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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. (5)

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 ALCOHOL 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
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.
26
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)
27
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.
28
Zollinger Ellison syndrome managment
* surgical resection * PPIs * chemotherapy and somatostatin analogues may be considered.
29
Ascites
abnormal accumulation of fluid within the peritoneal cavity.
30
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
31
What is the term for the position of a structure relative to the front of the body?
Anterior relations
32
What is the term for the position of a structure relative to the back of the body?
Posterior relations
33
What is the vertebral level of T12?
12th thoracic vertebra
34
What is the vertebral level of L4?
4th lumbar vertebra
35
List the vertebral bodies from L1 to L4
* L1 * L2 * L3 * L4
36
What structure connects the stomach to the liver?
Lesser omentum
37
Which organ is primarily responsible for detoxification and metabolism?
Liver
38
What vein drains the left kidney?
Left renal vein
39
What vein drains the gastrointestinal tract and connects to the superior mesenteric vein?
Inferior mesenteric vein
40
Which part of the duodenum is referred to as the third part?
Third part of duodenum
41
Which organ is located behind the stomach and is involved in digestion?
Pancreas
42
What layer of the abdominal cavity lines the abdominal wall?
Parietal peritoneum
43
What is the term for the space within the abdomen that contains the intestines, liver, and other organs?
Peritoneal cavity
44
What is the name of the right portion of the diaphragm?
Right crus of the diaphragm
45
What is the name of the lymphatic structure that collects lymph from the lower body?
Cisterna chyli
46
What vein is responsible for draining blood from the thoracic wall into the superior vena cava?
Azygos vein
47
What does IVC stand for in the context of venous drainage?
Inferior vena cava
48
What is the fourth part of the duodenum called?
4th part of duodenum
49
What is the term for the bend between the duodenum and jejunum?
Duodenal-jejunal flexure
50
What structure is part of the sympathetic nervous system located on the left side of the vertebral column?
Left sympathetic trunk
51
What are the right lateral relations of a structure?
Right lateral relations
52
What are the left lateral relations of a structure?
Left lateral relations
53
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 ## Footnote These branches supply various organs and structures in the abdominal region.
54
At what level does the abdominal aorta primarily branch?
T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4 ## Footnote The levels indicate the vertebral locations where the branches emerge.
55
Which abdominal aortic branches are paired? (4)
Renal, Gonadal, Lumbar, Common iliac ## Footnote Paired branches typically supply symmetrical structures on either side of the body.
56
Which abdominal aortic branches are unpaired?
Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral ## Footnote Unpaired branches usually supply midline structures in the abdomen.
57
What type of branches are the Inferior phrenic and Lumbar?
Parietal ## Footnote Parietal branches supply the body wall.
58
What type of branches are the Coeliac and Superior mesenteric?
Visceral ## Footnote Visceral branches supply the organs within the abdominal cavity.
59
Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.
Inferior phrenic
60
True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.
False ## Footnote The Middle suprarenal branch is unpaired.
61
Which branches of the abdominal aorta are classified as terminal?
Common iliac ## Footnote Terminal branches are the final branches of the abdominal aorta before it bifurcates.
62
What are the branches of the abdominal aorta? (9)
1. Inferior phrenic 2. Coeliac 3. Superior mesenteric 4. Middle suprarenal 5. Renal 6. Gonadal, Lumbar 7. Inferior mesenteric 8. Median sacral 9. Common iliac ## Footnote These branches supply various organs and structures in the abdominal region.
63
At what level does the abdominal aorta primarily branch?
T12 (Upper border), T12, L1, L1, L1-L2, L2, L1-L4, L3, L4, L4 ## Footnote The levels indicate the vertebral locations where the branches emerge.
64
Which abdominal aortic branches are paired?
Renal, Gonadal, Lumbar, Common iliac ## Footnote Paired branches typically supply symmetrical structures on either side of the body.
65
Which abdominal aortic branches are unpaired? (4)
Coeliac, Superior mesenteric, Inferior mesenteric, Median sacral ## Footnote Unpaired branches usually supply midline structures in the abdomen.
66
What type of branches are the Inferior phrenic and Lumbar?
Parietal ## Footnote Parietal branches supply the body wall.
67
What type of branches are the Coeliac and Superior mesenteric?
Visceral ## Footnote Visceral branches supply the organs within the abdominal cavity.
68
Fill in the blank: The _______ branch of the abdominal aorta is responsible for supplying the diaphragm.
Inferior phrenic
69
True or False: The Middle suprarenal branch is a paired branch of the abdominal aorta.
False ## Footnote The Middle suprarenal branch is unpaired.
70
Which branches of the abdominal aorta are classified as terminal?
Common iliac ## Footnote Terminal branches are the final branches of the abdominal aorta before it bifurcates.
71
What is the location of the appendix?
Base of caecum
72
How long can the appendix be?
Up to 10cm long
73
What type of tissue mainly composes the appendix?
Lymphoid tissue ## Footnote This is significant because mesenteric adenitis may mimic appendicitis.
74
What anatomical feature helps in identifying the appendix during surgery?
Convergence of caecal taenia coli at base of appendix
75
What is the arterial supply to the appendix?
Appendicular artery (branch of the ileocolic)
76
Is the appendix intra or retroperitoneal?
Intra peritoneal
77
Where is McBurney's point located?
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus
78
What percentage of appendices are found in the retrocaecal position?
74%
79
What percentage of appendices are found in the pelvic position?
21%
80
List the six positions of the appendix. (6)
* Retrocaecal * Pelvic * Postileal * Subcaecal * Paracaecal * Preileal
81
Where is the caecum located?
Proximal right colon below the ileocaecal valve ## Footnote The caecum is intraperitoneal.
82
What are the posterior relations of the caecum?
* Psoas * Iliacus * Femoral nerve * Genitofemoral nerve * Gonadal vessels ## Footnote These structures are located behind the caecum.
83
What are the anterior relations of the caecum?
Greater omentum ## Footnote The greater omentum is a fold of peritoneum that hangs down from the stomach.
84
What is the arterial supply of the caecum?
Ileocolic artery ## Footnote The ileocolic artery branches from the superior mesenteric artery.
85
What accompanies the venous drainage of the caecum?
Mesenteric nodes ## Footnote Lymphatic drainage is important for immune function and fluid balance.
86
What is the most distensible part of the colon?
Caecum ## Footnote This characteristic makes it vulnerable in cases of bowel obstruction.
87
In complete large bowel obstruction, where is the most likely site of eventual perforation?
Caecum ## Footnote This occurs specifically with a competent ileocaecal valve.
88
What is the length of the ureter?
25-35 cm long
89
What type of epithelium lines the ureter?
Transitional epithelium
90
What surrounds the ureter?
Thick muscular coat
91
How many muscular layers does the ureter have as it crosses the bony pelvis?
3 muscular layers
92
Where is the ureter located in relation to the transverse processes?
Retroperitoneal structure overlying transverse processes L2-L5
93
What lies anterior to the bifurcation of the iliac vessels?
Ureter
94
What is the blood supply to the ureter?
Segmental; renal artery, aortic branches, gonadal branches, common iliac and internal iliac
95
Where does the ureter lie in relation to the uterine artery?
Beneath the uterine artery
96
What is the diaphragm?
A muscle that separates the thoracic cavity from the abdominal cavity and is the primary muscle involved in respiration.
97
What are diaphragm apertures?
Openings within the diaphragm that allow specific structures to pass from the thoracic cavity to the abdominal cavity.
98
List the three main diaphragm apertures and their vertebral levels.
* Aortic hiatus - T12 * Oesophageal hiatus - T10 * Vena cava foramen - T8
99
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).
100
What are lesser diaphragmatic apertures?
Smaller openings in the diaphragm that allow much smaller structures to pass through.
101
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
102
What is Klinefelter's syndrome associated with?
Karyotype 47, XXY ## Footnote Klinefelter's syndrome is a genetic condition resulting from the presence of an extra X chromosome.
103
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 ## Footnote These features contribute to the diagnosis and understanding of the syndrome's impact on individuals.
104
How is Klinefelter's syndrome diagnosed?
By karyotype (chromosomal analysis) ## Footnote Karyotyping helps to confirm the presence of the extra chromosome associated with the syndrome.
105
True or False: Individuals with Klinefelter's syndrome are typically fertile.
False ## Footnote Infertility is a common feature of Klinefelter's syndrome due to testicular dysfunction.
106
Fill in the blank: Klinefelter's syndrome results in _______ levels of testosterone.
Low ## Footnote The low testosterone levels are due to testicular dysgenesis associated with the syndrome.
107
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.
108
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
109
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).
110
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.
111
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).
112
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.
113
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.
114
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.
115
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).
116
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.
117
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.
118
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.
119
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.
120
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).
121
What is the commonest approach to the abdomen?
Midline incision ## Footnote Structures divided include linea alba, transversalis fascia, extraperitoneal fat, and peritoneum, while avoiding the falciform ligament above the umbilicus.
122
Which incision allows for access to the bladder via an extraperitoneal approach?
Midline incision ## Footnote Access is achieved through the space of Retzius.
123
What is a paramedian incision?
An incision parallel to the midline (about 3-4cm) ## Footnote Structures divided/retracted include anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, and peritoneum.
124
What structures are divided or retracted in a paramedian incision?
* Anterior rectus sheath * Rectus (retracted) * Posterior rectus sheath * Transversalis fascia * Extraperitoneal fat * Peritoneum ## Footnote The incision is closed in layers.
125
What is the Battle incision?
Similar location to paramedian but rectus displaced medially ## Footnote This incision is now seldom used.
126
Describe Kocher's incision.
Incision under right subcostal margin ## Footnote Commonly used for cholecystectomy (open).
127
What is the purpose of the Lanz incision?
Incision in right iliac fossa ## Footnote Typically used for appendicectomy.
128
What is the Gridiron incision used for?
Oblique incision centered over McBurney's point ## Footnote Usually performed for appendicectomy and is less cosmetically acceptable than Lanz.
129
What type of incision is Pfannenstiel's incision?
Transverse supra pubic incision ## Footnote Primarily used to access pelvic organs.
130
What is McEvedy's incision used for?
Groin incision ## Footnote Used for emergency repair of strangulated femoral hernia.
131
What is the Rutherford Morrison incision known for?
Extraperitoneal approach to left or right lower quadrants ## Footnote Provides excellent access to iliac vessels and is the approach of choice for first time renal transplantation.
132
What is a characteristic feature of duodenal ulcers?
Epigastric pain relieved by eating ## Footnote Duodenal ulcers are more common than gastric ulcers.
133
What symptom is associated with gastric ulcers?
Epigastric pain worsened by eating ## Footnote Features of upper gastrointestinal hemorrhage may be seen.
134
What is the typical initial pain location in appendicitis?
Central abdomen ## Footnote Pain later localizes to the right iliac fossa.
135
What are common symptoms of appendicitis?
* Anorexia * Tachycardia * Low-grade pyrexia * Tenderness in RIF * Rovsing's sign ## Footnote Rovsing's sign indicates more pain in the RIF than LIF when palpating the LIF.
136
What is the most common cause of acute pancreatitis?
Alcohol or gallstones ## Footnote Severe epigastric pain and vomiting are common.
137
What are Cullen's sign and Grey-Turner's sign associated with?
Periumbilical and flank discoloration, respectively ## Footnote These signs are described in acute pancreatitis but are rare.
138
What is a characteristic feature of biliary colic?
RUQ pain radiating to the back and interscapular region ## Footnote Pain may follow a fatty meal and can persist for hours.
139
What may obstructive jaundice cause in terms of stool and urine color?
* Pale stools * Dark urine ## Footnote These changes are due to bile duct obstruction.
140
What are classic symptoms of acute cholecystitis?
* Continuous RUQ pain * Fever * Raised inflammatory markers * Positive Murphy's sign ## Footnote Murphy's sign involves arrest of inspiration on palpation of the RUQ.
141
What is the typical presentation of diverticulitis?
Colicky pain in the LLQ ## Footnote Fever and raised inflammatory markers are also common.
142
What type of pain is associated with an abdominal aortic aneurysm?
Severe central abdominal pain radiating to the back ## Footnote Presentation may be catastrophic or sub-acute.
143
What are common symptoms of intestinal obstruction?
* History of malignancy/previous operations * Vomiting * Not opened bowels recently * 'Tinkling' bowel sounds ## Footnote These symptoms indicate a possible blockage in the intestines.
144
What is the significance of pain in the RIF?
It is a sign associated with appendicitis ## Footnote RIF stands for Right Iliac Fossa, where appendicitis pain is typically localized.
145
What are common symptoms of appendicitis?
Pain on extending the hip and raised inflammatory markers ## Footnote Inflammatory markers indicate an immune response, which is common in appendicitis.
146
What demographic is more likely to experience appendicitis?
Thin, male patients ## Footnote This demographic has a higher likelihood of presenting with appendicitis.
147
What is the typical percentage likelihood of appendicitis in certain cases?
55% ## Footnote This statistic may refer to specific clinical scenarios involving appendicitis.
148
Appendicitis is often indicated by which combination of factors?
Raised inflammatory markers and compatible history ## Footnote A compatible history includes symptoms and clinical findings consistent with appendicitis.
149
Fill in the blank: Pain in the RIF is now considered a sign of _______.
appendicitis
150
True or False: Pain on extending the hip is not associated with appendicitis.
False ## Footnote This type of pain is indeed a sign of appendicitis.
151
What does RIF stand for in the context of appendicitis?
Right Iliac Fossa ## Footnote It is the anatomical location where appendicitis pain is typically felt.
152
What is Whipple's disease?
A rare multi-system disorder caused by Tropheryma whippelii infection ## Footnote More common in those who are HLA-B27 positive and in middle-aged men.
153
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
154
What does jejunal biopsy reveal in Whipple's disease?
Deposition of macrophages containing Periodic acid-Schiff (PAS) granules
155
What is the first-line management for Whipple's disease?
Oral co-trimoxazole for a year, sometimes preceded by a course of IV penicillin
156
True or False: Whipple's disease is more common in women than men.
False
157
Fill in the blank: Whipple's disease is associated with _______ positive individuals.
HLA-B27
158
What are the neurological symptoms associated with Whipple's disease?
* Ophthalmoplegia * Dementia * Seizures * Ataxia * Myoclonus
159
What are some gastrointestinal symptoms of Whipple's disease?
* Diarrhoea * Weight loss
160
What are the skin manifestations of Whipple's disease?
* Hyperpigmentation * Photosensitivity
161
What is the significance of HLA-B27 in Whipple's disease?
Its presence indicates a higher risk of developing the disease
162
What is Wilson's disease primarily associated with?
Copper accumulation in the body ## Footnote Wilson's disease leads to excessive copper deposition, particularly affecting the liver and brain.
163
Which part of the brain is primarily affected by copper deposition in Wilson's disease?
Basal ganglia, particularly the putamen and globus pallidus ## Footnote These regions are crucial for motor control and may lead to neurological symptoms.
164
What are common neurological manifestations of Wilson's disease?
* Asterixis * Chorea * Dementia * Behavioral problems ## Footnote These symptoms arise from copper accumulation affecting brain function.
165
What characteristic eye finding is associated with Wilson's disease?
Green-brown rings in the periphery of the iris ## Footnote This is due to copper accumulation in the Descemet membrane and is present in many patients.
166
In which percentage of patients with isolated hepatic Wilson's disease are Kayser-Fleischer rings present?
Around 50% ## Footnote Kayser-Fleischer rings are a key diagnostic feature of Wilson's disease.
167
What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson's disease?
Up to 90% ## Footnote This high prevalence indicates significant copper accumulation affecting neurological function.
168
What renal condition is associated with Wilson's disease?
Renal tubular acidosis ## Footnote This condition can manifest as part of the systemic effects of copper overload.
169
What is a potential new treatment agent currently under investigation for Wilson's disease?
Tetrathiomolybdate ## Footnote This agent aims to enhance copper excretion and reduce its toxic effects.
170
What is a physical sign that may indicate Wilson's disease?
Blue nails ## Footnote This is a less common manifestation but can be associated with copper dysregulation.
171
What is Wilson's disease primarily associated with?
Copper accumulation in the body ## Footnote Wilson's disease leads to excessive copper deposition, particularly affecting the liver and brain.
172
What are common neurological manifestations of Wilson's disease?
* Asterixis * Chorea * Dementia * Behavioral problems ## Footnote These symptoms arise from copper accumulation affecting brain function.
173
What characteristic eye finding is associated with Wilson's disease?
Green-brown rings in the periphery of the iris ## Footnote This is due to copper accumulation in the Descemet membrane and is present in many patients.
174
In which percentage of patients with isolated hepatic Wilson's disease are Kayser-Fleischer rings present?
Around 50% ## Footnote Kayser-Fleischer rings are a key diagnostic feature of Wilson's disease.
175
What is the prevalence of Kayser-Fleischer rings in patients with neurological involvement of Wilson's disease?
Up to 90% ## Footnote This high prevalence indicates significant copper accumulation affecting neurological function.
176
What renal condition is associated with Wilson's disease?
Renal tubular acidosis ## Footnote This condition can manifest as part of the systemic effects of copper overload.
177
What is a potential new treatment agent currently under investigation for Wilson's disease?
Tetrathiomolybdate ## Footnote This agent aims to enhance copper excretion and reduce its toxic effects.
178
What is Zollinger-Ellison syndrome?
A condition characterised by excessive levels of gastrin secondary to a gastrin-secreting tumour ## Footnote The majority of these tumours are found in the first part of the duodenum, with the pancreas being the second most common location.
179
Where are the majority of gastrin-secreting tumours found in Zollinger-Ellison syndrome?
First part of the duodenum ## Footnote The pancreas is the second most common location for these tumours.
180
What percentage of gastrinomas occur as part of MEN type I syndrome?
Around 30% ## Footnote MEN stands for Multiple Endocrine Neoplasia.
181
List three features of Zollinger-Ellison syndrome.
* Multiple gastroduodenal ulcers * Diarrhoea * Malabsorption
182
What is the single best screening test for Zollinger-Ellison syndrome?
Fasting gastrin levels ## Footnote This test is used to measure the amount of gastrin hormone in the blood.
183
What test is used to further evaluate Zollinger-Ellison syndrome after initial screening?
Secretin stimulation test
184
What is the scientific name for threadworms?
Enterobius vermicularis
185
In which population is threadworm infestation particularly common?
Children in the UK
186
How does threadworm infestation occur?
After swallowing eggs that are present in the environment
187
What percentage of threadworm infestations are asymptomatic?
90%
188
What are possible features of threadworm infestation?
* Perianal itching, particularly at night * Vulval symptoms in girls
189
What diagnostic method can be used for threadworm infestation?
Applying Sellotape to the perianal area and sending it for microscopy
190
What is the recommended management approach for threadworm infestation?
* Combination of anthelmintic with hygiene measures for all household members
191
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole
192
How is mebendazole administered for threadworm infestation?
A single dose is given unless infestation persists
193
True or False: Most patients with threadworm infestation are treated empirically.
True
194
What are desmoid tumours?
Fibrous neoplasms arising from musculoaponeurotic structures containing clonal proliferations of myofibroblasts ## Footnote Desmoid tumours are not classified as malignant but can be aggressive in behavior, infiltrating surrounding tissues.
195
What is the typical appearance of desmoid tumours?
Firm overgrowths of tissue with a propensity to local infiltration ## Footnote These characteristics make desmoid tumours challenging to treat and manage.
196
In what percentage of patients with familial adenomatous polyposis coli do desmoid tumours occur?
Up to 15% ## Footnote Familial adenomatous polyposis coli is a genetic condition that increases the risk for colorectal cancer.
197
What genetic mutations are typically seen in desmoid tumours?
Bi allelic APC mutations ## Footnote APC gene mutations are commonly associated with familial adenomatous polyposis and are critical in tumorigenesis.
198
In which demographic do desmoid tumours most commonly occur?
Women after childbirth in the rectus abdominis muscle ## Footnote This demographic factor may relate to hormonal changes and physical stress during and after pregnancy.
199
What is the primary treatment for desmoid tumours?
Radical surgical resection ## Footnote Surgical intervention is preferred due to the high tendency for local recurrence.
200
What are the alternative treatments for desmoid tumours, if surgery is not an option?
Radiotherapy and chemotherapy may be considered ## Footnote However, the results of non-surgical therapy are generally inferior to surgical resection.
201
What is the prognosis for abdominal desmoid tumours?
Some may spontaneously regress ## Footnote In selected cases, a period of observation may be preferred, particularly if the tumours are not causing significant symptoms.
202
True or False: Desmoid tumours have a low tendency to local recurrence.
False ## Footnote Desmoid tumours are known for their high tendency to recur locally after treatment.
203
Fill in the blank: Desmoids consist of sheets of differentiated _______.
fibroblasts ## Footnote This cellular composition is significant in understanding their pathological behavior.
204
What type of bacteria is Helicobacter pylori?
Gram-negative bacteria ## Footnote Associated with various gastrointestinal problems, particularly peptic ulcer disease.
205
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 ## Footnote These mechanisms increase bacterial survival in the stomach.
206
What type of cytotoxins does Helicobacter pylori release?
Bacterial cytotoxins (e.g., CagA toxin) ## Footnote These toxins disrupt the gastric mucosa.
207
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 ## Footnote Eradication of H pylori can lead to regression of B cell lymphoma in 80% of patients.
208
Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?
No, there is currently no role for eradication in GORD ## Footnote The relationship between H pylori and GORD is unclear.
209
What is the standard management for Helicobacter pylori infection?
A 7-day course of: * Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole) ## Footnote If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.
210
What type of bacteria is Helicobacter pylori?
Gram-negative bacteria ## Footnote Associated with various gastrointestinal problems, particularly peptic ulcer disease.
211
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 ## Footnote These mechanisms increase bacterial survival in the stomach.
212
What type of cytotoxins does Helicobacter pylori release?
Bacterial cytotoxins (e.g., CagA toxin) ## Footnote These toxins disrupt the gastric mucosa.
213
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 ## Footnote Eradication of H pylori can lead to regression of B cell lymphoma in 80% of patients.
214
Is there a role for Helicobacter pylori eradication in Gastro-oesophageal reflux disease (GORD)?
No, there is currently no role for eradication in GORD ## Footnote The relationship between H pylori and GORD is unclear.
215
What is the standard management for Helicobacter pylori infection?
A 7-day course of: * Proton pump inhibitor + Amoxicillin + (Clarithromycin OR Metronidazole) ## Footnote If penicillin-allergic: use Proton pump inhibitor + Metronidazole + Clarithromycin.
216
What is coeliac disease?
An autoimmune condition caused by sensitivity to the protein gluten ## Footnote It affects around 1% of the UK population.
217
What happens with repeated exposure to gluten in coeliac disease?
Leads to villous atrophy, causing malabsorption
218
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis (a vesicular, pruritic skin eruption)
219
What autoimmune disorders are associated with coeliac disease?
* Type 1 diabetes mellitus * Autoimmune hepatitis
220
What HLA types are strongly associated with coeliac disease?
* HLA-DQ2 (95% of patients) * HLA-DQ8 (80%)
221
According to NICE guidelines, which patients should be screened for coeliac disease?
Patients with specific signs and symptoms
222
Name two signs or symptoms of coeliac disease.
* Chronic or intermittent diarrhoea * Failure to thrive or faltering growth in children
223
What is a common gastrointestinal symptom of coeliac disease?
Persistent or unexplained gastrointestinal symptoms, including nausea and vomiting
224
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
225
True or False: Folate deficiency is more common than vitamin B12 deficiency in coeliac disease.
True
226
What are rare complications associated with coeliac disease?
* Oesophageal cancer * Other malignancies
227
Fill in the blank: Coeliac disease is associated with _______ thyroid disease.
Autoimmune
228
What is a common gastrointestinal condition that may be confused with coeliac disease?
Irritable bowel syndrome
229
Who are considered first-degree relatives in relation to coeliac disease?
* Parents * Siblings * Children
230
What is Coeliac disease caused by?
Sensitivity to the protein gluten
231
What is the consequence of repeated exposure to gluten in Coeliac disease?
Villous atrophy leading to malabsorption
232
At what age do children typically present with Coeliac disease?
Before the age of 3 years
233
What genetic markers are strongly associated with Coeliac disease?
HLA-DQ2 and HLA-DQ8
234
What is the incidence of Coeliac disease?
Around 1:100
235
What symptoms may coincide with the introduction of cereals in children with Coeliac disease?
* Failure to thrive * Diarrhoea * Abdominal distension * Anaemia in older children
236
What is a common issue regarding the diagnosis of Coeliac disease?
Many cases are not diagnosed until adulthood
237
What findings are seen in a jejunal biopsy for Coeliac disease?
Subtotal villous atrophy
238
What are useful screening tests for Coeliac disease?
* Anti-endomysial antibodies * Anti-gliadin antibodies
239
What causes coeliac disease?
Coeliac disease is caused by sensitivity to the protein gluten.
240
What leads to malabsorption in coeliac disease?
Repeated exposure to gluten leads to villous atrophy, which in turn causes malabsorption.
241
What are conditions associated with coeliac disease?
Conditions include dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis.
242
How is coeliac disease diagnosed?
Diagnosis is made by a combination of serology and endoscopic intestinal biopsy.
243
What happens to villous atrophy and immunology on a gluten-free diet?
Villous atrophy and immunology normally reverses on a gluten-free diet.
244
What did NICE issue in 2009 regarding coeliac disease?
NICE issued guidelines on the investigation of coeliac disease.
245
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.
246
What is the first-choice serology test according to NICE?
Tissue transglutaminase (TTG) antibodies (IgA) are the first-choice test.
247
What is needed to look for selective IgA deficiency?
Endomyseal antibody (IgA) is needed to look for selective IgA deficiency.
248
Are anti-gliadin antibody tests recommended by NICE?
No, anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE.
249
What is the 'gold standard' for diagnosing coeliac disease?
Endoscopic intestinal biopsy is the 'gold standard' for diagnosis.
250
Where is the endoscopic intestinal biopsy traditionally performed?
Traditionally done in the duodenum, but jejunal biopsies are also sometimes performed.
251
What are findings supportive of coeliac disease?
Findings include villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes.
252
Is rectal gluten challenge widely used?
No, rectal gluten challenge has been described but is not widely used.
253
What happens to clotting factors in liver failure?
All clotting factors are low, except for factor VIII which is paradoxically supra-normal. ## Footnote Factor VIII is synthesized in endothelial cells throughout the body, unlike other clotting factors synthesized in hepatic endothelial cells.
254
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. ## Footnote This leads to increased circulating levels despite liver dysfunction.
255
What do conventional coagulation studies indicate in chronic liver disease?
Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk. ## Footnote However, patients are paradoxically at an increased risk of thrombosis.
256
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. ## Footnote This is due to various factors including reduced synthesis of anticoagulants.
257
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). ## Footnote These reductions lead to an imbalance favoring thrombosis.
258
True or False: Patients with chronic liver disease are only at risk for bleeding.
False. ## Footnote They are also at an increased risk for thrombosis.
259
Fill in the blank: In liver failure, factor VIII is _______.
supra-normal
260
What leads to the paradoxical increase in factor VIII during liver failure?
Good hepatic function is required for the clearance of activated factor VIII. ## Footnote Impaired hepatic function leads to decreased clearance and increased levels.
261
What happens to clotting factors in liver failure?
All clotting factors are low, except for factor VIII which is paradoxically supra-normal. ## Footnote Factor VIII is synthesized in endothelial cells throughout the body, unlike other clotting factors synthesized in hepatic endothelial cells.
262
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. ## Footnote This leads to increased circulating levels despite liver dysfunction.
263
What do conventional coagulation studies indicate in chronic liver disease?
Increased PT, APTT, and decreased fibrinogen suggesting increased bleeding risk. ## Footnote However, patients are paradoxically at an increased risk of thrombosis.
264
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. ## Footnote This is due to various factors including reduced synthesis of anticoagulants.
265
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). ## Footnote These reductions lead to an imbalance favoring thrombosis.
266
True or False: Patients with chronic liver disease are only at risk for bleeding.
False. ## Footnote They are also at an increased risk for thrombosis.
267
Fill in the blank: In liver failure, factor VIII is _______.
supra-normal
268
What leads to the paradoxical increase in factor VIII during liver failure?
Good hepatic function is required for the clearance of activated factor VIII. ## Footnote Impaired hepatic function leads to decreased clearance and increased levels.
269
What does acute liver failure describe?
The rapid onset of hepatocellular dysfunction leading to various systemic complications ## Footnote Acute liver failure can be life-threatening and requires immediate medical attention.
270
List three common causes of acute liver failure.
* Paracetamol overdose * Alcohol * Viral hepatitis (usually A or B) ## Footnote Other causes include acute fatty liver of pregnancy.
271
What are the main features of acute liver failure?
* Jaundice * Coagulopathy: raised prothrombin time * Hypoalbuminaemia * Hepatic encephalopathy * Renal failure (hepatorenal syndrome) ## Footnote These features indicate severe liver dysfunction.
272
True or False: Liver function tests always accurately reflect the synthetic function of the liver.
False ## Footnote Liver function tests may not provide a complete picture; prothrombin time and albumin levels are better indicators.
273
What is the best way to assess the synthetic function of the liver?
By looking at the prothrombin time and albumin level ## Footnote These parameters provide insight into the liver's ability to synthesize proteins.
274
Fill in the blank: Renal failure is common in acute liver failure and is referred to as _______.
hepatorenal syndrome ## Footnote This condition results from the interplay between liver failure and kidney function.
275
What is acute mesenteric ischaemia typically caused by?
An embolism resulting in occlusion of an artery supplying the small bowel ## Footnote Commonly the superior mesenteric artery is involved.
276
What medical history is classically associated with acute mesenteric ischaemia?
Atrial fibrillation ## Footnote This condition can lead to the formation of emboli.
277
Describe the nature of abdominal pain in acute mesenteric ischaemia.
Severe, of sudden onset, and out-of-keeping with physical exam findings ## Footnote This discrepancy often raises suspicion for the condition.
278
What is the typical management for acute mesenteric ischaemia?
Immediate laparotomy ## Footnote Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.
279
What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?
Poor prognosis ## Footnote Timely intervention is critical for better outcomes.
280
What is acute mesenteric ischaemia typically caused by?
An embolism resulting in occlusion of an artery supplying the small bowel ## Footnote Commonly the superior mesenteric artery is involved.
281
What medical history is classically associated with acute mesenteric ischaemia?
Atrial fibrillation ## Footnote This condition can lead to the formation of emboli.
282
Describe the nature of abdominal pain in acute mesenteric ischaemia.
Severe, of sudden onset, and out-of-keeping with physical exam findings ## Footnote This discrepancy often raises suspicion for the condition.
283
What is the typical management for acute mesenteric ischaemia?
Immediate laparotomy ## Footnote Particularly necessary if there are signs of advanced ischemia such as peritonitis or sepsis.
284
What is the prognosis for patients with acute mesenteric ischaemia if surgery is delayed?
Poor prognosis ## Footnote Timely intervention is critical for better outcomes.
285
GET SMASHED
- Gall stones - Ethanol - Trauma - Scoropion bites - M umps - Autoimmune - Steroids - Hypercalmeia orhypertriglycerdemia - ERCP - Drugs (NSAIDs, Azithromycin)
286
What is the most common cause of acute pancreatitis?
Alcohol or gallstones
287
What is the pathophysiological mechanism of acute pancreatitis?
Antedigestion of pancreatic tissue by pancreatic enzymes
288
What are common physical examination findings in acute pancreatitis?
Epigastric tenderness, ileus, and low-grade fever
289
What are Cullen's sign and Grey-Turner's sign associated with?
Acute pancreatitis (rarely seen)
290
What rare complication can occur due to pancreatitis?
Blindness due to retinopathy
291
What laboratory test is typically raised in 75% of acute pancreatitis cases?
Serum amylase
292
What does a serum amylase level > 3 times the upper limit of normal indicate?
Possible acute pancreatitis
293
What is the specificity of serum amylase for pancreatitis?
Around 90%
294
What other conditions can cause raised serum amylase levels?
* Pancreatic pseudocyst * Mesenteric infarct * Perforated viscus * Acute cholecystitis * Diabetic ketoacidosis
295
Which enzyme is more sensitive and specific than serum amylase in diagnosing pancreatitis?
Serum lipase
296
What is a unique characteristic of serum lipase compared to serum amylase?
Longer half-life
297
When might serum lipase be particularly useful?
In late presentations (> 44 hours)
298
Can acute pancreatitis be diagnosed without imaging?
Yes, with characteristic pain + amylase/lipase > 3 times normal
299
What imaging is important for diagnosing gallstones or biliary obstruction in pancreatitis?
Early ultrasound imaging
300
What imaging technique can also be used for diagnosing acute pancreatitis?
Contrast-enhanced CT
301
Is the actual amylase level of prognostic value in acute pancreatitis?
No
302
What percentage of acute pancreatitis cases experience Erinacetis fluid collections?
25% ## Footnote Erinacetis fluid collections are located in or near the pancreas and lack a wall of granulation or fibrous tissue.
303
What may happen to Erinacetis fluid collections in acute pancreatitis?
They may resolve or develop into pseudocysts or abscesses ## Footnote Aspiration and drainage are best avoided as they may precipitate infection.
304
What characterizes pseudocysts in acute pancreatitis?
Result from organization of peripancreatic fluid collection ## Footnote They may or may not communicate with the ductal system.
305
What is the typical occurrence time for pseudocysts after an attack of acute pancreatitis?
4 weeks or more ## Footnote The collection is walled by fibrous or granulation tissue.
306
What proportion of symptomatic pseudocysts may resolve within 12 weeks?
Up to 50% ## Footnote Treatment options include endoscopic or surgical interventions.
307
What does pancreatic necrosis involve?
Both the pancreatic parenchyma and surrounding fat ## Footnote Complications are directly linked to the extent of necrosis.
308
What is associated with a high mortality rate in pancreatic necrosis?
Extent of parenchymal necrosis ## Footnote Some centers perform fine-needle aspiration sampling of necrotic tissue if infection is suspected.
309
What is a pancreatic abscess?
A localized collection of pus associated with the pancreas ## Footnote This occurs in the absence of hemorrhage.
310
What may infected necrosis involve that can lead to hemorrhage?
Vascular structures ## Footnote Hemorrhage may occur de novo or post-surgery.
311
What systemic complication is associated with a high mortality rate of around 20%?
Acute respiratory distress syndrome ## Footnote This condition is a significant concern in cases of acute pancreatitis.
312
What is necrotising enterocolitis?
One of the leading causes of death among premature infants.
313
What are initial symptoms of necrotising enterocolitis?
* Feeding intolerance * Abdominal distension * Bloody stools
314
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
315
What is the most common type of oesophageal cancer?
Adenocarcinoma
316
Which condition is associated with an increased risk of adenocarcinoma of the oesophagus?
Gastro-oesophageal reflux disease (GORD) or Barrett's oesophagus.
317
Where are adenocarcinomas typically located in the oesophagus?
Near the gastroesophageal junction.
318
What is the most common presenting symptom of oesophageal cancer?
Dysphagia
319
What is the preferred method for locoregional staging of oesophageal cancer?
Endoscopic ultrasound
320
What is the most common procedure for operable oesophageal cancer?
Ivor-Lewis type oesophagectomy
321
What is the typical presentation of pancreatic cancer?
Classically painless jaundice.
322
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
323
What is Courvoisier's law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones.
324
What imaging technique is the investigation of choice for suspected pancreatic cancer?
High-resolution CT scanning.
325
What is the treatment for resectable lesions in the head of the pancreas?
Whipple's resection (pancreaticoduodenectomy).
326
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus.
327
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
328
What is the gold standard imaging for anorectal abscesses?
MRI
329
What is secondary peritonitis?
An inflammatory condition of the peritoneum from spillage of gastrointestinal or biliary contents.
330
What are common causes of secondary peritonitis?
* Perforated peptic ulcer * Ruptured appendicitis * Diverticulitis * Trauma or neoplasia
331
What are the clinical features of secondary peritonitis?
* Acute abdominal pain * Fever * Tachycardia * Rebound tenderness * Guarding
332
What is the cornerstone of management for secondary peritonitis?
Surgical intervention and broad-spectrum antibiotic therapy.
333
What is spontaneous bacterial peritonitis (SBP)?
A form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis.
334
What is the most common organism found in ascitic fluid culture for SBP?
E. coli
335
What is primary biliary cholangitis?
A chronic liver disorder typically seen in middle-aged females.
336
What are common associations with primary biliary cholangitis?
* Sjogren's syndrome * Rheumatoid arthritis * Systemic sclerosis * Thyroid disease
337
What is the first-line treatment for primary biliary cholangitis?
Ursodeoxycholic acid.
338
What is the incubation period for Hepatitis A?
2-4 weeks.
339
What is a significant complication of Hepatitis B infection?
Chronic hepatitis.
340
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
341
What percentage of adults fail to respond or respond poorly to 3 doses of the hepatitis B vaccine?
5-10% ## Footnote Risk factors include age over 40 years, obesity, smoking, alcohol excess, and immunosuppression.
342
Who is recommended to be tested for anti-HBs?
Individuals at risk of occupational exposure and patients with chronic kidney disease ## Footnote Anti-HBs levels should be checked 1-4 months after primary immunization.
343
What does an anti-HBs level of > 100 mIU/ml indicate?
Adequate response, no further testing required, booster at 5 years ## Footnote This indicates strong immunity.
344
What is indicated by an anti-HBs level of 10 - 100 mIU/ml?
Suboptimal response - one additional vaccine dose should be given ## Footnote If immunocompetent, no further testing is required.
345
What should be done if anti-HBs is < 10 mIU/ml?
Test for current or past infection; give further vaccine course with testing following ## Footnote If still fails to respond, HBIG would be required for protection if exposed to the virus.
346
What was the only treatment available for hepatitis B before newer antivirals?
Pegylated interferon-alpha ## Footnote It reduces viral replication in up to 30% of chronic carriers.
347
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
348
What are some antiviral medications used to treat hepatitis B?
Tenofovir, entecavir, telbivudine ## Footnote These aim to suppress viral replication.
349
What screening is offered to all pregnant women regarding hepatitis B?
Screening for hepatitis B ## Footnote Babies born to infected mothers should receive complete vaccination + hepatitis B immunoglobulin.
350
What is the vertical transmission rate of hepatitis B from mother to child?
6% ## Footnote The risk is higher if there is coexistent HIV.
351
True or False: Hepatitis B can be transmitted via breastfeeding.
False ## Footnote Unlike HIV, hepatitis B cannot be transmitted through breastfeeding.
352
What does HBsAg indicate in hepatitis B serology?
Ongoing infection, either acute or chronic if present > 6 months ## Footnote HBsAg is the first marker to appear.
353
What does the presence of anti-HBs imply?
Immunity (either exposure or immunization) ## Footnote It is negative in chronic disease.
354
What does anti-HBc indicate?
Previous or current infection ## Footnote IgM anti-HBc appears during acute infection and is present for about 6 months.
355
What is the chronic hepatitis C defined as?
Persistence of HCV RNA in the blood for 6 months
356
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
357
What is the goal of hepatitis C treatment?
Sustained virological response (SVR) ## Footnote Defined as undetectable serum HCV RNA six months after the end of therapy.
358
What are common side effects of ribavirin?
* Haemolytic anaemia * Cough ## Footnote Women should avoid pregnancy within 6 months of stopping ribavirin as it is teratogenic.
359
What are the side effects of interferon alpha?
* Flu-like symptoms * Depression * Fatigue * Leukopenia * Thrombocytopenia
360
What is the estimated number of people chronically infected with hepatitis C in the UK?
Around 200,000 people. ## Footnote This number indicates a significant public health concern.
361
What is the incubation period for hepatitis C?
6-9 weeks.
362
What is the vertical transmission rate of hepatitis C from mother to child?
About 6%.
363
True or False: Breastfeeding is contraindicated in mothers with hepatitis C.
False.
364
What is the risk of transmission of hepatitis C during a needle stick injury?
About 2%.
365
What percentage of patients will develop chronic hepatitis C after an acute infection?
55-85%.
366
What defines chronic hepatitis C?
Persistence of HCV RNA in the blood for 6 months.
367
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.
368
What is the aim of treatment for chronic hepatitis C?
Sustained virological response (SVR), defined as undetectable serum HCV RNA six months after therapy.
369
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.
370
What is the risk associated with interferon alpha treatment?
Flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia.
371
Fill in the blank: Hepatitis D is an incomplete RNA virus that requires _______ for replication.
Hepatitis B surface antigen.
372
What is the term used for simultaneous Hepatitis B and Hepatitis D infections?
Co-infection.
373
What is the major risk associated with Hepatitis D superinfection?
High risk of fulminant hepatitis, chronic hepatitis status, and cirrhosis.
374
How is Hepatitis D diagnosed?
Reverse polymerase chain reaction of hepatitis D RNA.
375
What is the incubation period for Hepatitis E?
3-8 weeks.
376
List the common symptoms of irritable bowel syndrome (IBS).
* Abdominal pain * Bloating * Change in bowel habit.
377
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.
378
What is the first-line pharmacological treatment for pain in IBS?
Antispasmodic agents.
379
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.
380
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm.
381
What are the two types of hiatus hernias?
* Sliding * Rolling (paraoesophageal).
382
What is the most sensitive test for investigating hiatus hernias?
Barium swallow.
383
What is diverticular disease?
Herniation of colonic mucosa through the muscular wall of the colon.
384
List the complications of diverticular disease.
* Diverticulitis * Haemorrhage * Development of fistula * Perforation and faecal peritonitis * Development of diverticular phlegmon.
385
What is the traditional mnemonic for the risk factors of biliary colic?
The '4 F's': Fat, Female, Fertile, Forty.
386
What is the primary management for biliary colic?
Elective laparoscopic cholecystectomy.
387
What are the features of anal fissures?
* Painful, bright red rectal bleeding * 90% occur on the posterior midline.
388
What is the first-line treatment for chronic anal fissures?
Topical glyceryl trinitrate (GTN).
389
What are the risk factors for alcoholic liver disease?
N/A
390
What should be tried if lactulose is not tolerated?
Lubricants such as petroleum jelly ## Footnote Lubricants may be used to ease defecation.
391
What is the first-line treatment for a chronic anal fissure?
Topical glyceryl trinitrate (GTN) ## Footnote GTN is often applied to promote healing.
392
What conditions are covered under alcoholic liver disease?
* Alcoholic fatty liver disease * Alcoholic hepatitis * Cirrhosis ## Footnote These conditions represent a spectrum of liver disease due to alcohol consumption.
393
What is characteristically elevated in alcoholic liver disease?
Gamma-GT ## Footnote This enzyme is commonly used as a marker for liver disease.
394
What is the typical AST:ALT ratio in alcoholic hepatitis?
> 2 ## Footnote A ratio of > 3 is strongly suggestive of acute alcoholic hepatitis.
395
Which glucocorticoid is often used during acute episodes of alcoholic hepatitis?
Prednisolone ## Footnote Glucocorticoids help manage inflammation during acute episodes.
396
What formula is used in Maddrey's discriminant function (DF)?
Prothrombin time and bilirubin concentration ## Footnote This formula helps determine the need for glucocorticoid therapy.
397
What did the STOPAH study compare?
Pentoxyphylline and prednisolone ## Footnote The study found that prednisolone improved survival at 28 days.
398
What is the most common acute abdominal condition requiring surgery?
Acute appendicitis ## Footnote It is most common in young people aged 10-20 years.
399
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 ## Footnote This sequence leads to inflammation and potential perforation of the appendix.
400
What type of abdominal pain is typically seen in appendicitis?
Peri-umbilical abdominal pain radiating to the right iliac fossa (RIF) ## Footnote This pain migration is a strong indicator of appendicitis.
401
What are common symptoms of acute appendicitis?
* Vomiting * Mild pyrexia * Anorexia * Localised right lower quadrant pain ## Footnote Anorexia and peri-umbilical pain are often present alongside nausea.
402
What examination findings suggest perforation in appendicitis?
* Generalised peritonitis * Localised peritonism * Rebound tenderness * Guarding and rigidity ## Footnote These signs indicate potential complications from appendicitis.
403
What laboratory finding is seen in 80-90% of appendicitis cases?
Neutrophil-predominant leucocytosis ## Footnote This is a common marker of infection.
404
What is the first-line investigation for acute cholecystitis?
Ultrasound ## Footnote This imaging modality is preferred for assessing gallbladder inflammation.
405
What are the typical features of acute cholecystitis?
* Right upper quadrant pain * Fever * Murphy's sign ## Footnote Murphy's sign is positive if there is inspiratory arrest upon palpation.
406
What is the recommended treatment for acute cholecystitis?
* Intravenous antibiotics * Cholecystectomy ## Footnote Early laparoscopic cholecystectomy is now recommended.
407
What percentage of children are affected by cow's milk protein intolerance/allergy (CMPI/CMPA)?
3-6% ## Footnote CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.
408
What are the two types of reactions associated with cow's milk protein allergy/intolerance?
Immediate (IgE mediated) and delayed (non-IgE mediated) ## Footnote CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.
409
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
410
What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?
Extensive hydrolysed formula (eHF) ## Footnote Amino acid-based formula (AAF) is used in infants with severe CMPA.
411
What should breastfeeding mothers do if their infant has cow's milk protein intolerance?
Eliminate cow's milk protein from their diet ## Footnote Consider prescribing calcium supplements to prevent deficiency.
412
What is the prognosis for children with cow's milk protein intolerance?
Usually resolves in most children ## Footnote 55% of children with IgE mediated intolerance will be milk tolerant by age 5.
413
What are the common locations for hemorrhoids?
3, 7, 11 o'clock position ## Footnote Hemorrhoids can be internal or external.
414
What are the typical features of an anal fissure?
Painful rectal bleeding and typically midline location (6 & 12 o'clock position) ## Footnote Chronic fissures present with a triad of ulcer, sentinel pile, and enlarged anal papillae.
415
What are common causes of proctitis?
* Crohn's * Ulcerative colitis * Clostridioides difficile
416
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus ## Footnote It has tracked from the tissue surrounding the anal sphincter.
417
What is the most common form of anorectal abscess?
Perianal abscess ## Footnote They make up around 60% of cases.
418
What is the average age of patients with perianal abscess?
Around 40 years
419
What is the first-line treatment for perianal abscess?
Incision and drainage ## Footnote Usually performed under local anaesthetic.
420
Identify two imaging techniques useful for diagnosing anorectal abscesses.
* MRI * Transperineal ultrasound
421
What are common symptoms of threadworm infestation?
* Perianal itching, particularly at night * Vulval symptoms in girls
422
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole ## Footnote A single dose is given unless infestation persists.
423
True or False: Most patients with threadworm infestation are asymptomatic.
True
424
What percentage of children are affected by cow's milk protein intolerance/allergy (CMPI/CMPA)?
3-6% ## Footnote CMPI/CMPA typically presents in the first 3 months of life in formula-fed infants.
425
What are the two types of reactions associated with cow's milk protein allergy/intolerance?
Immediate (IgE mediated) and delayed (non-IgE mediated) ## Footnote CMPA is used for immediate reactions, and CMPI for mild-moderate delayed reactions.
426
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
427
What is the first-line replacement formula for infants with mild-moderate symptoms of CMPA?
Extensive hydrolysed formula (eHF) ## Footnote Amino acid-based formula (AAF) is used in infants with severe CMPA.
428
What should breastfeeding mothers do if their infant has cow's milk protein intolerance?
Eliminate cow's milk protein from their diet ## Footnote Consider prescribing calcium supplements to prevent deficiency.
429
What is the prognosis for children with cow's milk protein intolerance?
Usually resolves in most children ## Footnote 55% of children with IgE mediated intolerance will be milk tolerant by age 5.
430
What are the common locations for hemorrhoids?
3, 7, 11 o'clock position ## Footnote Hemorrhoids can be internal or external.
431
What are the typical features of an anal fissure?
Painful rectal bleeding and typically midline location (6 & 12 o'clock position) ## Footnote Chronic fissures present with a triad of ulcer, sentinel pile, and enlarged anal papillae.
432
What are common causes of proctitis?
* Crohn's * Ulcerative colitis * Clostridioides difficile
433
What is a perianal abscess?
A collection of pus within the subcutaneous tissue of the anus ## Footnote It has tracked from the tissue surrounding the anal sphincter.
434
What is the most common form of anorectal abscess?
Perianal abscess ## Footnote They make up around 60% of cases.
435
What is the average age of patients with perianal abscess?
Around 40 years
436
What is the first-line treatment for perianal abscess?
Incision and drainage ## Footnote Usually performed under local anaesthetic.
437
Identify two imaging techniques useful for diagnosing anorectal abscesses.
* MRI * Transperineal ultrasound
438
What are common symptoms of threadworm infestation?
* Perianal itching, particularly at night * Vulval symptoms in girls
439
What is the first-line treatment for threadworm infestation in children over 6 months old?
Mebendazole ## Footnote A single dose is given unless infestation persists.
440
True or False: Most patients with threadworm infestation are asymptomatic.
True
441
What is the commonest bacterial cause of infectious intestinal disease in the UK?
Campylobacter jejuni ## Footnote Campylobacter is primarily spread by the faecal-oral route.
442
What are the common features of Campylobacter jejuni infection?
* Prodrome: headache, malaise * Diarrhoea: often bloody * Abdominal pain: may mimic appendicitis
443
What is the incubation period for Campylobacter jejuni?
1-6 days
444
What is the first-line antibiotic for severe Campylobacter jejuni infections?
Clarithromycin
445
True or False: Ciprofloxacin is frequently indicated for treating Campylobacter jejuni infections.
False ## Footnote Strains with decreased sensitivity to ciprofloxacin are commonly isolated.
446
What complications may follow Campylobacter jejuni infections?
* Guillain-Barre syndrome * Reactive arthritis * Septicaemia * Endocarditis * Arthritis
447
What is Clostridioides difficile commonly associated with?
Pseudomembranous colitis
448
What type of bacteria is Clostridioides difficile?
Gram-positive rod
449
What are the two exotoxins released by Clostridioides difficile?
* Toxin A * Toxin B
450
What are common risk factors for Clostridioides difficile infection?
* Broad-spectrum antibiotics * Proton pump inhibitors
451
What characterizes the white blood cell count in Clostridioides difficile infection?
A raised white blood cell count (WCC) is characteristic
452
What is the first-line therapy for a first episode of C. difficile infection?
Oral vancomycin for 10 days
453
What is the recurrence rate of C. difficile infection after the first episode?
Around 20%
454
What is a key feature of travellers' diarrhoea?
At least 3 loose to watery stools in 24 hours
455
What is the most common cause of travellers' diarrhoea?
Escherichia coli
456
What pathogens are typically associated with acute food poisoning?
* Staphylococcus aureus * Bacillus cereus * Clostridium perfringens
457
What type of illness does Bacillus cereus cause when vomiting occurs within 6 hours?
Vomiting subtype
458
What is the incubation period for Staphylococcus aureus food poisoning?
1-6 hours
459
What are the common features of Salmonella infections?
* Diarrhoea * Nausea and vomiting * Abdominal cramps * Fever * Lethargy
460
What are the two types of enteric fevers caused by Salmonella?
* Typhoid * Paratyphoid
461
What is the management for Shigella infection?
Usually self-limiting; antibiotics indicated for severe disease
462
Fill in the blank: Howell-Jolly bodies are associated with _______.
hyposplenism
463
What increases the risk of post-splenectomy sepsis?
Loss of spleen's ability to respond to encapsulated organisms
464
What vaccines should be administered post-splenectomy?
* Pneumococcal * Haemophilus type b * Meningococcal type C
465
What is a common feature of alcoholic liver disease?
Gamma-GT is characteristically elevated
466
What is the typical AST:ALT ratio in alcoholic hepatitis?
> 2
467
What is the most common cause of acute pancreatitis?
Alcohol or gallstones
468
What scoring systems are used to identify severe pancreatitis?
* Ranson score * Glasgow score * APACHE II
469
What does the mnemonic GET SMASHED stand for in relation to pancreatitis causes?
* Gallstones * Ethanol * Trauma * Steroids * Mumps * Autoimmune * Scorpion venom * Hypertriglyceridaemia * ERCP * Drugs
470
What are common causes of acute pancreatitis?
Gallstones, ethanol, trauma, steroids, mumps, autoimmune conditions, Ascaris infection, scorpion venom, hypertriglyceridaemia, hyperchylomicronaemia, hypercalcaemia, hypothermia, certain drugs ## Footnote Drugs include azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate.
471
How much more common is pancreatitis in patients taking mesalazine compared to sulfasalazine?
7 times more common
472
What is the prognostic value of the actual amylase level in pancreatitis?
Not of prognostic value
473
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 ## Footnote They may resolve or develop into pseudocysts or abscesses.
474
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
475
What investigations are used for pseudocysts?
CT, ERCP, MRI, endoscopic USS
476
What is pancreatic necrosis?
Involves both pancreatic parenchyma and surrounding fat, with complications linked to the extent of necrosis
477
What is the management for sterile pancreatic necrosis?
Managed conservatively at least initially
478
What are the systemic complications of acute pancreatitis?
Acute respiratory distress syndrome, associated with a high-mortality rate of around 20%
479
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
480
What are key aspects of care for acute pancreatitis?
* Fluid resuscitation * Analgesia * Nutrition * Role of antibiotics * Role of surgery
481
What is the recommended fluid resuscitation for severe acute pancreatitis?
3-6 litres of crystalloids to manage third space fluid loss
482
When should enteral nutrition be offered in acute pancreatitis?
Within 72 hours of presentation for moderately severe or severe cases
483
What is the role of antibiotics in acute pancreatitis according to NICE?
Do not offer prophylactic antimicrobials; potential indications include infected pancreatic necrosis
484
What surgical intervention is recommended for patients with acute pancreatitis due to gallstones?
Early cholecystectomy
485
What is chronic pancreatitis?
An inflammatory condition affecting both exocrine and endocrine functions of the pancreas, often due to alcohol excess
486
What are common features of chronic pancreatitis?
* Pain worse 15-30 minutes after meals * Steatorrhoea * Diabetes mellitus development
487
What is the sensitivity and specificity of CT in detecting pancreatic calcification?
Sensitivity: 80%, Specificity: 85%
488
What is a key management strategy for chronic pancreatitis?
Pancreatic enzyme supplements, analgesia, antioxidants
489
What is the incidence of gastric cancer in the developed world?
Accounts for around 2% of all cancer diagnoses
490
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
491
What are the typical symptoms of gastric cancer?
* Abdominal pain * Weight loss * Nausea and vomiting * Dysphagia
492
What is the diagnosis method for gastric cancer?
Oesophago-gastro-duodenoscopy with biopsy
493
What is the management approach for ovarian cancer?
Combination of surgery and platinum-based chemotherapy
494
What are common clinical features of ovarian cancer?
* Abdominal distension * Abdominal pain * Urinary symptoms * Early satiety * Diarrhoea
495
What is the most common symptom of haemorrhoids?
Painless rectal bleeding
496
What are the two types of haemorrhoids?
* External: below the dentate line, prone to thrombosis * Internal: above the dentate line, generally painless
497
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
498
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
499
What is coeliac disease?
An autoimmune condition caused by sensitivity to the protein gluten.
500
What percentage of the UK population is thought to be affected by coeliac disease?
Around 1%.
501
What is a consequence of repeated exposure to gluten in coeliac disease?
Villous atrophy leading to malabsorption.
502
What skin condition is associated with coeliac disease?
Dermatitis herpetiformis.
503
What autoimmune disorders are associated with coeliac disease?
* Type 1 diabetes mellitus * Autoimmune hepatitis
504
What HLA types are strongly associated with coeliac disease?
* HLA-DQ2 (95% of patients) * HLA-DQ8 (80%)
505
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
506
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
507
What are the WHO definitions of diarrhoea?
* Diarrhoea: > 3 loose or watery stools per day * Acute diarrhoea: < 14 days * Chronic diarrhoea: > 14 days
508
What is the most common cause of acute diarrhoea?
Gastroenteritis.
509
What are the typical symptoms of irritable bowel syndrome (IBS)?
* Abdominal pain * Bloating * Change in bowel habit
510
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
511
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
512
What is the significance of the carcinoembryonic antigen (CEA) test in colorectal cancer?
It is used for staging colorectal cancer.
513
What is the most common type of colon cancer?
Sporadic colon cancer (95%).
514
What is hereditary non-polyposis colorectal carcinoma (HNPCC) also known as?
Lynch syndrome.
515
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
516
What is familial adenomatous polyposis (FAP)?
A rare autosomal dominant condition leading to hundreds of polyps and inevitable carcinoma.
517
What mutation is associated with familial adenomatous polyposis (FAP)?
Mutation in the adenomatous polyposis coli gene (APC).
518
What is the typical management for colorectal cancer?
Surgery, chemotherapy, radiation therapy, and targeted therapies.
519
What is the role of Faecal Immunochemical Test (FIT) in colorectal cancer screening?
Used to guide referral for suspected cancer.
520
What should be done if a FIT test result is positive?
Refer the patient on the suspected cancer pathway.
521
What are some symptoms of colorectal cancer?
* Change in bowel habits * Rectal bleeding * Abdominal pain * Unexplained weight loss * Anaemia * Bowel obstruction
522
What does the TNM staging system stand for?
Tumour, Node, Metastasis.
523
What is the common treatment for obstructing colon cancer?
Stenting or resection.
524
What is a Hartmann's procedure?
Resection of the sigmoid colon with formation of an end colostomy.
525
What is the age range for the NHS screening program in England?
60 to 74 years ## Footnote Patients aged over 74 years may request screening.
526
What test is used in the NHS screening program to detect human blood in stool samples?
Faecal Immunochemical Test (FIT) ## Footnote FIT tests are sent through the post to eligible patients.
527
What does the Faecal Immunochemical Test (FIT) specifically recognize?
Human haemoglobin (Hb) ## Footnote It is a type of faecal occult blood (FOB) test.
528
What is the main advantage of the FIT test over conventional FOB tests?
Only detects human haemoglobin ## Footnote Conventional tests may detect animal haemoglobin from diet.
529
How many faecal samples are needed for the FIT test?
One ## Footnote Conventional FOB tests typically require 2-3 samples.
530
What happens to patients with abnormal FIT test results?
Offered a colonoscopy ## Footnote This is to further investigate the cause of the abnormal results.
531
What percentage of patients at colonoscopy will have a normal exam?
50% ## Footnote Approximately 5 out of 10 patients will have a normal exam.
532
What is the likelihood of finding polyps during a colonoscopy?
40% ## Footnote Approximately 4 out of 10 patients will be found to have polyps.
533
What is the risk associated with polyps found during colonoscopy?
Premalignant potential ## Footnote Polyps may be removed due to this risk.
534
What percentage of patients undergoing colonoscopy will be found to have cancer?
10% ## Footnote Approximately 1 out of 10 patients will be found to have cancer.
535
When was the one-off flexible sigmoidoscopy trial at age 55 abandoned?
2021 ## Footnote This was mainly due to recruitment issues exacerbated by the COVID-19 pandemic.
536
What was the impact of screening for colorectal cancer on mortality?
Reduced mortality by 16% ## Footnote This is based on evidence showing the effectiveness of screening.
537
What are the new symptoms that warrant a FIT test for patients under 60 years?
Changes in bowel habit OR iron deficiency anaemia ## Footnote These symptoms indicate the need for further investigation.
538
True or False: The FIT test reports numerical values to patients.
False ## Footnote Patients are informed if the test is normal or abnormal, but not the numerical value.
539
What is Crohn's disease?
A form of inflammatory bowel disease that can affect any part of the gastrointestinal tract from mouth to anus.
540
Which areas are most commonly affected by Crohn's disease?
Terminal ileum and colon.
541
What is the cause of Crohn's disease?
Unknown, but there is strong genetic susceptibility.
542
What are the common complications of Crohn's disease?
Strictures, fistulas, and adhesions.
543
What percentage of Crohn's disease patients have small bowel involvement?
80%.
544
What is the most prominent symptom of Crohn's disease in adults?
Diarrhoea.
545
What is the most prominent symptom of Crohn's disease in children?
Abdominal pain.
546
What are the common investigations for Crohn's disease?
Raised inflammatory markers, increased faecal calprotectin, anaemia, low vitamin B12 and vitamin D.
547
Name two extra-intestinal features related to disease activity in Crohn's disease.
* Arthritis (pauciarticular, asymmetric) * Erythema nodosum.
548
What is the investigation of choice for Crohn's disease?
Colonoscopy.
549
What histological features are observed in Crohn's disease?
* Inflammation in all layers from mucosa to serosa * Goblet cells * Granulomas.
550
What is the first-line treatment for inducing remission in Crohn's disease?
Glucocorticoids.
551
What is azathioprine used for in Crohn's disease?
As an add-on medication to induce remission.
552
What percentage of Crohn's disease patients will eventually require surgery?
Around 80%.
553
What is the standard incidence ratio for small bowel cancer in Crohn's disease?
40.
554
True or False: Ulcerative colitis inflammation always starts at the rectum.
True.
555
What are common symptoms of ulcerative colitis?
Bloody diarrhoea, urgency, tenesmus, abdominal pain, particularly in the left lower quadrant.
556
What is the typical endoscopic finding in ulcerative colitis?
Red, raw mucosa that bleeds easily.
557
What is the management approach for mild ulcerative colitis?
Topical (rectal) aminosalicylate.
558
What factors can trigger flares of ulcerative colitis?
* Stress * Medications * NSAIDs * Antibiotics * Cessation of smoking.
559
What is the recommended follow-up colonoscopy interval for lower risk ulcerative colitis patients?
5 years.
560
What autoimmune condition is caused by sensitivity to gluten?
Coeliac disease.
561
What are the associations of coeliac disease?
* Dermatitis herpetiformis * Type 1 diabetes mellitus * Autoimmune hepatitis.
562
What genetic markers are strongly associated with coeliac disease?
* HLA-DQ2 (95% of patients) * HLA-DQ8 (80%).
563
What is the typical presentation of coeliac disease?
Villous atrophy leading to malabsorption.
564
What dietary component must be eliminated in patients with coeliac disease?
Gluten.
565
What is coeliac disease?
An autoimmune condition caused by sensitivity to the protein gluten ## Footnote It affects around 1% of the UK population and leads to villous atrophy and malabsorption.
566
What are common conditions associated with coeliac disease?
* Dermatitis herpetiformis * Type 1 diabetes mellitus * Autoimmune hepatitis ## Footnote Dermatitis herpetiformis presents as a vesicular, pruritic skin eruption.
567
What genetic associations are strongly linked to coeliac disease?
* HLA-DQ2 (95% of patients) * HLA-DQ8 (80%) ## Footnote These genetic markers are critical in understanding susceptibility to the disease.
568
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 ## Footnote These symptoms indicate a potential need for further investigation.
569
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) ## Footnote Complications can significantly impact health and quality of life.
570
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 ## Footnote Symptoms may coincide with the introduction of gluten-containing foods.
571
What is the gold standard for diagnosing coeliac disease?
Endoscopic intestinal biopsy ## Footnote This should be performed in all patients suspected of having coeliac disease.
572
What serological tests are first-choice for coeliac disease diagnosis according to NICE?
* Tissue transglutaminase (TTG) antibodies (IgA) * Endomysial antibody (IgA) ## Footnote These tests help confirm the diagnosis and assess compliance with a gluten-free diet.
573
What dietary management is required for coeliac disease?
A gluten-free diet ## Footnote This includes avoiding gluten-containing cereals such as wheat, barley, rye, and sometimes oats.
574
Which foods are gluten-free?
* Rice * Potatoes * Corn (maize) ## Footnote These foods can be safely consumed by patients with coeliac disease.
575
True or False: Whisky is safe for patients with coeliac disease.
True ## Footnote Whisky is made from malted barley, but gluten proteins are removed during distillation.
576
What vaccination is recommended for patients with coeliac disease?
Pneumococcal vaccine ## Footnote Due to functional hyposplenism, vaccination is crucial for preventing infections.
577
Fill in the blank: Anti-gliadin antibody tests are _______ by NICE.
not recommended ## Footnote These tests are not considered reliable for diagnosing coeliac disease.
578
What is ulcerative colitis?
A chronic inflammatory bowel disease affecting the colon and rectum ## Footnote Ulcerative colitis causes inflammation and ulcers in the digestive tract.
579
What are common factors linked to ulcerative colitis flares?
* Stress * Medications * NSAIDs * Antibiotics * Cessation of smoking ## Footnote These factors may contribute to the onset of symptoms in patients.
580
How are ulcerative colitis flares classified?
Mild, Moderate, Severe ## Footnote Each classification reflects the severity and symptoms experienced by the patient.
581
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 ## Footnote Patients with mild flares typically do not have significant systemic effects.
582
What are the symptoms of a moderate ulcerative colitis flare?
Four to six stools a day, with minimal systemic disturbance ## Footnote Moderate flares indicate a need for closer monitoring but may not require hospitalization.
583
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 ## Footnote Severe flares require urgent medical attention and often hospitalization.
584
True or False: Most ulcerative colitis flares occur with an identifiable trigger.
False ## Footnote Most flares occur without a clear trigger, although certain factors may be linked.
585
What should be done for patients with evidence of severe ulcerative colitis?
They should be admitted to hospital ## Footnote Hospitalization is necessary to manage severe symptoms and prevent complications.

UKMLA Prep (48 decks)

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