GI

Question 1

what is proctitis

Answer 1

where inflammation is limited to the rectum

Question 2

microscopic aetiology of UC

Answer 2

involves only the mucosa
formation of crypt abscesses and a coexisting depletion of goblet mucin cells (they secrete mucin and create protective mucus layer)

Question 3

2 classifications of UC

Answer 3

left sided colitis -> inflammation up to the splenic flexure
extensive colitis -> inflammation beyond the splenic flexure

Question 4

Key diagnostic factors of UC

Answer 4

Presence of risk factors (FH of IBD, being HLA-B27 positive)
Rectal bleeding
Diarrhoea
Blood in stool

Other diagnostic factors:
abdominal pain
arthritis
malnutrition
abdominal tenderness

Question 5

Describe mild UC rectal bleeding

Answer 5

confined to the rectum (proctitis) or rectosigmoid (distal colitis) area, often have insidious presentation with intermittent rectal bleeding associated with the passage of mucus and development of diarrhoea with <4 loose stools a day

Question 6

what is tenesmus

Answer 6

feeling like you need to pass stools although your bowel is empty

Question 7

First order investigations for UC

Answer 7

• Stool studies for infective pathogens
  
  • Look for infective cause as patients with IBD are higher risk of infection
  • Result → Negative culture and C. diff toxins A and B; WBC present
• Faecal calprotectin
  
  • Elevated if there is bowel inflammation and correlates with endoscopic and histological gradings of disease severity
• FBC
  
  • May show leukocytosis, thrombocytosis and anaemia
    
    • Leuko → because of inflammation
    • Anaemia → because of bleeding
• Comprehensive metabolic panel (including LFTs)
  
  • LFTs should be checked every 6-12 months to check for primary sclerosing cholangitis
  • Result → hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, aspartate aminotransferase; hypoalbuminaemia
  • Inflammation reduces the absorption of sodium, chloride, and calcium
• ESR
  
  • Variable degree of elevation (>30mm/hour is suggestive of a severe flare up)
• CRP
  
  • Persistently raised CRP > 45mg/L during a severe flare up and following 3 days of IV hydrocortisone suggests that unless treatment is changed, surgery may be necessary
• Plain abdominal radiograph
  
  • Ulcerated colon usually contains no solid faeces
  • Result → dilated loops of air-fluid secondary to ileus; free air is consistent with perforation
• Flexible sigmoidoscopy
  
  • does not require sedation
  • Can be done during surgery
  • Findings → same as in colonoscopy, examination is limited to distal colon
• Colonoscopy
  
  • Requires full bowel preparation and sedation
  • Used in patients with UC who are not responding well to treatment to rule out infections and to evaluate need for surgery
  • result → rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum
• Biopsies

Question 8

Some differentials to consider with someone presenting with UC

Answer 8

• Crohns disease
  
  • Similar signs and symptoms to those with UC
  • Often has perianal involvement, rectal sparing, and a tendency to form fistulae
  • Investigations → distinguished from UC by inflammation that extends deep to the muscularis mucosal, presence of granulomata, and relative lack of depletion of goblet cells
    
    • Crohns can often affect upper GI tract including the small bowel
• Infectious colitis
  
  • History of recent exposure or travel
  • Usually self - limiting (resolves without treatment)
• Diverticulitis
  
  • Signs/symptoms → older age, fever, nausea, diarrhoea, or constipation
  • Investigations → Leukocytosis, CT scan
    → CT scan can show evidence of colitis which is different from diverticulitis→ sigmoidoscopy and barium studies are contraindicated in acute diverticulitis because of perforation
• IBS
  
  • Patients may have an normal laboratory results and normal levels of inflammatory markers
  • Endoscopy and biopsy are normal
• Mesenteric ischaemia
  
  • Older age, history of CVS disease
  • CT scan/endoscopy → typical finding of thickening of bowel wall in segmental pattern
  • Endoscopic findings → pale mucosa with petechial bleeding. Bluish haemorrhagic nodules
• Vasculitis

Question 9

Treatment of acute severe UC

Answer 9

• Hospital admission and IV corticosteroid
  
  • Plus: Supportive measures
    
    • Such as blood transfusions, fluids and electrolyte replacement
• Ciclosporin or infliximab
  
  • If patients do not respond to corticosteroid in 3 days
• Surgery
  
  • Any patient with intractable symptoms or intolerable medicine adverse side effects

Question 10

Treatment of moderate to severe UC

Answer 10

• Oral corticosteroid
  
  • Prenisolone or budesonide
• Biological agent
  
  • infliximab, (anything ending with mab)
• CONSIDER: immunomodulator
  
  • azathioprine or methotrexate
• 2nd line: Tofaitnib
• 3rd line: colectomy

Question 11

Treatment of mild UC

Answer 11

Proctitis → topical (rectal) aminosalicylate
- Mezalasine rectal

Left-sided colitis → Oral aminosalicylate and topical aminosalicylate
- consider oral budesonide

Extensive colitis → Oral aminosalicylate (mezalasine, anything ending with zine)
- Consider oral corticosteroid (prednisolone)

Question 12

Complications of UC

Answer 12

• Colorectal cancer
• Osteoporosis
  
  • Because of prolonged corticosteroid use
• Primary sclerosing cholangitis

Question 13

What is Bacillus cereus?

Answer 13

Gram positive rod
commonly associated with consumption of reheated rice contaminated with its toxin
symptomatic management is carried out

Question 14

What is Campylobacter jejuni

Answer 14

gram negative
can cause bloody diarrhoea, and treatment is usually symptomatic

Question 15

What is Escherichia coli

Answer 15

Gram negative
diarrhoea can range from mild to bloody but management is exclusively supportive

Question 16

What is Giardia lamblia

Answer 16

a parasite
causes smelly diarrhoea and cramps

Question 17

A 27-year-old man with a 3-month history of rectal bleeding and diarrhoea is referred for evaluation. Laboratory tests show mild anaemia, a slightly elevated erythrocyte sedimentation rate, and the presence of white blood cells in stool. Stool culture is negative. Colonoscopy shows continuous active inflammation with loss of vascular pattern and friability from the anal verge up to 35 cm, with a sharp cut-off. The colonic mucosa above 35 cm appears normal, as does the terminal ileum. Biopsy specimens show active chronic colitis.

Answer 17

Ulcerative colitis

Question 18

Complication of coeliac disease?
anal cancer
epilepsy
hyposplenism
pyoderma gangrenosum
toxic megacolon

Answer 18

Hyposplenism is a complication of coeliac disease. Hyposplenism is clinically significant as around 1/3 of people with coeliac disease will develop it. Patients with this complication are less equipped to combat infections, leaving them at greater risk of an overwhelming infection which may result in morbidity/mortality.

Question 19

What is an adhesion

Answer 19

Bands of scar like tissue that form between two surfaces inside the body and cause them to stick together

Question 20

What is a stricture

Answer 20

an area of narrowing in the intestine C

Question 21

A 25-year-old white man presents to his general practitioner with cramping abdominal pain for 2 days. He reports having loose stools and losing 6.8 kg over a 3-month duration. He also reports increased fatigue. On physical examination, his temperature is 37.6°C (99.6°F). Other vital signs are within normal limits. Abdomen is soft with normal bowel sounds and moderate tenderness in the right lower quadrant, without guarding or rigidity. Rectal examination is normal and the stool is guaiac positive. The rest of the examination is unremarkable.

Answer 21

Crohns disease

Question 22

A 16-year-old girl presents to emergency care with perianal pain and discharge. She reports a 2-year history of intermittent bloody diarrhoea with nocturnal symptoms. On examination, she is apyrexial with normal vital signs. Her abdomen is soft and slightly tender on palpation in the left lower quadrant. Rectal examination is difficult to perform due to pain, but an area of erythematous swelling is visible close to the anal margin, discharging watery pus from its apex. Several anal tags are also present.

Answer 22

Crohns disease

Question 23

Management of acute admission peptic ulcer disease

Answer 23

ABC approach as with any upper GI haemorrhage
IV PPI
First-line treatment is endoscopic intervention
if this fails then: urgent interventional angiography with transarterial embolisation or surgery

Question 24

Retroperitoneal structures

Answer 24

Duodenum (2nd, 3rd and 4th parts)
Ascending colon
Descending colon
Pancreas
Kidneys
Ureters
Aorta
Inferior Vena Cava

Question 25

Intraperitoneal structures

Answer 25

Stomach duodenum (1st part) Jejunum Ileum transverse colon Sigmoid colon

Question 26

Most common cause of small bowel obstructions

Answer 26

adhesions

Question 27

What would an abdominal radiograph show in bowel perforation

Answer 27

signs of penumoperitoneum classically the double wall/ Riglers sign

Question 28

What bowel obstruction is diverticular disease most likely to cause

Answer 28

large bowel obstruction

Question 29

Features of small bowel obstruction

Answer 29

diffuse, central abdominal pain nausea and vomiting (typically bilious vomiting - yellow greenish) constipation with complete obstruction and lack of flatulence abdominal distention may be apparent tinkling bowel sounds in early obstruction

Question 30

Abdominal X-ray findings in small bowel obstruction

Answer 30

usually first line in suspected small bowel obstruction distended bowel loops with fluid levels (consider dilated if >3mm diameter)

Question 31

Management of small bowel obstruction

Answer 31

Initial steps: NBM IV fluids Nasogastric tube with free drainage (some settle with conservative management but otherwise will require surgery_

Question 32

What deficiencies is coeliac disease associated with

Answer 32

iron folate B12

Question 33

First line test for coeliac disease

Answer 33

Anti-TTG anti-TTG antibodies are IgA, so if the patient has an IgA deficiency they can appear falsely low or normal. If anti-TTG levels are low or normal and IgA levels are low, we should retest the patient but with the IgG version of anti-TTG.

Question 34

what is coeliac disease

Answer 34

autoimmune condition caused by sensitivity to protein gluten

Question 35

Conditions associated with coeliac disease

Answer 35

dermatitis herpetiformis (cluster of itchy bumps that can be easily confused with acne or eczema) and autoimmune disorders (T1DM and autoimmune hepatitis) Autoimmune thyroid disease IBS

Question 36

Signs and symptoms of coeliac disease

Answer 36

-chronic or intermittent diarrhoea -failure to thrive (children) -persistent or unexplained GI symptoms including nausea and vomiting -prolonged fatigue -recurrent abdominal pain, cramping or distention -sudden or unexplained weight loss -unexplained iron-deficiency anaemia or other unspecified anaemia

Question 37

Complications of coeliac disease

Answer 37

Anaemia (iron, folate, B12) Hypersplenism osteoporosis/osteomalacia lactose intolerance sub fertility rare: oesophageal cancer, other malignancies

Question 38

What does hormone gastrin do

Answer 38

increases acid secretions by gastric parietal cells, pepsinogen and IF secretion increases gastric motility , stimulates parietal cell maturation

Question 39

Source of Gastrin hormone

Answer 39

G cells in antrum of the stomach

Question 40

Stimulus for gastrin hormone

Answer 40

distention of the stomach, vagus nerve (mediated by gastrin-releasing peptide), luminal peptides/amino acids inhibited by: low antral pH , somatostatin

Question 41

Source of CCK hormone

Answer 41

I cells in upper small intestine

Question 42

Stimulus of CCK hormone

Answer 42

partially digested proteins and triglycerides

Question 43

Action of CCK hormones

Answer 43

Increases secretion of enzyme rich fluid from pancreas contraction of the gallbladder and relaxation of the sphincter of Oddi Decreases gastric emptying Trophic effect induces satiety (feeling full)

Question 44

Source of Secretin hormone

Answer 44

S cells in upper small intestine

Question 45

Stimulus of secretin hormone

Answer 45

acidic chyme fatty acids

Question 46

Action of secretin hormone

Answer 46

Increases secretions of bicarbonate rich fluid from pancreas and hepatic duct cells decreases gastric acid secretion trophic effect on pancreatic acinar cells

Question 47

Source of VIP hormone

Answer 47

Small intestine pancreas

Question 48

Stimulus of VIP hormone

Answer 48

neural

Question 49

Action of VIP hormone

Answer 49

Stimulates secretion by pancreas and intestines Inhibits acid secretion

Question 50

Source of somatostatin

Answer 50

D cells in the pancreas and stomach

Question 51

Stimulus fo somatostatin

Answer 51

Fat bile salts glucose in the intestinal lumen

Question 52

Action of somatostatin

Answer 52

Decreases acid and pepsin secretion decreases gastrin secretion decreases pancreatic enzyme secretion decreases insulin and glucagon secretion inhibits trophic effects of gastrin stimulates gastric mucous production

Question 53

What is primary biliary cirrhosis

Answer 53

chronic liver disorder typically seen in middle aged females thought to be an autoimmune condition Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis

Question 54

Condition associations with primary biliary cirrhosis

Answer 54

Sjorgens syndrome Rheumatoid arthritis Systemic sclerosis Thyroid disease

Question 55

Clinical features of primary biliary Cirrhosis

Answer 55

Early: may be asymptomatic (raised ALP on LFTs) or fatigue, pruritus Cholestatic jaundice Hyperpigmentation especially on pressure points Around 10% have RUQ pain xanthelesma, xanthomata Also: clubbing, hepatosplenomegaly Late: may progress to liver failue

Question 56

How to diagnose PBC

Answer 56

Immunology: anti-mitochondrial antibodies (AMA) Smooth muscle antibodies raised serum IgM Imaging: Usually MRCP to exclude extra hepatic biliary obstruction

Question 57

Management of PBC

Answer 57

First line : Ursodeoxycholic acid (slows disease progression and improves symptoms) Pruritus: cholestryamine fat soluble vitamin supplements liver transplantation: If bilirubin > 100

Question 58

Complications of PBC

Answer 58

Cirrhosis -> portal hypertension -> ascites, variceal haemorrhage osteomalacia/osteoporosis 20 fold risk of hepatocellular carcinoma

Question 59

Hepatomegaly with a history of malignancy what do you think?

Answer 59

Think liver metastasis

Question 60

Common causes of hepatomegaly

Answer 60

Cirrhosis if early disease associated with a non tender firm liver (later disease the liver reduces in size) Malignancy: metastatic spread or primary hepatoma, associated with a hard irregular liver edge Right heart failure: firm, smooth, tender liver edge, may be pulsatile

Question 61

what anti-emetic do you avoid in bowel obstruction

Answer 61

metoclopramide (it promotes gastric emptying

Question 62

What is Budd-Chiari syndrome also known as

Answer 62

hepatic vein thrombosis

Question 63

Features of Budd-chiari syndrome

Answer 63

classically a triad of Abdominal pain - severe and sudden onset Ascites -> abdominal distention tender hepatomegaly

Question 64

With GI bleeds what does high urea indicate

Answer 64

indicates that its an upper GI bleed rather than a lower one

Question 65

Oesophageal causes of Upper GI bleed

Answer 65

Oesophageal varices Oesophagitis Cancer Mallory weiss tear

Question 66

Gastric causes of GI bleed

Answer 66

Gastric ulcer Gastric cancer Dieulafoy lesion Diffuse erosive gastritis

Question 67

Duodenal causes of upper GI bleed

Answer 67

Duodenal ulcer Aorto-enteric fistula

Question 68

Management of variceal bleed

Answer 68

Terlipressin and prophylactic antibiotics should be given at presentation Band litigation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Question 69

What is the blatchford score used for

Answer 69

risk scoring tool used to predict the need to treat patients presenting with upper gastrointestinal bleeding.

Question 70

What does the gastroduodenal artery supply

Answer 70

pylorus of the stomach superior part of duodenum head of the pancreas

Question 71

What does the inferior mesenteric artery supply

Answer 71

hindgut, comprising the distal third of the colon and the rectum superior to the pectinate line

Question 72

First line antibiotic in patients with C. Diff infection

Answer 72

vancomycin

Question 73

Risk factors for developing C.diff

Answer 73

Antibiotics Proton pump inhibitors

Question 74

Features of a C.diff infection

Answer 74

diarrhoea abdominal pain raised WCC (characteristic of infection)

Question 75

What is Gilbert's syndrome

Answer 75

autosomal recessive condition of defective bilirubin conjugation due to deficiency of UDP glucuronosyltransferase

Question 76

Features of Gilberts syndrome

Answer 76

Unconjugated hyperbilirubinaemia (i.e. not in urine) Jaundice only to be seen during incurrent illness, exercise or fasting

Question 77

Investigation and management of Gilberts syndrome

Answer 77

investigation -> rise in bilirubin following prolonged fasting or IV nicotinic acid No treatment required

Question 78

Strongest risk factor for development of Barrets oesophagus

Answer 78

GORD

Question 79

What is Barrets oesophagus

Answer 79

Metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium Increased risk of oesophageal adenocarcinoma 50-100 fold

Question 80

Histological features of barrets oesophagus

Answer 80

the columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border)

Question 81

Risk factors for Barrets oesophagus

Answer 81

GORD (single strongest factor) Male gender (7:1 ratio) Smoking Central obesity

Question 82

Management of Barrets oesophagus

Answer 82

Endoscopic surveillance and biopsies (every 3-5 years) High dose PPI

Question 83

What is acute pancreatitis usually due to?

Answer 83

alcohol and/or gallstones

Question 84

Features of acute pancreatitis

Answer 84

Severe epigastric pain that may radiate through to the back Vomiting is common Examination may reveal epigastric tenderness, ileus and low grade fever Periumbilical discolouration (cullens sign) and flank discolouration (grey turners sign) is described but rare

Question 85

Investigations for acute pancreatitis

Answer 85

Amylase -> raised in 75% patients >3 times the normal limit levels do not correlate with disease severity lipase -> More sensitive and specific than amylase has a longer half life so may be useful for later presentations Imaging -> U/S to asses for aetiology diagnosis can be made without if characteristic pain and amylase/lipase >3 times normal limit

Question 86

Reasons why serum amylase could be high

Answer 86

Pancreatitis Pancreatic psuedocyst mesenteric infarct perforated viscus acute cholecystitis DKA

Question 87

How to diagnose IBS

Answer 87

has had the following for the past 6 months: Abdominal pain and/or Bloating and/or Change in bowel habit

Question 88

Type A gastritis

Answer 88

Autoimmune Circulating antibodies to parietal cells, causes reduction in cell mass and hypochlorhydria loss of parietal cells = loss of intrinsic factor = B12 malabsorption Absence of antral involvement Hypochlorhydria causes elevated gastrin levels- stimulating enterochromaffin cells and adenomas may form

Question 89

Type B gastritis

Answer 89

Antral gastritis Associated with infection with helicobacter pylori infection Intestinal metaplasia may occur in stomach and require surveillance endoscopy Peptic ulceration may occur

Question 90

Reflux gastritis features

Answer 90

Bile refluxes into stomach, either post surgical or due to failure of pyloric function Histologically, evidence of chronic inflammation, and foveolar hyperplasia May respond to therapy with prokinetics

Question 91

Erosive gastritis

Answer 91

Agents disrupt the gastric mucosal barrier Most commonly due to NSAIDs and alcohol With NSAIDs the effects occur secondary to COX 1 inhibition

Question 92

Stress ulceration features

Answer 92

This occurs as a result of mucosal ischaemia during hypotension or hypovolaemia The stomach is the most sensitive organ in the GI tract to ischaemia following hypovolaemia Diffuse ulceration may occur Prophylaxis with acid lowering therapy and sucralfate may minimise complications

Question 93

Menetreirs disease features

Answer 93

Gross hypertrophy of the gastric mucosal folds, excessive mucous production and hypochlorhydria Pre malignant condition

Question 94

Risk factors for gastric cancer

Answer 94

H pylori (triggers inflammation of the mucosa -> atrophy and intestinal metaplasia Atrophic gastritis Diet (salt and salt-preserved foods, nitrates) Smoking blood group

Question 95

Features of gastric cancer

Answer 95

Abdominal pain (typically vague, epigastric pain, may present as dyspepsia) Weight loss and anorexia Nausea and vomiting Dysphagia (if cancer arises above proximal stomach) Overt upper GI bleeding (rare) If lymphatic spread then: Virchows node (left supraclavicular lymph node) and Sister Mary Joseph nodule (Periumbilical nodule)

Question 96

Investigations for gastric cancer

Answer 96

Diagnosis: endoscopy with biopsy (Signet ring cells) Staging: CT

Question 97

Management of gastric cancer

Answer 97

Surgical options depend on extent and side but: endoscopic mucosal resection partial gastrectomy total gastrectomy and chemotherapy

Question 98

GET SMASHED pneumonic for pancreatitis

Answer 98

Gallstones Ethanol Trauma Steroids Mumps Autoimmune (e.g. polyarteritis nodosa) Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Question 99

Risk factors for femoral hernias

Answer 99

Female gender and pregnancy Increasing age Increased abdominal pressure -> heavy lifting, chronic cough

Question 100

Features of a femoral hernia

Answer 100

Lump within the groin that is usually mild painful Femoral hernias are inferolateral to the pubic tubercle typically non-reducible though can be Cough impulse is normally absent because of small size of femoral ring

Question 101

Features of Crohns disease (in comparison to UC)

Answer 101

diarrhoea usually non-bloody weight loss more prominent Upper GI symptoms: mouth ulcers, perianal disease abdominal mass usually palpable in RIF

Question 102

Features of UC (in comparison to crohns)

Answer 102

Bloody diarrhoea more common Abdominal tenderness in LLQ tenesmus

Question 103

Extra intestinal manifestations of crohns disease

Answer 103

gallstones are more common secondary to reduced bile acid reabsorption (oxalate renal stones)

Question 104

Extra intestinal manifestations of UC

Answer 104

Primary sclerosing cholangitis more common

Question 105

Complications of Crohns disease

Answer 105

obstruction, fistula, colorectal cancer

Question 106

complications of UC

Answer 106

risk of colorectal cancer higher in UC than in Crohns

Question 107

Difference in pathology between Crohns and UC

Answer 107

Crohns: lesions can be seen anywhere from mouth to anus - skip lesions may be present UC : inflammation always starts at rectum and never spreads beyond ileocaecal valve (continuous disease)

Question 108

Endoscopy for Crohns

Answer 108

deep ulcers skip lesions cobble-stone appearance

Question 109

Endoscopy for UC

Answer 109

Widespread ulceration with preservation of adjacent mucosa which has appearance of polyps (pseudo polyps)

Question 110

Describe what type of bacteria C.diff is

Answer 110

gram positive anaerobic bacillus

Question 111

What is Murphys sign

Answer 111

inspiratory arrest upon palpation of RUQ

Question 112

3Fs for developing gallstones

Answer 112

Fat Female Forty

Question 113

Features of acute cholecystitis

Answer 113

RUQ pain - may radiate to right shoulder Fever and signs of systemic upset Murphys sign one examination LFTs typically normal - deranged if Mirizzi syndrome (gallstone impacted in the distal cystic duct causing extrinsic compression fo the common bile duct)

Question 114

Investigation for acute cholecystitis

Answer 114

US first line investigation

Question 115

Treatment for acute cholecystitis

Answer 115

IV antibiotics ( penicillins, cephalosporins, or fluoroquinolones.) Early laparoscopic cholecystectomy within 1 week of diagnosis

Question 116

Difference in location between femoral and inguinal hernia

Answer 116

inguinal = superior and medial to pubic tubercle femoral = inferior and lateral to pubic tubercle

Question 117

What is Oesophageal candidiasis characterised by

Answer 117

white spots in oropharynx with extension into the oesophagus

Question 118

What is oesophageal candidiasis associated with

Answer 118

broad spectrum antibiotic usage immunosuppression immunological disorders

Question 119

glasgow prognostic score used for?

Answer 119

severity of acute pancreatitis Remember PANCREAS P - PaO2 <8kpa A - Age > 55 N -Neutrophils (WBC >15) C - calcium <2 R- uRea >16 E - Enzymes (LDH>600 or AST/ALT >200) A - albumin <32 S- sugar (glucose >10)

Question 120

What is a Spontaneous bacterial peritonitis (SBP)

Answer 120

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

Question 121

Most common organism found on an ascitic fluid culture (drained from ascites) with someone who has spontaneous bacterial peritonitis (SBP)

Answer 121

E. coli

Question 122

features of spontaneous bacterial peritonitis

Answer 122

ascites abdominal pain fever

Question 123

How to diagnose spontaneous bacterial peritonitis

Answer 123

Paracentisis -> neutrophil count >250cells/ul

Question 124

Management of spontaneous bacterial peritonitis

Answer 124

IV cefotaxime

Question 125

Different types of laxatives

Answer 125

osmotic laxatives stimulant bulk-forming faecal softners

Question 126

Examples of osmotic laxatives

Answer 126

lactulose, macrogols, and rectal phosphate

Question 127

Examples of stimulant laxatives

Answer 127

Senna, docusate, bisocodyl, and glycerol co-danthramer should only be prescribed to palliative patients due to its carcinogenic potential

Question 128

Examples of bulk-forming laxatives

Answer 128

examples include ispaghula husk and methylcellulose

Question 129

Example of faecal softner laxatives

Answer 129

include arachis oil enemas not commonly prescribed

Question 130

Genetic causes of chronic pancreatitis

Answer 130

cystic fibrosis hereditary haemachromatosis

Question 131

Features of chronic pancreatitis

Answer 131

pain is typically worse 15 to 30 minutes following a meal steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin

Question 132

Investigations for chronic pancreatitis

Answer 132

abdominal x-ray shows pancreatic calcification in 30% of cases CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85% functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive

Question 133

Management of chronic pancreatitis

Answer 133

pancreatic enzyme supplements analgesia antioxidants: limited evidence base - one study suggests benefit in early disease

Question 134

What is Wilsons disease

Answer 134

Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13.

Question 135

Features of Wilsons disease

Answer 135

result from excessive copper deposition in the tissues, especially the brain, liver and cornea: Liver -> hepatitis, cirrhosis Neuro -> basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus speech, behavioural and psychiatric problems are often the first manifestations also: asterixis, chorea, dementia, parkinsonism eyes -> Kayser-Fleischer rings green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement other -> renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Question 136

Investigations for Wilsons disease

Answer 136

slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion the diagnosis is confirmed by genetic analysis of the ATP7B gene

Question 137

Management of Wilsons disease

Answer 137

penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Question 138

what does a serum-ascites albumin gradient (SAAG) > 11g/L indicate

Answer 138

indicates portal hypertension

Question 139

What area is most likely affected in ischaemic colitis

Answer 139

the splenic flexure

Question 140

Common predisposing factors in bowel ischeamia

Answer 140

-increasing age -AF(particularly for mesenteric ischamia) -Other causes of emboli: endocarditis, malignancy -CVS risk factors: smoking, HTN, diabetes -cocaine

Question 141

Common features of bowel ischaemia

Answer 141

-abdominal pain -rectal bleeding -diarrhoea -fever

Question 142

What structure does a patients bowel have to travel through to be classed as a direct inguinal hernia

Answer 142

Hesselbachs triangle

Question 143

Investigations for carcinoid tumours?

Answer 143

Urinary 5-HIAA Plasma chromogranin A y

Question 144

What is pernicious anaemia

Answer 144

an autoimmune disease caused by antibodies to intrinsic factor +/- gastric parietal cells Autoimmune destruction of gastric parietal cells take place

Question 145

What is B12 important in

Answer 145

production of blood cells and myelination of nerves -> megaloblastic anaemia and neuropathy

Question 146

Pernicious anaemia risk factors

Answer 146

-More common in females -Develops middle-old age -Autoimmune disorders: vitiligo, thyroid disease, T1DM, Addisons, rheumatoid -More common if blood group A

Question 147

Features of pernicious anaemia

Answer 147

- anaemia features: lethargy pallor dyspnoea neurological features -peripheral neuropathy: 'pins and needles', numbness. Typically symmetrical and affects the legs more than the arms subacute combined degeneration of the spinal cord: progressive weakness, ataxia and paresthesias that may progress to spasticity and paraplegia neuropsychiatric features: memory loss, poor concentration, confusion, depression, irritabiltiy -other features mild jaundice: combined with pallor results in a 'lemon tinge' glossitis → sore tongue

Question 148

Investigations for pernicious anaemia

Answer 148

FBC: -Macrocytic anaemia -Hypersegmented polymorphs on blood film -Low WCC and platelets can be seen Vit B12 and folate levels Antibodies: anti-intrinsic antibodies anti gastric parietal cell antibodies (not often used clinically)

Question 149

Management of pernicious anaemia

Answer 149

vitamin B12 replacement usually given intramuscularly no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections more frequent doses are given for patients with neurological features

Question 150

Contents of inguinal canal in men and women

Answer 150

men - spermatic cord and ilioinguinal nerve women - round ligament of uterus and ilioinguinal nerve

Question 151

sentinel lymph node of the gall bladder

Answer 151

Lunds node (cystic lymph node)

Question 152

Which artery supplies the posterior part of the stomach

Answer 152

Splenic artery

Question 153

What is the 1st part of the duodenum known for (pathologically)

Answer 153

peptic ulcers

Question 154

What can the 3rd part of the duodenum be affected by

Answer 154

by superior mesenteric artery syndrome, where the duodenum is compressed between the SMA and the aorta, often in cases of reduced body fat.

Question 155

What is the distal 1/3 of the transverse colon supplied by

Answer 155

Inferior mesenteric artery

Question 156

What does GI mucosa contain

Answer 156

muscularis mucosae lamina propia

Question 157

What does the GI muscularis externa contain

Answer 157

Auerbach's (myenteric) plexus

Question 158

Quick comparison between ascending cholangitis and biliary colic

Answer 158

ascending cholangitis -> RUQ pain, fever, jaundice Biliary colic -> female, middle-aged, episodic RUQ pain

Question 159

Infective causes of acute abdominal pain

Answer 159

gastroenteritis appendicitis diverticulitis pyelonephritis cholecystitis cholangitis pelvic inflammatory disease hepatitis pneumonia

Question 160

Inflammatory causes of acute abdominal pain

Answer 160

pancreatitis peptic ulcer disease

Question 161

Vascular causes of acute abdominal pain

Answer 161

ruptured abdominal aortic aneurysm mesenteric ischaemia myocardial infarction

Question 162

Traumatic causes of acute abdominal pain

Answer 162

ruptured spleen perforated viscus (e.g. oesophagus, stomach, bowel)

Question 163

Metabolic causes of acute abdominal pain

Answer 163

renal/ureteric stone diabetic ketoacidosis

Question 164

Describe mechanism of oemeprazole

Answer 164

Irreversible blockade of H+/K+ ATPase

Question 165

Examples of Antagonist of the P2Y12 adenosine diphosphate (ADP) receptor

Answer 165

clopidogrel prasugrel ticagrelor ticlopidine

Question 166

Foregut structures and blood supply

Answer 166

structure : mouth to proximal half of duodenum Blood supply: coeliac trunk

Question 167

Midgut structures and blood supply

Answer 167

distal half of duodenum to the splenic flexure of the colon SMA

Question 168

Hindgut structures and blood supply

Answer 168

descending colon to the rectum IMA

Question 169

What is H.Pylori

Answer 169

Gram-negative bacteria associated with a variety of GI problems, primarily peptic ulcer disease

Question 170

Associations of H Pylori

Answer 170

peptic ulcer disease 95% of duodenal ulcers 75% of gastric ulcers gastric cancer B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients) atrophic gastritis

Question 171

Management of H pylori

Answer 171

eradication may be achieved with a 7-day course of a proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole) if penicillin-allergic: a proton pump inhibitor + metronidazole + clarithromycin

Question 172

What is odynophagia

Answer 172

a painful sensation in the oesophageal region that occurs in relation to swallowing.

Question 173

Abdominal pain, rectal bleeding, metabolic acidosis in a question is most likely to indicate:

Answer 173

Mesenteric ischaemia

Question 174

What is achalasia

Answer 174

an oesophageal motor disorder characterised by a loss of oesophageal peristalsis and failure of the lower oesophageal sphincter to relax in response to swallowing.

Question 175

Clinical features of achalasia

Answer 175

-Dysphagia of BOTH liquids and solids -typically variation in severity of symptoms -Heart burn -regurgitation of food (may lead to cough, aspiration pneumonia etc.) -malignant change seen in small number of patients

Question 176

Investigations for achalasia

Answer 176

oesophageal manometry: -excessive LOS (loss of sphincter)tone which doesn't relax on swallowing -considered the most important diagnostic test barium swallow: -shows grossly expanded oesophagus, fluid level -'bird's beak' appearance chest x-ray: -wide mediastinum -fluid level

Question 177

Irreversible complications of haemachromatosis

Answer 177

Liver cirrhosis** Diabetes mellitus Hypogonadotrophic hypogonadism Arthropathy

Question 178

A 20-year-old obese woman with a 2-year history of gallstones presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea, and vomiting after eating fried chicken for dinner. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation, but no evidence of jaundice.

Answer 178

Acute cholecystitis

Question 179

A 53-year-old man with a history of hepatitis C presents with a complaint of abdominal distention, fever, vomiting, and blood in his stool. Paracentesis has improved symptoms on the numerous occasions that he has previously presented with abdominal distension.

Answer 179

Spontaneous Bacterial peritonitis

Question 180

A 46-year-old woman with a history of long-standing alcoholism and previous episodes of hepatic encephalopathy presents with altered mental status and worsening abdominal distention.

Answer 180

Spontaneous Bacterial peritonitis

Question 181

A 34-year-old man presents 2 weeks after returning from a month-long trip to India. He denies attending pre-travel vaccination clinic and did not take prophylaxis of any sort while in India. He reports a 6-day history of malaise, anorexia, abdominal pain, nausea with emesis, and dark urine. He admits to dietary indiscretion and consumed salad at a road-side vendor 3 weeks before onset of symptoms. On examination there is icterus. His alanine transaminase (ALT) is 5660 units/L, and total bilirubin 153.9 micromols/L (9 mg/dL). Serum IgM anti-hepatitis A virus antibodies are detected.

Answer 181

Hepatitis A

Question 182

A 40-year-old asymptomatic man presents for a routine visit with an elevated alanine aminotransferase level (55 IU/mL). His mother died of hepatocellular carcinoma and he has a middle-aged sister with hepatitis B infection. He has a normal physical examination and has no stigmata of chronic liver disease.

Answer 182

Hepatitis B

Question 183

A 45-year-old woman presents with insidious onset of fatigue, malaise, lethargy, anorexia, nausea, abdominal discomfort, mild pruritus, and arthralgia involving the small joints. Her past medical history includes coeliac disease. Physical examination reveals hepatomegaly and spider angiomata.

Answer 183

Autoimmune hepatitis

Question 184

A 40-year-old man with a history of alcohol-misuse is brought to the emergency department by police, who found him lying down by the side of the street. On examination he is somnolent and confused. He has a horizontal gaze palsy with impaired vestibulo-ocular reflexes and severe truncal ataxia in the presence of normal motor strength and muscle stretch reflexes.

Answer 184

Wernickes encephalopathy

Question 185

A 30-year-old woman underwent bariatric surgery for Class III (BMI ≥40) obesity. The postoperative course was complicated by a bronchopneumonia, vomiting, and poor oral intake. Four weeks after surgery she complained of vertigo and headache and soon became apathetic and developed vertical nystagmus that was worse on downward gaze.

Answer 185

Wernickes encephalopathy

Question 186

A 35-year-old man comes to the emergency department with a history of nausea, vomiting, and watery diarrhoea of 1 day's duration. The patient and his wife have just returned from a Caribbean cruise, and his wife also has mild diarrhoea. The patient denies any blood or mucus in the stool. He has chills but no fever. On examination, the patient is afebrile and anicteric, but has dry mucous membranes. His heart rate is 95 beats per minute and blood pressure (BP) is 110/70 mmHg. His abdomen is soft and non-tender, with hyperactive bowel sounds.

Answer 186

Viral Gastroentertitis

Question 187

A 70-year-old woman is brought to the emergency department from her nursing home with a history of nausea, projectile vomiting, and non-bloody diarrhoea of 1 day's duration. She also describes generalised body aches, chills, and fatigue. Her roommate in the nursing home has also had diarrhoea for 2 days. Past medical history included hypertension and coronary artery disease. BP on examination is 100/60 mmHg and heart rate is 110 beats per minute. Abdomen is non-distended and is non-tender.

Answer 187

Viral Gastroenteritis

Question 188

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by famotidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

Answer 188

Peptic ulcer disease

Question 189

A 42-year-old man presents with a recent history of abdominal pain, distension, and nausea. Urea breath testing for Helicobacter pylori is positive.

Answer 189

Gastritis

Question 190

A 58-year-old white woman of North European descent presents with a 2-month history of increasing fatigue, difficulty with ambulation, and memory deficits. Family history is notable for autoimmune disease. Laboratory findings are remarkable for a macrocytic anaemia, a markedly reduced serum vitamin B₁₂, and presence of anti-parietal cell antibodies.

Answer 190

Gastritis

Question 191

A 55-year-old man presents with severe dysphagia to solids and worsening dysphagia to liquids. His social history is significant for 40 pack-year cigarette smoking and a 6-pack of beer per day. He has lost over 10% of his body weight and currently is nourished only by milkshake supplements. He complains of some mild odynophagia and is constantly coughing up mucus secretions.

Answer 191

Oesophageal cancer

Question 192

An otherwise healthy 45-year-old male executive complains of heartburn. He has tried over-the-counter medications with no relief. He was tried on a course of proton pump inhibitors for 6 weeks, but still has heartburn. He has no weight loss or dysphagia.

Answer 192

Oesophageal cancer

Question 193

A 70-year-old man who smokes heavily presents with a 6-month history of intermittent abdominal pain and nausea. He has lost 10 kg of weight in the past 2 months, which he thinks is due to a decreased appetite, and he complains of pruritus. On physical examination there is icterus in the conjunctival sclerae and epigastric tenderness but no abdominal mass or lymphadenopathy. Blood tests demonstrate elevated bilirubin and alkaline phosphatase; the rest of the blood tests are within the normal range.

Answer 193

Pancreatic cancer

Question 194

A 45-year-old woman presents to her physician with vague upper abdominal (epigastric) pain. After treatment with proton-pump inhibitors, analgesics, and antacids over a period of 3 months, which were ineffective, the patient also started to experience back pain. This prompted an initial upper gastrointestinal endoscopy, which was normal. Nearly 4 months after initial presentation, an upper abdominal ultrasound reveals a pancreatic mass with liver metastases.

Answer 194

Pancreatic cancer

Question 195

A 51-year-old man with moderate obesity (body mass index of 34 kg/m²) is seen in consultation for heartburn and regurgitation. He has a diagnosis of gastro-oesophageal reflux disease and has been treated with proton-pump inhibitors. His heartburn is less severe with the medication, but he is still bothered by regurgitation. His physical examination is unremarkable. A barium oesophagram and upper endoscopy demonstrate a type I (sliding) hiatus hernia, with about one third of the upper stomach in the chest. The patient has free reflux to the level of the cervical oesophagus.

Answer 195

Hiatal hernia

Question 196

A 68-year-old retired labourer presents to his primary medical doctor with a 3-week history of a dull dragging discomfort in his right groin toward the end of the day. The discomfort is associated with a lump while standing but disappears when lying supine. He denies any other significant past medical or surgical history. On physical examination, a bulge is present when standing that disappears when supine.

Answer 196

Inguinal hernia

Question 197

A 6-month-old healthy girl presents with a bulge at her umbilicus that her parents have noticed since birth. She has no accompanying symptoms and has been growing and developing normally. Physical examination of the abdomen reveals a soft, non-tender bulge at the umbilicus that is easily reduced into the peritoneal cavity with gentle pressure. Reduction allows palpation of the abdominal fascia, revealing an 8 mm fascial defect.

Answer 197

Umbilical hernia

Question 198

A 48-year-old woman experiences intermittent diffuse abdominal pain, worse after eating meals. The pain has been present for the previous 6 months, but has worsened recently. She has had significant weight loss since the onset of symptoms. Her past medical history includes systemic lupus erythematosus, which has been difficult to manage medically.

Answer 198

Intestinal ischaemia

Question 199

A 54-year-old man presents with 2 days of worsening generalised abdominal pain. He is nauseated and the pain is worse after eating. He was hospitalised last month with acute pancreatitis and was found to have a splenic vein thrombus during that admission.

Answer 199

Intestinal ischaemia

Question 200

A man in his early 70s presents with acute-onset, colicky, lower abdominal pain and distension, failing to pass flatus or faeces in the preceding 12 to 24 hours. He reports a recent change in his bowel habit with increased frequency of defecation, some weight loss, and the passage of blood mixed with his stools. On examination he is generally unwell, is pyrexial, and has a distended tympanic abdomen along the distribution of the large bowel, with tenderness in the right lower quadrant. He has an empty rectum on digital rectal examination.

Answer 200

Large bowel obstruction

Question 201

A 27-year-old male presents with cramping abdominal pain of sudden onset, emesis, and failure to pass any flatus or stool for 24 hours. The patient has no history of prior surgery. Physical examination reveals peritonitis. Computed tomography reveals the level of the obstruction.

Answer 201

Small bowel obstruction

Question 202

A 43-year-old female with a prior history of open cholecystectomy presents with gradual onset of nausea, vomiting, absolute constipation, and abdominal distention. Physical examination does not demonstrate peritonitis. Computed tomography is used to confirm the diagnosis.

Answer 202

Small bowel obstruction

Question 203

A 52-year-old man undergoes an elective sigmoid resection with primary colorectal anastomosis for chronic diverticulitis. The operative course is routine. Postoperatively, he starts on a clear-liquid diet and receives morphine via patient-controlled analgesia pump. On the second postoperative day, he has a distended abdomen, is nauseated, and has not passed flatus. He vomits repeatedly and requires nasogastric decompression. CT-scan shows uniform small bowel distention and no evidence of a transition zone between dilated and collapsed bowel (a key indicator of obstruction).

Answer 203

Ileus

Question 204

A 34-year-old mother of three presents to her family physician with a 3-week history of abdominal cramping pain in both lower quadrants. She has been having frequent small, soft stools accompanied by some mucus but no blood. Her symptoms are improved with bowel movement or passage of flatus. She has had these symptoms almost monthly since she was in college, but they have been worse recently. Past history is negative except for three normal pregnancies. Family history is negative for colon cancer. A sister has similar symptoms but has not seen a physician. Personal/social history reveals that she is an accountant working long hours. Her firm is about to merge with another, and she fears her job situation is tenuous. She has not lost any weight or had any other constitutional symptoms. On physical examination, the only finding is some mild tenderness in the right lower quadrant. No mass is felt.

Answer 204

IBS

Question 205

A 40-year-old housewife complains of recurrent constipation. She has had problems since her 20s, but they are worse now. The constipation is accompanied by abdominal bloating and abdominal pain, and the discomfort is only better when she has a bowel movement. On her gynaecologist's advice, she has tried more fibre in her diet, including fresh fruits and leafy vegetables, but that has only made the bloating worse. Her past history includes a cholecystectomy and a hysterectomy. Physical examination is entirely normal. Rectal examination reveals normal consistency stool. Stool samples test negative for occult blood.

Answer 205

IBS

Question 206

A 42-year-old woman has heartburn after meals and a sour taste in her mouth. For the past 4-6 months she has had symptoms several times per week. Symptoms are worse when she lies down or bends over. Antacids help somewhat. She has no dysphagia, vomiting, abdominal pain, exertional symptoms, melaena, or weight loss. Past medical history and family history are non-contributory. The patient drinks alcohol occasionally and does not smoke. On physical examination, height is 1.63 m, weight 77.1 kg, and blood pressure 140/88 mmHg. The remainder of the examination is unremarkable.

Answer 206

GORD

Question 207

A 39-year-old woman presents with a 2-year history of gradually worsening constipation. She complains of bloating, gas, and lower abdominal discomfort with irregular bowel habits. She describes her stool as mostly sausage-shaped, hard, and lumpy. She takes metoprolol for hypertension and lansoprazole for heartburn. She has previously used senna and bisacodyl without improvement of her symptoms. She also increased her daily fibre and fluid intake without relief. Physical examination is unremarkable except for mild abdominal distension and palpable stool in the right and left lower quadrants. Perianal inspection is normal, and the anocutaneous reflex is present in all 4 quadrants. Digital rectal examination reveals a large amount of stool in the rectum. When asked to push and bear down, she shows adequate pelvic descent with normal anal relaxation.

Answer 207

Constipation

Question 208

A 50-year-old woman presents with a lifelong history of constipation that has worsened over the past 2 years. She reports decreased stool frequency and straining during defecation. She has a feeling of incomplete evacuation and admits to applying pressure over her posterior vaginal wall during defecation. She describes her stool as separate hard lumps. She has had 2 vaginal deliveries, with no known history of tears. She has had a hysterectomy and bladder suspension surgery. She has used ispaghula and milk of magnesia with limited relief. Examination is unremarkable. Her abdomen is soft and non-distended with no palpable masses. Perianal inspection is normal, and the anocutaneous reflex is present in all 4 quadrants. Digital rectal examination reveals no stool in the rectum. On digital rectal examination, resting anal tone is weak but her squeeze tone is normal. She does not relax the puborectalis muscle or the external anal sphincter when simulating defecation; she also has 2-cm perineal descent with straining.

Answer 208

Constipation

Question 209

A 56-year-old man with a remote history of intravenous drug use presents to an initial visit complaining of increased abdominal girth but denies jaundice. He drinks about 2 to 4 glasses of wine with dinner and recalls having had abnormal liver enzymes in the past. Physical examination reveals spider naevi, a palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function is found to be deranged with elevated aminotransferases (aspartate aminotransferase [AST]: 90 U/L, alanine aminotransferase [ALT]: 87 U/L), and the patient is positive for anti-hepatitis C antibody.

Answer 209

Cirrhosis

Question 210

A 60-year-old woman with a past medical history of obesity, diabetes, and dyslipidaemia is noted to have abnormal liver enzymes with elevated aminotransferases (ALT: 68 U/L, AST: 82 U/L), and normal alkaline phosphatase and bilirubin. She denies significant alcohol consumption, and tests for viral hepatitis and autoimmune markers are negative. An abdominal ultrasound reveals evidence of fatty infiltration of the liver and slight enlargement of the spleen.

Answer 210

Cirrhosis

Question 211

A 42-year-old man presents to his primary care physician complaining of a 3-month history of lower intestinal bleeding. He describes the bleeding as painless, bright blood appearing on the tissue following a bowel movement. He has had 2 episodes recently where blood was visible in the toilet bowl following defecation. He denies any abdominal pain and any family history of gastrointestinal malignancy. Physical examination reveals a healthy man with the only finding being bright blood on the examining finger following a digital rectal examination.

Answer 211

Haemorrhoids

Question 212

A 28-year-old woman presents complaining of rectal pain of 3 days' duration. She states that on the day before the onset of symptoms she had been moving boxes at her home. She describes the pain as sharp and present constantly, but worse with bowel movements or sitting. She denies any fevers or chills or perianal discharge. Physical examination reveals a 2-cm, painful, bluish lesion adjacent to the anal canal.

Answer 212

Haemorrhoids

Question 213

A 77-year-old man presents to his general practitioner with weight loss of 6.8 kg (15 lbs) and a 3-month history of dysphagia and abdominal pain. The only abnormal finding on physical examination is stools positive for occult blood. He is referred for an upper endoscopy, which shows an exophytic, ulcerated mass in the cardia of the stomach. Biopsy reveals moderately differentiated adenocarcinoma.

Answer 213

Gastric cancer

Question 214

A 46-year-old obese woman presents with a 6-hour history of moderate steady pain in the right upper quadrant (RUQ) that radiates through to her back. This pain began after eating dinner, gradually increased, and has remained constant over the last few hours. She has experienced previous episodes of similar pain for which she did not seek medical advice. Her vital signs are normal. The pertinent findings on physical examination are tenderness to palpation in the RUQ without guarding or rebound..

Answer 214

Gallstones

Question 215

A 57-year-old woman with a history of hypertension and hypercholesterolaemia presents to the accident and emergency department with a 24-hour history of gradually worsening left-lower quadrant abdominal pain associated with nausea and vomiting. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems, except slight constipation and occasional dyspepsia after heavy meals. She felt feverish but did not take her temperature. Her family history is negative for GI disorders.

Answer 215

Diverticular disease

Question 216

A 32-year-old obese, but otherwise healthy, man presents to the accident and emergency department with onset of acute lower abdominal pain of 2-hour duration. He has no fever and there is no history of any previous significant illness, except loud snoring, possible sleep apnoea, and being overweight.

Answer 216

Diverticular disease

Question 217

A 32-year-old obese, but otherwise healthy, man presents to the accident and emergency department with onset of acute lower abdominal pain of 2-hour duration. He has no fever and there is no history of any previous significant illness, except loud snoring, possible sleep apnoea, and being overweight.

Answer 217

Diverticular disease

Question 218

A 70-year-old man presents to his primary care physician with a complaint of rectal bleeding. He describes blood mixed in with the stool, and a change from his normal bowel habit as he is going more frequently than normal. He has also experienced some crampy left-sided abdominal pain and weight loss. He has previously been fit and well and there is no family history of gastrointestinal disease. Examination of his abdomen and digital rectal examination are normal.

Answer 218

Colorectal cancer

Question 219

A 46-year-old woman presents with fatigue and is found to have iron deficiency with anaemia. She has experienced intermittent episodes of mild diarrhoea for many years, previously diagnosed as irritable bowel syndrome and lactose intolerance. She has no current significant gastrointestinal symptoms such as diarrhoea, bloating, or abdominal pain. Examination reveals two oral aphthous ulcers and pallor. Abdominal examination is normal and results of faecal testing for occult blood are negative.

Answer 219

Coeliac disease

Question 220

A 9-year-old boy presents with vomiting for 5 days. His sister, who has coeliac disease, has had similar symptoms. His growth has been normal and he has not experienced any other possible symptoms of coeliac disease, except for intermittent constipation. Immunoglobulin A-tissue transglutaminase titre is 5 times the upper limit of normal.

Answer 220

Coeliac disease

Question 221

A 28-year-old woman presents with a history of severe pain on defecation for the last 3 months. She has noticed a small amount of blood on the stool. The pain is severe and she is worried about the pain she will experience with the next bowel action.

Answer 221

Anal fissure

Question 222

A 50-year-old man presents to his general practitioner with complaints of fatigue for 2 months. He also notes distension of his abdomen and shortness of breath beginning 2 weeks ago. His wife reports that the patient has been having episodes of confusion lately. The patient has a significant medical history of chronic heavy alcohol consumption of about half a pint of vodka daily for around 20 years. On physical exam the patient is noted to have scleral icterus, tremors of both hands, and spider angiomata on the chest. There is abdominal distension with presence of shifting dullness, fluid waves, and splenomegaly. Laboratory examination shows low haemoglobin, low platelets, low sodium, aspartate aminotransferase (AST) elevation > alanine aminotransferase (ALT) elevation, and high prothrombin time (PT) and international normalised ratio (INR). Ultrasound of the abdomen shows liver hyperechogenicity, portal hypertension, splenomegaly, and ascites.

Answer 222

Alcoholic liver disease

Question 223

A 38-year-old man presents to the emergency department for severe alcohol abuse with nausea and vomiting. He has a significant medical history of chronic heavy alcohol consumption of about one bottle of wine each day for about 5 years until 1 year ago; since then he has had severe intermittent binge alcohol intake. He reports no other significant medical problems. The patient is confused and slightly obtunded, and hepatomegaly is discovered on physical exam. His body mass index is 22. Pertinent positive laboratory values show low haemoglobin, AST elevation > ALT elevation, normal PT and INR, and very high serum alcohol level. Ultrasound of the abdomen shows fatty infiltration in the liver.

Answer 223

Alcoholic liver disease

Question 224

A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea, and low-grade fever. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. Physical examination reveals a low-grade fever (38°C [100.5°F]), tenderness on palpation at right lower quadrant (McBurney's sign), and leukocytosis (12 x 109/L or 12,000/microlitre) with 85% neutrophils.

Answer 224

Appendicitis

Question 225

A 12-year-old girl presents with sudden-onset severe generalised abdominal pain associated with nausea, vomiting, and diarrhoea. On examination she appears unwell and has a temperature of 40°C (104°F). Her abdomen is tense with generalised tenderness and guarding. No bowel sounds are present.

Answer 225

Appendicitis

Question 226

A 53-year-old man presents to the emergency department with severe mid-epigastric abdominal pain that radiates to the back. The pain evolved over 1 hour. He also describes nausea, vomiting, and anorexia, and gives a history of heavy alcohol intake over many years, including this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic and tender in the epigastric region with guarding and rebound tenderness.

Answer 226

Acute pancreatitis

Question 227

A 47-year-old overweight woman is admitted with generalised abdominal pain. She has been unable to eat or drink due to nausea and vomiting. She states the pain started in the right upper quadrant suddenly 6 hours ago, but is now in the epigastric region. An ultrasound obtained on her last visit to the emergency department revealed gallstones with no inflammation of the gallbladder, and she was told that she should see a surgeon. She looks jaundiced and in distress. She has point tenderness under her ribs on the right, which is worsened with deep palpation. No mass is palpable.

Answer 227

Acute pancreatitis

Question 228

A 65-year-old woman presents to the emergency department with a 2-day history of progressive right upper quadrant (RUQ) pain that she rates as 9/10. She reports experiencing fever, and being unable to eat or drink due to nausea and abdominal pain at baseline, exacerbated by food ingestion. Her bowel movements are less frequent and have become loose. Her pain is not relieved by bowel movement and is not related to food. She has not recently taken antibiotics, nor does she use non-steroidal anti-inflammatory drugs or drink alcohol. On examination, she is febrile at 39.4°C (102.9°F); supine BP is 97/58 mmHg; standing BP is 76/41 mmHg; HR is 127 bpm; and respiratory rate is 24 breaths per minute with normal oxygen saturation. Her examination is remarkable for scleral and sublingual icterus, tachycardia, RUQ pain with no rebound, and involuntary guarding on the right side. Faecal occult blood test is negative. Laboratory results show a WBC of 18.0 × 10⁹/L (18,000/microlitre) (reference range 4.8-10.8 × 10⁹/L or 4800-10,800/microlitre) with 17% (reference range 0% to 4%) bands and PMNs of 82% (reference range 35% to 70%). AST is 207 units/L (reference range 8-34 units/L), ALT is 196 units/L (reference range 7-35 units/L), alkaline phosphatase is 478 units/L (reference range 25-100 units/L), total bilirubin is 107.7 micromol/L (6.3 mg/dL) (reference range 3.4 to 22.2 micromol/L or 0.2 to 1.3 mg/dL), and amylase is 82 units/L (53-123 units/L).

Answer 228

Acute cholangitis

Question 229

Long term management for bleeding varices

Answer 229

Non-cardioselective beta-blocker (e.g. propranolol)

Question 230

Gene mutation assoicated with pancreatic cancer

Answer 230

KRAS

Question 231

RIsk factors for Barret's oesophagus

Answer 231

GORD male gender smoking central obesity

Question 232

Management of Barret's

Answer 232

endoscopic surveillance with biopsies (every 3-5 years for patients with metaplasia) high dose PPI

Question 233

Pathogenesis of acute appendicitis

Answer 233

lymphoid hyperplasia or a faecolith → obstruction of appendiceal lumen

Question 234

Courvoisiers law states what

Answer 234

states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is likely to be cholangiocarcinoma or pancreatic cancer.

Question 235

Why does HRT need to be stopped before surgery

Answer 235

Oestrogen-containing contraception (e.g., the combined contraceptive pill) or hormone replacement therapy (e.g., in perimenopausal women) need to be stopped 4 weeks before surgery to reduce the risk of venous thromboembolism (NICE guidelines 2010).

Question 236

What does Hartmann's procedure involve

Answer 236

removal of rectosigmoid colon with closure of the anorectal stump and formation of a colostomy

Question 237

What does a coffee bean sign on an abdominal xray indicate

Answer 237

sigmoid volvulus

Question 238

What are you risking if you give normal saline 0.9%

Answer 238

has a concentration of sodium of 154 mmols/L. The normal blood concentration of sodium is 135-145 mmols/L. When you use normal saline, you are adding a lot of sodium into the system, significantly increasing the risk of hypernatraemia. Normal saline also carries a risk of causing metabolic acidosis due to adding so much chloride (hyperchloraemic acidosis)

Question 239

Risk factors for post operative nausea and vomiting

Answer 239

Female History of motion sickness or previous PONV Non-smoker Use of postoperative opiates Younger age Use of volatile anaesthetics

Question 240

When wouldn't you give the anti-emetic ondansetron

Answer 240

5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval

Question 241

When wouldn't you give dexamethasone as a prophylactic anti-emetic

Answer 241

caution in diabetic or immunocompromised patients

Question 242

When wouldnt you give cyclizine as a prophylactic anti-emetic

Answer 242

(histamine (H1) receptor antagonist) – caution with heart failure and elderly patients

Question 243

What is an ileus

Answer 243

condition affecting the small bowel where the normal peristalsis temporarily stops can be called a paralytic or adynamic ileus

Question 244

Causes of ileus

Answer 244

injury to the bowel handling of the bowel during surgery Inflammation or infection in or nearby the bowel electrolyte imbalance

Question 245

What is Meckel's diverticulum

Answer 245

malformation of the distal ileum that occurs in around 2% of the population usually asymptomatic and does not require treatment however, it can bleed, become inflamed, rupture or causes a volvulus or intussusception Can mimic the presentation of appendicitis

Question 246

Where is McBurney's point

Answer 246

refers to a specific area one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus. indicative of appendicitis

Question 247

What is Rovsing sign

Answer 247

palpation of the left iliac fossa elicits pain on the right iliac fossa inidicative of appendicitis

Question 248

What acid base disturbance is found in profuse vomiting

Answer 248

metabolic alkalosis

Question 249

Tumour marker that is raised in cholangiocarcinoma.

Answer 249

CA 19-9 (carbohydrate antigen) cancer of the head of the pancreas

Question 250

Describe a colostomy bag

Answer 250

where large intestine is brought to the skin (usually flush with the skin because solid contents are less irritating than that of an ileostomy) typically located in the left iliac fossa

Question 251

Describe an ileostomy bag

Answer 251

where end portion of small bowel is brought out of the skin drain more liquid stools have a spout so content do not touch and irritate surrounding skin typically located in right iliac fossa

Question 252

When are end colostomies deemed permanent

Answer 252

after resection of abdomino-pernieal resection (APR) because the entire anus and rectum have been removed

Question 253

When are end ileostomies deemed permanent

Answer 253

after a panprotocolectomy (total colectomy with removal of the large bowel , rectum and anus) an alternative to this is to create an ileo-anal anastomosis (j-pouch)

Question 254

Describe a J pouch

Answer 254

where the ileum is folded back on itself and fashioned into a larger pouch which functions a bit like a rectum The j pouch is then attached to the anus and collects stools prior to the person passing a motion

Question 255

Describe a loop ileostomy

Answer 255

temporary stoma to allow a distal portion of the bowel and anastamosis to heal after surgery usually reversed after 6-8 weeks Bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle Loop refers to it being the two ends (proximal and distal) Proximal end is the productive side and is turned inside out to form a spout to the surrounding skin, this is where bowel habits comes out, distal end is flatter

Question 256

Complications of stomas

Answer 256

psycho-social impact local skin irritation parastomal hernia loss of bowel length leading to high output, dehydration and malnutrition constipation (colostomies) stenosis obstruction retraction (sinking into the skin) prolapse (telescoping of bowel through hernia site) bleeding granulomas causing raised red lumps around the stoma

Question 257

Obese 50 year old women presents with pain in RUQ which radiates to interscapular region apyrexial and not jaundiced

Answer 257

think biliary colic

Question 258

What hormones decrease gastric empyting

Answer 258

CCK somatostatin

Question 259

When testing for heb B previous immunisation would show what

Answer 259

Anti-Hbs positive all other negative

Question 260

When testing for hep B previous infection >6months ago and not a carrier wpuld show what

Answer 260

anti-HBc positive (mini c = caught, negative if immunised) HBaAg negative

Question 261

when testing for hep B now a carrier what would it show

Answer 261

anti-HBc positive HBsAg positive

Question 262

What is bilirubin

Answer 262

chemical by-product of the breakdown of heme (component of RBCs)

Question 263

when does jaundice appear in terms of bilirubin

Answer 263

reaches an excess of 35umol/l

Question 264

What can raised levels conjugated bilirubin result from

Answer 264

defective excretion of bilirubin for example Dubin Johnson syndrome or cholestasis

Question 265

define sepsis

Answer 265

infection that triggers a particular systemic inflammatory response syndrome (SIRS) Characterised by body temperature outside 36-38 Hr >90 RR > 20 WBC >12,000 or <4,000

Question 266

What is superior to spleen? anterior? Posterior? Inferior?

Answer 266

Superior - diaphragm anterior - gastric impression posterior - kidney inferior - colon

Question 267

What nerve is at risk of damage during varicose vein surgery

Answer 267

sural nerve damage Loss of sensation to the lateral foot and posterolateral leg

Question 268

What nerve is at risk of damage during a posterior triangle lymph node biopsy

Answer 268

accessory nerve lesion

Question 269

what nerve is at risk of damage on a thyroidectomy

Answer 269

laryngeal nerve

Question 270

What nerve is at risk of damage during an anterior resection of the rectum

Answer 270

hypogastric autonomic nerve

Question 271

What nerve is at risk of damage during inguinal hernia repair

Answer 271

inguinal nerve

Question 272

What is APC

Answer 272

adenomatous polyposis coli (APC) gene is a tumour suppressor gene involved in cell adhesion. Mutation or deletion of this gene can result in familial adenomatous polyposis (FAP), which causes almost inevitable bowel cancer in those affected, by early middle age.

Question 273

Lynch syndrome

Answer 273

HNPCC (autosomal dominant gene) most common form of inherited colon cancer often proximal colon, poorly differentiated and highly aggressive Most common genes involved : MSH2, MLH1

Question 274

Diverticulosis

Answer 274

common disorder characterised by multiple outpouchings of the bowel wall most commonly the sigmoid colon Risk factors: increasing age low fibre diet Diverticular disease - term used for symptomatic patients

Question 275

Classic presentation of diverticulitis

Answer 275

LIF pain and tenderness anorexia, nausea and vomiting diarhhoea features of infection (pyrexia, raised WCC and CRP)

Question 276

Management of diverticulitis

Answer 276

Mild attacks treated with antibiotics More significant episodes managed in hospital: patients are NBM, IV fluids and IV antibiotics (cephalosporin + metronidazole)

Question 277

Complications of diverticulitis

Answer 277

abscess formation peritonitis obstruction perforation

Question 278

Which antibiotic is associated with C.diff

Answer 278

Clindamycin treatment can cause C.diff

Question 279

Metabolic consequences of refeeding syndrome

Answer 279

Hypophoshataemia Hypokalaemia Hypomagnesaemia abnormal fluid balance

Question 280

Patients considered high risk of referring syndrome

Answer 280

BMI <16kg/m2 unintentional weight loss >15% over 3-6 months little nutritional intake >10days hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

Question 281

What is often used for detecting cholangiocarcinoma in patients with primary sclerosing cholangitis

Answer 281

CA 19-9 levels

Question 282

Features of chronic pancreatitis

Answer 282

pain worse 15-30 mins following a meal Steatorrhea : develop between 5-25 years after onset of pain DM occurs 20yrs after symptoms begin

Question 283

Post splenectomy blood film features:

Answer 283

Howell- Jolly bodies Pappenheimer bodies Target cells Irregular contracted erythrocytes

Question 284

What is Zollinger-Ellison syndrome

Answer 284

condition characterised by excessive levels of gastrin usually from a gastrin secretin tumour of the duodenum or pancreas

Question 285

Features of Zollinger-Ellison syndrome

Answer 285

multiple gastroduodenal ulcers diarrhoea malabsorption

Question 286

How to diagnose Zollinger-Ellison syndrome

Answer 286

fasting gastrin levels : single best screen (will be very high) secretin stimulation test

Question 287

Pyloric stenosis

Answer 287

presents in second - fourth weeks of life with vomiting caused by hypertrophy of the circular muscles of the pylorus

Question 288

features of pyloric stenosis

Answer 288

projectile vomiting typically 30 mins after a meal constipation and dehydration palpable mass in upper abdomen hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

Question 289

Diagnosis and management of pyloric stenosis

Answer 289

made by US Ramstedt pyloromyotomy.

Question 290

Primary biliary cholangitis clinical signs on examination

Answer 290

jaundice xanthelesma spider naevi splenomegaly

Question 291

What is used to initially treat primary biliary cholangitis

Answer 291

Cholestyramine ursodeoxycholic acid fat soluble vitamin prophylaxis

Question 292

Anti-smooth muscle antibodies and anti mitochondrial antibodies are typical of what

Answer 292

Autoimmune hepatitis and primary biliary cirrhosis respectively

Question 293

High serum transferrin reflects what

Answer 293

iron overload in haemachromatosis

Question 294

What is the combination of steatosis and Mallory’s hyaline on liver biopsy is suggestive of

Answer 294

alcoholic hepatitis

Question 295

Jaundice and gilberts syndrome

Answer 295

transient jaundice after physiological stress such as exercise and fasting is seen in gilberts syndrome

Question 296

What is pneumobilia

Answer 296

air in the gallbladder

Question 297

cholecystoenteric fistula

Answer 297

rare and late complication of cholecystolithiasis Spontaneous tract between an inflamed gallbladder and one or more parts of the surrounding GI tract

Question 298

Retroperitoneal structures

Answer 298

SAD PUCKER S: suprarenal (adrenal gland)# A: Aorta/IVC D: Duodenum (2/3 parts) P: pancreas (except tail) U: ureters C: colon (ascending and descending) K: kidneys E: oesophagus R: rectum

Question 299

Retroperitoneal structures

Answer 299

SAD PUCKER S: suprarenal (adrenal gland)# A: Aorta/IVC D: Duodenum (2/3 parts) P: pancreas (except tail) U: ureters C: colon (ascending and descending) K: kidneys E: oesophagus R: rectum

Question 300

What brain structure is most affected in wilsons disease

Answer 300

most copper is deposited in the basal ganglia

Question 301

Plummer Vinson syndrome

Answer 301

oesophageal disorder triad of: dysphagia (secondary to oesophageal webs) Glossitis Iron-deficiency anaemia

Question 302

Mallory weiss syndrome

Answer 302

Severe vomiting -> painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis common in alcoholics

Question 303

Boerhaave syndrome

Answer 303

severe vomiting esophageal rupture

Question 304

Tension pnuemothorax

Answer 304

Often laceration to lung parenchyma with flap pressure develops in thorax most common cause is mechanical ventilation symptoms overlap with cardiac tamponae, hyper-resonant percussion suggests pnuemothorax

Question 305

Flail chest

Answer 305

chest wall disconnects from thoracic cage multiple rib fractures association with pulmonary contusion abnormal chest motion avoid over hydration and fluid overload

Question 306

Cardiac tamponade signs

Answer 306

Becks triad: low BP, distended JVP, muffled heart sounds Pulsus paradoxus - pulse pressure decreases during inspiration

Question 307

Pulmonary contusion

Answer 307

most common potentially lethal chest injury ABGs and pulse oximetry important early intubation within an hour if significant hypoxia

Question 308

Blunt cardiac injury

Answer 308

usually occurs secondary to chest wall injury ECG may show features of MI Dequelae: hypotension, arrhythmias, cardiac wall motion abnormalities

Question 309

Symptoms of diverticular disease

Answer 309

altered bowel habit rectal bleeding abdominal pain

Question 310

Complications of diverticular disease

Answer 310

diverticulitis haemorrhage development of fistula perforation and faecal peritonitis perforation and development of abscess development of diverticular phlegmon

Question 311

How to diagnose diverticular disease

Answer 311

colonoscopu CT cologram or barium enema

Question 312

Hinchey severity classification

Answer 312

for diverticular disease I - para colonic abscess II - pelvic abscess III - purulent peritonitis IV faecal peritonitis

Question 313

Management of diverticular disease

Answer 313

Increase dietary fibre Mild attacks of diverticulitis managed with antibiotics peri coloic abscesses should be drained surgically or radiologically

Question 314

Pernicious anaemia

Answer 314

autoimmune disorder affecting gastric mucosa that results in vitamin B12 deficiency (symptoms and signs are often subtle and diagnosis is often delayed

Question 315

Risk factors for pernicious anaemia

Answer 315

more common in females associated with autoimmune disorders more common if blood group A

Question 316

Features of pernicious anaemia

Answer 316

Anaemia: lethargy, pallor, dyspnoea Neurological: peripheral pins and needles(affects arms more than legs), progressive spinal cord weakness, ataxia and [paraesthesias other: mild jaundice, glossitis

Question 317

Investigations for pernicious anaemia

Answer 317

FBC (macrocytic anaemia, hypersegmented polymorphs on blood film, low WCC and platelets) Vitamin B12 and folate (>200nh/L is normal) Antibodies (Anti intrinsic factor antibodies and anti gastric parietal cell antibodies

Question 318

Management of pernicious anaemia

Answer 318

Vitamin B12 replacement usually given IM no neurological features = 3 injections per week for 2 weeks followed by 3 monthly treatments More frequent doses if they have neurological features folic acid supplementation may also be required

Question 319

Clinical features Large bowel obstruction

Answer 319

absence of passing flatus or stool abdominal pain abdominal distention nausea and vomiting (late symptoms_ peritonism if associated bowel perforation

Question 320

How to differentiate large and small bowel obstructions

Answer 320

small bowel would cause vomiting earlier on before constipation large bowel is would have longer history of constipation and later onset of vomiting

Question 321

How to differentiate large and small bowel obstructions

Answer 321

small bowel would cause vomiting earlier on before constipation large bowel is would have longer history of constipation and later onset of vomiting

Question 322

Peutz Jeghers syndrome

Answer 322

Autosomal dominant characterised by numerous hamartomatous polyps in GI tract associated with pigmented freckles on lips, face, palms and soles although polyps themselves dont have malignant potential 50% patients have died from GI tract cancer by age of 60

Question 323

Features of peutz jeghers syndrome

Answer 323

hamartomatous polyps in GI tract (mainly small bowel) Small bowel obstruction is common PC pigmented lesions on lips, oral mucosa, face, palms and soles Hamartomatous = A benign (not cancer) growth made up of an abnormal mixture of cells and tissues normally found in the area of the body where the growth occurs.

Question 324

Secretory diarrhoea

Answer 324

involves transformation of what is normally an absorptive gut into a secretory gut via toxins or secretagogues

Question 325

The most common type of pancreatic cancer

Answer 325

ductal adenocarcinoma

Question 326

Pancreatic head is supplied by which artery

Answer 326

pancreaticoduodenal artery

Question 327

Pancreatic tail is supplied by which artery

Answer 327

branches of the splenic artery

Question 328

What is an invagination

Answer 328

a cavity or pouch formed by being turned inside out or folded back.

Question 329

What is Intussusception

Answer 329

invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region.

Question 330

Features of intussusception

Answer 330

paroxysmal abdominal colic pain during paroxysm the infant will characteristically draw their knees up and turn pale vomiting bloodstained stool - 'red-currant jelly' - is a late sign sausage-shaped mass in the right upper quadrant

Question 331

Investigation for intussusception

Answer 331

US

Question 332

Hepatic encephalopathy

Answer 332

The aetiology is not fully understood but is thought to include excess absorption of ammonia and glutamine from bacterial breakdown of proteins in the gut.

Question 333

Features of hepatic encephalopathy

Answer 333

confusion, altered GCS (see below) asterix: 'liver flap', arrhythmic negative myoclonus with a frequency of 3-5 Hz constructional apraxia: inability to draw a 5-pointed star triphasic slow waves on EEG raised ammonia level (not commonly measured anymore)

Question 334

Grading of hepatic encephalopathy

Answer 334

Grade I: Irritability Grade II: Confusion, inappropriate behaviour Grade III: Incoherent, restless Grade IV: Coma

Question 335

Precipitating factors of hepatic enceophalopathy

Answer 335

infection e.g. spontaneous bacterial peritonitis GI bleed post transjugular intrahepatic portosystemic shunt constipation drugs: sedatives, diuretics hypokalaemia renal failure increased dietary protein (uncommon)

Question 336

management of hepatic encephalopathy

Answer 336

>treat any underlying precipitating cause >NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy >lactulose is thought to work by promoting the excretion of ammonia and increasing the metabolism of ammonia by gut bacteria >antibiotics such as rifaximin are thought to modulate the gut flora resulting in decreased ammonia production other options include embolisation of portosystemic shunts and liver transplantation in selected patients

Question 337

contents of the femoral triangle lateral to medial

Answer 337

NAVEL femoral nerve femoral artery femoral vein empty space lymphatics

Question 338

The presence of what cell confirms gastric adenocarcinoma

Answer 338

Signet rings

Question 339

Where are bile salts absorbed

Answer 339

in the terminal ileum

Question 340

Function of amylase

Answer 340

breaks starch into sugar

Question 341

Function of maltase

Answer 341

cleaves disaccharide maltose to glucose + glucose

Question 342

Function of sucrase

Answer 342

cleaves sucrose to fructose and glucose

Question 343

Function of lactase

Answer 343

cleaves disaccharide lactose to glucose + galactose

Question 344

Terlipressin - method of action

Answer 344

constriction of the splanchnic vessels

Question 345

What two structures merge together to form the Ampulla of Vater?

Answer 345

Pancreatic duct and common bile duct

Question 346

What does h pylori secrete to survive in the stomach

Answer 346

urease

Question 347

Raised urea and upper gi bleed

Answer 347

Upper GI bleed can act as a protein meal and cause a temporary disproportionate rise in the blood urea

Question 348

Pharyngeal pouch

Answer 348

posteromedial diverticulu through killians dehiscence (triangular area in the wall of the pharynx ) more common in older patients and is 5 times more common in men

Question 349

Features of pharyngeal pouch

Answer 349

dysphagia regurgitation aspiration neck swelling which gurgles on palpation halitosis

Question 350

Investigation for pharyngeal pouch

Answer 350

barium swallow combined with dynamic video fluoroscopy

Question 351

Management of a pharyngeal pouch

Answer 351

sugery

Question 352

First line treatment for diarrhoea in IBS

Answer 352

Loperamide

Question 353

early signs of haemachromatosis

Answer 353

fatigue erectile dysfunction and arthralgia

Question 354

What cancer does pernicious anaemia predispose you to

Answer 354

gastric carcinoma

Question 355

What would a severe flare up of UC look like

Answer 355

associated with passing >6 stools per day containing blood patient will also have systemic features (fever)

Question 356

Best way to measure acute liver failure

Answer 356

look at prothrombin time and albumin level because ALT does not always accurately reflect function of the liver

Question 357

Associated factors of NAFLD

Answer 357

obesity T2Dm hyperliidaemia jejunoileal bypass sudden weight loss/starvation

Question 358

Features if NAFLD

Answer 358

usually asymptomatic hepatomegaly ALT is typically greater than AST increased echogenicity on US

Question 359

Management of NAFLD

Answer 359

lifestyle changes (weight loss) and monitoring on-going research of gastric banding and insulin sensitising drugs

Question 360

Life threatening C.diff infection management

Answer 360

ORAL vancomycin and IV metronidazole

Question 361

Viral hepatitis features

Answer 361

nausea and vomiting myalgia lethargy RUQ pain questions may point to risk factors such as foreign travel or IV drug use

Question 362

Gallstone ileus

Answer 362

small bowel obstruction secondary to impacted gallstone may develop if a fistula forms between gangrenous gallbladder and the duodenum abdominal pain, distention and vomiting are seen

Question 363

features of carcinoid tumours

Answer 363

flushing diarrhoea bronchospasm hypotension right heart valvular stenosis ACTH and GHRH may also be secreted

Question 364

Investigation and management of carcinoid tumours

Answer 364

investigation = urinary 5-HIAA and plasma chromogranin A y management = somatostatin analogues (octreotide) and for diarrhoea cyproheptadine

Question 365

Variceal haemorrhage management

Answer 365

ABC: patients should be resuscitated before endoscopy 2. correct clotting: FFP, vitamin K 3. Vasoactive agents: Terlipressin or octreotide 4. Prophylactic IV antibiotic (typically Quinolones) - both terlipressin and antibiotics should be given BEFORE endoscopy 5. Endoscopic variceal band ligation 6. Sengstaken-Blakemore tube if uncontrolled haemorrhage 7. Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if all other measures fail

Question 366

TIPSS procedure

Answer 366

Transjugular Intrahepatic Portosystemic Shunt Used if everything else fails to control a variceal haemorrhage connects hepatic vein to portal vein exacerbation of hepatic encephalopathy is a common complication

Question 367

Prophylaxis of variceal haemorrhage

Answer 367

propranolol - reduced rebleeding and mortality endoscopic variceal band ligation (EVL) at two weekly intervals until all varices have been eradicated

Question 368

What vaccine do people with coeliac disease have every 5 years

Answer 368

pneumococcal due to hyposplenism

Question 369

Best test for B12 deficiency

Answer 369

intrinsic factor antibodies over gastric parietal cell antibodies

Question 370

Management of pyogenic liver abscess

Answer 370

drainage (usually percutaneous) and antibiotics amoxicillin + ciprofloxacin + metronidazole if penicillin allergic then ciprofloxacin + clindamycin

Question 371

Management of pyogenic liver abscess

Answer 371

drainage (usually percutaneous) and antibiotics amoxicillin + ciprofloxacin + metronidazole if penicillin allergic then ciprofloxacin + clindamycin

Question 372

Endoscopic findings supportive of coeliac disease

Answer 372

villous atrophy crypt hyperplasia increase in intraepithelial lymphocytes lamina propria infiltration with lymphocytes

Question 373

Functions of vitamin A

Answer 373

converted into retinal (important visual pigment) important in epithelial cell differentiation antioxidant (teratogenic in high doses)

Question 374

What does an SAAG>11g/L indicate

Answer 374

portal hypertension

Question 375

Investigations for ischaemic colitis

Answer 375

ABG - metabolic acidosis, elevated lactate imaging - xray may show thumbprinting but CT is gold stanadard

Question 376

transferrin, ferritin and TIBC for someone with haemachromatosis

Answer 376

transferrin high ferritin high TIBC low

Question 377

Management for haemachromatosis

Answer 377

first line - venesection (transferrin should be kept below 50% and serum ferritin below 50ug/l second line - desferrioxamine

Question 378

Management of appendicitis

Answer 378

appendicectomy IV prophylactic antibiotics given before

Question 379

Management of hepatic encephalopathy

Answer 379

Treat any underlying precipitating cause first line - lactulose with addition of rifaximin for secondary prophylaxis of hepatic encephalopathy lactulose (works by promoting excretion of ammonia and increasing metabolism of ammonia by gut bacteria) rifaximin (modulate the gut flora resulting in decreased ammonia production)

Question 380

How to test for H.pylori post-eradication therapy

Answer 380

urea breath test

Question 381

What anaemia can sulphasalazine cause

Answer 381

This drug, used in the treatment of ulcerative colitis and rheumatoid arthritis, can cause haemolytic anaemia with Heinz bodies.

Question 382

Adverse effects of metoclopramide

Answer 382

extrapyramidal effects (acute dystonia) diarrhoea hyperprolactinaemia tardive dyskinesia parkinsonism should be avoided in bowel obstruction but may be helpful in paralytic ileus

Question 383

Red flag symptoms for gastric cancer

Answer 383

new-onset dysphagia in a patient >55years unexplained persistent vomiting unexplained weight loss progressively worsening dysphagia odynophagia epigastric pain

Question 384

Common source of Hep A infections

Answer 384

shellfish

Question 385

Other medication that can cause C.diff

Answer 385

omeprazole

Question 386

C.diff recurrent episode management within 12 weeks of symptom resolution

Answer 386

treated with oral fidaxomicin

Question 387

features and treatment of a fissure in ano

Answer 387

painful bright red rectal bleeding treatment - stool softners, topicak diltiazem or GTN, botulinum toxin, sphincterotomy

Question 388

Features and treatment of fissure in ano

Answer 388

Painful bright red rectal bleeding treatment - stool softeners, topical diltiazem or GTN, botulinum toxin, sphincterotomy

Question 389

Features and treatment of haemorroids

Answer 389

Painless, bright red rectal bleeding occurs following defaecation and bleeds onto the toilet paper and into the toilet pan treatment - stool softeners, avoid straining, surgery

Question 390

Features and treatment of fistula in ano

Answer 390

May initially present with an abscess and then persisting discharge onto the perineum, seperate from the anus treatment - laying it open (fistulotomy)

Question 391

deficiency in what vitamin causes easy bruising

Answer 391

vitamin c