GI Flashcards
1
Q
Define intestinal obstruction
A
Blockage of the lumen of the gut
Arrest of onward propulsion of intestinal contents
2
Q
Name 3 broad types of causes of intestinal obstruction
A
- Intraluminal obstruction = something in the bowel
- Intramural obstruction = something in the wall of the bowel
- Extraluminal obstruction = something outside of the bowel
3
Q
Give 3 causes of intraluminal obstruction of the intestine
A
- Tumour - carcinoma, lymphoma
- Diaphragm disease
- Meconium ileus
- Gallstone ileus
4
Q
What is diaphragm disease?
A
Mucosa/submucosa fold due to fibroid diaphragm leaving a pinhole lumen
5
Q
What is thought to cause diaphragm disease?
A
NSAIDs
6
Q
Give 3 causes of intramural obstruction of the intestine
A
- Inflammatory disease = Chron’s, Diverticulitis
- Tumours
- Neural = Hirschsprung’s disease
7
Q
Describe how Crohn’s disease can cause intestinal obstruction
A
Crohn’s disease –> fibrosis –> contraction –> obstruction
8
Q
Describe how diverticular disease can cause intestinal obstruction
A
Out pouching of mucosa –> faeces trapped –> inflammation in bowel wall –> contraction –> obstruction
9
Q
What is Hirschsprung’s disease?
A
A congenital condition where there is a lack of nerves in the bowel –> no ganglion cells –> no contraction –> distal obstruction and gross dilation of the bowel
10
Q
Give 3 causes of extraluminal obstruction of the intestine
A
- Adhesions
- Volvulus
- Peritoneal tumour
11
Q
What are adhesions?
A
Fibrous bands stick 2 bits of bowel together so bowel is pulled and distorted
12
Q
What causes adhesions?
A
Often formed after abdominal surgery (pelvic, gynaecologist, colorectal)
13
Q
What is volvulus?
A
Bowel twisting around each other cuts off blood supply/ lumen
Risk of ischaemia, necrosis and perforation
14
Q
Which areas of the bowel are most likely to be affected by volvulus?
A
Occurs in areas of bowel that have mesentery
Often in the sigmoid colon
15
Q
Give 4 common causes of small bowel obstruction in adults
A
- Adhesions
- Hernias
- Crohn’s disease
- Malignancy
16
Q
Give 3 common causes of small bowel obstruction in children
A
- Appendicitis
- Volvulus
- Intussusception
17
Q
What is intussusception?
A
One part of the intestine telescopes into another section of the intestine
Caused by force in-balances
18
Q
Give 5 symptoms of small bowel obstruction
A
- vomiting more common
- periumbilical
- cramping and intermittent pain
- lasts for a few minutes at a time
- Nausea and anorexia
- Early feculent vomit
- Diffuse colicky pain
- Late constipation
- Distention
- Tenderness
- bowel sounds
19
Q
Does abdominal distension occur more distal or proximal to an intestinal obstruction?
A
More distal = greater distension
20
Q
What investigations might you do in someone who you suspect to have a small bowel obstruction?
A
- FBC
- abdominal x-ray - shows central gas shadow that completely cross the lumen, distended loops of bowel proximal to obstruction, fluid levels seen
- CT - gold standard to localise lesion accurately
21
Q
What is the management/treatment for small bowel obstruction?
A
- Fluid resuscitation
- Bowel decompression
- Analgesia and antiemetics
- Antibiotics
- Surgery - laparotomy, bypass segment, resection
22
Q
Which is more common, small or large bowel obstruction?
A
Small bowel obstruction = 60-75% of intestinal obstruction
23
Q
What can untreated intestinal obstruction lead to?
A
- Ishcaemia
- Necrosis
- Perforation
24
Q
Give 2 common causes of large bowel obstruction
A
- Colorectal malignancy - most common in UK
2. Volvulus - more common in Africa
25
Where is the usual site of perforation in large bowel obstruction if the ileocaecal valve is competent?
Caecum
26
How long does acute presentation of large bowel obstruction last?
Average of 5 day of symptoms = abdominal pain and constipation
27
Give 5 symptoms of large bowel obstruction
- lower abdominal pain
- less frequent pain
- episodes last longer
1. Bloating/fullness/nausea
2. Late vomiting (more faecal like) - may be absent
3. Colicky pain - more constant than SBO
4. Distension
5. Blood in stool
6. constipation
7. palpable mass
8. bowel sounds normal then increase then quiet later
28
What investigations might you do in someone who you suspect to have a large bowel obstruction?
1. Digital rectal examination - empty rectum, hard stools, blood
2. abdominal X ray - peripheral gas shadows proximal to blockage, caecum and ascending colon distended
3. CT scan
4. FBC - low Hb
29
Describe the management for a large bowel obstruction
1. IV fluid replacement
2. Bowel decompression
3. Surgery - laparotomy
4. analgesia and antiemetic
5. antibiotics
30
Define hernia
Abnormal protrusion of an organ into a body cavity it doesn't normally belong
31
What are the risks of hernia's if left untreated?
Become strangulated
32
Give 2 symptoms of hernias
1. Pain
| 2. Palpable lump
33
Describe the progression from normal epithelium to colorectal cancer
Normal epithelia --> adenoma --> colorectal adenocarcinoma --> metastatic colorectal adenocarcinoma
34
Define adenocarcinoma
A malignant tumour of glandular epithelium
35
What is familial adenomatous polyposis?
Autosomal dominant condition
| - arise from mutation in APC gene- where you develop thousands of polyps in the duodenum and colorectal in teens
36
What are precursors to colorectal cancer?
Polyploid adenomas
37
Describe the epidemiology of colorectal cancer
```
Normally adenocarcinoma
- majority in distal colon
Incidence peaks around 60-65 years
Males > females
2nd most common cause of cancer death in UK
```
38
Give 5 risk factors for colorectal cancer
1. Increasing age
2. Family history
3. Western diet - saturated animal fat, red meat consumption, low fibre, high sugar
4. Alcohol
5. Smoking
39
Give 3 reasons why bowel cancer survival has increased over recent years
1. Introduction of the bowel cancer screening programme
2. Colonoscopic techniques
3. Improvements in treatment options
40
What can affect the clinical presentation of a colorectal cancer?
How close the cancer is to the rectum
41
Give 2 signs of a left sided/sigmoid colorectal cancer
1. Altered bowel habit
2. diarrhoea
3. blood in stool
4. alternating diarrhoea and constipation
42
Give 3 signs of a right sided colorectal cancer
1. assymptomatic until presenting with Iron deficiency anaemia
2. Right iliac fossa mass
3. Weight loss
4. low Hb
5. abdominal pain
43
Give 4 signs of rectal carcinoma
- rectal bleeding and mucus
- when cancer grows there will be thinner stools and tenesmus (cramping rectal pain)
1. Abdominal mass
2. Perforation
3. Haemorrhage
4. Fistulae
44
What investigations might you do in someone who you suspect might have colorectal cancer?
- Faecal occult blood test
>50 + bowel habit change / iron deficient anaemia
>60 + anaemia
- Colonoscopy + biopsy
- Flexible sigmoidoscopy / barium enema / CT colonoscopy
45
How can adenoma formation be prevented?
NSAIDs
46
What screening programme is used to identify bowel cancer?
Faecal occult blood (FOB) screening
| For over 65s+ve result = biopsy
47
What is the management for colorectal adenocarcinoma?
- Surgical resection
- endoscopic stenting for palliative care
- radiation
- chemotherapy - if duke's stage C
48
What is the treatment for metastatic colorectal adenocarcinoma?
Chemotherapy and palliative
49
Explain Dukes staging and prognosis
```
A = limited to muscularis mucosae = 95% 5-year survival
B = extension through muscularis mucosae (not lymph) = 75% 5-year survival
C = involvement of regional lymph nodes = 35% 5-year survival
D = distant metastases = 25% 5-year survival
```
50
What does T refer to in the staging of cancer?
T = refers to primary tumour and suffixed by number that denotes tumour size
51
What does N refer to in the staging of cancer?
N = refers to lymph node status and is suffixed by numbers that denotes number of lymph nodes or group of lymph nodes containing metastases
52
What does M refer to in the staging of cancer?
M = refers to anatomical extent of distant metastases
53
What does the T mean for colorectal cancer staging?
```
T1 = invades submucosa
T2 = Muscularis propria
T3 = Bowel wall
T4 = Peritoneum
```
54
What does the N mean for colorectal cancer staging?
```
N1 = spread to lymph nodes
N2 = spread to lymph nodes above the diaphragm
```
55
What does the M mean for colorectal cancer staging?
M1 = surrounding structure involvement (liver)
56
Name 5 things that can break down the mucin layer in the stomach and cause gastritis
1. Mucosal ischameia
2. H. pylori
3. Aspirin, NSAIDs - most common
4. Increased acid (stress)
5. Bile reflux
6. Alcohol
57
Give 3 symptoms of gastritis
1. Epigastric pain
2. Nausea and vomiting (recurrent upset stomach)
3. Indigestion
4. Haematemesis
5. dyspepsia
58
What investigations are done with someone you suspect has gastritis?
- Endoscopy (erythema)
- Biopsy (histology change)
- Blood tests (inflammation)
- H.pylori testing - urea breath test, stool antigen test
59
Describe the treatment for gastritis
1. Decrease alcohol and smoking
2. Antacid (magnesium carbonate)
3. PPI (omeprazole)
4. H2 receptor antagonist (ranitidine)
5. Enteric coated aspirin
6. decrease stress
60
How do you treat H. pylori?
Triple therapy:
Normal --> amoxicillin, omeprazole and clarithromycin/metronidazole
Penicillin resistance --> clarithromycin, omeprazole and metronidazole
61
Give 4 causes of peptic ulcers
1. NSAIDs
2. Mucosal ischaemia
3. Increased acid production (stress)
4. Bile reflux
5. Alcohol
6. H. pylori
62
How does mucosal ischaemia cause ulcer formation?
Lack of blood flow to cells --> no mucin production = no mucosal protection --> ulcer formation
63
How does increased acid production (stress) cause ulcer formation?
Mucosa overwhelmed --> corrosion --> ulcer formation
64
How does NSAIDs cause ulcer formation?
Reduced prostaglandin synthesis due to salicylic acid release --> cell death --> no mucin production = no mucosal protection --> ulcer formation
65
How does bile reflux cause ulcer formation?
Mucosal cell damages --> no mucin production = no mucosal protection --> ulcer formation
66
How does H. pylori cause ulcer formation?
- causes decrease in HCO3- which increases acidity
- H.pylori secretes urease
- splits urea into CO2 and ammonia
- ammonia + H+ forms ammonium which is toxic to gastric mucosa
- Acute inflammatory reaction (neutrophils) with less mucosal defence
67
Give 3 symptoms of peptic ulcers
1. recurrent burning epigastric pain
2. pain relieved by antacids and is worse when hungry
3. pain occurs at night
4. nausea
5. anorexia and weight loss
68
What investigations might you do in someone who you suspect to have peptic ulcers?
H. Pylori Test (Urease breath test)
| Endoscopy (if Over 55 or Red Flags Present)
69
How can you treat peptic ulcers?
- lifestyle changes
- reduce stress, avoid irritating food, reduce smoking
- Stop NSAIDs
- H.Pylori eradication (triple therapy):
- PPI - OMEPRAZOLE
- 2 of following:
- AMOXICILLIN
- CLARITHROMYCIN
70
Name 2 complications of peptic ulcers
- Haemorrhage due to erosion to artery
| - Peritonitis due to erosion through wall
71
Give 5 broad causes of malabsorption
1. Defective intraluminal digestion
2. Insufficient absorptive area
3. Lack of digestive enzymes
4. Defective epithelial transport
5. Lymphatic obstruction
72
Malabsorption: what can cause defective intraluminal digestion?
1. Pancreatic insufficiency due to pancreatitis/CF - lack of digestive enzymes
2. Defective bile secretion due to biliary obstruction or ileal resection
3. Bacterial overgrowth
73
Malabsorption: what can cause insufficient absorptive area?
1. Coeliac disease
2. Crohn's disease
3. Extensive surface parasitisation
4. Small intestinal resection or bypass
74
Malabsorption: give an example of when there is a lack of digestive enzymes
Lactose intolerance - disaccharide enzyme deficiency
75
Malabsorption: what can cause lymphatic obstruction?
1. Lymphoma
| 2. TB
76
Describe the distribution of inflammation seen in Crohn's disease
Patchy (skip lesions), granulomatous, transmural inflammation
77
Describe the distribution of inflammation seen in Ulcerative colitis
Continuous inflammation affecting only the mucosa
78
What part of the bowel is commonly affected by Crohn's disease?
Can affect anywhere from the mouth to anus
| Terminal ileum is most affected
79
What part of the bowel is commonly affected by Ulcerative colitis?
Spreads proximally from the rectum but only affects the colon
80
give 3 microscopic features that will be seen in ulcerative colitis
1. Crypt abscess
2. goblet cell depletion
3. mucosal inflammation - does not go deeper
81
what are the macroscopic features of crohn's disease?
- Deep ulcers and fissures --> cobblestone look
- skip lesions
- involved bowel often thickened and narrowed
82
In Crohn's or UC is smoking a protective factor?
Ulcerative colitis
83
Name 3 causes of IBD
1. Genetic
2. Stress/depression
3. Inappropriate immune response
84
Give 4 signs and symptoms of Ulcerative colitis
1. Episodic/chronic diarrhoea +/- blood/ mucus
2. Abdominal pain - left lower quadrant
3. Systemic - fever, malaise, anorexia, weight loss
4. Clubbing
5. Erythema nodosum
6. Amyloidosis
85
Give 4 signs and symptoms of Crohn's disease
1. Diarrhoea - urgency
2. Abdominal pain
3. Systemic - weight loss, fatigue, fever, malaise
4. Bowel ulceration
5. Anal fistulae/stricture
6. Clubbing
7. Skin/joint/eye problems
86
What investigations might you do in someone with IBD?
1. Bloods - FBC, ESR, CRP
2. Faecal calprotectin - shows inflammation but is not specific for IBD
3. Flexible sigmoidoscopy
4. Colonoscopy - biopsy to confirm
5. examination
87
What is the treatment for Crohn's disease?
- Smoking cessation
- 1st line = Corticosteroids - BUDESONIDE (controlled release) or ORAL PREDNISOLONE (for severe attacks)
- Surgical resection - only minimal
88
What is the treatment for Ulcerative colitis?
- Aminosalicylates
- 5-ASA (SULFASALAZINE)
- PREDNISOLONE
- HYDROCORTISONE
- Surgical resection
89
Give 5 complications of Ulcerative colitis
1. Colon --> blood loss, colorectal cancer, toxic dilatation
2. Arthritis
3. Iritis, episcleritis
4. Fatty liver and primary sclerosing cholangitis
5. Erythema nodosum
90
Give 5 complications of Crohn's
PERFORATION AND BLEEDING = MAJOR
1. Malabsorption
2. Obstruction --> toxic dilatation
3. Fistula/abscess formation
4. Anal skin tag/fissures/fistula
5. Neoplasia
6. Amyloidosis
91
Describe the pathophysiology of Coeliac disease
1. Gliadin from gluten deaminated by tissue transglutaminase --> increases immunogenicity
2. Gliadin recognised by HLA-DQ2 receptor on APC --> inflammatory response
3. Plasma cells produce anti-gliadin and tissue transglutaminase --> T cell/cytokine activated
4. Villous atrophy and crypt hyperplasia --> malabsorption
92
When does Coeliac disease usually present?
2 peaks - infancy and 5th decade
93
Give 5 symptoms of Coeliac disease
1. Diarrhoea and steatorrhoea (stinking/fatty)
2. Weight loss
3. Irritable bowel
4. Iron deficiency anaemia
5. Osteomalacia
6. Fatigue
7. abdominal pain
8. angular stomatitis
9. dermatitis herpetiform
94
What investigations might you do in someone who you suspect to have coeliac disease?
- anti-tTg antibody test - must keep gluten diet 6 weeks prior
- Endoscopy - duodenal biopsy post 6 weeks gluten diet (gold standard)
95
What 3 histological features are needed in order to make a diagnosis of coeliac disease?
1. Raised intraepithelial lymphocytes
2. Crypt hyperplasia
3. Villous atrophy
96
What part of the bowel is mostly affected in coeliac disease?
Proximal small bowel (duodenum)
| mean B12, folate and iron cannot be absorbed = anaemia
97
How do you treat coeliac disease?
- Lifelong gluten free diet
- correction of mineral and vitamin deficiency
- DEXA scan for osteoporosis risk
98
Give 3 complications of Coeliac disease
1. Osteoporosis
2. Anaemia
3. Increased risk of GI tumours
4. secondary lactose intolerance
5. T-cell lymphoma
99
What cells normally line the oesophagus?
Stratified squamous non-keratinising cells
100
Give 3 causes of squamous cell carcinoma
1. Smoking
2. Alcohol
3. Poor diet/obesity
4. coeliac disease
101
Name 2 types of Oesophageal cancer
1. Adenocarcinoma - distal 1/3rd of oesophagus
| 2. Squamous cell carcinoma - proximal 2/3rds of oesophagus
102
What can cause oesophageal adenocarcinoma?
Barrett's oesophagus
103
Give 5 symptoms of oesophageal carcinoma
1. progressive dysphagia
2. Weight loss
3. Heartburn
4. Haematemesis
5. Anorexia
6. Pain
104
What investigations might be done on someone you suspect has oesophageal cancer?
upper GI endoscopy and biopsy = 1st line
Barium swallow - to see strictures
CT/MRI for staging
105
How can you treat oesophageal cancer?
- Surgical resection
- best chance of cure if not infiltrated through oesophageal wall
- Chemotherapy - Palliative care
106
Give 3 causes of gastric cancer
1. Smoked foods
2. Pickles
3. H. pylori infection
4. Pernicious anaemia
5. Gastritis
6. family history
107
Describe how gastric cancer can develop from normal gastric mucosa
Smoked/pickled food diet leads to intestinal metaplasia of normal gastric mucosa
Several genetic changes lead to dysplasia and then eventually intra-mucosal and invasive carcinoma
108
Give 3 symptoms and signs of gastric cancer
1. Weight loss
2. Anaemia (pernicious)
3. nausea and Vomiting
4. Dyspepsia and dysphasia
5. palpable epigastric mass
6. Hepatomegaly, jaundice and ascites
7. Enlarged supraclavicular nodes
8. epigastric pain
109
What investigations might you do in someone who you suspect has gastric cancer?
1. gastroscopy - biopsy
2. endoscopic USS - depth of invasion
3. CT /MRI /PET
110
What is the advantage of doing a laparoscopy in someone with gastric cancer?
It can detect metastatic disease that may not be detected on USS/endoscopy
111
what is the management for gastric cancer?
Nutritional support
Surgical resection
Chemo
112
what are the red flag signs for upper GI cancer?
For people with an upper abdominal mass consistent with stomach cancer:
- Dysphagia of any age
- Aged ≥ 55yr + weight loss with any of the following:
- Upper abdominal pain/(or)
- Reflux/ (or)
- Dyspepsia
113
What vitamin supplement will a patient need following gastrectomy?
They will be deficiency in intrinsic factor so will need vitamin B12 supplements to prevent pernicious anaemia
114
Give 3 causes of appendicitis
1. Faecolith
2. Lymphoid hyperplasia
3. Filarial worms
115
Describe the pathophysiology of appendicitis
Lumen of appendix is obstructed --> invasion of gut organism into appendix wall --> inflammation
- if the appendix ruptures, faecal matter will enter the peritoneum resulting in peritonitis
116
Give 4 symptoms of appendicitis
1. Right sided pain located at McBurneys point
2. Anorexia
3. Nausea and vomiting
4. Constipation
5. Tenderness with guarding and rebound
6. Tachycardia
117
What investigations might be done in a patient you suspect has appendicitis?
- Blood tests = raised WCC,
- CRP, ESR
- USS
- CT - gold standard
118
What is the treatment for appendicitis?
- Appendicectomy
| - IV antibiotics pre-op
119
Give 2 complications of appendicitis
1. Ruptured appendix --> peritonitis
2. Appendix mass
3. Appendix abscess
120
Who is most likely to be affected by diverticular disease?
Patients over 50 and those with low fibre diets
121
Describe the pathophysiology of diverticulitis
Out-pouching of bowel mucosa --> faeces can get trapped here and obstruct the diverticula --> abscess and inflammation --> diverticulitis
122
What part of the bowel is most likely to be affected by diverticulitis?
sigmoid colon - smallest luminal diameter and highest pressure
also descending colon
123
What is acute diverticulitis?
A sudden attack of swelling in the diverticula
| Can be due to surgical causes
124
Describe the signs of acute diverticulitis
Pain in left iliac fossa region
Fever and constipation
Tachycardia
signs and symptoms similar to appendicitis but on left side
125
Give 3 causes of Gastro-oesophageal reflux disease (GORD)
1. Hiatus hernia - sliding or rolling hiatus
2. Smoking
3. Obesity
4. Alcohol
5. pregnancy
126
Describe the pathophysiology of GORD
Lower oesophageal sphincter dysfunction --> reflux of gastric contents --> oesophagitis
127
Name 3 oesophageal symptoms of GORD
1. Heartburn - retrosternal chest pain, after meals, worse when lying down, relieved by antacids
2. Bleching
3. Food/acid and water brash
4. Odynophagia - (painful swallowing)
5. Dysphagia - (difficulty swallowing)
128
Name 3 extra oesophageal symptoms of GORD
1. Nocturnal asthma
2. Chronic cough
3. Laryngitis
4. Sinusitis
129
What investigations are done for someone you suspect has GORD?
- Diagnosis can be made without investigations
- Endoscopy (if red flags)
- Barium swallow
- 24hr oesophageal pH monitoring
130
What is the treatment of GORD?
conservative
- stop smoking
- stop alcohol
- lose weight
- change sleep position
medical
- PPI (omeprazole)
- H2 receptor antagonist (ranitidine)
surgical
- nissen fundoplication
131
Give an example of a functional bowel disorder
IBS
132
Describe the multi-factorial pathophysiology of IBS
The following factors can all contribute to IBS:
- Psychological morbidity
- trauma in early life
- Abnormal gut motility
- Genetics
- Altered gut signalling (visceral hypersensitivity)
133
Give 3 symptoms of IBS
1. Abdominal pain
2. Bloating
3. Change in bowel habit
4. Mucus
5. Fatigue
6. Backache
134
Give an example of a differential diagnosis for IBS
1. Coeliac disease
2. Lactose intolerance
3. Bile acid malabsorption
4. IBD
5. Colorectal cancer
135
What investigations might you do in someone who you suspect has IBS?
Rule out differentials
1. Bloods - FBC, U+E, LFT
2. CRP
3. Coeliac serology
4. Colonoscopy
136
Describe the non pharmacological treatment of IBS
Education
Resistance
Dietary modification - reduce caffeine, plenty of fluids, increase fibre intake
137
Describe the pharmacological treatment of IBS
1. Antispasmoidics for bloating - mebeverine, buscopan
2. Laxatives for constipation - Senna, Movicol
3. Anti-motility agent for diarrhoea - loperamide
4. Tricyclic antidepressants
138
Which of the following is FALSE regarding colorectal cancer?
a. Bowel cancer screening is offered to people aged 65 or over
b. The majority of cancers occur in the proximal colon
c. FAP and HNPCC are 2 inherited causes of colon cancer
d. Proximal cancers usually have a worse prognosis
e. Patients with PSC and UC have an increased risk of developing colon cancer
b. The majority of cancers occur in the proximal colon
139
A 50-year-old man presents with dysphagia. Which one of the following suggest a benign nature of his disease?
a. Weight loss
b. Dysphagia to solids initially then both solids and liquids
c. Dysphagia to solids and liquids occurring form the start
d. Anaemia
e. Recent onset of symptoms
c. Dysphagia to solids and liquids occurring form the start
140
A 19-year-old girl presents with abdominal pain and loose stool. Which of the features suggest that she has irritable bowel syndrome?
a. Anaemia
b. Nocturnal diarrhoea
c. Weight loss
d. Blood in stool
e. Abdominal pain relieved by defecation
e. Abdominal pain relieved by defecation
141
Which statement is true regarding H. pylori?
a. It is a gram-positive bacterium
b. HP prevalence is similar in developing and developed countries
c. 15% of patients with a duodenal ulcer are infected with H. pylori
d. PPIs should be stopped 1 week before a H. pylori stool antigen test
e. It is associated with an increased risk of gastric cancer
e. It is associated with an increased risk of gastric cancer
142
A 56-year-old man presents with abdominal distension and shortness of breath. Examination revealed fever of 38C, a tense distended abdomen with shifting dullness. He also has dullness to percussion in the right lung base. Several spider naevi are seen on his chest. Which is the most important test in the management of this patient?
a. CXR
b. USS abdomen
c. Echocardiogram
d. Ascitic tap
d. Ascitic tap
143
Which of the following features best distinguishes Ulcerative colitis from Crohn’s disease?
a. Ileal involvement
b. Continuous colonic involvement
c. Non-caseating granuloma
d. Transmural inflammation
e. Perianal disease
b. Continuous colonic involvement
144
A 68-year-old lady presents with abdominal pain and distention. She last opened her bowels 5 days ago. She has a poor appetite and has lost some weight recently. Her PMH includes an abdominal hysterectomy and diverticulosis. She drinks 20 units of alcohol a week and smokes 5 a day. Examination reveals a distended abdomen with tympanic percussion throughout. There is a small left groin lump with a cough impulse. Which one of the following is NOT likely to be the cause of her abdominal pain and distention?
a. Colon cancer
b. Adhesions
c. Ascites
d. Diverticulitis
e. Strangled hernia
c. Ascites
145
A patient drinks 4 pints (567ml = 1 pint) of beer (4%) a day, and 2 standard (175ml) glasses of red wine (13%) on Saturday and Sunday additionally. How many units of alcohol is he drinking per week?
a. 73 units
b. 62 units
c. 94 units
d. 57 units
e. 49 units
a. 73 units
| Alcohol unit = strength of the drink (%ABV) x amount of liquids in mls / 1000
146
A 71-year-old man was admitted to hospital with pneumonia after he returned from a cruise holiday in the Mediterranean Sea. He was treated with a week of augmentin (co-amoxiclav) for his pneumonia. On day 7 of his admission, he started having diarrhoea 10 times a day without any blood. He feels unwell and dehydrated. He had a flexible sigmoidoscopy which showed this. What is the likely organism responsible for his diarrhoea?
a. Norovirus
b. Escherichia coli
c. Giardia lamblia
d. Clostridium difficile
e. Salmonella enteritidis
d. Clostridium difficile
147
A 52-year-old lady presents with fatigue and itching. She noticed pale stool and dark urine. She suffers from hypercholesterolaemia and rheumatoid arthritis. She takes simvastatin and cocodamol. Examination revealed jaundice, xanthelasma, spider naevi, and hepatomegaly. Her bloods showed Bili 150, ALP 988, ALT 80, positive AMA and a raised IgM. What is the most likely diagnosis?
a. Simvastatin induced liver injury
b. Primary biliary cirrhosis
c. Gallstones
d. Autoimmune hepatitis
e. Primary sclerosing cholangitis
b. Primary biliary cirrhosis
148
A 16-year-old girl is admitted with vomiting and abdominal pain. She reports taking 20 paracetamol tablets after her boyfriend split up with her. Which one of the following test results would you NOT expect to see?
a. A metabolic acidosis
b. A prolonged prothrombin time
c. A raised creatinine
d. Hyperglycaemia
e. ALT 1000
d. Hyperglycaemia
149
A 68-year-old unkempt and malnourished homeless man was brought to the hospital with haematemesis. Endoscopy found bleeding varices. Subsequent USS showed a coarse shrunken liver. On day 2 admission he was found to be ataxic, confused with nystagmus. What is the most likely cause of his neurological presentation?
a. Alcohol toxicity
b. Alcohol withdrawal
c. Delirium tremens
d. Wernicke’s encephalopathy
e. Korsakoff syndrome
d. Wernicke’s encephalopathy
150
A 23-year-old man was brought in at 2am with RIF pain and was diagnosed with acute appendicitis. He was stable and was scheduled for appendicectomy in the morning. During the ward round, he acutely deteriorated. He was immediately brought to theatre for a perforated appendix. What clinical signs would you NOT expect to see?
a. Fever
b. Bowel sounds
c. Tachycardia
d. Rebound tenderness
e. Guarding
b. Bowel sounds
151
Which antibody is associated with coeliac disease?
a. Anti-ds-DNA
b. Anti-phospholipid
c. ANCA
d. Alpha gliadin
e. Rheumatoid factor
What are the other antibodies associated with?
d. Alpha gliadin = coeliac
a. Anti-ds-DNA = SLE
b. Anti-phospholipid = Anti phospholipid syndrome
c. ANCA = small vessel vasculitis
d. Alpha gliadin = coeliac
e. Rheumatoid factor = RA
152
Jenny’s been non-stop to the loo and has recently been diagnosed with IBS using the Rome III criteria. She’s tried out a low FODMAP diet, but her diarrhoea won’t budge. Which of the following drug sis the most appropriate pharmacological intervention for this patient?
a. Ferrous sulphate
b. Loperamide
c. Methotrexate
d. Metronidazole
e. Omeprazole
What are the other types of medication?
b. Loperamide = anti-diarrhoeal, anti-motilitica.
```
Ferrous sulphate = iron supplement
Loperamide = anti-diarrhoeal, anti-motilitic
Methotrexate = DMARDs
Metronidazole = Antibiotic
Omeprazole = PPI
```
153
A 34-year-old South African patient presents to A&E with severe pain in his left iliac abdominal region. He describes hat the pain has come on suddenly and since its onset he has not been able to pass stool. He has had no previous abdominal surgery, is a non-smoker and his tissue transglutamase results are negative. What is the most likely diagnosis?
a. Coeliac
b. Colorectal cancer
c. Large bowel obstruction – volvulus
d. Small bowel obstruction – adhesion
e. Strangulation hernia
c. Large bowel obstruction – volvulus
154
Which if the following is not a feature of Crohns disease?
a. Mouth ulcers
b. Mucosal inflammation
c. Granulomatous skip lesion
d. Raised CRP levels
e. Smoking decreased the risk of the disease
e. Smoking decreased the risk of the disease
| Protective in UC
155
Which indicates IBD not IBS?
a. Smelly stool
b. DXA scan revealing decreased bone mineral density
c. Nocturnal diarrhoea
d. Abdominal cramps
e. Feeling fatigued
c. Nocturnal diarrhoea
156
Which 2 of the following statements about ascending cholangitis are false?
a. Caused by bacterial infection of biliary tree
b. Patients experience epigastric pain
c. Patients present with temperature
d. Patients present with yellowing of the skin and sclera
e. Murphy’s sign is negative
b. Patients experience epigastric pain
| e. Murphy’s sign is negative
157
What is the cystic artery a branch of?
a. Coeliac trunk
b. Gastroduodenal artery
c. Last gastroepiploic artery
d. Right hepatic artery
e. Splenic artery
d. Right hepatic artery
158
Haemochromatosis is a metabolic liver disease caused by uncontrolled intestinal absorption of which ion?
a. Ca2+
b. Cu2+
c. Fe2+
d. Li+
e. K+
c. Fe2+
159
H. pylori eradication = PPI and 2 antibiotics. Which antibiotics?
a. Amoxicillin and clarithromycin
b. Doxycycline and metronidazole
c. Ethambutol and trimethoprim
d. Lithium and clarithromycin
e. Rifampicin and amoxicillin
a. Amoxicillin and clarithromycin
160
what are the microscopic features of crohns disease?
- transmural inflammation
- granulomas
- increase in inflammatory cells
- goblet cells
- less crypt abscesses
161
what is the epidemiology of crohns disease?
- highest incidence and prevalence in Northern Europe, UK and N America
- lower incidence than UC
- female>male
- 1/5 have 1st degree relative with disease
- present mostly 20-40 yrs old
162
what are the risk factors for crohn's disease?
- genetic association - mutation on NOD2 (CARD15) gene on chromosome 16
- smoking
- NSAIDs
- family history
- chronic stress and depression
- good hygiene
- appendicectomy
163
what are the macroscopic features of ulcerative colitis?
- affect the colon only
- begins in rectum and extends proximally
- continuous involvement - no skip lesions
- red mucosa that bleeds easily (friability)
- ulcers and pseudo-polyps in severe disease
164
what are the risk factors for ulcerative colitis?
- family history
- NSAIDs
- chronic stress and depression
165
what is the epidemiology of ulcerative colitis?
- highest prevalence in Northern Europe, UK and N America
- higher incidence than Crohn's
- Male = females
- present 15-30yrs
- 3x more common in non-smokers/ex-smokers
- 1 in 6 will have 1st degree relative with UC
166
what are the different types of ulcerative colitis?
- proctitis = just affects rectum
- left-sided colitis = rectum and left colon
- pancolitis = affects entire colon up to ileocecal valve
167
what are the risk factors for coeliac disease?
- HLA DQ2/DQ8
- other autoimmune diseases e.g. T1DM, thyroid disease, Sjogren's
- IgA deficiency
- breast feeding
- age of introduction to gluten into diet
- rotavirus infection in infancy
168
what is the epidemiology of coeliac disease?
- 1% of population affected- peaks in infancy, and 50-60 years
- 10% risk in 1st degree relatives and 30% risk in siblings
169
what are the risk factors for oesophageal cancer?
ABCDEF
- Achalasia
- Barret's oesophagus
- Corrosive oesophagitis
- Diverticulitis
- oEsophageal web
- Familial
170
what are the causes of adenocarcinoma of the oesophagus?
- smoking
- tobacco
- GORD
- obesity - increases reflux
171
what is the epidemiology of oesophageal cancer?
- 6th most common cancer worldwide
- mainly occurs 60-70yrs
- poor prognosis (10% 5yr survival)
- squamous = 5-10 per 100,000 in UK
- male>female- incidence increasing in western world
172
what is the epidemiology of appendicitis?
- most common surgical emergency
- males>females
- high incidence 10-20yrs
- rare before age of 2
- should be considered for all RHS pain if appendix is present
173
what are the complications of GORD?
- peptic stricture
| - barrett's oesophagus
174
how is intestinal obstruction classified?
- according to site
- extent of luminal obstruction
- according to mechanism
- according to pathology
175
what is a mallory-weiss tear?
a linear mucosal tear occurring at the gastroesophageal junction
176
when do mallory-weiss tears happen?
- produced by a sudden increase in intra-abdominal pressure
| - follows a bout of coughing or retching - classically seen after alcoholic dry heaves
177
what is the epidemiology of mallory-weiss tears?
- most common in males
| - mainly 20-50 years old
178
what are the risk factors for mallory weiss tears?
- alcoholism
- forceful vomiting
- eating disorders
- NSAID abuse
- male
- chronic cough
179
what are the clinical features of mallory-weiss tears?
- vomiting
- haematemesis after vomiting
- retching
- postural hypotension
- dizziness
180
what are the investigations for mallory-weiss tears?
Rockall score (assess blood loss: <3 = low risk)
FBC, U&E, coag studies, group & save
ECG & cardiac enzymes
endoscopy to confirm tear
181
what is the treatment for mallory weiss tears?
- ABCDE
- Terlipressin + Urgent Endoscopy
- Rockall Score + Inpatient Observation
- Banding/clipping, adrenaline, thermocoag
182
what are oesophageal varices?
Abnormal, enlarged veins in the oesophagus, that develop when normal blood flow to the liver is blocked by a clot / scar tissue
183
where do varices tend to occur?
- gastroesophageal junction
- rectum
- left renal vein
- diaphragm
- anterior abdominal wall
184
when do gastroesophageal varices tend to rupture?
when blood pressure in portal vein exceeds 12mmHg
185
what is the epidemiology of gastroesophageal varices?
- 90% of patients with cirrhosis develop varices over 10 years - 1/3 will bleed
- bleeding likely in large varices
- varices tend to develop in lower oesophagus and gastric cardia
186
what are the main causes of gastroesophageal varices?
- alcoholism
- viral cirrhosis
- portal hypertension
187
what are the risk factors for gastroesophageal varices?
- cirrhosis
- portal hypertension
- schistosomiasis infection
- alcoholism
188
what is the pathophysiology of gastroesophageal varices?
- liver injury causes increased resistance to flow -> portal hypertension
- hyperdynamic circulation -> formation of collaterals between portal and systemic systems
- pressure >10mmHg start to bleed (rupture >12mmHg)
189
what is the clinical presentation of gastroesophageal varices?
- haematemesis/melena
- abdominal pain (epigastric)
- shock (if major blood loss)
- fresh rectal bleeding
- hypotension and tachycardia
- pallor
- splenomegaly
- ascites
- hyponatraemia
- signs of chronic liver damage (jaundice, increased bruising)
190
what investigations should be undertaken for gastroesophageal varices?
1. Urgent endoscopy
2. FBC, U&E, clotting (INR), LFTs, group & save
3. CXR / ascitic tap / further Ix for PHT
191
what is the treatment for gastroesophageal varices?
- ABCDE
- Rockfall Score (Prediction of Rebleeding and Mortality)
- Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
- Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
192
how can gastroesophageal varices be prevented?
- PROPRANOLOL - reduce resting pulse rate to decrease portal pressure
- variceal banding
- liver transplant
193
what is IBS?
a mixed group of abdominal symptoms for which no organic cause can be found
194
what is the epidemiology of IBS?
- age of onset is under 40
- females>males
- 1/5 western world experience symptoms
195
what are the 3 different types of IBS?
- IBS-C with constipation
- IBS-D with diarrhoea
- IBS-M with constipation and diarrhoea
196
what are the risk factors for IBS?
- previous severe diarrhoea
- female
- high hypochondriac anxiety and neurotic score at time of illness
197
what are the causes of IBS?
```
depression,
anxiety,
stress,
trauma,
abuse
GI infection
eating disorders
```
198
what is the pathophysiology of IBS?
dysfunction in brain-gut axis results in disorder of intestinal mobility and/or enhanced perception
199
what are the extra-intestinal symptoms of IBS?
- painful periods
- urinary frequency, urgency, nocturia, incomplete bladder emptying
- back pain and joint hypermobility
- fatigue
200
what is the clinical presentation of IBS?
ABC
- A = abdominal pain/discomfort - relieved by defecation
- B = bloating
- C = change in bowel habit
2 or more of following
- urgency
- incomplete evacuation
- abdominal bloating/distention
- mucous in stool
- worsening of symptoms after food
201
what are the red flag symptoms for GI cancers?
- unexplained weight loss
- PR bleeding/blood in stool
- family history of bowel or ovarian cancer
202
what investigations should be undertaken for IBS?
diagnosis is made by ruling out differentials
- bloods
- FBC
- ESR and CRP
- coeliac serology
- faecal calprotectin
- colonoscopy
203
what is the rome III diagnostic criteria for IBS?
- recurrent abdominal pain at least 3 days a month in last 3 months
- associated with 2 of following:
- onset associated with change in frequency of stool
- onset associated with change in form (appearance) of stool
204
what is the management of IBS?
- dietary/lifestyle modification = avoid alcohol, caffeine and fizzy drinks, small frequent meals, FODMAP diet
- antispasmodics - MEBERVERINE or BUSCOPAN
- laxatives - MOVICOL
- antimotility agents - LOPERAMIDE
- if no better try tricyclic antidepressants AMITRIPTYLINE - warn about drowsiness
205
what should be considered if you see atrial fibrillation and abdominal pain?
mesenteric ischaemia
206
what is the definition of acute diarrhoea?
diarrhoea lasting less than 2 weeks
207
what is the definition of chronic diarrhoea?
diarrhoea lasting more than 2 weeks
208
what are the causes of diarrhoea?
- viral (majority)
- in children = rotavirus
- in adults = norovirus
- bacterial
- Campylobacter jejuni
- E.coli
- Salmonella
- Shigella
- parasitic
- Giardia lamblia
- Entamoeba histolyitca
- Cryptosporidium
209
what is the management for diarrhoea?
- treat underlying causes
- bacterial treated with METRONIDAZOLE- oral rehydration therapy
- anti-emetics - METOCLOPRAMIDE
- anti-motility agents - LOPERAMIDE
210
what are the effects of helicobacter pylori?
- inflammation
- antral gastritis
- gastric cancer
- peptic ulcers
211
what is the treatment for helicobacter pylori infection?
triple therapy
- PPI - LANSOPRAZOLE / OMEPRAZOLE
- 2 of the following: METRONIDAZOLE, CLARITHROMYCIN , AMOXICILLIN, TETRACYCLINE, BISMUTH
212
what are the investigations for H.pylori infection?
urea breath test
| stool antigen test
213
what is the epidemiology of gastric cancer?
● 4th most common cancer worldwide
● Second leading cause of cancer-related mortality
● Incidence increases with age
● Men > women
● More common in Japan and Chile, less common in USA
● 10% 5yr survival
214
what is lynch syndrome?
hereditary non-polyposis colon cancer
autosomal dominant condition caused by mutation in hMSH1 or hMSH2 genes, in highly repeated short DNA sequences
215
what is the effect of lynch syndrome?
polyps form in the colon and rapidly progress to colon cancer
216
what is diverticulosis?
presence of diverticulum
217
what is diverticular disease?
diverticula are symptomatic
218
what is diverticulitis?
inflammation of diverticulum
219
what is the clinical presentation of diverticulitis?
- febrile
- tachycardia
- tenderness, guarding and rigidity on left side
- palpable tender mass sometimes felt in left iliac fossa
220
what are the investigations for diverticulitis?
Bloods - Raised WCC, ESR & CRP
Pregnancy test in women of childbearing age
Stool culture
Imaging - Erect CXR, AXR and CT
```
Imaging May Show
Pneumoperitoneum
Dilated Bowel Loops
Obstruction
Abscess
```
221
what is the management for diverticulitis?
Oral/IV Abx - Ciprofloxacin, Metronidazole
Analgesia + liquid diet +/- fluid resus
Surgical Resection - Rare Cases
222
what are the complications of diverticulitis?
```
● Perforation
● Fistula formation into the bladder or vagina
● Intestinal obstruction
● Bleeding
● Mucosal inflammation
```
223
what are the clinical features of volvulus?
consistent with bowel obstruction (absolute constipation and distention)
Comes on extremely quickly
Rarely nausea and vomiting
224
what are the investigations for volvulus?
abdominal XR - coffee bean sign
225
what is the management for volvulus?
rigid sigmoidoscopy and rectal tube
226
what are the biliary complications of crohns disease vs ulcerative colitis?
crohn's = gallstones
ulcerative colitis = primary sclerosing cholangitis
227
what is the appearance of crohn's and colitis on X rays?
crohn's = string appearance
colitis = lead-pipe sign
228
what are the causes of actue mesenteric ischaemia?
thrombus
embolism
non-occlusive
229
what are the investigations for acute mesenteric ischaemia?
ABG - raised lactate and acidosis
angiography, doppler ultrasound
CT with contrast
230
what is the physiology of swallowing?
Tongue presses against hard palate and forces hard bolus of food into oropharynx
Tongue blocks off mouth and larynx and uvula rise to prevent food from entering lungs
Upper oesophageal sphincter relaxes allowing food to enter oesophagus
Constrictor muscles of the pharynx contract forcing food down
Food moves down by peristalsis
Gastroesophageal sphincter surrounding cardiac orifice opens and food enters stomach
231
what are the causes of dysphagia?
Disease of mouth and tongue - tonsillitis
Neuromuscular disorders - bulbar palsy, myasthenia gravis
Esophageal motility - achalasia, scleroderma, DM
Extrinsic pressure - goitre, mediastinal glands
Intrinsic lesion - stricture, pharyngeal pouch
232
what is achalasia?
Failure of esophageal smooth muscle to relax resulting in LOS remaining closed
233
what are the clinical features of achalasia?
Dysphagia of liquids and solids - solids more than liquids
regurgitation more than reflux
no apparent underlying cause
234
where do pharyngeal pouches occur?
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
235
what is barrett's oesophagus?
Metaplasia of the lower esophageal mucosa (stratified squamous to columnar epithelium with goblet cells)
236
what are the causes/ risk factors of barrett's oesophagus?
```
GORD,
Male (7:1),
caucasian,
FHx,
Hiatus hernia,
Obesity,
Smoking,
Alcohol
```
237
what are the clinical features of barrett's oesophagus?
Classic history: middle aged caucasian male with long history GORD & dysphagia
238
what are the investigations for barrett's oesophagus?
OGD + biopsy
239
what is the management for barrett's oesophagus?
- Lifestyle: weight loss, smoking cessation, reduce alcohol, small reg meals, avoid hot drinks/alcohol/eating <3hrs before bed, avoid certain drugs (nitrates, anticholinergics, TCAs, NSAIDs, K+ salts, alendronate)
Endoscopic Surveillance with Biopsies
High Dose PPI
Dysplasia - Endoscopic Mucosal Resection, Radiofrequency Ablation
Severe: oesophagectomy
240
which are the most common types of oesophageal cancer in the developing and developed world?
developing = squamous cell carcinoma
developed = adenocarcinoma
241
where is adenocarcinoma of the oesophagus found?
lower 1/3 - near GO junction
242
where is squamous cell carcinoma of the oesophagus found?
upper 2/3
243
what are the red flag symptoms for GORD that requires further investigation?
```
Dysphagia (difficulty swallowing)
> 55yrs
Weight loss
Epigastric pain / reflux
Treatment resistant dyspepsia
Nausea and vomiting
Anaemia
Raised platelets
```
244
what is the difference in presentation of gastric ulcers vs duodenal ulcers?
gastric ulcers = epigastric pain worse after eating, eased by antacids. haematemesis, weight loss, heart burn
duodenal ulcers = epigastric pain before meals and at night, relieved by eating or milk. melaena, weight gain
245
which drugs can cause gastric/duodenal ulcers?
NSAIDS
SSRI
corticosteroids
bisphosphonates
246
what are the causes/risk factors of gastritis?
```
autoimmune disease
H.pylori
bile reflux
NSAIDS
stress
```
247
what is meckel's diverticulum?
Common Congenital Abnormality of GI Tract
248
what will imaging show in diverticulitis?
```
Imaging May Show
Pneumoperitoneum
Dilated Bowel Loops
Obstruction
Abscess
```
249
what are the causes/risk factors of diverticular disease?
low fibre diet
obesity
age >40
250
what is the clinical presentation of diverticular disease?
Altered Bowel Habit
Abdominal Pain
Bleeding PR
251
what are the investigations for diverticular disease?
CT (Acute)
| Colonoscopy
252
what is the management for diverticular disease?
High Fibre Diet and Fluids +/- Laxatives
| Surgery
253
what are the 2 different types of gastric cancer?
type 1 = intestinal / differentiated (70-80%) - found in antrum and lesser curvature
type 2 = diffuse / undifferentiated (20%) - found elsewhere
254
what are the following features for crohns and ulcerative colitis?
- location
- inflammatory pattern
- layers affected
- granuloma
- crypt abscesses
- goblet cells
location
- crohns = any part of GI tract
- UC = colon only
inflammatory pattern
- crohns = skip lesions (cobblestone appearance)
- UC = continuous
layers affected
- crohns = transmural
- UC = mucosal
granulomas
- crohns = granulomas
- UC = no gramulomas
crypt abscesses
- crohns = present
- UC = present
goblet cells
- crohns = present
- UC = depletion
255
what are the non-infectious causes of diarrhoea?
IBS
IBD - crohns, ulcerative colitis
bowel cancer
256
what are the causes of diarrhoea that are not related to disease or infection?
- stress
- medication related
- toxin ingestion
257
which HLA is associated with coeliac disease?
HLA DQ2/DQ8
258
what is the difference in presentation of internal and external haemorrhoids?
internal = painless bleeding with bowel movements
external = pain and discomfort
259
what is the prevention for diverticulitis?
Regular exercise, avoid smoking, high-fibre diet, drink plenty of water
260
what is the clinical presentation of c.diff?
- watery diarrhoea with mucus/blood
- abdominal distention, cramps
- malaise
- fever
261
what is the treatment for c.diff?
1st line = vancomycin orally for 10 days
262
what is a pilonidal sinus?
abnormal pocket in the skin near the tailbone containing hair and skin debris
263
what is mesenteric ischaemia?
narrowed/blocked arteries restrict blood flow to small intestine
264
what is ischaemic colitis?
temporary restriction of blood supply to the large intestine due to vasoconstriction or low pressure flow
265
what are the risk factors for ischaemic colitis?
- age >60
- sex F>M
- factor V Leiden
- high cholesterol
- reduced blood flow - HF, low BP, shock, DM, RA
- previous abdominal surgery
- heavy exercise
- surgery on aorta
266
what are the complications of ischaemic colitis?
- sepsis
- bowel necrosis
- death
- fear of eating
- unintentional weight loss
267
what are the investigations for ischaemic colitis?
CT abdomen - rule out IBD
colonoscopy
stool culture
268
how would you treat mesenteric ischaemia?
surgical - stent
269
how would you treat ischaemic colitis?
- bowel resection due to necrosis
| - surgically repair hole
270
what causes dark stools in oesophageal varices?
The bleeding varices can result in swallowing large amounts of blood, which causes black, tarry stools
also known as melaena
