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Medicine Finals > GI & General Surgery > Flashcards

GI & General Surgery Flashcards

1
Q

What is the treatment for H.pylori?

A

Triple therapy
PPI + amoxicillin + ciprofloxacin/metronidazole

If penicillin allergic
PPI + ciprofloxacin + metronidazole

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2
Q

How is H.pylori infection diagnosed?

A

Urea breath test

C13 stool test

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3
Q

What is the most common type of peptic ulcer?

A

Duodenal ulcer

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4
Q

How do peptic ulcers present?

A

Abdominal pain

Nausea/vomiting

Dyspepsia

May be history of NSAID use

Gastric ulcer - worse after eating

Duodenal ulcer - worse when hungry.

Can present with bleeding - Melaena, coffee ground vomiting

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5
Q

How are H.pylori positive peptic ulcers managed?

A

History of NSAID use - 8 weeks of PPI, then eradication therapy

No history of NSAID use - straight in with eradication therapy

Eradication therapy = PPI + Amoxicillin + Clarithromycin/Metronidazole

2nd line = PPI + Amoxicillin + Doxycycline

If penicillin allergy = PPI + Clarithromycin + Metronidazole

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6
Q

How is H.pylori negative peptic ulcer managed?

A

No NSAID use - 4 weeks PPI

NSAID use - 8 weeks PPI

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7
Q

How is a peptic ulcer managed if they present with acute bleeding?

A

IV PPI

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8
Q

If a peptic ulcer perforates, what is seen on x-ray?

A

Free air under the diaphragm (Pneumoperitoneum)

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9
Q

What is the most common cause of non-progressive dysphagia?

A

Achalsia

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10
Q

What is achalasia?

A

Failure of the lower oesophageal sphincter to relax when swallowing

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11
Q

How is achalasia diagnosed?

A

Birds beak appearance on barium swallow

Increased lower oesophageal sphincter tone on oesophageal manometry

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12
Q

How is achalasia managed?

A

Balloon dilation

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13
Q

How does achalasia present?

A

Dysphagia of both solids and liquids
Dyspepsia
Regurgitation

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14
Q

What does birds beak appearance on barium swallow indicate?

A

Achalasia

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15
Q

How is GORD managed ?

A

Trial a PPI for 4 weeks

If no improvement- test and treat for H pylori

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16
Q

What is Barrett’s oesophagus?

A

Normal squamous cell epithelium of the oesophagus turns to columnar epithelium

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17
Q

How do you monitor Barrett’s oesophagus?

A

Endoscopy every 3-5 years

If dysplasia is seen - resection/ablation

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18
Q

What are the indications for Upper GI 2WW?

A

Dysphagia in any person

Upper abdominal mass

> 55 years, weight loss + dyspepsia/abdominal pain/reflux

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19
Q

What do you do if GORD has not improved after 4 weeks of PPI?

A

Trial h2 receptor antagonist

if >55 refer to secondary care

Otherwise test and treat for H.pylori

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20
Q

How long does PPI treatment need to be stopped before testing for H.pylori?

A

2 weeks

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21
Q

What is the most common type of oesophageal cancer seen in those with a history of GORD/Barrett’s oesophagus?

A

Adenocarcinoma

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22
Q

How does oesophageal cancer present?

A

Progressive dysphagia

Weight loss

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23
Q

What is the most common cause of an upper GI bleed?

A

Peptic ulcer

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24
Q

How does bleeding due to a peptic ulcer present?

A

Melaena

Coffee ground vomiting (dark red blood)

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25
Q

What is the most common cause of bright red haematemesis?

A

Mallory-Weiss tear

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26
Q

What is the Initial management of suspected variceal bleeding?

A

Terlipressin + prophylactic broad-spectrum abx

Then endoscopy.

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27
Q

How is variceal bleeding treated?

A

Band ligation unless bleeding profusely

If bleeding profusely and unable to visualise with endoscopy - sengstaken-Blakemore tube

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28
Q

What medication is given for prophylaxis of variceal haemorrhage?

A

Propranolol

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29
Q

How can you differentiate between a lower or upper GI cause of bleeding?

A

Check urea
Upper GI = high urea
Lower GI = low/normal urea

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30
Q

How does Crohn’s disease present?

A

Abdominal pain
Diarrhoea (non-bloody)
Weight loss, lethargy
Mouth ulcers

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31
Q

What marker is raised in inflammatory bowel disease?

A

Faecal calprotectin

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32
Q

What is seen on histology for Crohn’s disease?

A 
Goblet cells
Transmural inflammation
Skip lesions (Cobblestone appearance)
Granulomas
Rose thorn ulcers
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33
Q

How is remission induced in Crohn’s disease?

A
  1. Oral prednisolone / IV hydrocortisone
  2. ADD Azathioprine (check TPMT activity first) - if TPMT activity deficient then add Methotrexate
  3. Add biologic
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34
Q

How is remission maintained in Crohn’s disease? (first line and second line)

A

1st line = azathioprine or mercaptopurine

2nd line = methotrexate/infliximab/Adalimumab

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35
Q

Which liver condition is associated with ulcerative colitis?

A 
Primary sclerosing cholangitis
Jaundice
Itchiness
Raised ALP and bilirubin 
MRCP = diagnosis
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36
Q

How does ulcerative colitis present?

A

Bloody diarrhoea
Abdominal pain - more so on the left side
Urgency
Tenesmus - feeling the need to open the bowels when the bowels are empty.

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37
Q

What is seen on histology for ulcerative colitis?

A

Ulcerative colitis:

Goblet cell depletion

Submucosal inflammation only

Continuous inflammation

Crypt abscesses

Pseudopolyps

Loss of haustrations

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38
Q

How do you induce remission in ulcerative colitis?

A

Topical sulfasalazine/mesalazine (aminosalicylate)

If no improvement - try oral

If no improvement - oral prednisolone

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39
Q

How do you induce remission in severe UC?

A

IV methylprednisolone / IV Hydrocortisone

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40
Q

How to maintain remission in UC?

A
  1. Topical sulfasalazine/mesalazine
  2. Oral sulfasalazine
  3. Oral Azathioprine/Mercaptopurine (If severe UC/ 2 exacerbations in last year - go straight to this)
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41
Q

How to maintain remission in someone with severe UC or who has had 2 exacerbations in a year ?

A

Oral azathioprine/mercaptopurine

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42
Q

What classes as mild UC?

A

Less than 4 stools a day, not much blood

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43
Q

What classes as moderate UC?

A

4-6 stools a day, varying amount of blood, no systemic upset

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44
Q

What counts as severe UC?

A

More than 6 bloody stools a day

Needs to be some form of systemic upset - fever, anaemia, tachycardia, raised WCC

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45
Q

Which type of IBD is smoking protective for?

A

Ulcerative colitis

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46
Q

What does an ileostomy look like?

A

Spouted
Liquid stool
Usually RIF

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47
Q

What is a colostomy?

A

Flat
Solid stools
Usually LIF

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48
Q

What is the diagnostic criteria for IBS?

A

Abdominal pain which improves on defaecating
Bloating
Change in bowel habit - diarrhoea/constipation

May be mucus in stool

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49
Q

Is faecal calprotectin raised in IBS?

A

No - normal

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50
Q

How is IBS managed?

A

For diarrhoea - Loperamide

For cramping - Buscopan

For constipation - Laxatives
AVOID Lactulose - lactulose can cause bloating

2nd line = Amitriptyline
3rd line = SSRI

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51
Q

What is the second line treatment for IBS?

A

Amitriptyline

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52
Q

What is coeliac disease?

A

Autoimmune sensitivity to gluten

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53
Q

How does coeliac disease present?

A 
In children - failure to thrive
Diarrhoea 
Abdominal pain
Bloating
Steatorrhoea (greasy stools hard to flush)

Symptoms of malabsorption - anaemia, fatigue

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54
Q

Which autoantibody is raised in coeliac disease?

A

Anti-TTG antibody

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55
Q

How long does gluten need to be introduced before checking anti-TTG levels?

A

6 weeks

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56
Q

What is seen on histology for coeliac disease?

A

Villous atrophy

Crypt hyperplasia

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57
Q

Which vaccine do those with coeliac disease need?

A

Pneumococcal vaccine every 5 years

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58
Q

Which electrolyte abnormalities are seen in refeeding syndrome?

A

Low phosphate
Low magnesium
Low potassium

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59
Q

What are the two most common causes of small bowel obstruction?

A

Adhesions and hernias

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60
Q

What is the most common cause of large bowel obstruction?

A

Malignancy

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61
Q

How does bowel obstruction present?

A

Abdominal pain
Constipation
Green billous vomiting
Tinkling bowel sounds

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62
Q

How is bowel obstruction treated?

A

Nil by mouth

Large bore NG tube with free drainage

IV fluids

Treat underlying cause

63
Q

What is an ileus?

A

Pseudoobstruction due to halting of peristalsis
Presents the same way as mechanical bowel obstruction

Absent bowel sounds

64
Q

What is a sigmoid volvulus and how is it seen on X-ray?

A

Sigmoid colon wraps around itself and its own mesentery, causing a closed-loop obstruction

Coffee bean sign

65
Q

What is the main risk factor for a sigmoid volvulus?

A

Chronic constipation

66
Q

What are the three complications of a hernia?

A

Incarceration
Obstruction
Strangulation

67
Q

How is an inguinal hernia managed?

A

Surgical mesh repair even if asymptomatic (not urgent)

68
Q

How is a femoral hernia managed?

A

Urgent surgical repair due to high risk of strangulation and obstruction

69
Q

What are risk factors for diverticular disease?

A

Old age
Low fibre diet
Obesity
NSAID use

70
Q

How does acute diverticulitis present?

A

Abdominal pain in left iliac fossa

Diarrhoea

Fever

May be nausea/vomiting

Rectal bleeding

71
Q

What are complications of acute diverticulitis?

A 
Peritonitis
Haemorrhage 
Perforation
Peridiverticular abscess
Large haemorrhage
Fistula
72
Q

What is the management of acute diverticulitis?

A

If uncomplicated - oral Co-amoxiclav

Avoid solid foods until symptoms have resolved

Review after 48-72 hours

If no improvement - admit for IV Ceftriaxone + metronidazole

If complicated - hospital admission

73
Q

What is mesenteric ischaemia?

A

Lack of blood flow through the mesenteric vessels causing intestinal ischaemia - due to embolus

74
Q

What is the biggest risk factor for mesenteric ischaemia?

A

Atrial fibrillation

75
Q

How does mesenteric ischaemia present?

A

Sudden onset Acute abdomen

Pain worse on eating

Lab results show increased lactate

76
Q

How is mesenteric ischaemia diagnosed?

A

First line = Blood gas for raised lactate

Definitive diagnosis =
CT angiogram Abdomen

77
Q

How is mesenteric ischaemia managed?

A

Immediate laparotomy

78
Q

What is the management of spontaneous bacterial peritonitis?

A

IV cefotaxime

79
Q

What medication is given prophylactically in patients who have had an episode of spontaneous bacterial peritonitis?

A

Oral ciprofloxacin (ciprofloxacin is a quinolone Abx)

80
Q

What is the 2WW criteria for lower GI malignancy?

A

40 and over + abdominal pain + weight loss

50 and over + unexplained rectal bleeding

60 and over + change in bowel habit

60 and over + unexplained iron deficiency

81
Q

How does colorectal cancer present?

A 
Change in bowel habit - usually loose
Blood in stool
Abdominal pain
Iron deficiency anaemia 
Weight loss
82
Q

How is colorectal cancer investigated?

A

If the patient does not meet 2WW criteria - FIT (Faecal immunochemical tests) human haemoglobin stool testing

Definitive diagnosis = Colonoscopy

83
Q

What kind of bacteria is clostridium difficile?

A

Gram-positive rod shaped

Anaerobic

84
Q

Which drugs cause clostridium difficile infection?

A

Clindamycin
Cephalosporins - Cefuroxime, Cefotaxime, Ceftriaxone
Quinolones e.g. ciprofloxacin
Amoxicillin

PPIs !!

85
Q

How does clostridium difficile infection present?

A

Diarrhoea
Abdominal pain
Raised white blood cell count
History of broad spectrum antibiotics

86
Q

How is clostridium difficile infection diagnosed?

A

Presence of toxin in stool

87
Q

What if the stool is positive for clostridium difficile antigen but negative for the toxin?

A

Monitor patient but no antibiotics needed

88
Q

How is clostridium difficile managed?

A

First line = oral vancomycin

89
Q

What is second line for clostridium difficile?

A

Oral fidaxomicin

90
Q

What do you test for in coeliac disease?

A

Total IgA and IgA TTG antibodies

If total IgA is low - do IgG TTG antibodies

91
Q

What is an incarcerated hernia?

A

A hernia which cannot be reduced back into its normal position

Risk of strangulation or obstruction

92
Q

What is a strangulated hernia?

A

Hernia is non reducible and the base of the hernia is so tight that it cuts off blood supply

Leads to ischaemia

Presents with significant pain

A strangulated hernia = surgical emergency

93
Q

What is a direct inguinal hernia?

A

Hernia passes through Hesselbach’s triangle

94
Q

What is an indirect inguinal hernia?

A

Bowel herniates through the inguinal canal

95
Q

How can you differentiate between a direct and indirect inguinal hernia?

A

Reduce hernia, apply pressure to deep inguinal ring and ask patient to cough,

Indirect = hernia remains reduced

Direct = hernia comes back up

96
Q

How is life threatening c diff managed?

A

Oral Vancomycin + IV Metronidazole

97
Q

Which skin condition is associated with coeliac disease? How is it treated?

A

Dermatitis herpetiformis - itchy blistering rash on extensor surfaces and buttocks

Treated with Dapsone

98
Q

Which type of cancer is associated with coeliac disease?

A

Enteropathy-associated T cell lymphoma

99
Q

How long must patients eat gluten before testing for anti-TTG?

100
Q

Which part of the bowel is most commonly affected in Crohn’s disease?

A

The terminal ileum

101
Q

Which part of the bowel is most commonly affected in ulcerative colitis?

102
Q

How do you treat a recurrent episode of C diff within 12 weeks of symptom resolution?

A

Oral fidaxomicin

If it has been more than 12 weeks, can use vancomycin or fidaxomicin

103
Q

What is the major adverse effect of aminosalicylates e.g. sulfasalazine/mesalazine?

A

Agranulocytosis

If someone presents with infection in ulcerative colitis taking aminosalicylates - check FBC

104
Q

What should you do if someone taking an Aminosalicylate (e.g. Sulfasalazine) presents with an infection? Why?

A

Check FBC

Risk of Agranulocytosis

105
Q

Which laxative should be avoided in IBS and why?

A

Lactulose

Risk of bloating

106
Q

Which blood marker is raised in mesenteric ischaemia?

107
Q

Where should you do a biopsy to diagnose coeliac disease?

108
Q

Which test is recommended to check if H.pylori has been eradicated?

A

C13 urea breath test

109
Q

How does vitamin A deficiency present?

A

Night blindness

110
Q

How does vitamin B1 (thiamine) deficiency present? What are causes of this deficiency?

A

Causes = Alcohol excess, malnutrition

Can lead to Wernicke’s/Korsakoff’s

111
Q

How does vitamin B3 (niacin) deficiency present?

A

Also known as Pellagra

Dermatitis

Diarrhoea

Dementia

112
Q

How does vitamin B6 deficiency present?

A

Peripheral neuropathy

Sideroblastic anaemia

Can be caused by isoniazid

113
Q

How does vitamin C deficiency present?

A

Bleeding

Poor wound healing

Gingivitis

Bruising

114
Q

Crypt hyperplasia vs. crypt abscesses

A

Crypt abscess - UC

Crypt hyperplasia - coeliac disease

115
Q

Patient with UC has a rash on extensor surfaces and buttocks - how is this treated?

116
Q

What do you give to someone waiting for endoscopy for suspected variceal bleeding?

A

Terlipressin + broad-spectrum abx

117
Q

Which cancer is associated with Achalasia?

A

Squamous cell carcinoma of the oesophagus

118
Q

Where is the best place to take a biopsy from in Crohn’s disease?

119
Q

Where is the best place to take a biopsy from in Ulcerative Colitis?

120
Q

What is the difference between mesenteric ischaemia and ischaemic colitis?

A

Ischaemic colitis – large bowel
Mesenteric ischaemia – small bowel

Mesenteric ischaemia - urgent laparotomy

Ischaemic colitis - conservative management

121
Q

What is seen on CXR in ischaemic colitis?

A

Thumbprinting

122
Q

What is Toxic megacolon?

A

A complication commonly associated with UC
Swelling and inflammation which spreads into the deeper layers of colon
Colon stops working and widens

123
Q

How does Toxic megacolon present?

A 
Abdominal pain
Fever
Shock
Tachycardia
Diarrhoea
124
Q

How is toxic megacolon diagnosed?

A

Abdominal XR showing huge dilated loops of bowel

125
Q

How is toxic megacolon managed?

A

IV fluids + IV steroids

If no improvement in 48-72 hours – consider for surgery

126
Q

What do you need to check before prescribing Azathioprine/Mercaptopurine?

A

TPMT activity

127
Q

How does an anal fissure present and how is it managed?

A

Painful, bright red bleeding
Increase water and fibre intake

Acute anal fissure - bulk forming laxatives

Chronic anal fissure - Can try topical GTN

128
Q

Where are the majority of anal fissures?

A

Posterior midline

129
Q

How do haemorrhoids present?

A

Rectal bleeding
Itching
May be some pain

130
Q

How are haemorrhoids graded?

A

Grade I - do not prolapse out of anal canal
Grade II - prolapse on defection but reduce spontaneously
Grade III - can be manually reduced
Grade IV - cannot be reduced

131
Q

How are haemorrhoids managed?

A

Increase water and fibre intake
Topical steroid cream

Rubber band ligation / surgery

132
Q

How does an acutely thrombosed haemorrhoid present?

A

Significant pain
Purple oedematous perianal mass
If presents within 72 hours - excision

133
Q

How does a perianal abscess present? What is the usual causative organism and how is it managed?

A

Collection of pus within the subcutaneous tissue of the anus

Pain around anus may be worse on sitting

Usually caused by E.coli

Incision+drainage

134
Q

What is small bowel bacterial overgrowth syndrome? How does it present?

A

Excessive bacteria in the small bowel leads to GI syndrome

Chronic diarrhoea
Bloating and flatulence
Abdominal pain

135
Q

How is small bowel bacterial overgrowth syndrome diagnosed?

A

Hydrogen breath test

136
Q

How is small bowel bacterial overgrowth syndrome managed?

137
Q

What is Whipple’s disease?

A

A rare systemic condition caused by Trophenyma WHipplei

Causes diarrhoea, abdominal pain and joint pain

138
Q

What is seen on small bowel biopsy in Whipple’s disease?

A

Acid-Schiff-positive macrophages

139
Q

How is Whipple’s disease managed?

A

Co-trimoxazole

140
Q

What is Boerhaave syndrome?

A

Acute oesophageal rupture due to extreme vomiting

Presents as prolonged vomiting then leading to sudden onset chest pain and signs of shock

141
Q

What are extra-intestinal features of IBD?

A 
Arthritis
Erythema nodosum
Episcleritis - more common in Crohn's
Uveitis - more common in UC
Primary sclerosing cholangitis - more common in UC
142
Q

Who should be given oral azathioprine to maintain remission in UC?

A

If they have severe UC or 2 exacerbations in the last year

143
Q

What electrolyte abnormalities can PPIs cause?

A

Hyponatraemia

Hypomagnasaemia

144
Q

How is a perianal fistula diagnosed and managed?

A

MRI

Oral metronidazole

145
Q

What is the most common hereditary condition associated with colorectal cancer? What other cancers are associated with this condition?

A

HNPCC (Lynch syndrome)

Endometrial cancer and gastric cancer

146
Q

What is the familial condition with the highest risk of developing colorectal cancer? How is it monitored?

A

Familial adenomatous polyposis

Annual flexible sigmoidoscopy from 15 years old

147
Q

What is the location of femoral and inguinal hernias in relation to the pubic tubercle?

A

Inguinal hernia = superior and medial to pubic tubercle

Femoral hernia = inferior and lateral to pubic tubercle

148
Q

How to approximate surface area of burns?

A 
Head = 9%
Whole arm = 9%
Whole leg = 9%
Front of torso = 18%
Back of torso = 18%
Hand = 1%
149
Q

What is Meckel’s diverticulum? How is it managed?

A

Congenital diverticulum of the small intestine
Often presents with painless rectal bleeding in children aged 1-2 years

Management = removal of diverticula

150
Q

Who is screened for colorectal cancer?

A

Those between 60 and 74 years

Every 2 years

151
Q

What is the Duke’s staging criteria for colorectal cancer?

A

Dukes A = Confined to Mucosa

Dukes B = Invading bowel wall

Dukes C = Lymph node mets

Dukes D = distant mets

152
Q

What is the 3:6:9 rule?

A

On abdominal XR
Small bowel should be no more than 3cm
Colon should be no more than 6cm
Caecum should be no more than 9cm

153
Q

How is Boerhaave syndrome diagnosed?

A

CT contrast swallow

Medicine Finals (32 decks)

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