treat and manage.
In what percentage of patients with familial adenomatous polyposis coli do desmoid tumours occur?
Up to 15%
Familial adenomatous polyposis coli is a genetic condition that increases the risk for colorectal cancer.
What genetic mutations are typically seen in desmoid tumours?
Bi allelic APC mutations
APC gene mutations are commonly associated with familial adenomatous polyposis and are critical in tumorigenesis.
In which demographic do desmoid tumours most commonly occur?
Women after childbirth in the rectus abdominis muscle
This demographic factor may relate to hormonal changes and physical stress during and after pregnancy.
What is the primary treatment for desmoid tumours?
Radical surgical resection
Surgical intervention is preferred due to the high tendency for local recurrence.
What are the alternative treatments for desmoid tumours, if surgery is not an option?
Radiotherapy and chemotherapy may be considered
However, the results of non-surgical therapy are generally inferior to surgical resection.
What is the prognosis for abdominal desmoid tumours?
Some may spontaneously regress
In selected cases, a period of observation may be preferred, particularly if the tumours are not causing significant symptoms.
True or False: Desmoid tumours have a low tendency to local recurrence.
False
Desmoid tumours are known for their high tendency to recur locally after treatment.
Fill in the blank: Desmoids consist of sheets of differentiated _______.
fibroblasts
This cellular composition is significant in understanding their pathological behavior.
What type of bacteria is Helicobacter pylori?
Gram-negative bacteria
Associated with various gastrointestinal problems, particularly peptic ulcer disease.
What are the two main mechanisms Helicobacter pylori uses to survive in acidic gastric environments?
- 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.
What type of cytotoxins does Helicobacter pylori release?
Bacterial cytotoxins (e.g., CagA toxin)
These toxins disrupt the gastric mucosa.
What gastrointestinal conditions are associated with Helicobacter pylori?
- 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.
Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?
No, there is currently no role for eradication in GORD
The relationship between H pylori and GORD is unclear.
What is the standard management for Helicobacter pylori infection?
A 7-day course of:
* Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole)
If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.
What type of bacteria is Helicobacter pylori?
Gram-negative bacteria
Associated with various gastrointestinal problems, particularly peptic ulcer disease.
What are the two main mechanisms Helicobacter pylori uses to survive in acidic gastric environments?
- 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.
What type of cytotoxins does Helicobacter pylori release?
Bacterial cytotoxins (e.g., CagA toxin)
These toxins disrupt the gastric mucosa.
What gastrointestinal conditions are associated with Helicobacter pylori?
- 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.
Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?
No, there is currently no role for eradication in GORD
The relationship between H pylori and GORD is unclear.
What is the standard management for Helicobacter pylori infection?
A 7-day course of:
* Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole)
If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.
What is coeliac disease?
An autoimmune condition caused by sensitivity to the protein gluten
It affects around 1% of the UK population.
What happens with repeated exposure to gluten in coeliac disease?
Leads to villous atrophy, causing malabsorption
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis (a vesicular, pruritic skin eruption)
What autoimmune disorders are associated with coeliac disease?
- Type 1 diabetes mellitus
- Autoimmune hepatitis
What HLA types are strongly associated with coeliac disease?
- HLA-DQ2 (95% of patients)
- HLA-DQ8 (80%)
According to NICE guidelines, which patients should be screened for coeliac disease?
Patients with specific signs and symptoms
Name two signs or symptoms of coeliac disease.
- Chronic or intermittent diarrhoea
- Failure to thrive or faltering growth in children
What is a common gastrointestinal symptom of coeliac disease?
Persistent or unexplained gastrointestinal symptoms, including nausea and vomiting
What are some complications of coeliac disease?
- Iron deficiency anemia
- Folate deficiency
- Vitamin B12 deficiency
- Osteoporosis
- Osteomalacia
- Enteropathy-associated T-cell lymphoma of the small intestine
- Unfavorable pregnancy outcomes
True or False: Folate deficiency is more common than vitamin B12 deficiency in coeliac disease.
True
What are rare complications associated with coeliac disease?
- Oesophageal cancer
- Other malignancies
Fill in the blank: Coeliac disease is associated with _______ thyroid disease.
Autoimmune
What is a common gastrointestinal condition that may be confused with coeliac disease?
Irritable bowel syndrome
Who are considered first-degree relatives in relation to coeliac disease?
- Parents
- Siblings
- Children
What is Coeliac disease caused by?
Sensitivity to the protein gluten
What is the consequence of repeated exposure to gluten in Coeliac disease?
Villous atrophy leading to malabsorption
At what age do children typically present with Coeliac disease?
Before the age of 3 years
What genetic markers are strongly associated with Coeliac disease?
HLA-DQ2 and HLA-DQ8
What is the incidence of Coeliac disease?
Around 1:100
What symptoms may coincide with the introduction of cereals in children with Coeliac disease?
- Failure to thrive
- Diarrhoea
- Abdominal distension
- Anaemia in older children
What is a common issue regarding the diagnosis of Coeliac disease?
Many cases are not diagnosed until adulthood
What findings are seen in a jejunal biopsy for Coeliac disease?
Subtotal villous atrophy
What are useful screening tests for Coeliac disease?
- Anti-endomysial antibodies
- Anti-gliadin antibodies
What causes coeliac disease?
Coeliac disease is caused by sensitivity to the protein gluten.
What leads to malabsorption in coeliac disease?
Repeated exposure to gluten leads to villous atrophy, which in turn causes malabsorption.
What are conditions associated with coeliac disease?
Conditions include dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis.
How is coeliac disease diagnosed?
Diagnosis is made by a combination of serology and endoscopic intestinal biopsy.
What happens to villous atrophy and immunology on a gluten-free diet?
Villous atrophy and immunology normally reverses on a gluten-free diet.
What did NICE issue in 2009 regarding coeliac disease?
NICE issued guidelines on the investigation of coeliac disease.
What should patients do if they are already on a gluten-free diet before testing?
They should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.
What is the first-choice serology test according to NICE?
Tissue transglutaminase (TTG) antibodies (IgA) are the first-choice test.
What is needed to look for selective IgA deficiency?
Endomyseal antibody (IgA) is needed to look for selective IgA deficiency.
Are anti-gliadin antibody tests recommended by NICE?
No, anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE.
What is the ‘gold standard’ for diagnosing coeliac disease?
Endoscopic intestinal biopsy is the ‘gold standard’ for diagnosis.
Where is the endoscopic intestinal biopsy traditionally performed?
Traditionally done in the duodenum, but jejunal biopsies are also sometimes performed.
What are findings supportive of coeliac disease?
Findings include villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes.
Is rectal gluten challenge widely used?
No, rectal gluten challenge has been described but is not widely used.
What happens to clotting factors in liver failure?
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.
Why is factor VIII levels increased in liver failure?
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.
What do conventional coagulation studies indicate in chronic liver disease?
Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk.
However, patients are paradoxically at an increased risk of thrombosis.
What paradoxical condition occurs in patients with chronic liver disease?
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.
Which natural anticoagulants are reduced in chronic liver disease?
Reduction in protein C, protein S (vitamin K dependent), and anti-thrombin (non-vitamin K dependent).
These reductions lead to an imbalance favoring thrombosis.
True or False: Patients with chronic liver disease are only at risk for bleeding.
False.
They are also at an increased risk for thrombosis.
Fill in the blank: In liver failure, factor VIII is _______.
supra-normal
What leads to the paradoxical increase in factor VIII during liver failure?
Good hepatic function is required for the clearance of activated factor VIII.
Impaired hepatic function leads to decreased clearance and increased levels.
What happens to clotting factors in liver failure?
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.
Why is factor VIII levels increased in liver failure?
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.
What do conventional coagulation studies indicate in chronic liver disease?
Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk.
However, patients are paradoxically at an increased risk of thrombosis.
What paradoxical condition occurs in patients with chronic liver disease?
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.
Which natural anticoagulants are reduced in chronic liver disease?
Reduction in protein C, protein S (vitamin K dependent), and anti-thrombin (non-vitamin K dependent).
These reductions lead to an imbalance favoring thrombosis.
True or False: Patients with chronic liver disease are only at risk for bleeding.
False.
They are also at an increased risk for thrombosis.
Fill in the blank: In liver failure, factor VIII is _______.
supra-normal
What leads to the paradoxical increase in factor VIII during liver failure?
Good hepatic function is required for the clearance of activated factor VIII.
Impaired hepatic function leads to decreased clearance and increased levels.
What does acute liver failure describe?
The rapid onset of hepatocellular dysfunction leading to various systemic complications
Acute liver failure can be life-threatening and requires immediate medical attention.
List three common causes of acute liver failure.
- Paracetamol overdose
- Alcohol
- Viral hepatitis (usually A or B)
Other causes include acute fatty liver of pregnancy.
What are the main features of acute liver failure?
- Jaundice
- Coagulopathy: raised prothrombin time
- Hypoalbuminaemia
- Hepatic encephalopathy
- Renal failure (hepatorenal syndrome)
These features indicate severe liver dysfunction.
True or False: Liver function tests always accurately reflect the synthetic function of the liver.
False
Liver function tests may not provide a complete picture; prothrombin time and albumin levels are better indicators.
What is the best way to assess the synthetic function of the liver?
By looking at the prothrombin time and albumin level
These parameters provide insight into the liver’s ability to synthesize proteins.
Fill in the blank: Renal failure is common in acute liver failure and is referred to as _______.
hepatorenal syndrome
This condition results from the interplay between liver failure and kidney function.
What is acute mesenteric ischaemia typically caused by?
An embolism resulting in occlusion of an artery supplying the small bowel
Commonly the superior mesenteric artery is involved.
What medical history is classically associated with acute mesenteric ischaemia?
Atrial fibrillation
This condition can lead to the formation of emboli.
Describe the nature of abdominal pain in acute mesenteric ischaemia.
Severe, of sudden onset, and out-of-keeping with physical exam findings
This discrepancy often raises suspicion for the condition.
What is the typical management for acute mesenteric ischaemia?
Immediate laparotomy
Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.
What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?
Poor prognosis
Timely intervention is critical for better outcomes.
What is acute mesenteric ischaemia typically caused by?
An embolism resulting in occlusion of an artery supplying the small bowel
Commonly the superior mesenteric artery is involved.
What medical history is classically associated with acute mesenteric ischaemia?
Atrial fibrillation
This condition can lead to the formation of emboli.
Describe the nature of abdominal pain in acute mesenteric ischaemia.
Severe, of sudden onset, and out-of-keeping with physical exam findings
This discrepancy often raises suspicion for the condition.
What is the typical management for acute mesenteric ischaemia?
Immediate laparotomy
Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.
What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?
Poor prognosis
Timely intervention is critical for better outcomes.
GET SMASHED
- Gall stones
- Ethanol
- Trauma
- Scoropion bites
- M umps
- Autoimmune
- Steroids
- Hypercalmeia orhypertriglycerdemia
- ERCP
- Drugs (NSAIDs, Azithromycin)
What is the most common cause of acute pancreatitis?
Alcohol or gallstones
What is the pathophysiological mechanism of acute pancreatitis?
Antedigestion of pancreatic tissue by pancreatic enzymes
What are common physical examination findings in acute pancreatitis?
Epigastric tenderness, ileus, and low-grade fever
What are Cullen’s sign and Grey-Turner’s sign associated with?
Acute pancreatitis (rarely seen)
What rare complication can occur due to pancreatitis?
Blindness due to retinopathy
What laboratory test is typically raised in 75% of acute pancreatitis cases?
Serum amylase
What does a serum amylase level > 3 times the upper limit of normal indicate?
Possible acute pancreatitis
What is the specificity of serum amylase for pancreatitis?
Around 90%
What other conditions can cause raised serum amylase levels?
- Pancreatic pseudocyst
- Mesenteric infarct
- Perforated viscus
- Acute cholecystitis
- Diabetic ketoacidosis
Which enzyme is more sensitive and specific than serum amylase in diagnosing pancreatitis?
Serum lipase
What is a unique characteristic of serum lipase compared to serum amylase?
Longer half-life
When might serum lipase be particularly useful?
In late presentations (> 44 hours)
Can acute pancreatitis be diagnosed without imaging?
Yes, with characteristic pain + amylase/lipase > 3 times normal
What imaging is important for diagnosing gallstones or biliary obstruction in pancreatitis?
Early ultrasound imaging
What imaging technique can also be used for diagnosing acute pancreatitis?
Contrast-enhanced CT
Is the actual amylase level of prognostic value in acute pancreatitis?
No
What percentage of acute pancreatitis cases experience Erinacetis fluid collections?
25%
Erinacetis fluid collections are located in or near the pancreas and lack a wall of granulation or fibrous tissue.
What may happen to Erinacetis fluid collections in acute pancreatitis?
They may resolve or develop into pseudocysts or abscesses
Aspiration and drainage are best avoided as they may precipitate infection.
What characterizes pseudocysts in acute pancreatitis?
Result from organization of peripancreatic fluid collection
They may or may not communicate with the ductal system.
What is the typical occurrence time for pseudocysts after an attack of acute pancreatitis?
4 weeks or more
The collection is walled by fibrous or granulation tissue.
What proportion of symptomatic pseudocysts may resolve within 12 weeks?
Up to 50%
Treatment options include endoscopic or surgical interventions.
What does pancreatic necrosis involve?
Both the pancreatic parenchyma and surrounding fat
Complications are directly linked to the extent of necrosis.
What is associated with a high mortality rate in pancreatic necrosis?
Extent of parenchymal necrosis
Some centers perform fine-needle aspiration sampling of necrotic tissue if infection is suspected.
What is a pancreatic abscess?
A localized collection of pus associated with the pancreas
This occurs in the absence of hemorrhage.
What may infected necrosis involve that can lead to hemorrhage?
Vascular structures
Hemorrhage may occur de novo or post-surgery.
What systemic complication is associated with a high mortality rate of around 20%?
Acute respiratory distress syndrome
This condition is a significant concern in cases of acute pancreatitis.
What is necrotising enterocolitis?
One of the leading causes of death among premature infants.
What are initial symptoms of necrotising enterocolitis?
- Feeding intolerance
- Abdominal distension
- Bloody stools
What imaging findings can be seen in necrotising enterocolitis?
- Dilated bowel loops
- Bowel wall oedema
- Pneumatosis intestinalis
- Portal venous gas
- Pneumoperitoneum
- Rigler sign
- Football sign
What is the most common type of oesophageal cancer?
Adenocarcinoma
Which condition is associated with an increased risk of adenocarcinoma of the oesophagus?
Gastro-oesophageal reflux disease (GORD) or Barrett’s oesophagus.
Where are adenocarcinomas typically located in the oesophagus?
Near the gastroesophageal junction.
What is the most common presenting symptom of oesophageal cancer?
Dysphagia
What is the preferred method for locoregional staging of oesophageal cancer?
Endoscopic ultrasound
What is the most common procedure for operable oesophageal cancer?
Ivor-Lewis type oesophagectomy
What is the typical presentation of pancreatic cancer?
Classically painless jaundice.
What are some common associations with pancreatic cancer?
- Increasing age
- Smoking
- Diabetes
- Chronic pancreatitis
- Hereditary non-polyposis colorectal carcinoma
- Multiple endocrine neoplasia
- BRCA2 gene
- KRAS gene mutation
What is Courvoisier’s law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones.
What imaging technique is the investigation of choice for suspected pancreatic cancer?
High-resolution CT scanning.
What is the treatment for resectable lesions in the head of the pancreas?
Whipple’s resection (pancreaticoduodenectomy).
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus.
What are common features of a perianal abscess?
- Pain around the anus
- Hardened tissue in the anal region
- Pus-like discharge
- Features of systemic infection if longstanding
What is the gold standard imaging for anorectal abscesses?
MRI
What is secondary peritonitis?
An inflammatory condition of the peritoneum from spillage of gastrointestinal or biliary contents.
What are common causes of secondary peritonitis?
- Perforated peptic ulcer
- Ruptured appendicitis
- Diverticulitis
- Trauma or neoplasia
What are the clinical features of secondary peritonitis?
- Acute abdominal pain
- Fever
- Tachycardia
- Rebound tenderness
- Guarding
What is the cornerstone of management for secondary peritonitis?
Surgical intervention and broad-spectrum antibiotic therapy.
What is spontaneous bacterial peritonitis (SBP)?
A form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
What is the most common organism found in ascitic fluid culture for SBP?
E. coli
What is primary biliary cholangitis?
A chronic liver disorder typically seen in middle-aged females.
What are common associations with primary biliary cholangitis?
- Sjogren’s syndrome
- Rheumatoid arthritis
- Systemic sclerosis
- Thyroid disease
What is the first-line treatment for primary biliary cholangitis?
Ursodeoxycholic acid.
What is the incubation period for Hepatitis A?
2-4 weeks.
What is a significant complication of Hepatitis B infection?
Chronic hepatitis.
Which groups should be vaccinated against Hepatitis B?
- Healthcare workers
- Intravenous drug users
- Sex workers
- Close family contacts of individuals with Hepatitis B
- Chronic kidney disease patients
What percentage of adults fail to respond or respond poorly to 3 doses of the hepatitis B vaccine?
5-10%
Risk factors include age over 40 years, obesity, smoking, alcohol excess, and immunosuppression.
Who is recommended to be tested for anti-HBs?
Individuals at risk of occupational exposure and patients with chronic kidney disease
Anti-HBs levels should be checked 1-4 months after primary immunization.
What does an anti-HBs level of > 100 mIU/ml indicate?
Adequate response, no further testing required, booster at 5 years
This indicates strong immunity.
What is indicated by an anti-HBs level of 10 - 100 mIU/ml?
Suboptimal response - one additional vaccine dose should be given
If immunocompetent, no further testing is required.
What should be done if anti-HBs is < 10 mIU/ml?
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.
What was the only treatment available for hepatitis B before newer antivirals?
Pegylated interferon-alpha
It reduces viral replication in up to 30% of chronic carriers.
What factors predict a better response to pegylated interferon treatment?
Being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy
What are some antiviral medications used to treat hepatitis B?
Tenofovir, entecavir, telbivudine
These aim to suppress viral replication.
What screening is offered to all pregnant women regarding hepatitis B?
Screening for hepatitis B
Babies born to infected mothers should receive complete vaccination + hepatitis B immunoglobulin.
What is the vertical transmission rate of hepatitis B from mother to child?
6%
The risk is higher if there is coexistent HIV.
True or False: Hepatitis B can be transmitted via breastfeeding.
False
Unlike HIV, hepatitis B cannot be transmitted through breastfeeding.
What does HBsAg indicate in hepatitis B serology?
Ongoing infection, either acute or chronic if present > 6 months
HBsAg is the first marker to appear.
What does the presence of anti-HBs imply?
Immunity (either exposure or immunization)
It is negative in chronic disease.
What does anti-HBc indicate?
Previous or current infection
IgM anti-HBc appears during acute infection and is present for about 6 months.
What is the chronic hepatitis C defined as?
Persistence of HCV RNA in the blood for 6 months
List some potential complications of chronic hepatitis C.
- Rheumatological problems: arthralgia, arthritis
- Eye problems: Sjogren’s syndrome
- Cirrhosis
- Hepatocellular cancer
- Cryoglobulinaemia
- Porphyria cutanea tarda
- Membranoproliferative glomerulonephritis
What is the goal of hepatitis C treatment?
Sustained virological response (SVR)
Defined as undetectable serum HCV RNA six months after the end of therapy.
What are common side effects of ribavirin?
- Haemolytic anaemia
- Cough
Women should avoid pregnancy within 6 months of stopping ribavirin as it is teratogenic.
What are the side effects of interferon alpha?
- Flu-like symptoms
- Depression
- Fatigue
- Leukopenia
- Thrombocytopenia
What is the estimated number of people chronically infected with hepatitis C in the UK?
Around 200,000 people.
This number indicates a significant public health concern.
What is the incubation period for hepatitis C?
6-9 weeks.
What is the vertical transmission rate of hepatitis C from mother to child?
About 6%.
True or False: Breastfeeding is contraindicated in mothers with hepatitis C.
False.
What is the risk of transmission of hepatitis C during a needle stick injury?
About 2%.
What percentage of patients will develop chronic hepatitis C after an acute infection?
55-85%.
What defines chronic hepatitis C?
Persistence of HCV RNA in the blood for 6 months.
List potential complications of chronic hepatitis C.
- Rheumatological problems (arthralgia, arthritis)
- Eye problems (Sjogren’s syndrome)
- Cirrhosis (5-20% of cases)
- Hepatocellular cancer
- Cryoglobulinaemia (type II)
- Porphyria cutanea tarda
- Membranoproliferative glomerulonephritis.
What is the aim of treatment for chronic hepatitis C?
Sustained virological response (SVR), defined as undetectable serum HCV RNA six months after therapy.
What are the first-line treatments for chronic hepatitis C?
Combination of protease inhibitors (e.g., daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin.
What is the risk associated with interferon alpha treatment?
Flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia.
Fill in the blank: Hepatitis D is an incomplete RNA virus that requires _______ for replication.
Hepatitis B surface antigen.
What is the term used for simultaneous Hepatitis B and Hepatitis D infections?
Co-infection.
What is the major risk associated with Hepatitis D superinfection?
High risk of fulminant hepatitis, chronic hepatitis status, and cirrhosis.
How is Hepatitis D diagnosed?
Reverse polymerase chain reaction of hepatitis D RNA.
What is the incubation period for Hepatitis E?
3-8 weeks.
List the common symptoms of irritable bowel syndrome (IBS).
- Abdominal pain
- Bloating
- Change in bowel habit.
What are ‘red flag’ features that should be investigated in IBS?
- Rectal bleeding
- Unexplained/unintentional weight loss
- Family history of bowel or ovarian cancer
- Onset after 60 years of age.
What is the first-line pharmacological treatment for pain in IBS?
Antispasmodic agents.
What dietary advice is recommended for managing IBS?
- 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.
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm.
What are the two types of hiatus hernias?
- Sliding
- Rolling (paraoesophageal).
What is the most sensitive test for investigating hiatus hernias?
Barium swallow.
What is diverticular disease?
Herniation of colonic mucosa through the muscular wall of the colon.
List the complications of diverticular disease.
- Diverticulitis
- Haemorrhage
- Development of fistula
- Perforation and faecal peritonitis
- Development of diverticular phlegmon.
What is the traditional mnemonic for the risk factors of biliary colic?
The ‘4 F’s’: Fat, Female, Fertile, Forty.
What is the primary management for biliary colic?
Elective laparoscopic cholecystectomy.
What are the features of anal fissures?
- Painful, bright red rectal bleeding
- 90% occur on the posterior midline.
What is the first-line treatment for chronic anal fissures?
Topical glyceryl trinitrate (GTN).
What are the risk factors for alcoholic liver disease?
N/A
What should be tried if lactulose is not tolerated?
Lubricants such as petroleum jelly
Lubricants may be used to ease defecation.
What is the first-line treatment for a chronic anal fissure?
Topical glyceryl trinitrate (GTN)
GTN is often applied to promote healing.
What conditions are covered under alcoholic liver disease?
- Alcoholic fatty liver disease
- Alcoholic hepatitis
- Cirrhosis
These conditions represent a spectrum of liver disease due to alcohol consumption.
What is characteristically elevated in alcoholic liver disease?
Gamma-GT
This enzyme is commonly used as a marker for liver disease.
What is the typical AST:ALT ratio in alcoholic hepatitis?
> 2
A ratio of > 3 is strongly suggestive of acute alcoholic hepatitis.
Which glucocorticoid is often used during acute episodes of alcoholic hepatitis?
Prednisolone
Glucocorticoids help manage inflammation during acute episodes.
What formula is used in Maddrey’s discriminant function (DF)?
Prothrombin time and bilirubin concentration
This formula helps determine the need for glucocorticoid therapy.
What did the STOPAH study compare?
Pentoxyphylline and prednisolone
The study found that prednisolone improved survival at 28 days.
What is the most common acute abdominal condition requiring surgery?
Acute appendicitis
It is most common in young people aged 10-20 years.
What is the pathogenesis of acute appendicitis?
- 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.
What type of abdominal pain is typically seen in appendicitis?
Peri-umbilical abdominal pain radiating to the right iliac fossa (RIF)
This pain migration is a strong indicator of appendicitis.
What are common symptoms of acute appendicitis?
- Vomiting
- Mild pyrexia
- Anorexia
- Localised right lower quadrant pain
Anorexia and peri-umbilical pain are often present alongside nausea.
What examination findings suggest perforation in appendicitis?
- Generalised peritonitis
- Localised peritonism
- Rebound tenderness
- Guarding and rigidity
These signs indicate potential complications from appendicitis.
What laboratory finding is seen in 80-90% of appendicitis cases?
Neutrophil-predominant leucocytosis
This is a common marker of infection.
What is the first-line investigation for acute cholecystitis?
Ultrasound
This imaging modality is preferred for assessing gallbladder inflammation.
What are the typical features of acute cholecystitis?
- Right upper quadrant pain
- Fever
- Murphy’s sign
Murphy’s sign is positive if there is inspiratory arrest upon palpation.
What is the recommended treatment for acute cholecystitis?
- Intravenous antibiotics
- Cholecystectomy
Early laparoscopic cholecystectomy is now recommended.
What percentage of children are affected by cow’s milk protein intolerance/allergy (CMPI/CMPA)?
3-6%
CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.
What are the two types of reactions associated with cow’s milk protein allergy/intolerance?
Immediate (IgE mediated) and delayed (non-IgE mediated)
CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.
List some symptoms of cow’s milk protein intolerance/allergy.
- Regurgitation and vomiting
- Diarrhea
- Urticaria
- Atopic eczema
- ‘Colic’ symptoms (irritability, crying)
- Wheeze
- Chronic cough
- Rarely angioedema and anaphylaxis
What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?
Extensive hydrolysed formula (eHF)
Amino acid-based formula (AAF) is used in infants with severe CMPA.
What should breastfeeding mothers do if their infant has cow’s milk protein intolerance?
Eliminate cow’s milk protein from their diet
Consider prescribing calcium supplements to prevent deficiency.
What is the prognosis for children with cow’s milk protein intolerance?
Usually resolves in most children
55% of children with IgE mediated intolerance will be milk tolerant by age 5.
What are the common locations for hemorrhoids?
3, 7, 11 o’clock position
Hemorrhoids can be internal or external.
What are the typical features of an anal fissure?
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.
What are common causes of proctitis?
- Crohn’s
- Ulcerative colitis
- Clostridioides difficile
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus
It has tracked from the tissue surrounding the anal sphincter.
What is the most common form of anorectal abscess?
Perianal abscess
They make up around 60% of cases.
What is the average age of patients with perianal abscess?
Around 40 years
What is the first-line treatment for perianal abscess?
Incision and drainage
Usually performed under local anaesthetic.
Identify two imaging techniques useful for diagnosing anorectal abscesses.
- MRI
- Transperineal ultrasound
What are common symptoms of threadworm infestation?
- Perianal itching, particularly at night
- Vulval symptoms in girls
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole
A single dose is given unless infestation persists.
True or False: Most patients with threadworm infestation are asymptomatic.
True
What percentage of children are affected by cow’s milk protein intolerance/allergy (CMPI/CMPA)?
3-6%
CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.
What are the two types of reactions associated with cow’s milk protein allergy/intolerance?
Immediate (IgE mediated) and delayed (non-IgE mediated)
CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.
List some symptoms of cow’s milk protein intolerance/allergy.
- Regurgitation and vomiting
- Diarrhea
- Urticaria
- Atopic eczema
- ‘Colic’ symptoms (irritability, crying)
- Wheeze
- Chronic cough
- Rarely angioedema and anaphylaxis
What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?
Extensive hydrolysed formula (eHF)
Amino acid-based formula (AAF) is used in infants with severe CMPA.
What should breastfeeding mothers do if their infant has cow’s milk protein intolerance?
Eliminate cow’s milk protein from their diet
Consider prescribing calcium supplements to prevent deficiency.
What is the prognosis for children with cow’s milk protein intolerance?
Usually resolves in most children
55% of children with IgE mediated intolerance will be milk tolerant by age 5.
What are the common locations for hemorrhoids?
3, 7, 11 o’clock position
Hemorrhoids can be internal or external.
What are the typical features of an anal fissure?
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.
What are common causes of proctitis?
- Crohn’s
- Ulcerative colitis
- Clostridioides difficile
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus
It has tracked from the tissue surrounding the anal sphincter.
What is the most common form of anorectal abscess?
Perianal abscess
They make up around 60% of cases.
What is the average age of patients with perianal abscess?
Around 40 years
What is the first-line treatment for perianal abscess?
Incision and drainage
Usually performed under local anaesthetic.
Identify two imaging techniques useful for diagnosing anorectal abscesses.
- MRI
- Transperineal ultrasound
What are common symptoms of threadworm infestation?
- Perianal itching, particularly at night
- Vulval symptoms in girls
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole
A single dose is given unless infestation persists.
True or False: Most patients with threadworm infestation are asymptomatic.
True
What is the commonest bacterial cause of infectious intestinal disease in the UK?
Campylobacter jejuni
Campylobacter is primarily spread by the faecal-oral route.
What are the common features of Campylobacter jejuni infection?
- Prodrome: headache, malaise
- Diarrhoea: often bloody
- Abdominal pain: may mimic appendicitis
What is the incubation period for Campylobacter jejuni?
1-6 days
What is the first-line antibiotic for severe Campylobacter jejuni infections?
Clarithromycin
True or False: Ciprofloxacin is frequently indicated for treating Campylobacter jejuni infections.
False
Strains with decreased sensitivity to ciprofloxacin are commonly isolated.
What complications may follow Campylobacter jejuni infections?
- Guillain-Barre syndrome
- Reactive arthritis
- Septicaemia
- Endocarditis
- Arthritis
What is Clostridioides difficile commonly associated with?
Pseudomembranous colitis
What type of bacteria is Clostridioides difficile?
Gram-positive rod
What are the two exotoxins released by Clostridioides difficile?
- Toxin A
- Toxin B
What are common risk factors for Clostridioides difficile infection?
- Broad-spectrum antibiotics
- Proton pump inhibitors
What characterizes the white blood cell count in Clostridioides difficile infection?
A raised white blood cell count (WCC) is characteristic
What is the first-line therapy for a first episode of C. difficile infection?
Oral vancomycin for 10 days
What is the recurrence rate of C. difficile infection after the first episode?
Around 20%
What is a key feature of travellers’ diarrhoea?
At least 3 loose to watery stools in 24 hours
What is the most common cause of travellers’ diarrhoea?
Escherichia coli
What pathogens are typically associated with acute food poisoning?
- Staphylococcus aureus
- Bacillus cereus
- Clostridium perfringens
What type of illness does Bacillus cereus cause when vomiting occurs within 6 hours?
Vomiting subtype
What is the incubation period for Staphylococcus aureus food poisoning?
1-6 hours
What are the common features of Salmonella infections?
- Diarrhoea
- Nausea and vomiting
- Abdominal cramps
- Fever
- Lethargy
What are the two types of enteric fevers caused by Salmonella?
- Typhoid
- Paratyphoid
What is the management for Shigella infection?
Usually self-limiting; antibiotics indicated for severe disease
Fill in the blank: Howell-Jolly bodies are associated with _______.
hyposplenism
What increases the risk of post-splenectomy sepsis?
Loss of spleen’s ability to respond to encapsulated organisms
What vaccines should be administered post-splenectomy?
- Pneumococcal
- Haemophilus type b
- Meningococcal type C
What is a common feature of alcoholic liver disease?
Gamma-GT is characteristically elevated
What is the typical AST:ALT ratio in alcoholic hepatitis?
> 2
What is the most common cause of acute pancreatitis?
Alcohol or gallstones
What scoring systems are used to identify severe pancreatitis?
- Ranson score
- Glasgow score
- APACHE II
What does the mnemonic GET SMASHED stand for in relation to pancreatitis causes?
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hypertriglyceridaemia
- ERCP
- Drugs
What are common causes of acute pancreatitis?
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.
How much more common is pancreatitis in patients taking mesalazine compared to sulfasalazine?
7 times more common
What is the prognostic value of the actual amylase level in pancreatitis?
Not of prognostic value
What are peripancreatic fluid collections?
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.
What is a pseudocyst in the context of pancreatitis?
A collection of fluid walled by fibrous or granulation tissue, typically occurring 4 weeks or more after an attack of acute pancreatitis
What investigations are used for pseudocysts?
CT, ERCP, MRI, endoscopic USS
What is pancreatic necrosis?
Involves both pancreatic parenchyma and surrounding fat, with complications linked to the extent of necrosis
What is the management for sterile pancreatic necrosis?
Managed conservatively at least initially
What are the systemic complications of acute pancreatitis?
Acute respiratory distress syndrome, associated with a high-mortality rate of around 20%
What are the three classifications of severity for acute pancreatitis?
- 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
What are key aspects of care for acute pancreatitis?
- Fluid resuscitation
- Analgesia
- Nutrition
- Role of antibiotics
- Role of surgery
What is the recommended fluid resuscitation for severe acute pancreatitis?
3-6 litres of crystalloids to manage third space fluid loss
When should enteral nutrition be offered in acute pancreatitis?
Within 72 hours of presentation for moderately severe or severe cases
What is the role of antibiotics in acute pancreatitis according to NICE?
Do not offer prophylactic antimicrobials; potential indications include infected pancreatic necrosis
What surgical intervention is recommended for patients with acute pancreatitis due to gallstones?
Early cholecystectomy
What is chronic pancreatitis?
An inflammatory condition affecting both exocrine and endocrine functions of the pancreas, often due to alcohol excess
What are common features of chronic pancreatitis?
- Pain worse 15-30 minutes after meals
- Steatorrhoea
- Diabetes mellitus development
What is the sensitivity and specificity of CT in detecting pancreatic calcification?
Sensitivity: 80%, Specificity: 85%
What is a key management strategy for chronic pancreatitis?
Pancreatic enzyme supplements, analgesia, antioxidants
What is the incidence of gastric cancer in the developed world?
Accounts for around 2% of all cancer diagnoses
What are the risk factors for gastric adenocarcinoma?
- Helicobacter pylori infection
- Pernicious anaemia
- Atrophic gastritis
- Diet (salt, nitrates)
- Ethnicity (Japan, China)
- Smoking
- Blood group A
What are the typical symptoms of gastric cancer?
- Abdominal pain
- Weight loss
- Nausea and vomiting
- Dysphagia
What is the diagnosis method for gastric cancer?
Oesophago-gastro-duodenoscopy with biopsy
What is the management approach for ovarian cancer?
Combination of surgery and platinum-based chemotherapy
What are common clinical features of ovarian cancer?
- Abdominal distension
- Abdominal pain
- Urinary symptoms
- Early satiety
- Diarrhoea
What is the most common symptom of haemorrhoids?
Painless rectal bleeding
What are the two types of haemorrhoids?
- External: below the dentate line, prone to thrombosis
- Internal: above the dentate line, generally painless
What are the grades of internal haemorrhoids?
- Grade I: Do not prolapse
- Grade II: Prolapse on defecation, reduce spontaneously
- Grade III: Manually reducible
- Grade IV: Cannot be reduced
What is the management for acutely thrombosed external haemorrhoids?
Referral for excision if presented within 72 hours; otherwise manage with stool softeners, ice packs, and analgesia
What is coeliac disease?
An autoimmune condition caused by sensitivity to the protein gluten.
What percentage of the UK population is thought to be affected by coeliac disease?
Around 1%.
What is a consequence of repeated exposure to gluten in coeliac disease?
Villous atrophy leading to malabsorption.
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis.
What autoimmune disorders are associated with coeliac disease?
- Type 1 diabetes mellitus
- Autoimmune hepatitis
What HLA types are strongly associated with coeliac disease?
- HLA-DQ2 (95% of patients)
- HLA-DQ8 (80%)
List some signs and symptoms that should prompt screening for coeliac disease.
- 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
What are common complications of coeliac disease? (7)
- 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
What are the WHO definitions of diarrhoea?
- Diarrhoea: > 3 loose or watery stools per day
- Acute diarrhoea: < 14 days
- Chronic diarrhoea: > 14 days
What is the most common cause of acute diarrhoea?
Gastroenteritis.
What are the typical symptoms of irritable bowel syndrome (IBS)?
- Abdominal pain
- Bloating
- Change in bowel habit
What features indicate a positive diagnosis of IBS?
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
What are red flag features in the context of IBS?
- Rectal bleeding
- Unexplained weight loss
- Family history of bowel or ovarian cancer
- Onset after 60 years
What is the significance of the carcinoembryonic antigen (CEA) test in colorectal cancer?
It is used for staging colorectal cancer.
What is the most common type of colon cancer?
Sporadic colon cancer (95%).
What is hereditary non-polyposis colorectal carcinoma (HNPCC) also known as?
Lynch syndrome.
What are the Amsterdam criteria for HNPCC diagnosis?
- At least 3 family members with colon cancer
- Cases spanning at least two generations
- At least one case diagnosed before age 50
What is familial adenomatous polyposis (FAP)?
A rare autosomal dominant condition leading to hundreds of polyps and inevitable carcinoma.
What mutation is associated with familial adenomatous polyposis (FAP)?
Mutation in the adenomatous polyposis coli gene (APC).
What is the typical management for colorectal cancer?
Surgery, chemotherapy, radiation therapy, and targeted therapies.
What is the role of Faecal Immunochemical Test (FIT) in colorectal cancer screening?
Used to guide referral for suspected cancer.
What should be done if a FIT test result is positive?
Refer the patient on the suspected cancer pathway.
What are some symptoms of colorectal cancer?
- Change in bowel habits
- Rectal bleeding
- Abdominal pain
- Unexplained weight loss
- Anaemia
- Bowel obstruction
What does the TNM staging system stand for?
Tumour, Node, Metastasis.
What is the common treatment for obstructing colon cancer?
Stenting or resection.
What is a Hartmann’s procedure?
Resection of the sigmoid colon with formation of an end colostomy.
What is the age range for the NHS screening program in England?
60 to 74 years
Patients aged over 74 years may request screening.
What test is used in the NHS screening program to detect human blood in stool samples?
Faecal Immunochemical Test (FIT)
FIT tests are sent through the post to eligible patients.
What does the Faecal Immunochemical Test (FIT) specifically recognize?
Human haemoglobin (Hb)
It is a type of faecal occult blood (FOB) test.
What is the main advantage of the FIT test over conventional FOB tests?
Only detects human haemoglobin
Conventional tests may detect animal haemoglobin from diet.
How many faecal samples are needed for the FIT test?
One
Conventional FOB tests typically require 2-3 samples.
What happens to patients with abnormal FIT test results?
Offered a colonoscopy
This is to further investigate the cause of the abnormal results.
What percentage of patients at colonoscopy will have a normal exam?
50%
Approximately 5 out of 10 patients will have a normal exam.
What is the likelihood of finding polyps during a colonoscopy?
40%
Approximately 4 out of 10 patients will be found to have polyps.
What is the risk associated with polyps found during colonoscopy?
Premalignant potential
Polyps may be removed due to this risk.
What percentage of patients undergoing colonoscopy will be found to have cancer?
10%
Approximately 1 out of 10 patients will be found to have cancer.
When was the one-off flexible sigmoidoscopy trial at age 55 abandoned?
2021
This was mainly due to recruitment issues exacerbated by the COVID-19 pandemic.
What was the impact of screening for colorectal cancer on mortality?
Reduced mortality by 16%
This is based on evidence showing the effectiveness of screening.
What are the new symptoms that warrant a FIT test for patients under 60 years?
Changes in bowel habit OR iron deficiency anaemia
These symptoms indicate the need for further investigation.
True or False: The FIT test reports numerical values to patients.
False
Patients are informed if the test is normal or abnormal, but not the numerical value.
What is Crohn’s disease?
A form of inflammatory bowel disease that can affect any part of the gastrointestinal tract from mouth to anus.
Which areas are most commonly affected by Crohn’s disease?
Terminal ileum and colon.
What is the cause of Crohn’s disease?
Unknown, but there is strong genetic susceptibility.
What are the common complications of Crohn’s disease?
Strictures, fistulas, and adhesions.
What percentage of Crohn’s disease patients have small bowel involvement?
80%.
What is the most prominent symptom of Crohn’s disease in adults?
Diarrhoea.
What is the most prominent symptom of Crohn’s disease in children?
Abdominal pain.
What are the common investigations for Crohn’s disease?
Raised inflammatory markers, increased faecal calprotectin, anaemia, low vitamin B12 and vitamin D.
Name two extra-intestinal features related to disease activity in Crohn’s disease.
- Arthritis (pauciarticular, asymmetric)
- Erythema nodosum.
What is the investigation of choice for Crohn’s disease?
Colonoscopy.
What histological features are observed in Crohn’s disease?
- Inflammation in all layers from mucosa to serosa
- Goblet cells
- Granulomas.
What is the first-line treatment for inducing remission in Crohn’s disease?
Glucocorticoids.
What is azathioprine used for in Crohn’s disease?
As an add-on medication to induce remission.
What percentage of Crohn’s disease patients will eventually require surgery?
Around 80%.
What is the standard incidence ratio for small bowel cancer in Crohn’s disease?
40.
True or False: Ulcerative colitis inflammation always starts at the rectum.
True.
What are common symptoms of ulcerative colitis?
Bloody diarrhoea, urgency, tenesmus, abdominal pain, particularly in the left lower quadrant.
What is the typical endoscopic finding in ulcerative colitis?
Red, raw mucosa that bleeds easily.
What is the management approach for mild ulcerative colitis?
Topical (rectal) aminosalicylate.
What factors can trigger flares of ulcerative colitis?
- Stress
- Medications
- NSAIDs
- Antibiotics
- Cessation of smoking.
What is the recommended follow-up colonoscopy interval for lower risk ulcerative colitis patients?
5 years.
What autoimmune condition is caused by sensitivity to gluten?
Coeliac disease.
What are the associations of coeliac disease?
- Dermatitis herpetiformis
- Type 1 diabetes mellitus
- Autoimmune hepatitis.
What genetic markers are strongly associated with coeliac disease?
- HLA-DQ2 (95% of patients)
- HLA-DQ8 (80%).
What is the typical presentation of coeliac disease?
Villous atrophy leading to malabsorption.
What dietary component must be eliminated in patients with coeliac disease?
Gluten.
What is coeliac disease?
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.
What are common conditions associated with coeliac disease?
- Dermatitis herpetiformis
- Type 1 diabetes mellitus
- Autoimmune hepatitis
Dermatitis herpetiformis presents as a vesicular, pruritic skin eruption.
What genetic associations are strongly linked to coeliac disease?
- HLA-DQ2 (95% of patients)
- HLA-DQ8 (80%)
These genetic markers are critical in understanding susceptibility to the disease.
What symptoms should prompt screening for coeliac disease according to NICE guidelines?
- 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.
What are some complications of coeliac disease?
- 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.
At what age do children typically present symptoms of coeliac disease?
Before the age of 3 years, following the introduction of cereals into the diet
Symptoms may coincide with the introduction of gluten-containing foods.
What is the gold standard for diagnosing coeliac disease?
Endoscopic intestinal biopsy
This should be performed in all patients suspected of having coeliac disease.
What serological tests are first-choice for coeliac disease diagnosis according to NICE?
- Tissue transglutaminase (TTG) antibodies (IgA)
- Endomysial antibody (IgA)
These tests help confirm the diagnosis and assess compliance with a gluten-free diet.
What dietary management is required for coeliac disease?
A gluten-free diet
This includes avoiding gluten-containing cereals such as wheat, barley, rye, and sometimes oats.
Which foods are gluten-free?
- Rice
- Potatoes
- Corn (maize)
These foods can be safely consumed by patients with coeliac disease.
True or False: Whisky is safe for patients with coeliac disease.
True
Whisky is made from malted barley, but gluten proteins are removed during distillation.
What vaccination is recommended for patients with coeliac disease?
Pneumococcal vaccine
Due to functional hyposplenism, vaccination is crucial for preventing infections.
Fill in the blank: Anti-gliadin antibody tests are _______ by NICE.
not recommended
These tests are not considered reliable for diagnosing coeliac disease.
What is ulcerative colitis?
A chronic inflammatory bowel disease affecting the colon and rectum
Ulcerative colitis causes inflammation and ulcers in the digestive tract.
What are common factors linked to ulcerative colitis flares?
- Stress
- Medications
- NSAIDs
- Antibiotics
- Cessation of smoking
These factors may contribute to the onset of symptoms in patients.
How are ulcerative colitis flares classified?
Mild, Moderate, Severe
Each classification reflects the severity and symptoms experienced by the patient.
What characterizes a mild ulcerative colitis flare?
Fewer than four stools daily, with or without blood; no systemic disturbance; normal erythrocyte sedimentation rate and C-reactive protein values
Patients with mild flares typically do not have significant systemic effects.
What are the symptoms of a moderate ulcerative colitis flare?
Four to six stools a day, with minimal systemic disturbance
Moderate flares indicate a need for closer monitoring but may not require hospitalization.
What characterizes a severe ulcerative colitis flare?
More than six stools a day, containing blood; evidence of systemic disturbance, e.g. fever, tachycardia, abdominal tenderness, distension or reduced bowel sounds, anaemia, hypoalbuminaemia
Severe flares require urgent medical attention and often hospitalization.
True or False: Most ulcerative colitis flares occur with an identifiable trigger.
False
Most flares occur without a clear trigger, although certain factors may be linked.
What should be done for patients with evidence of severe ulcerative colitis?
They should be admitted to hospital
Hospitalization is necessary to manage severe symptoms and prevent complications.
