GI and General III Flashcards
Normal Ranges Haemoglobin 12 - 16.5 g/dl MCV 85 - 95 fL Calcium 2.2 - 2.6 mmol/L Alkaline phosphatase 50 - 110 U/L
A 65-year-old male presents with a four month history of weight loss, pale stools and diarrhoea. Investigations reveal a haemoglobin of 11.5 g/dl, MCV of 90 fl, serum calcium of 2 mmol/l and an alkaline phosphatase of 400 iu/l.
Pancreatic carcinoma
The history of pale stool and malabsorption of fat-soluble vitamins (low vitamin D and hence low calcium) together with elevated alkaline phosphatase suggests biliary obstruction and hence pancreatic carcinoma.
Folate and B12 absorption are unaffected and so mean corpuscular volume (MCV) is normal though a normochromic normocytic anaemia is often a feature.
The grossly elevated alkaline phosphatase would be excessive for purely a vitamin D deficiency and is far more in keeping with biliary obstruction.
Normal Ranges Haemoglobin 12 - 16.5 g/dl MCV 85 - 95 fL Calcium 2.2 - 2.6 mmol/L Alkaline phosphatase 50 - 110 U/L
A 69-year-old male presents with a three month history of weight loss and loose motions. His haemoglobin concentration of 10.1 g/dl, MCV of 80 fl and a calcium of 2.5 mmol/l with an alkaline phosphatase of 510 iu/l.
Colonic carcinoma
Change in bowel habit in an elderly patient with a microcytic anaemia and elevated alkaline phosphatase yet normal calcium suggests colonic carcinoma with hepatic metastases as the likely diagnosis.
Normal Ranges Haemoglobin 12 - 16.5 g/dl MCV 85 - 95 fL Calcium 2.2 - 2.6 mmol/L Alkaline phosphatase 50 - 110 U/L
A 22-year-old male presents with weight loss and loose motions of approximately six months duration. Investigations show a haemoglobin concentration of 11.5 g/dl, a MCV of 105 fl, a calcium of 2.1 mmol/l and an alkaline phosphatase of 150 iu/l.
Coeliac disease
The young male with change in bowel habit, elevated MCV associated with folate/B12 malabsorption and hypocalcaemia with mildly elevated alkaline phosphatase (more in keeping with a vitamin D deficiency/osteomalacia) suggests a diagnosis of coeliac disease. All patients with iron deficiency anaemia should be screened for coeliac disease (see BSG guidelines 2011).
A 35-year-old male is found on colonoscopy to have an ulcer. There is also found a fistula in ano and skin tags.
Crohn’s disease
The triad of:
Fistula in ano
Anal skin tags
Ulceration on colonoscopy
is usually associated with Crohn’s disease. Other differentials are tuberculosis, ulcerative colitis, watering can perineum from gonorrhoea.
Crohn’s disease is also associated with extra-gastrointestinal (GI) features such as:
Clubbing
Arthropathy
Sacro-iliitis
Uveitis.
A man complains of intense pain on defecation. On PR a very tender dark purple swelling is found near the anal verge.
Anal haematoma
This gentleman has characteristic features of an anal haematoma (also called thrombotic pile or a seven day pile).
Piles are particularly common and can present with marked pain - strangulation and thrombosis.
Usually, the thrombosed piles appear much darker in colour - dark purple/black.
A 48-year-old woman is referred as an emergency with severe right upper quadrant (RUQ) pain. On examination she pyrexial,38.8, and has a tender, palpable right subcostal mass with local peritonism.
Empyema
An empyema is effectively a complication of a complication. It arises when a stone lodges in the cystic duct orifice, behind which mucous continues to be produced, forming a mucocele. The stagnant mucous then becomes secondarily infected leading to an abscess.
It requires urgent cholecystectomy or cholecystostomy in the unfit.
A 43-year-old obese, multiparous lady is seen in the emergency department reporting a first episode of RUQ pain and nausea. By the time her blood results come back, the pain has settled completely. She is apyrexial and there is only minimal tenderness.
Biliary colic
Biliary colic is probably caused by a stone transiently impacting in Hartmann’s pouch, preventing emptying of the gallbladder. the pain typically lasts 15-20 minutes and follows ingestion of a fatty meal. The pain is recurrent and associated with nausea but there are no systemic signs.
A 54-year-old woman is admitted with a severe epigastric pain and vomiting. She has a longstanding history of RUQ pain and a USS arranged by her GP had shown gallstones but she had not been referred. On examination she has a blood pressure of 100/65 mm Hg and a pulse rate of 110/min. There is marked epigastric tenderness.
Acute pancreatitis
Gallstones are the commonest cause of acute pancreatitis in the United Kingdom followed closely by alcohol. The pain is often more central than for other manifestations of gallstone disease. It is relieved by sitting forward as this allows the stomach and small bowel to fall away from the pancreas in the retroperitoneum.
A 47-year-old woman who is on the waiting list for a cholecystectomy, having experienced recurrent episodes of biliary colic, is admitted with severe RUQ pain associated with a pyrexia of 38°C and localised tenderness at the tip of the ninth right rib.
Acute cholecystitis
Acute cholecystitis is characterised by biliary pain, together with signs of inflammation including local tenderness over the tip of the ninth rib consistent with local peritonism and an elevated temperature, WBC/CRP.
In cancer of the oesophagus in the UK which of the following is true?
(Please select 1 option)
Chest pain is a late symptom
Squamous cell carcinoma is the most common histology
Is associated with Crohn’s disease
The commonest site is the lower third of the oesophagus
When occurring at the gastro-oesophageal level is equally likely to be an adenocarcinoma as a squamous carcinoma
The commonest site is the lower third at ~45-55% (increasing in incidence), followed by the middle at ~25-30%, then the upper with ~15%. (Some tumours will overlap these artificial divisions).
Adenocarcinoma accounts for 65% of oesophageal cancers in the UK but squamous cell still remains the most common form worldwide. Adenocarcinoma is the most common form at the gastro-oesophageal level.
Chest pain is the presenting symptom in 20% (invasion/achalasia) and it is associated with Barrett’s and coeliac disease.
Regarding hypomagnesaemia, which of the following statements is correct?
(Please select 1 option)
Causes a broad QRS complex on the ECG
Causes hypercalcaemia
Causes tetany
Is often due to prolonged use of potassium sparing diuretics
Is seen in chronic obstructive pulmonary disease
Tetany
The ECG changes are almost the same as those of hypokalaemia:
Flattening of T waves ST segment depression Prominent U waves Prolonged PR interval Prolonged QT interval There is a risk of atrial and ventricular ectopics and ventricular arrhythmias. There is an increased risk of digoxin toxicity.
In chronic hypomagnesaemia there is impaired synthesis and release of parathyroid hormone (PTH), and target organ response to PTH is impaired. This produces secondary hypocalcaemia.
Hypomagnesaemia may result (like hypokalaemia) from the use of potassium ‘wasting’ diuretics (loop diuretics and thiazides, for example, furosemide).
Which of the following is not associated with the development of colonic carcinoma? (Please select 1 option) Familial colonic polyposis Gardner syndrome Ménétrier's disease Peutz-Jegher's syndrome Ulcerative colitis
Menetriers disease
In familial adenomatous polyposis (FAP) the risk of colonic malignancy is 100% by the age of 40. Between 24-93% of those affected also have duodenal polyps. These are most common in the second part of the duodenum and 2-12% develop periampullary carcinoma.
Gardner syndrome (described in 1951) is a phenotypic variant of FAP. There are extracolonic clinical features that include desmoid tumours, epidermoid cysts and osteomas.
Ménétrier’s disease is giant hyperplasia of the gastric folds. There is an increased risk of gastric carcinoma.
Peutz-Jegher’s syndrome comprises gastrointestinal polyps (hamartomas) associated with pigmented lesions of the face, lips buccal mucosa, palms and soles of the feet. There is a 2-3% risk of malignancy. This is more common in duodenal polyps (which are more numerous) than in colonic polyps.
The risk of malignant change in ulcerative colitis is 15% at 20 years, and 45% at 35 years.
Which of the following is a method of sterilisation?
(Please select 1 option)
Alpha irradiation
Cellulose filtration
Dry heat at 134°C for 3 minutes
Moist heat at 121°C for 15 minutes
Steam at 80°C and sub-atmospheric pressure
Cellulose filtration Moist heat (e.g. autoclave) is a method of sterilisation and the process kills all organisms and spores. It should be applied at 122°C at 1 atm for 30 minutes, 126°C at 1.5 atm for 10 minutes, or 134°C at 2 atm for 3 minutes to sterilise non-heat sensitive surgical instruments.
Steam is used to increase the temperature, so dry heat needs to be at a higher temperature for a longer time, e.g. 160°C for 1 hour, to have a similar effect to moist heat. Dry heat is used to sterilise glassware and powders.
Steam at low pressure and 80°C will only disinfect instruments, and it does not destroy spores. The addition of formaldehyde will cause sterilisation, and is used to sterilise heat sensitive equipment such as cannulae.
Cellulose filtration is used to sterilise heat sensitive fluids, but it may not remove viral particles.
Which of the following paediatric conditions is not associated with a palpable abdominal mass? (Please select 1 option) Congenital adrenal hyperplasia Hirschsprung's disease Meckel's diverticulum Nephroblastoma (Wilms' tumour) Neuroblastoma
CAH
Congenital adrenal hyperplasia may present with vomiting, weight loss and dehydration, with girls having virilised genitalia.
Hirschsprung’s presents with
Lower bowel obstruction Constipation Abdominal distension Left-sided faecal mass. On rectal examination, the rectum is empty and there is a squirt of foul-smelling faeces and gas.
Meckel’s usually presents with rectal bleeding, or intussusception which may be palpable.
Nephroblastoma is also known as Wilms’ tumour, and any child with an abdominal lump should be suspected as having a Wilms’ tumour. Patients look less ill than neuroblastoma patients. Often the patient is asymptomatic; they may have abdominal pain and vomiting, and some are hypertensive due to renal artery involvement.
Neuroblastoma is a firm tumour derived from nervous tissue. Seventy per cent arise in the abdomen, with over 50% of these in the adrenal glands. It may present as an asymptomatic mass, although it may bleed spontaneously causing pallor and hypotension.
An irregular liver edge is found in which of the following?
(Please select 1 option)
Amoebic liver abscess
Budd-Chiari syndrome
Congestive cardiac failure
Early alcoholic cirrhosis where the patient has stopped drinking
Sarcoid
Amoebic liver abscess
Irregular hepatomegaly may be found in
Late alcoholic hepatitis with underlying cirrhosis
Malignancy
Carcinoid
Tertiary syphilis
Actinomycosis.
Amoebic abscess would also cause irregular liver edge.
Smooth hepatomegaly is usually found in congestive cardiac failure, sarcoid affecting the liver.
Hepatomegaly tends not to be a feature of Budd-Chiari - portal vein thrombosis.
Which of the following is correct regarding solitary rectal ulcer syndrome?
(Please select 1 option)
The epithelial cells demonstrate cytological atypia
The highest incidence is seen between the ages of 55 and 75 years
The surrounding mucosa is usually normal
The ulcers are usually located on the posterior rectal wall
There is a weak association with rectal prolapse
The epithelial cells demonstrate cytological atypia
Many of the epithelial cells demonstrate cytological atypia with:
Hyperchromasia Eosinophilic nucleoli Pleomorphism, and Mitoses. These cytological features may suggest high-grade dysplasia or adenocarcinoma, but the cells typically show evenly distributed chromatin and evidence of maturation toward the luminal surface in contrast to cells from neoplastic tissue.
Important additional differential diagnostic considerations include:
Inflammatory pseudopolyps of ulcerative and Crohn’s colitis
Ischaemia
Benign pseudopolyps
Drugs (non-steroidal anti-inflammatory drugs or NSAIDs, corticosteroids, and oral contraceptives)
Infection, and
Stercoral ulceration associated with faecal stasis.
Solitary rectal ulcer syndrome is most common between the ages of 25 and 35 years, but has been described in elderly patients.
The surrounding non-ulcerated mucosa usually has characteristic histological findings.
The ulcers are usually located 6-12 cm above the anus.
Rectal prolapse can be shown in the majority of patients. The aetiology is thought to involve chronic trauma due to repeated mucosal prolapse associated with puborectalis muscle dysfunction.
Persistent contraction of the puborectalis muscle during attempted defecation maintains an acute anorectal angle, which keeps the anal canal closed and results in increased intra-rectal pressure.
This leads to severe straining during defecation in an attempt to overcome the functional obstruction. Consequently, the mucosa of the anterior rectal wall is forced against or into the anal canal, and the stress of repeated mucosal prolapse induces focal ischaemia and ultimately ulceration.
Patients will often report attempts to remove hard stool digitally from the rectum; self-induced trauma may thus also contribute to ulceration.
