GI COPY Flashcards

Question

What are the risk factors, histology, appearance and location of type 2 (diffuse/undifferentiated) gastric cancer?

Answer 1

- Risk factors: blood type A, genetic, younger age, diet (nitrates, nitrosamines), smoking, alcohol - Histology: poorly differentiated, signet ring cells - Appearance: GASTRIC LINITIS. Submucosa invasion. No movement on barium swallow (late sign) - Location: anywhere, especially cardia (defective adhesion because of CDH-1 mutation = defective E-cadherin = increased ability to invade and spread

Answer 2

CDH1 - 80% chance of gastric cancer. Prophylactic gastrectomy is done in these patients

Answer 3

- Often late presentation: - Anorexia, nausea, weight loss, anaemia, dysphagia, vomiting - Haematemesis - Malaena - Epigastric pain - better with ant-acids - Paraneoplastic syndromes, e.g. polycythaemia - Metaplastic signs, e.g. Krukenberg tumour

Answer 4

- Gastroscopy with biopsy: 8-10 biopsies - CT/MRI/PET - Endoscopic USS. 2 week wait for endoscopy if upper abdominal mass consistent with stomach cancer and: dysphagia of any age, \>55 + weight loss with upper abdominal pain, reflux or dyspepsia. Consider non-urgent endoscopy if haematemesis, treatment resistant dyspepsia, upper abdominal pain + anaemia - Laparoscopy final line

Answer 5

- Nutritional support - Proximal gastric cancer with no spread: 3 cycles of chemo and then a full gastrectomy. Lymph node removal too - Distal gastric cancer with no spread: 3 rounds of chemotherapy and then a partial gastrectomy if the tumour is causing stenosis or bleeding. Lymph node removal too - Gastrectomy = lack of intrinsic factor = give vitamin B12 to prevent pernicious anaemia

Answer 6

They will be deficient in intrinsic factor and so will need vitamin B12 supplements to prevent pernicious anaemia

Answer 7

- 3rd most common cancer in Western world, 4th leading cause of cancer deaths in the US - Risk factors: - Family history of bowel cancer - FAMILIAL ADENAMATOUS POLYPOSIS (FAP) (autsomal dominant) - HEREDITARY NONPOLYPOSIS COLORECTAL CANCER (HNPCC) - also known as LYNCH SYNDROME - IBD (Crohn's or ulcerative colitis) - Increased age - Diet (high in red and processed meat and low in fibre) - Obesity and sedentary lifestyle - Smoking - Alcohol - Radiotherapy - Hormonal factors; nulliparity, late first pregnancy, early menopause

Answer 8

Rectum (38%) and sigmoid colon (20%)

Answer 9

- Change in bowel habit, e.g. more frequent and loose stools - Rectal bleeding - Unexplained weight loss

Answer 10

- Change in bowel habit (more loose/frequent stools) - Abdominal pain - Abdominal mass upon inspection - Rectal bleeding

Answer 11

1. Abdominal pain 2. Abdominal mass upon inspection 3. Unexplained weight loss 4. Change in bowel habit (more frequent and loose stools)

Answer 12

- Colonoscopy - gold standard - Flexible sigmoidoscopy, barium enema, CT colonography - Faecal immunochemical test - look for amount of human haemoglobin in the stool. Used for patients who do not meet the specific criteria for a two week wait referral: - \>50 with unexplained weight loss and no other symptoms - \<60 with a change in bowel habit

Answer 13

USED to be Dukes' classification but has been replaced by TNM staging

Answer 14

- Dukes A – confined to mucosa and part of the muscle of the bowel wall - Dukes B – extending through the muscle of the bowel wall - Dukes C – lymph node involvement - Dukes D – metastatic disease

Answer 15

- T for Tumour: TX – unable to assess size T1 – submucosa involvement T2 – involvement of muscularis propria (muscle layer) T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa T4 – spread through the serosa (4a) reaching other tissues or organs (4b) - N for Nodes: NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes - M for Metastasis: M0 – no metastasis M1 – metastasis

Answer 16

- Caecal, ascending or proximal transverse colon = right hemicolectomy - Distal transverse, descending colon = left hemicolectomy - Sigmoid colon = high anterior resection - Upper rectum = anterior resection (TME) - Low rectum = anterior resection (low TME) - Anal verge = abdomino-perineal resection of rectum

Answer 17

- (FAP) = autosomal dominant condition involving malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC). It results in many polyps (adenomas) developing along the large intestine. These polyps have the potential to become cancerous (usually before the age of 40) - Colonoscopy every 1-2 years, beginning at 10-12 years of age - Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy)

Answer 18

- HNPCC (a.k.a. Lynch syndrome) is an autosomal dominant condition that results from mutations in DNA mismatch repair (MMR) genes. Patients are at a higher risk of a number of cancers, but particularly colorectal cancer. Unlike FAP, it does not cause adenomas and tumours develop in isolation - Colonoscopy every 1-2 years, beginning at 20-25 years of age. After surgery, sigmoidoscopy every 1-2 years if subtotal colectomy was performed, or colonoscopy if segmental resection was performed

Answer 19

- GORD is where acid from the stomach refluxes through the lower oesophageal sphincter (due to dysfunction) and irritates the lining of the oesophagus - The oesophagus has a squamous epithelial lining, whereas the stomach has a columnar epithelial lining, so the oesophagus is more sensitive

Answer 20

- Lifestyle factors: obesity, smoking, alcoholism, fat rich diet, caffeine - Medications, e.g. antihistamines, CCBs, antidepressants - inhibit the strength at which the LOS can contract - Hiatus hernia = lowers LOS pressure = increase reflux - Pregnancy

Answer 21

Dyspepsia is a non-specific term used to describe indigestion. It covers the symptoms of GORD: - Heartburn (retrosternal chest pain) - related to meals, worse when lying, relieved by antacids - Acid regurgitation - Retrosternal or epigastric pain - Bloating - Unexplained weight loss, anaemia, dysphagia, upper abdo mass, persistent vomiting (red flags) - Nocturnal cough - Hoarse voice

Answer 22

- Clinical diagnosis - First line = therapeutic challenge = give PPI = will get better - Gold standard = oesophageal manometry = 24hr of pH and pressure montoring - X-ray with barium contrasts = shows stenosis and ulcers - Endoscopy to assess for peptic ulcers, oesophageal or gastric malignancy. Red flags for urgent referral: - DYSPHAGIA (difficulty swallowing) - \>55 - Weight loss - Epigastric pain / reflux - Treatment resistant dyspepsia - Nausea and vomiting - Low haemoglobin (anaemia) - Raised platelets

Answer 23

- Conservative: - Quit smoking - Reduce alcohol - Weight loss - Avoid heavy meals before bed time and stay upright after meals rather than lying flat - Medical: - PPIs (first line) and H2 receptor antagonists (second line, e.g. ranitidine) - both decrease acidification of gastric acid secretions - Surgical: - GOLD STANDARD = Nissen Fundoplication = upper part of stomach wrapped around LOS = strengthens sphincters, prevents acid reflux

Answer 24

- Barrett's oesophagus (pre-malignant condition). This is because the cells try to adapt - stratified squamous to simple columnar - Oesophageal adenocarcinoma - Oesophagitis - Oesophageal strictures

Answer 25

- H. pylori is a gram negative aerobic bacteria. It lives in the stomach. It causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer. It avoids the acidic environment by forcing its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid - It also produces ammonia to neutralise the stomach acid, which directly damages the epithelial cells

Answer 26

- Peptic ulcers - Gastric carcinomas - Gastritis

Answer 27

- Urea breath test using radiolabelled carbon 13 - Stool antigen test - Rapid urease test can be performed during endoscopy. Also known as a CLO test (Campylobacter-like organism test). It is performed during endoscopy and involves taking a small biopsy of the stomach mucosa. Urea is added to this sample. If H. pylori are present, they produce urease enzymes that converts the urea to ammonia. The ammonia makes the solution more alkali giving a positive result on when the pH is tested

Answer 28

- TRIPLE THERAPY: - Proton pump inhibitor, e.g. omeprazole - 2 antibiotics, e.g. amoxicillin and clarithromycin for 7 days

Answer 29

- Barret's oesophagus = metaplasia of lower oesophagus epithelium from stratified squamous to simple columnar - It is caused by the constant reflux of acid - It is classified as a 'premaligant' condition. It is a risk factor for adenocarcinoma of the oesophagus - Pathology = squamous - metaplasia (goblet cells) - dysplastic (precancer) - neoplastic (cancer)

Answer 30

- GORD - Male (7:1) - Caucasian - FHx - Hiatus hernia - Obesity - Smoking - Alcohol

Answer 31

CLASSIC HISTORY - middle aged caucasian male with a long history of GORD and dysphagia

Answer 32

1. Upper GI endoscopy (oesophago-gastro-duodenoscopy) 2. Biopsy

Answer 33

1. Lifestyle: weight loss, smoking cessation, reduce alcohol, small meals, avoid hot drinks/alcohol/eating \<3 hrs before bed, avoid certain drugs (nitrates, anticholinergics, TCAs, NSAIDs, K+ salts, alendronate) 2. Endoscopic Surveillance with Biopsies 3. High dose PPI if non-dysplastic 4. Low grade dysplasia - radiotherapy with endoscopic mucosal resection 5. Severe (high grade dysplasia): radiotherapy with oesophagectomy

Answer 34

- Dilated veins at sites of portosystemic anastomosis (left gastric + inferior oesophageal veins) - As these vessels are thin and not meant to transport higher pressure blood, they can easily RUPTURE = haematemesis OR rupture = blood digested = malaena

Answer 35

- Pre-hepatic = portal vein thrombosis/obstruction - Hepatic = cirrhosis, schistosomiasis - Post-hepatic = Budd-Chiari, RHF, constrictive pericarditis, compression

Answer 36

- Haematemesis and/or melena - Epigastric discomfort - Sudden collapse - Sx haemodynamic instability

Answer 37

1ST LINE/GOLD STANDARD: upper GI endoscopy - FBC, U+E, clotting (INR), LFTs - CXR/ascitic tap/further Ix for PHT

Answer 38

- GOLD STANDARD - ENDOSCOPIC THERAPY: BAND LIGATION OR SCLEROTHERAPY - Small oesophageal varices = watch and wait - ABCDE - Medical for medium to large = beta blocker to reduce CO -\> reduce portal pressure and band ligation - Acute bleeding = ROCKALL SCORE (predicition of re-bleeding and mortality) - Nitrate to reduce portal pressure - Terlipressin – analogue of ADH -\> reduce portal pressure - Surgical: - Band ligation - Transjugular intrahepatic portosystemic shunt (TIPSS)

Answer 39

- Haematemesis from tear in oesophageal mucosa - Pathophysiology: severe vomiting = sudden increase in intra-abdominal pressure = partial laceration at gastro-oesophageal junction = bleeding from mucosa

Answer 40

- Alcoholism - Hypermesis gravidarum - Gastroenteritis - Bulimia - Chronic cough

Answer 41

- Haematemesis - Malaena - Sx of hypovolaemic shock

Answer 42

- Rockall score (assess blood loss: \<3 = low risk) - Endoscopy - FBC, U+E, coagulation studies, haematocrit - ECG + cardiac enzymes

Answer 43

- ABCDE - Urgent endoscopy - Anti-emetics if N+V persists - PPI to suppress acid

Answer 44

- Rupture through the oesophagus - Caused by an increased intraoesophageal pressure and a negative intrathoracic pressure - Meckler's triad: vomiting, chest pain and subcutaneous emphysema

Answer 45

- Rare disorder that makes it difficult for food to pass through oesophagus (LOS won't relax) - Degeneration of ganglion cells = oesophageal smooth muscle fibres fail to relax = oesophageal sphincter remains closed/fails to open - Will affect solids at the SAME POINT it affects liquids as it is a MOTILITY problem. In carcinomas, it will be PROGRESSIVE DYSPHAGIA (important)

Answer 46

- Dysphagia affecting solids and liquids AT THE SAME POINT - Heartburn - Weight loss - Coughing while lying horizontally

Answer 47

- Barium swallow X-ray and continuous fluoroscopy - normal peristalsis not seen - Oesophageal endoscopy with or without endoscopic ultrasound

Answer 48

- Medications: CCBs for mild to moderate, nitrates effective before dilation occurs, PPIs effective after surgery - Gold standard = Laparoscopic Heller myotomy = oesophageal dilation via surgical cleaving of muscle - Endoscopic myotomy

Answer 49

- Ischaemic bowel diseases can be classified into 3 main types: - Acute mesenteric ischaemia - Chronic mesenteric ischaemia - Ischaemic colitis - Acute & chronic mesenteric ischaemia almost always affect the small bowel, whereas ischaemic colitis affects the large bowel

Answer 50

- The bowel mostly gets its blood supply from the superior & inferior mesenteric arteries - "Watershed areas” like the splenic flexure + caecum are the most susceptible to ischaemia

Answer 51

- Mesenteric ischemia occurs when narrowed or blocked arteries restrict blood flow to your small intestine - Aetiology: - Superior mesenteric artery (SMA) THROMBOSIS - SMA EMBOLISM (DUE TO AF) - Mesenteric vein thrombosis - typically young patients who are in hypercoaguable states - Non-occlusive disease, e.g. poor blood flow, poor cardiac output

Answer 52

- Classical triad: - Acute, severe abdo pain - usually constant & central - No abdo signs on exam - Rapid hypovolaemia \> shock - The symptoms are often way out of proportion with clinical signs - IF YOU SEE AF WITH SEVERE ABDOMINAL PAIN, THINK AMI

Answer 53

Chronic mesenteric ischaemia is very similar to AMI, except the symptoms are on a lower level & persist for much longer. It is described as “abdominal angina”

Answer 54

- Bloods = ^^Hb due to blood loss and persistent metabolic acidosis due to ischaemia - ABDOMINAL X-RAY = used to rule out bowel obstruction - Laparoscopy = used to visualise the necrosis - CT/MRI ANGIOGRAPHY = non-invasive way to look at arteries to see blockages, but is a difficult scan to perform

Answer 55

- FLUID RESUSCITATION - Antibiotics - Metronidazole, Gentamicin - IV HEPARIN TO REDUCE CLOTTING - Surgery to remove necrotic bowel

Answer 56

- Sepsis - Peritonitis

Answer 57

- Ischaemic colitis = inflammation of the large intestine resulting from a lack of blood flow - Aetiology: - Thrombosis - Emboli - Low flow states - Low cardiac output/arrhythmias - Surgery - Vasculitis - Coagulation disorders - Oral contraceptive pill - Idiopathic

Answer 58

- SUDDEN ONSET LIF PAIN - Passage of bright red blood - SIGNS OF HYPOVOLAEMIC SHOCK

Answer 59

- Urgent CT to rule out perforation - Flexible sigmoidoscopy w/ biopsy - will show epithelial cell apoptosis - Colonoscopy w/ biopsy = Gold standard = only done AFTER patient has fully recovered to exclude the formation of a strictures at the site and to confirm mucosal healing - Barium enema

Answer 60

- Most patients will be fine with only symptomatic treatment - Fluid replacement - Antibiotics = reduce infection risks due to translocation of bacteria across the drying bowel wall - Strictures at the disease site are common - Gangrenous ischaemic colitis = peritonitis & hypovolaemic shock, will require surgical intervention

Answer 61

- Inflammation of the mucosa of the upper small bowel in response to GLUTEN (general name for proteins found in wheat) - AUTOIMMUNE - T cell mediated - Intolerance to PROLAMIN (in wheat, barley, rye, oats) - component of gluten protein - Causes VILLOUS ATROPHY, which leads to MALABSORPTION

Answer 62

- 1% of the UK population (yet only 25% diagnosed) - Males and females equally - Any age, peaks in infancy and 40-60 years

Answer 63

- FAMILY history - 10% risk in 1st degree relatives - HLA associated - HLA-DQ2 and HLA-DQ8 - Other AUTOIMMUNE diseases, e.g T1DM - IgA deficiency

Answer 64

- ALPHA-GLIADIN is resistant to digestion from protease enzymes (pepsin & chymotrypsin) in small intestine lumen - Passes through damaged epithelial wall, into cells - Deaminated by tissue TRANSGLUTAMINASE - Interacts with antigen-presenting cells via HLA-DQ2 or HLA-DQ8 - These activate gluten-sensitive CD4+ T-CELLS - T-cells produce pro-inflammatory cytokines -\> inflammatory cascade - Causes VILLOUS ATROPY and CRYPT HYPERPLASIA

Answer 65

Villous atrophy leads to MALABSORPTION

Answer 66

- Steatorrhoea + stinking stools - inability to properly absorb fat from diet - Anaemia - due to inability to absorb B12, folate, iron - Weight loss, fatigue & weakness, diarrhoea, abdominal pain, bloating, N+V - Aphthous ulcers - Angular stomatitis - Osteomalacia - decreased absorption of Vitamin D - Failure to thrive (children) - Dermatitis herpetiformis: - Raised red patched of skin - Blisters, burst with scratching - Elbows, knees, buttocks, torso, scalp - Deposition of IgA in skin

Answer 67

- Most patients who follow a strict diet recover, but a few are non-responsive - ANAEMIA - Osteoporosis - Hyposplenism - Neuropathies - Increased risk of MALIGNANCY: - T-cell lymphoma = increased T-cells in GI wall - Gastric, oesophageal, small bowel, colorectal cancer = increased cell turnover

Answer 68

- Serum antibody testing = FIRST LINE: - IgA TISSUE TRANSGLUTAMINASE (tTG) (can also test for IgA anti-endomysial antibody (EMA) = less sensitive) - Very high sensitivity & specificity, false negatives in IgA deficiency, offered to people with other autoimmune diseases - Positive/negative with high index of suspicion = biopsy - Duodenal BIOPSY = GOLD STANDARD: - Endoscopically, required for definite diagnosis - Postive findings: villous atrophy, crypt hyperplasia, increased epithelial WBCs - FBC: low Hb, low folate, low ferritin, low B12, ~50% have mild anaemia - Genetic testing: HLA-DQ2 and HLA-DQ8 genotyping - DEXA scan - because of the increased risk of osteoporosis

Answer 69

- Lifelong GLUTEN-FREE DIET: - Avoid foods containing wheat, barley, rye, oats - GLUTEN-FREE FOOD are now more available - Poor compliance is the main reason for recurrence - Symptoms and serology used to monitor response and compliance

Answer 70

- Inflammatory bowel disease = a term used to mainly describe two CHRONIC and AUTOIMMUNE conditions: - ULCERATIVE COLITIS - CROHN'S DISEASE - Mucosal immune system responds inappropriately to luminal antigens, e.g. bacteria when they enter mucosa via leaky epithelium - Jewish people are the most affected group

Answer 71

- Ulcerative colitis = inflammation of colon, ulcers are present - MACROSCOPIC: - ONLY COLON affected - STARTS AT RECTUM, can progress as far as ileocaecal valve - CIRCUMFERENTIAL AND CONTINUOUS inflammation – no skip lesions - ULCERS + PSEUDO-POLYPS in severe disease - MICROSCOPIC: - MUCOSA ONLY inflamed - no deeper (not transmural) - CRYPT ABCESSES - Depleted goblet cells

Answer 72

- Cause: “Inappropriate immune response against (possibly abnormal) colonic flora in genetically susceptible individuals - Risk factors: - Family history - NSAIDS - Chronic stress + depression

Answer 73

- Highest prevalence in northern Europe & North America - Affects males + females equally - Presentation mostly at 20-40 YEARS - Higher incidence than Crohn’s - SMOKING IS A PROTECTIVE FACTOR against UC - Incidence is 3x higher in non-smokers - Symptoms may relapse on stopping smoking

Answer 74

- Remissions + exacerbations - Abdo pain – lower left quadrant - Abdo cramps/discomfort - Episodic or chronic diarrhoea: blood and mucus, urgency, frequency relates to severity, night & day in severe attacks - Systemic symptoms in attacks: fever, anorexia, malaise, weight loss

Answer 75

- Might be no signs - Acute, severe UC = fever, tachycardia, tender, distended abdomen - Extraintestinal signs = clubbing, oral aphthous ulcers, nutritional deficits - Extraintestinal complications

Answer 76

- Colon: blood loss, perforation, toxic dilatation, colorectal cancer - Skin: erythema nodosum (tender red bumps, symmetrically on shins), pyoderma gangrenosum (painful ulcers on skin) - Joints: ankylosing spondylitis, arthritis (HLA-B27 associated) - Eyes: iritis, uveitis, episcleritis - Liver: fatty change, chronic pericholangitis, sclerosing cholangitis - Venous thromboembolism

Answer 77

- Blood tests: raised WCC, raised platelets, raised CRP + ESR - Anaemia: normocytic of chronic disease most likely - pANCA may be POSITIVE (it's negative in Crohn's) - Liver biochemistry may be abnormal - Hypoalbuminaemia - in severe disease - COLONOSCOPY - BIOPSY = GOLD STANDARD. Sigmoidoscopy - diagnosis, full colonoscopy - to define extent, once controlled - Stool samples = to exclude C.diff, Campylobacter + others - Faecal calprotectin - indicates IBD if raised, doesn't differentiate UC and Crohn's - Abdominal X-ray = to exclude colonic dilatation. Also useful when UC is too severe for colonoscopy

Answer 78

- Aiming to induce REMISSION SULFASALAZINE, mesalazine, olsalazine (all used in mild to moderate cases). Oral – FIRST LINE for left sided/extensive. Rectal (suppository) – for proctitis (inflammation of rectal lining) - Mild/moderate: ORAL PREDNISOLONE (glucocorticoid steroid). SECOND LINE – if they don’t respond to a 5-ASA. Also used in severe cases - Severe with systemic features: IV Hydrocortisone, ciclosporin, infliximab - Maintaining remission: 5-ASA or azathioprine if still relapsing on 5-ASA - SEVERE cases with NO RESPONSE to treatment = surgery: - Colectomy: - Whole colon removed - Ileoanal anastomosis OR ileostomy -\> stoma

Answer 79

- Crohn's disease = inflammation in the GI tract - MACROSCOPIC: - Affects ANY PART of GI tract – MOUTH TO ANUS - especially terminal ileum & proximal colon - NON-CONTINUOUS inflammation – SKIP LESIONS - Cobblestone appearance – ulcers + fissures in mucosa - MICROSCOPIC: - TRANSMURAL inflammation – through all layers of bowel wall - GRANULOMAS - non-caseating - Increased chronic inflammatory cells + lymphoid hyperplasia

Answer 80

- Cause: inappropriate immune response against (possibly abnormal) colonic flora in genetically susceptible individuals - Risk factors: - Family history - Stronger genetic association than UC - Smoking - 2-4x risk - NSAIDs - exacerbate it - Chronic stress + depression - triggers flares

Answer 81

- Highest prevalence in northern Europe & north America - Affects females more than males - Presentation mostly at 20-40 years - Lower incidence than UC

Answer 82

- Small bowel: - ABDOMINAL PAIN - WEIGHT LOSS - Terminal ileum - RIGHT iliac fossa pain mimicking appendicitis - less common - Colon: - BLOODY DIARRHOEA = URGENCY - PAIN ON DEFECATION - Systemic symptoms on attack: fever, anorexia, malaise, fatigue

Answer 83

- Bowel ulceration - Abdominal tenderness - Abdominal mass - Perianal disease - Extraintestinal signs: - Clubbing - ORAL APHTHOUS ULCERS - more common than in UC - Skin, joint + eye problems

Answer 84

- Bowel: - Malabsorption, either from Crohn’s or following surgery -\> malnutrition - Small bowel obstruction - Toxic dilatation - Bowel perforation - Abscess formation - Fistula formation - Sclerosing cholangitis - Colorectal cancer - Anaemia - Iron/folate deficiency - Perianal disease: abscesses, fistulae, skin tags, fissures - Amyloidosis (systemic) = rare - Venous thromboembolism - Extra-intestinal complications are rarer than in UC

Answer 85

MARSH CLASSIFICATION: - Marsh 1 - solely intraepithelial lymphocytes with NO crypt hyperplasia - Marsh 2 - intraepithelial lymphocytes and crypt hyperplasia - Marsh 3a - intraepithelial lymphocytes and partial/mild villous atrophy - Marsh 3b - intraepithelial lymphocytes and subtotal/moderate villous atrophy - Marsh 3c - intraepithelial lymphocytes and total villous atrophy

Answer 86

- Blood tests: raised WCC, raised platelets, raised CRP & ESR - Anaemia: normocytic of chronic disease. Iron, folate or B12 deficiency - Liver biochemistry may be abnormal - Hypoalbuminemia – in severe disease - pANCA NEGATIVE - COLONOSCOPY - BIOPSY = GOLD STANDARD. Granulomatous transmural inflammation - Stool samples = to exclude C.diff, Campylobacter & others - Faecal calprotectin = indicates IBD if raised, doesn’t differentiate UC & Crohn’s - Small bowel imaging = to detect proximal disease, e.g. capsule endoscopy - Abdominal X-Ray - MRI – strictures & fistulae - Ultrasonography

Answer 87

- Aiming to induce remission - Mild/moderate: - ORAL PREDNISOLONE = glucocorticoid steroid - FIRST LINE. 2nd line = 5-ASA - Severe disease: - IV hydrocortisone - Smoking cessation - Correct iron/folate/B12 deficiencies - Antibiotics for perianal disease, e.g. Metronidazole - Liquid enteral nutrition - If not responsive to steroids: - ANTI-TNF ANTIBODIES, e.g. infliximab, adalimumab - Maintaining remission: - AZATHIOPRINE (1st line) - Methotrexate (if intolerant to azathioprine - Infliximab/Adalimumab (if resistant to immunosuppressives) - Surgery: - Resection of worst affected areas of bowel. Up to 80% require 1+ operation. Never fully cures, so kept to a minimum. Recurrence is almost inevitable in remaining bowel. Short bowel syndrome - lifelong (diarrhoea, malabsorption) - Indications: failure of medical therapy, obstruction from strictures, istulae, abscesses, perianal disease, toxic dilatation & perforation - Temporary ileostomy - allows time for affected areas to rest

Answer 88

- IBS = mixed group of abdominal symptoms with NO ORGANIC CAUSE - Epidemiology: - Age of onset \<40 years - More common in FEMALES than males - 1 IN 5 in western world

Answer 89

- Disorders of intestinal motility - Enhanced visceral perception - Disfunction of brain-gut axis - Microbial dysbiosis (imbalance)

Answer 90

- Biologically female - GI infections - Previous severe long-term diarrhoea - Anxiety and depression - Psychological stress, trauma, abuse - Eating disorders

Answer 91

- IBS-C – with constipation - IBS-D – with diarrhoea - IBS-M – mixed, with alternating constipation & diarrhoea

Answer 92

- A diagnosis of IBS should be considered if patients report ANY of (ABC): - Abdominal pain/discomfort - Bloating - Change in bowel habit

Answer 93

- Diagnosis criteria: - ABDOMINAL PAIN/DISCOMFORT associated with 2+ of: - RELIEVED BY DEFECATION - ALTERED STOOL FORM - ALTERED BOWEL FREQUENCY - Other symptoms: - Urgency - Incomplete evacuation - Abdominal bloating/distension - Mucus in rectum & stool - Worsening of symptoms after food - Abdominal tenderness

Answer 94

- Painful periods - Bladder symptoms: frequency, urgency, nocturia, incomplete emptying - Back pain - Joint hypermobility - Fatigue - Nausea

Answer 95

- Symptoms are chronic – 6+ months - Symptoms are exacerbated by: - Stress - Menstruation - Gastroenteritis - Food

Answer 96

- Coeliac disease - Lactose intolerance - Bile acid malabsorption - Inflammatory bowel disease (IBD) - Colorectal cancer - GI infection - Pancreatic insufficiency

Answer 97

- Ulcerative colitis: colon only, continouous lesions (circumferential), only mucosal inflammation, lower RIGHT quadrant pain, pseudo-polyps, crypt abcesses, depleted goblet cells, mucus + blood in stools - Crohn's disease: whole GI tract, skip lesions - non-continuous, transmural inflammation, lower LEFT quadrant pain, granulomatous inflammation, cobblestone appearance, blood in stools

Answer 98

- Unexplained weight loss - Bleeding on defecation/wiping - Abdominal/rectal mass - Raised inflammatory markers - Anaemia - Family history - Aged over 50 - Nocturnal symptoms

Answer 99

- Blood tests: FBC – anaemia, ESR & CRP – inflammation, tTG/EMA – Coeliac's disease - Faecal calprotectin – raised in IBD - Colonoscopy – IBD, colorectal cancer

Answer 100

- Education & reassurance - Dietary modification: regular meals or small frequent meals. Plenty of fluids. Avoid caffeinated, alcoholic, fizzy drinks - Keep a food diary - identify trigger foods - Avoid fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs): found to cause IBS symptoms. Include apples, cherries, peaches, lactose, legumes, green vegetables (broccoli, sprouts, cabbage, peas), artificial sweeteners

Answer 101

- SOLUBLE FIBRE: - Dissolves in water - Broken down by bacteria - Softens stool - Barley, oats, beans, prunes, figs

Answer 102

- AVOID INSOLUBLE FIBRE: - Makes diarrhoea worse - Doesn’t dissolve in water - Passes through gut unchanged - Bulks up faeces - Increases gut motility - Cereals, whole-wheat bread, lentils, apples, avocados

Answer 103

- Pharmacotherapy: - For pain/bloating: - ANTISPASMODICS - mebeverine, buscopan - For diarrhoea: - LOPERAMIDE (IMODIUM) - For constipation: - LAXATIVES: macrogol, docusate, senna. Linactolide (12 months constipation not relieved by 2 different max. dose laxative classes). Prucalopride (alternative when other laxatives fail)

Answer 104

- TRICYCLIC ANTIDEPRESSANTS, e.g. amitriptyline, nortriptyline. Warn about drowsiness. Take about 4-6 weeks to have an effect. Dampen down gut severity - If tricyclic antidepressants aren't tolerated, move to SSRIs - consider side effects. Can be used in conjunction with psychological therapies, e.g. CBT - For severe IBS: refer to PAIN TREATMENT CENTRE

Answer 105

- The appendix is a vestigial organ with disputed functionality - It is located at McBurney’s point which lies 2/3rds of the way from the umbilicus to the anterior superior iliac spine

Answer 106

- Acute appendicitis = sudden inflammation of the appendix - Epidemiology: - Appendicitis can occur at any age, although its highest incidence is ~10-20yrs - Appendicitis is the most common surgical emergency and is commonly examined

Answer 107

- Most commonly, acute appendicitis occurs because of an obstruction within the appendix, however this obstruction can arise in many different ways: - FAECOLITHS - Bezoars/foreign bodies - Trauma - Intestinal worms - Lymphoid hyperplasia

Answer 108

The obstruction of the appendix results in the invasion of gut organisms into the appendix wall. This leads to inflammation, necrosis and eventually perforation

Answer 109

- EARLY PAIN/DISCOMFORT AROUND THE UMBILICUS THAT MIGRATES TO THE RIGHT ILIAC FOSSA. As the inflammation of the appendix progresses, it irritates the overlying peritoneum causing severe, localised pain at MCBURNEY'S POINT - GUARDING - Tender mass in RIF - PYREXIA - Anorexia - NAUSEA AND VOMITING - Rosving’s sign - left lower-quadrant palpated = right lower-quadrant pain - Moving/coughing causes pain due to peritonism - You can get chronic (grumbling) appendicitis, but this is not examined and presents with milder symptoms

Answer 110

- Acute Crohn’s disease - Ectopic pregnancy - UTI - Diverticulitis - Perforated ulcer - Food poisoning - Constipation - Strangulated hernia

Answer 111

- Blood tests: RAISED WCC (+/- ^neutrophils), RAISED CRP & ESR - Ultrasound: can detect an inflamed appendix, may show an appendiceal mass - CT = GOLD STANDARD = highly sensitive & specific - Pregnancy test to exclude ectopic pregnancy - Urinalysis to exclude UTI

Answer 112

- APPENDICECTOMY = GOLD STANDARD. This is a laparoscopic (keyhole) procedure in most cases, however in severe cases laparotomy (open) surgery is required - IV antibiotics & fluids both pre & post-operatively, e.g. metronidazole, cefuroxime

Answer 113

- PERFORATION - Appendix mass - small bowel & omentum adhere to appendix - Appendiceal abscess - ADHESIONS - Pelvic inflammatory disease (PID)

Answer 114

- Peptic ulcer = break in the lining of the gastric or duodenal mucosa = chronic mucosal ulceration of stomach/duodenum - Risk factors: - H.pylori infection (most common) - increased gastric acid secretion, decreases duodenal HCO3- secretion - NSAIDS - particularly low dose aspirin corticosteroids - Zollinger-Ellison syndrome (tumour that causes hypergastrinaemia) - Physiological stress

Answer 115

- Up to 70% asymptomatic - ROUND, CIRCULAR, CLEANED OUT BASE = peptic ulcer - Epigastric burning pain - may mimic MI. Usually occurs few hours after meal, worsens at night . Peptic ulcer = pain increases when eating and goes 2-3 hours later. Duodenal ulcer = pain decreases when eating and comes 2-3 hours later - Nausea and vomiting

Answer 116

- Duodenal ulcer = H.pylori test (faecal antigen test or urease breath test). No PPIs and antibiotics within 2 and 4 weeks respectively - 1st line - Peptic ulcer = upper GI endoscopy with biopsy (if \>55 or red flags present) - 1st line and gold standard

Answer 117

- Lifestyle modification (weight loss, smoking cessation etc.) - Treat cause (stop NSAIDS and/or eradicate H.pylori - PPIs, clarithromycin, amoxicillin). If no PPI then H2 receptor antagonists - Re-scoped 6-8 weeks after treatment to see if healed - Surgery: endoscopic ligation/coagulation of bleeding ulcers

Answer 118

- Bleeding - Perforation - Gastric cancer

Answer 119

- Gastric ulcers: - Pathology: lesser curvature of gastric antrum - Risk factors: H.pylori infection, smoking, drugs (NSAIDS, SSRIs, corticosteroids, bisphosphonates) - Presentation: epigastric pain - worse on eating, relieved by antacids - Complications: haemmorrhage, perforation, gastric outflow obstruction, malignancy

Answer 120

- Duodenal ulcers: - Pathology: more common than gastric ulcers, 1st part of duodenum - Risk factors: H.pylori, smoking, drugs, alcohol - Presentation: epigastric pain - before meals and at night, relieved by eating or milk - Complications: haemorrhage, perforation, gastric outflow obstruction, malignancy

Answer 121

- Gastritis: inflammation of the stomach's mucosal lining - Two types: - Acute gastritis - Atrophic gastritis (chronic gastritis)

Answer 122

- Acute: aspirin + NSAIDS (inhibit COX-1 = less prostaglandins = increase in acidity due to less bicarbonate release), H.pylori (releases urease and protease), alcohol, stress - Atrophic: infectious or autoimmune (damage to parietal cells = less intrinsic factor = less vitamin B12 absorption = pernicious anaemia)

Answer 123

- May be asymptomatic - Epigastric pain - N + V - Mucosal ulcers

Answer 124

- If H.pylori risk factors: H.pylori faecal antigen test (first line) H.pylori urea breath test (first line but not as important) - Endoscopy and biopsy (GOLD STANDARD)

Answer 125

- Encourage fluid intake, small light non-fatty meals (mild treatment) - Addressing cause, e.g. NSAIDs (PPI or H2 receptor antagonist to decrease acidity of the stomach) (moderate to severe treatment) - H.pylori eradication (triple therapy: PPI (omeprazole, given to reduce the side effects of antibiotics, e.g. ulcers), clarithromycin, amoxicillin) (moderate to severe treatment) - Correction of vitamin deficiency

Answer 126

a) diverticulum = outpouching of gut mucosa (gaps in wall of gut where blood vessels penetrate. Very common in those \>50 years. Can be true (all layers) or false (mucosa and submucosa) b) diverticulosis = presence of multiple diverticula c) diverticulitis = inflammation/infection of diverticulum d) diverticular disease = diverticula are symptomatic e) Meckel's diverticulum = common congenital abnormality of GI tract. 2-3% of the population. Usually asymptomatic

Answer 127

- Meckel's diverticulum is caused by incomplete obliteration of the vitelline duct - True diverticula of all 3 layers of the small intestines - Usually asymptomatic but can get painless bleeding due to ulcer caused by heteroscopic gastric tissue - Investigation: 99M TECHNETIUM PERTECHNETATE - MECKEL'S SCAN (nuclear medicine scan)

Answer 128

Sigmoid colon - it has the smallest luminal diameter and the highest pressure

Answer 129

- Risk factors: low fibre diet, obesity, smoking and NSAIDS - Complications: strictures (intestinal obstruction), fistula formation, e.g. bladder communication

Answer 130

- LIF pain with tenderness - Palpable LIF mass - Constipation - Tachycardia - Fever

Answer 131

- Bloods - raised WCC, ESR + CRP - Imaging: erect CXR, AXR and CT scan with contrast. May show: - Pneumoperitoneum - Dilated bowel loops - Obstruction - Abcess

Answer 132

- Oral/IV antibiotics - ciprofloxacin, metronidazole - Analgesia + liquid diet +/- fluid resus - Surgical resection - rare cases

Answer 133

- Risk factors: low fibre diet, obesity and age (\>40) - Presentation: altered bowel habit, abdominal pain, bleeding PR

Answer 134

- Abdominal CT scan - Colonoscopy - FBC

Answer 135

- High fibre diet and fluids +/- laxatives - Surgery

Answer 136

- Pink colonies on MacConkey agar (lactose-fermenting) - Commonly associated diseases: genitourinary tract infections (leading cause of cystitis, pyelonephritis, prostatitis), intra-abdominal infections (enteric infections, abcesses, cholecystitis, spontaneous bacterial peritonitis), meningitis (in neonates) - Different types: Enteroinvasive (EIEC), Enterotoxigenic (ETEC), Enteropathogenic (EPEC), Enterohaemorrhagic (EHEC)

Answer 137

- EIEC (enteroinvasive E.coli) = dystentery, mimics shigellosis; bloody diarrhoea, abdominal pain, tenesemus - EHEC (enterohaemorrhagic E.coli) = BLOODY DIARRHOEA AND SHIGA-LIKE TOXIN, malaise, fever - ETEC = watery diarrhoea (Travellers' diarrhoea), nausea, abdominal pain - EPEC = fever, watery diarrhoea - can last \>2 weeks, typically affects children

Answer 138

- Antimicrobial treatment (UTIs, pneumonia, meningitis, intra-abdominal infections, sepsis) - Antidiarrhoeal medications - contraindicated in children and EIEC infections - EHEC - antibiotics contraindicated - can increase the risk of HUP and TTP complications - ETEC - antibiotics useful; reduce diarrhoea duration

Answer 139

- Risk factors: antibiotic exposure, previous hospitalisation (increased risk for infection), children with neutropenia - Complications: - Multiple relapses, dehydration (due to diarrhoea) - GI complications: toxic megacolon, colon perforation, intussusception, pneumatosis, ascites - Extraintestinal complications: splenic abcess, osteomyelitis

Answer 140

- Watery diarrhoea (most common) with mucus and blood - Abdominal distension, cramps - Malaise - Fever

Answer 141

- C.difficile = DIFFICULT to treat: - Mild disease: oral metranidazole - Severe disease: oral vancomycin - Complications: combination of oral vancomycin, IV metronidazole - Surgery: colectomy

Answer 142

Pseudomembranous colitis refers to swelling or inflammation of the large intestine (colon) due to an overgrowth of Clostridioides difficile (C.difficile) bacteria. This infection is a common cause of diarrhoea after antibiotic use

Answer 143

- Haemorrhoid: anal cushions hypertrophy due to supportive tissue deterioration - Two types: - Internal: affecting haemorrhoidal venous cushions above the dentate line, 4 grades - External: affecting haemorrhoidal venous cushions below the dentate line

Answer 144

- Itching - Bleeding associated with bowel movement - Pain - Mucous discharge

Answer 145

- Anoscopic examination - Colonoscopy/flexible sigmoidoscopy

Answer 146

- Medications: stool softeners, topical + systemic analgesics - Surgery: sclerotherapy, rubber band ligation - Increase fibre and fluid intake

Answer 147

- Anal fistula = abnormal connection between anal canal and perianal skin - Different types: - Intersphincteric - Transsphinteric - Suprasphinteric - Extrasphinteric

Answer 148

Skin excorations, pus/serous fluid/faeces draining from the skin-opening, bleeding, itching, pain, redness, swelling

Answer 149

- Investigations: anal examination - delineate course of fistula - Treatment: surgery - drain infection, eradicate fistulous tract, preserve anal sphincter function, avoid recurrences

Answer 150

- Anal fissure = small tear in the anal mucosa - Risk factors: low fibre diet, diarrhoea, previous anal surgery

Answer 151

- Midline tear - Pain during bowel movements - Blood on toilet paper

Answer 152

- Clinical diagnosis - Anal manometry

Answer 153

- Medications: stool softeners, topical nitrates/CCBs - Surgery: sphincterotomy - Proper anal hygeine, fibre supplementation

Answer 154

Perianal abcess is a superficial infection that appears as a tender red lump under the skin near the anus. The infection occurs when bacteria gets trapped in the crypt glands that line the anal canal

Answer 155

A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks, where they divide (the cleft). It does not always cause symptoms and only needs to be treated if it becomes infected

Answer 156

1) Continuous lesions - UC 2) Can be managed with TCAs or SSRIs - IBS 3) Transmural lesions - Crohn's 4) Nocturnal diarrhoea - IBD, not IBS 5) Villous atrophy - Coeliac's 6) Mucoid diarrhoea - UC 7) Dermatitis herpetiformis - Coeliac's 8) pANCA positive IBD - UC 9) Smoking is a protective factor for this disease - UC 10) tTG & EMA positive - Coeliac's 11) Has 3 distinct sub-types - IBS 12) Can use methotrexate to maintain remission - Crohn's

Answer 157

C) Duodenal biopsy

Answer 158

D) Olsalazine

Answer 159

B) Metastases

Answer 160

B) Abdominal X-ray

Answer 161

E) Malignancy

Answer 162

A) Norovirus

Answer 163

1. Appendicitis, Diverticulitis, Peritonitis, GU Issues, Bowel Cancer 2. Bowel Cancer 3. Diverticulitis 4. Colonoscopy, due to increased risk of perforation 5. Oral/IV Antibiotics, Analgesia, Fluid Resus, Liquid Diet

Answer 164

1. Mallory-Weiss tear, oesophageal ulcer, PUD, gastritis, oesophageal rupture, cancer 2. NSAIDS, SSRIs, bisphosphonates 3. OGD + Biopsy 4. Liver Disease, Portal Hypertension/PVT, cirrhosis, BCS, constrictive pericarditis, RHF 5. ABCDE, Rockfall Score (Prediction of Rebleeding and Mortality), Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS, Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy

Answer 165

- Beer: 4% x 568ml x 4 x7 ÷ 1000 = 63.6 - Wine: 13% x 175ml x 2 x 2 ÷ 1000 = 9.1 - Total no. of units per week = 72.7 (73)

Answer 166

D. Hyperglycaemia - causes hypoglycaemia

Answer 167

d) Autoimmune gastritis

Answer 168

c) Admit to surgery

Answer 169

a) Encourage fluid intake. A = mild gastritis treatment, B = contraindicated as it's an infective cause, C = treatment for GORD, D = treatment for H.pylori if gastritis is severe

Answer 170

A. C = for E.coli

Answer 171

d) Duodenal ulcer

Answer 172

a) Serum gastrin. A = Zollinger-Ellinson - PPI resistant ulcers with GORD, C = he halready has GORD, D = PPIs already tried, E = would show stenosis but stenosis isn't associated with ulcers

Answer 173

b) Urease breath test

Answer 174

c) Faecal antigen test. A = first line for peptic ulcers, C = first line for duodenal ulcers, D = used to confirm absence of H.pylori

Answer 175

a) Biopsy. A = peptic ulcer with weight loss so malignancy more likely, B = duodenal ulcers and gastritis are more likely than H.pylori, C = reasonable but not

Answer 176

c) Squamous - metaplasia - dysplastic - neoplastic

Answer 177

b) Oesophageal cancer

Answer 178

b) Benign oesophageal cancer

Answer 179

D. Sigmoid volvulus

Answer 180

D. Dukes D

Answer 181

B. The majority of cancers occur in the proximal colon

Answer 182

C. Dysphagia to solids and liquids occurring from the start

Answer 183

D. Coeliac disease

Answer 184

E. Abdominal pain relieved by defaecation

Answer 185

E. It is associated with an increase in the risk of gastric cancer

Answer 186

B. Continuous colonic involvement on endoscopy

Answer 187

C. Ascites

Answer 188

D. Clostridium difficile

Answer 189

B. Tinkling bowel sounds

Answer 190

c) Endoscopy

Answer 191

b) Repeated sickness

Answer 192

d) Nothing

Answer 193

d) Mallory-Weiss tear

Answer 194

c) Focal lesions with normal adjacent mucosa in distal oesophagus = aka Mallory-Weiss tear

Answer 195

E. Sigmoid volvulus

Answer 196

A. Hepatic vein

Answer 197

C. Cleared previous infection

Answer 198

A. Transmural inflammation

Answer 199

B. Lipase inhibition

Answer 200

B. Cholangiocarcinoma of the pancreatic head

Answer 201

D. Ascending cholangitis

Answer 202

D. Acute mesenteric ischaemia

Answer 203

D. Coeliac disease

Answer 204

D. Acute diverticulitis

Answer 205

E. Duodenal ulcer

Answer 206

B. 30% of bile is reabsorbed by the enterohepatic circulation

Answer 207

B. Difficulty swallowing solids and liquids from the start

Answer 208

D. AST/ALT ratio \<1

Answer 209

C. Pernicious anaemia

Answer 210

C. Murphy's sign

Answer 211

C. Cholecystokinin

Answer 212

B. CT abdomen

Answer 213

C) 7 days PPI + clarithromycin and metronidazole

Answer 214

Note – you would do a nitrogen breath test first You would want to look for alternatives to the NSAID or at least prescribe gastric protection

Answer 215

D) Oral prednisolone. This is severe UC (severe as ≥10 per day, UC indicated by bloody diarrhoea and tenesmus) so high-dose IV steroids should be started as soon as possible

Answer 216

C) Increase oral fluid intake; watch and wait. ## Footnote Traveller’s diarrhoea is most likely to be E. coli and therefore the most appropriate treatment is supportive. He is managing at home so admission probably isn’t necessary, metronidazole would be used for e.g. Giardia but that has a longer, drawn out course. Generally try to avoid antimotility in diarrhoea ESPECIALLY if it might be E.coli.

Answer 217

d) Inflammation beyond the ileocaecal valve. ## Footnote Crohn’s disease is characterised by transmural (full-thickness) inflammation of anywhere within the GI tract, there are skip lesions and no goblet cell depletion. Answers A, B, C and E are characteristic of Ulcerative Colitis

Answer 218

This patient has achalasia. Dysphagia affecting solids more than liquids. No apparent underlying cause. REGURGITATION RATHER THAN REFLUX

Answer 219

a) Coeliac disease b) Bread, pasta. Anything containing whear, rye, barley, or oats c) Anti-tTG antibody. Patient must keep gluten in diet 6 weeks prior to this d) Villous atrophy, crypt hyperplasia e) Lifelong gluten-free diet

Answer 220

d) Duodenal ulcer, gastroduodenal artery. ## Footnote This man has a duodenal ulcer with an acute bleed: a posterior duodenal wall ulcer may erode into the gastroduodenal artery! You can differentiate between a gastric and duodenal ulcer by how it relates to eating: pain relieved with meals suggests duodenal; worse with meals suggests gastric. Despite the history of GORD, this presentation is too acute to be Barrett’s oesophagus. A Mallory-Weiss tear is a tear of the mucosa in the lower oesophagus and is preceded by a history of forceful coughing or vomiting

Answer 221

c) Laparoscopic appendicectomy. ## Footnote Chloe has appendicitis: Generalised abdominal pain localising to McBurney’s Point in the RIF. The Gold Standard for management is a laparoscopic appendicectomy. Laparoscopic cholecystectomy is the Gold Standard for management of cholecystitis, which would present similarly but localise to RUQ, not RLQ. Ultrasound scan abdomen would be an investigation, not management, and the other options are forms of symptomatic / conservative management

Answer 222

a) E.coli b) IBS c) Medication related

Answer 223

d) Associated with HLA-DQ2/DQ8. ## Footnote A = GORD, C = Crohn’s, E = Jaundice. 2 month old babies don’t eat gluten - so it must be D!

Answer 224

a) Prednisolone

Answer 225

a) Painless bleeding with bowel movements. A and C both involve pain and are mutually exclusive (i.e., both cannot be true) - therefore the answer must be A or C by default. A = Applies to internal haemorrhoids only: external = painful. A is the single best answer as it is the differentiating feature

Answer 226

b) Inflamed and infected pouches of the sigmoid. Julie has diverticulitis: ## Footnote Management: - If uncomplicated / mild infection: PO antibiotics & liquid diet - If complicated: IV antibiotics, drain any abscesses - Surgery may be indicated if: Complicated, recurrent, immunocompromised Primary bowel resection with anastomosis Bowel resection with colostomy

Answer 227

d) 125mg Vancomycin QD PO 10 days

Answer 228

c. Loperamide is an appropriate treatment for IBS-related constipation. ## Footnote Answers A, B, D and E are all correct. Loperamide, whilst used in the management of IBS, is an anti-motility drug - you don’t want to give this to a constipated patient! It is used to treat diarrhoea. Senna and Movicol are appropriate for IBS-related constipation. Buscopan is an antispasmodic used to treat pain

Answer 229

d) Abnormal pocket in the skin and rectum or anal canal causing discharge. A = rectal prolapse B = anal fissure C = fistula D = pilonidal sinus E = internal haemorrhoids

Answer 230

d) Ibuprofen A = appropriate for H.pylori infection, which is a cause of gastritis B = PPI - blocks acid production and promotes healing C = H2 receptor antagonist - reduces acid production D = NSAIDs - can damage the gastric mucosa by suppressing prostaglandin synthesis, impair barrier properties of mucosa and reduce mucosal blood flow E = Antacid - neutralise acid, appropriate symptom relief

Answer 231

b) Simple columnar epithelium with goblet cells

Answer 232

a) Bowel obstruction b) Intussusception c) Conservative management - treat the symptoms IV fluids, nasogastric suction Surgery if persists

Answer 233

a) Mesenteric ischaemia → narrowed / blocked arteries restrict blood flow to small intestine. Ischaemic colitis → temporary restriction of blood supply to the large intestine due to vasoconstriction or low pressure flow b) Demographic: Age (\>60), Sex (F\>M). Clotting Abnormalities: i.e., Factor V Leiden. High Cholesterol → Atherosclerosis → Vessel narrowing. Reduction of blood flow → HF, Low BP, Shock, DM, RA. Prev abdo surgery → scar tissue. Heavy exercise → may lead to reduced colonic blood flow. Surgery involving the aorta c) Sepsis, bowel necrosis (→ short bowel syndrome), death, fear of eating, unintentional weight loss d) CT Abdomen (rule out other things such as IBD), Colonoscopy, Stool culture (rule out infection). Investigate with angiography, doppler ultrasound e) Mesenteric ischaemia (surgical management of ischaemic colitis may involve bowel resection due to necrosis or blockage, or repairing a hole in the colon)

Answer 234

a) Abnormal, enlarged veins in the oesophagus that develop when normal blood flow to the liver is blocked by a clot/scar tissue b) The bleeding varices can result in swallowing large amounts of blood, which can cause black, tarry stools

Answer 235

b) Mallory-Weiss tear, bloody stools ## Footnote A = Lung cancer, ipsilateral anhidrosis → No symptoms of cancer or Horner’s syndrome B = Mallory-Weiss tear, bloody stools → Correct answer - fits clinical picture and history C = Gastric ulcer, left upper quadrant pain → May occur as complication but no history of reflux D = Oesophageal varices, chest pain → Would be a more acute picture E = Hiatus hernia, reflux → No symptoms of heartburn, reflux or feeling of fullness