GI Flashcards
Upper gastrointestinal haemorrhage A Acute erosive gastritis B Aorto-enteric fistula C Duodenal lymphoma D Gastric leiomyoma E Mallory-Weiss tear F Oesophageal varices G Oesophagitis H Peptic ulcer For each case below, choose the single most appropriate diagnosis from the given list of options. Each option may be used once, more than once, or not at all. A 47-year-old man known to abuse alcohol presents to the Emergency department with a profuse haematemesis. He is found on examination to be jaundiced, mildly confused, with ascites and a liver flap. His serum albumin is markedly low.
A 21-year-old student is brought into the Emergency department with severe vomiting and diarrhoea. He has just returned from a holiday in Sri Lanka and is dehydrated. He continues to vomit and then complains of severe retrosternal pain and has a haematemesis.
A warden in a block of flats is called to see a 62-year-old with a massive haematemesis. He has a midline laparotomy scar from an aortic aneurysm repair and is vomiting large quantities of fresh blood.
A 70-year-old man is taken to theatre with a massive upper gastrointestinal (GI) bleed. At laparotomy he is found to have a large mass in the gastric body which is rubbery in nature and is bleeding profusely.
A 42-year-old man who was previously fit and well presents with a sudden onset of haematemesis. He has noticed melaena stool during the day and is on no medication.
The alcohol abuse and profuse haematemesis are suggestive of varices. Plus, this patient has evidence of portal hypertension.
Typical history of recurrent vomiting, then blood.
The midline laparotomy and massive haematemesis after AAA repair are highly suggestive of aorto-enteric fistula.
A possibility is peptic ulceration/stress ulcer but, in the circumstances, the examiner is probably seeking the former answer.
The rubbery large mass suggests leiomyoma. These are prone to haemorrhage.
This patient has been previously fit and well and taking no medication. Of the options offered it seems most likely that this is due to an acute peptic ulceration.
Patients with severe upper GI haemorrhage require resuscitation with respect to their airway, breathing, and circulation. A history should be gained contemporaneously. The underlying cause should then be treated.
Bleeding ulcers are injected with adrenalin or underrun; varices may be injected or banded.
Swallowing problems
A Achalasia of the oesophagus
B Candidal oesophagitis
C Carcinoma of the oesophagus
D Diffuse oesophageal spasm
E Globus syndrome
F Herpes simplex oesophagitis
G Motor neurone disease
H Peptic oesophageal stricture
I Pharyngeal pouch
J Systemic sclerosis
Each of the following patients presents with dysphagia.
For each one, select the most likely diagnosis from the list of options.
Each option may be used once, more than once, or not at all
A 25-year-old man on cytotoxic therapy for a haematological malignancy complains of severe retrosternal pain and dysphagia for both liquids and solids, which began five days ago.
On three occasions a 65-year-old man has developed dysphagia after eating one mouthful of steak. Each time, vomiting has relieved this, and he has then been able to complete his meal. He has a left sided neck lump.
A 70-year-old man complains of choking, nasal regurgitation and coughing during meals. His wife has noticed a change in his voice and he has a spastic gait.
A 50-year-old man presents with a six week history of progressive dysphagia for solids. Endoscopic examination five years earlier showed oesophagitis and Barrett’s oesophagus.
For the past two years a 50-year-old woman has had dysphagia for solid and liquids with painless regurgitation of food after meals.
Candidal oesophagitis
Oesophageal candidiasis presents with odynophagia or pain on swallowing. Those at risk are the elderly, very young and the immunosuppressed.
Pharyngeal pouch is due to mucosal herniation of the inferior constrictor. There may be halitosis, regurgitation of food and a usually a left sided neck lump. Diagnosis is by barium swallow and treatment is surgical.
Twenty five per cent of motor neurone disease presents with bulbar palsy.
Barrett’s oesophagus is a risk factor for carcinoma of the oesophagus. Clinical features include dysphagia, weight loss, hoarseness and cough. Investigations include barium swallow, oesophagoscopy with biopsies and brushings.
Achalasia is due to failure of oesophageal peristalsis and loss of relaxation of the lower oesophageal sphincter due to loss of ganglia from Auerbach’s plexus. Clinical features include dysphagia for both solids and liquids at the outset, chest pain and regurgitation of old food. Diagnosis is by barium swallow and treatment is by balloon dilatation and cardiomyotomy.
Intestinal obstruction A Adhesions B Carcinoma caecum C Carcinoma rectum D Carcinoma sigmoid E Gallstone ileus F Intussusception G Pseudo-obstruction H Sigmoid volvulus I Strangulated femoral hernia J Strangulated inguinal hernia For each of the patients below, select the most likely diagnosis from the listed options: An 80-year-old man presents with a four day history of abdominal distension and pain. He is vomiting faeculent fluid. He has not been feeling well for three months and has lost 2 stone in weight. Clinical examination reveals visible peristalsis in the mid abdomen, distension and a mass in the right iliac fossa.
A 68-year-old lady presents with colicky abdominal pain and vomiting. Examination shows she is dehydrated, with abdominal distension and a lower midline scar from a perforated appendix. Plain abdominal film shows multiple distended small bowel loops and the presence of air in the biliary tree.
A 60-year-old man undergoes emergency lumbar disc decompression. Post operatively he is immobile. He becomes increasingly constipated and develops a distended abdomen. Rectal examination shows some hard stool but no other abnormality. A plain abdominal film show a grossly distended colon down to the pelvic brim.
A 78-year-old man presents with a three day history of vomiting faeculent fluid. He has a grossly distended abdomen and a palpable mass in the right groin. The mass is firm, slightly tender and lies below and lateral to the pubic tubercle.
An 88-year-old lady with dementia is referred by her GP because she seems to be in pain and unwell. She has a long history of constipation. On examination she has a grossly distended tympanitic abdomen which is non-tender. The plain abdominal x ray shows a large distended loop of colon.
This history of abdominal distension, pain and faeculent vomiting suggests small bowel obstruction. Examination reveals abdominal distension with visible peristalsis suggestive of small bowel obstruction.
The most likely diagnosis in someone of age 80, with a history of malaise and weight loss is caecal carcinoma.
Small bowel obstruction is suggested by the history. This could be due to adhesions from previous abdominal surgery but the abdominal x ray shows air in the biliary tree. This implies the presence of a choledochal fistula which is due to a gallstone eroding into the duodenum and causing small bowel obstruction when it lodges in the ileum.
Immobilised patients often develop an ileus, particularly after orthopaedic surgery. This is usually painless and may be associated with decreased potassium levels. The abdominal x ray shows grossly distended colon with no cut-off to imply obstruction.
This patient has symptoms of small bowel obstruction. There is a mass in the right groin, which in a man is usually due to irreducible inguinal hernia, but men can also get femoral hernias and this is implied by the fact that swelling is below and lateral to the pubic tubercle.
This is an elderly patient with dementia who often suffers with chronic constipation. In view of the dementia she is not able to give a good history but is just unwell with malaise and is obviously in some discomfort.
The presence of a very distended tympanitic abdomen is usually indicative of sigmoid volvulus and this is compatible with the abdominal x ray appearance.
Gastrointestinal Symptoms A Angiodysplasia B Duodenal ulcer C Caecal carcinoma D Crohn's disease E Mallory-Weiss tear F Oesophageal varices G Rectal carcinoma H Sigmoid carcinoma I Sigmoid diverticular disease For each of the patients below, select the most likely diagnosis from the listed options: A 56-year-old man presents with anaemia and weight loss. Examination reveals a mass in the right iliac fossa and hepatomegaly.
A 50-year-old alcoholic presents with melaena. On examination the patient is drowsy and hypotensive. Examination of the abdomen shows splenomegaly.
A 58-year-old man is admitted with acute onset of left iliac fossa pain. Recently he has noticed he has had some vague abdominal pain and felt more constipated. On examination he is pyrexial, pale and has localised peritonism in the left iliac fossa. His abdomen is distended. Investigations show a Hb of 7 g/dL (hypochromic, microcytic), WCC of 18 ×109/L.
A 77-year-old man presents with his fourth episode of acute rectal bleeding. The blood is a mixture of fresh blood and clots. On this occasion the bleeding has been severe enough to require a 4 unit blood transfusion. A barium enema is undertaken and is normal.
This patient has presented with anaemia which suggests chronic blood loss. The most likely diagnosis is that of a caecal carcinoma which is therefore associated with a mass in the right iliac fossa and weight loss. Hepatomegaly suggests metastatic disease.
An alcoholic person with haematemesis and melaena could have a duodenal ulcer or gastritis or oesophageal varices. The presence of splenomegaly however, suggests that he probably has portal hypertension and oesophageal varices are a possibility. Drowsiness implies hepatic encephalopathy precipitated by the bleeding.
Sigmoid carcinoma
The history suggests a perforated sigmoid carcinoma. The anaemia is due to chronic blood loss from the sigmoid carcinoma. This has also caused a recent change of bowel habit with increase in constipation. The presence of pyrexia and localised peritonism in the left iliac fossa suggests the presence of inflammation. The diagnosis could be diverticulitis (rather than diverticular disease) but a localised perforation of the obstructed carcinoma would be more in keeping with the iron deficiency anaemia.
Angiodysplasia
The differential diagnosis is diverticular disease or angiodysplasia. Both can produce a significant gastrointestinal blood loss which is painless. In contrast a sigmoid carcinoma would not usually bleed enough to require a transfusion but would be associated with chronic blood loss causing anaemia. Angiodysplasia is only diagnosed by colonoscopy. Diverticulae would be seen on a barium enema.
Pelvic inflammatory disease
Pelvic inflammatory disease
Pelvic inflammatory disease is associated with a malodorous, green or yellow discharge. It may be associated with STDs such as Chlamydia but may occur in a sexually inactive female.
Chronic IBD
The most likely answer in this case is chronic inflammatory bowel disease given the weight loss, abdominal pain and diarrhoea. Addison’s disease would present insidiously, and typically without bowel symptoms.
duodenal ulcer
This patient’s symptoms are typical of a duodenal ulcer. He has increased weight because of drinking milk and eating to relieve his epigastric pain. Although the signs and symptoms are the same for duodenal and gastric ulcers, the ratio respectively is 4:1 thus more likely to be a DU.
pyloric stenosis
This gentleman has a long history of peptic ulceration which has been left untreated. It has therefore healed with scarring to cause pyloric stenosis. He is dehydrated because of vomiting. The succussion splash suggests it. The classical biochemical abnormality is hypochloraemic alkalosis.
oesophageal adenocarcinoma
This gentleman has a history of reflux that has been self treated with antacids. This does put him at risk of developing a benign oesophageal stricture secondary to his oesophagitis. He is also at increased risk of oesophageal carcinoma particularly in a Barrett’s oesophagus which is related to reflux. The presence however of an iron deficiency anaemia and cachexia is more compatible with oesophageal adenocarcinoma. This is also related to the fact that he has progressive dysphagia and weight loss whereas with a benign oesophageal stricture the dysphagia may not be so progressive.
Oesophageal cancer Investigations:
Endoscopic ultrasonography. This patient has an oesophageal carcinoma. It could be staged by doing a CT scan which will look for liver metastases but a more accurate way of assessing whether or not it has spread to the local structures including thoracic aorta is by use of an endoscopic ultrasound.
Pancreatic cancer Investigations:
The history is suggestive of pancreatic carcinoma. An ultrasound has shown dilated common bowel duct. The possible diagnosis is carcinoma of the head of the pancreas. A CT scan would be the best way of staging this and would show the evidence of liver metastases and whether or not the pancreatic carcinoma involves the superior mesenteric vessels.
Gallstone Investigations:
The history is suggestive of gallstones and the most appropriate test to make this diagnosis is an abdominal ultrasound.
Dysphagia Investigations:
The history is suggestive of a pharyngeal pouch. It is not appropriate to do an endoscopy because of a risk of perforation. A barium meal looks at the stomach and duodenum and not the oesophagus. A barium swallow is therefore the most appropriate investigtion which will assess the function and anatomy of the oesophagus.
Stomach cancer Investigations:
Laparoscopy
This gentleman has carcinoma of the stomach. A CT scan has shown no evidence of liver metastases and an endoscopy shows a localised lesion in the antrum of the stomach. A CT scan suggests operability but a CT is not appropriate for diagnosing peritoneal metastases as they may not be evident on a CT. A laparoscopy is therefore, the appropriate way forward.
Reye’s syndrome
Reye’s syndrome is an acute disease of the liver often associated with a viral infection or salicylate toxicity. Laboratory findings include abnormal liver and muscle enzymes. Treatment is supportive.
Galactosaemia
Galactosaemia is a result of galactose-1-phosphate uridyl transferase. It accumulates in kidneys, liver and brain and clinical manifestations include jaundice, hepatomegaly, hypoglycaemia, vomiting, seizures and poor weight gain. Diagnosis is made by identifying urinary galactose. Treatment is dietary adjustment.
sentinel loop in pancreatitis
Acute onset of upper abdominal pain would suggest acute pancreatitis. The diagnosis will be confirmed by a markedly elevated serum amylase. The loop of small bowel seen on the plain film is due to an ileus of the duodenum and is known as the sentinel loop.
Gallstone ileus
Gallstone ileus is the most likely cause, as she is mobile and living independently. If air is seen in the biliary tree on plain abdominal x ray this is usually indicative of gallstone ileus. Ten percent of gallstones are radio-opaque and will be seen within the lumen of the small bowel.
sentinel loop in pancreatitis
Acute onset of upper abdominal pain would suggest acute pancreatitis. The diagnosis will be confirmed by a markedly elevated serum amylase. The loop of small bowel seen on the plain film is due to an ileus of the duodenum and is known as the sentinel loop.
A 72-year-old man presents to the Emergency Department with acute onset of abdominal pain. Examination reveals peritonitis. Following resuscitation a laparotomy was performed.
At surgery faecal peritonitis secondary to a perforated caecal tumour was found. A right hemicolectomy was performed. The proximal end of the bowel was exteriorised.
The operation of choice is a right hemicolectomy, thus removing the tumour. If there is no evidence of perforation then a primary anastomosis would be performed. However, there is a much higher risk of anastomotic breakdown in a contaminated field. Therefore an end ileostomy is formed. A mucus fistula is also required, to allow mucus to drain from the remaining colon.
A 79-year-old woman was admitted with a closed loop colonic obstruction. She suffers from mild angina but is otherwise well. An unprepared gastrografin enema revealed an obstructing lesion in the mid-sigmoid colon. At laparotomy the proximal colon was found to be healthy. A resection was performed.
Hartmann’s procedure
Carcinoma is the commonest of large bowel obstructions. The operation of choice for an obstructing sigmoid tumour is a Hartmann’s procedure. The tumour is removed (sigmoid colectomy) and a colostomy formed. (Sometimes there may be enough distal sigmoid to bring out as a mucous fistula rather than do a Hartmann’s procedure. This would be easier to close subsequently.)
Primary anastomosis should usually be avoided, as there is a higher risk of anastomotic leak in patients presenting with obstruction.
Nissen fundoplication
Nissen fundoplication; antireflux surgery is indicated for cases of failed medical therapy. In a Nissen’s the gastric fundus is mobilised and loosely wrapped around the oesophagus, which contains a large bore nasogastric tube to prevent the wrap from being sutured too tight. The wrap functions as a ‘flutter valve’ reducing transient lower oesophageal sphincter relaxation and increases the angle of oesophageal insertion.
Ivor lewis procedure
An Ivor-Lewis procedure involves a right thoracotomy and laparotomy and is best employed for mid and lower third tumours of the oesophagus. The advantage of this procedure is the excellent exposure and ease of anastomosis. However, the patient requires a thoracotomy with its associated morbidity. A direct, open approach is likely to be adopted in this patient as the tumour is locally advanced and nodes should be excised.
Intussusception
Intussusception in children can occur between 3 months and 6 years of age, but it is more common in the first three years.
Colicky abdominal pain, straining and lethargy are clinical features. Bloody mucus and vomiting occur late when the bowel becomes strangulated and ischaemic.
The condition involves the telescoping of one segment of the bowel into an adjacent segment.
Most cases are idiopathic however in a minority of cases there is a ‘mechanical leading segment’ which predisposes to the abnormality, for example, polyposis, Peutz-Jeghers syndrome.
Pneumatic or hydrostatic reduction is therapeutic in most cases which present within 24 hours. Pneumatic reduction appears to have a higher success rate.
