gi - las preguntas

Question 1

Types of diarrhoea?

Answer 1

(DISEO)
Dysentery
Inflammatory
Secretory
Exudative
Osmotic

Question 2

Presentation of inflammatory diarrhoea?

Answer 2

Blood in stool
Severe (very watery)
Fever
Abdo pains
Tenesmus - straining

Question 3

Clinical tool to classify faeces?

Answer 3

Bristol stool chart

Question 4

Red flag GI cancer symptoms?

Answer 4

Rectal bleeding
Unintentional weight loss
Abdo mass
FHx
Anaemia
Age 60+
Change in bowel habit > weeks

Question 5

Symptoms of small bowel obstruction?

Answer 5

Intermittent abdo pain
Constipation
Nausea
Vomiting
Abdo distention

Question 6

Abdo radiograph findings to confirm small bowel obstruction?

Answer 6

Dilated jejunum a/o ileum
Absence of gas in bowel distal to the obstruction

Question 7

Initial supportive management in small bowel obstruction?

Answer 7

‘Drip and suck’ management:
- Make the patient nil-by-mouth (NBM)
- Insert a nasogastric tube to decompress the bowel (‘suck’)
- Start IV fluids and correct any electrolyte disturbances (‘drip’)
- Urinary catheter and fluid balance
- Analgesia as required
- Suitable anti-emetics

Question 8

Complication of acute small bowel obstruction leading to emergency surgery?

Answer 8

Bowel ischaemia
Strangulation

Question 9

Causes of gastritis?

Answer 9

Helicobacter pylori infection
Bacterial invasion of the gastric wall
NSAIDs
Alcohol abuse
Bile reflux
Autoimmune-related
Mucosal ischaemia

Question 10

Investigating infective gastritis?

Answer 10

Helicobacter pylori urea breath test
Helicobacter pylori faecal antigen test

Question 11

Differentials for gastritis?
(nausea, vomiting, loss of appetite)

Answer 11

GORD
Gastric CARCINOMA
Peptic ulcer disease
Non-ulcer dyspepsia
Gastric lymphoma

Question 12

Clinical features of haemorrhoids?

Answer 12

Bright red bleeding (fresh blood on toilet paper and on the outside of stool)
Discomfort/pain (veins become thrombosed causing inflammation and pain)
Pruritus ani (irritation around the anus causing itchy sensation)
Mucus discharge
Pain on passing stools (external haemorrhoids only)

Question 13

2 types of haemorrhoids?

Answer 13

INTERNAL:
- arise internally
- painless
- covered in mucus
- can prolapse

EXTERNAL:
- form at the anal opening
- painful
- covered with skin

Question 14

Treatment of haemorrhoids?
(NON-SURG and SURG)

Answer 14

NON-SURG:
- stool softeners (or bulk-forming laxative)
- high fibre diet
- adequate fluid intake
- topical anusol (analgesia)
- topical hydrocortisone

SURG:
- band ligation
- haemorrhoidectomy (or resection)
- sclerotherapy (veins injected with a sclerosing agent causing them to shrink and eventually be absorbed by the body)

Question 15

Pathophysiology of haemorrhoids?

Answer 15

Swelling and inflammation of veins in the rectum and anus

Question 16

NICE guidelines for diagnosing IBS?

Answer 16

Abdominal bloating (more common in women than men), distension, tension or hardness
Abdo pain or discomfort, relieved by defecation
Abdo pain or discomfort, associated with altered bowel frequency or stool form
Altered stool passage (straining, urgency, incomplete evacuation)
Symptoms made worse by eating
Passage of mucus

Question 17

Non-pharmacological treatments for GORD?

Answer 17

Healthy eating
Eat smaller meals
Weight loss (if obese)
Smoking cessation
Eat evening meal 3-4 hours before going to bed
Reduce alcohol consumption
Raise the head off the bed / use more pillows

Question 18

Typical presentation of GORD?

Answer 18

Burning, restrosternal discomfort related to meals / lying down / stooping / straining
Odynophagia (painful swallowing)

Question 19

Complications of GORD?

Answer 19

Barrett’s oesophagus

Question 20

Drug treatment for GORD?

Answer 20

1st line = PPI (Lansoprazole)

Question 21

Features of Crohn’s disease?
(MACRO and MICRO)

Answer 21

MACROSCOPIC:
- deep ulcers and fissures - ‘cobblestone mucosa’
- affects any part of the GI tract (from mouth to anus)
- skip lesions (“patchy”)

MICRO:
- granuloma (in 50%)
- transmural inflammation
- goblet cells present
- fewer crypt abscesses than UC

(GALS: Granuloma, All, Layers and Levels, Skip lesions)

Question 22

Causes of acute diarrhoea?

Answer 22

ABx associated diarrhoea - eg. cephalosporins / clindamycin associated with C. difficile infections
Bacterial cause
- Salmonella from food poisoning
- Campylobacter infection fron puppies in small children
Viral cause
- Rotavirus - affects nearly all kids by age 4
- Norovirus - associated with cruise ships
Parasitic cause eg. Giardia Lamblia
Drugs eg. allopurinol / NSAIDs / PPIs …
Constipation with ‘overflow’ diarrhoea
Anxiety
Food allergy

Question 23

Antibodies that would raise suspicion of coeliac disease?

Answer 23

IgA-tTG
IgA-EMA

Question 24

Investigating coeliac disease?

Answer 24

Labs often look for either IgA-tTG or IgA-EMA then, if the result is vaguely positive, will look for the other.

Some coeliac patients are IgA deficient, in which case, IgG versions of the above would be tested for.

Note that the patient needs to eat a gluten containing diet for >6 weeks prior to their blood test in order for the serology to be accurate.

Negative serology does not exclude coeliac disease. If suspicion remains (or the serology is positive), a biopsy should be arranged.

Question 25

Risk factors for colorectal cancer?

Answer 25

Factors that increase damage to the colonic mucosa increase the risk of cancer formation
- Smoking
- Family history of GI cancer
- Obesity
- Increasing age/old age/elderly
- Alcohol
- Low fibre diet
- Saturated animal fat and red meat consumption
- Colorectal polyps
- Past medical history of cancer
- Presence of colorectal polyps
- Ulcerative colitis and Crohn’s disease
- Genetic predisposition – Familial adenomatous polyposis (FAP) (autosomal dominant) & Lynch syndrome (Hereditary Non-Polyposis Colon Cancer) (autosomal dominant)

Question 26

What is familial adenomatous polyposis?

Answer 26

Autosomal dominant genetic condition
Characterised by hundreds-thousands of colorectal and duodenal adenomas thereby increasing the chance than one of these becomes cancerous

Question 27

What is Lynch syndrome?

Answer 27

Causes adenomas to form rapidly rather than the usual 10-15 years that it normally takes, therefore increasing the chance of dysplastic change

Question 28

Nausea, vomiting and severe right lower quadrant pain.
Pain started around umbilicus, and has migrated to right iliac fossa.
On exam: pyrexic and right lower quadrant tenderness and guarding.

Most likely diagnosis?

Answer 28

Acute appendicitis

Question 29

Investigations for acute appendicitis?

Answer 29

GOLD STANDARD = CT scan - highly sensitive and specific for diagnosing appendicitis

WCC (blood test) – will show increased neutrophils
ESR (blood test) – will be elevated as it is a marker of inflammation
CRP (blood test) – will be elevated as it is a marker of inflammation
Ultrasound – can detect an inflamed appendix and an appendix mass, confirmation with a
CT scan would then be done
Pregnancy test – to exclude an ectopic pregnancy
Urinalysis – to exclude a UTI

Question 30

Possible differential diagnoses for appendicitis?

Answer 30

Crohn’s disease (causing acute terminal ileitis)
Ectopic pregnancy
UTI
Diverticulitis
Perforated ulcer
Food poisoning

Question 31

Treating haematemesis from ruptured oesophageal varices?

Answer 31

1st line = IV Terlipressin acts as a vasodilator to control variceal bleeding.

If contraindicated (for example in IHD) then IV somatostatin should be used.

Question 32

Complications of diverticulitis?

Answer 32

Large bowel perforation
- Can lead to paracolic/pelvic abscesses o Can cause peritonitis
- May require surgical intervention
Fistula formation
- An abnormal connection between two organs that do not usually connect
- To the bladder: Dysuria (pain when urinating); Pneumaturia (air bubbles in urine)
- To the vagina: Vaginal discharge
- Usually requires surgical intervention
Large bowel obstruction
- Usually after repeated diverticulitis episodes
- May require surgical intervention
Bleeding
- Can be very large volumes
- But stops in most cases
- Cause can be established by: Colonoscopy; Angiography
- May require surgical intervention
Mucosal inflammation
- Can mimic Crohn’s disease on endoscopy

Question 33

Risks for oesophageal cancer?

Answer 33

Smoking tobacco
Alcohol
Obesity
GORD
Achalasia

Question 34

Non-invasive tests for H.pylori infection?

Answer 34

IF PATIENT IS UNDER 55 - NON-INVASIVE
C-urea / 13C breath test (1st line)
- measures CO2 in breath after ingestion of C-urea (quick and reliable test, used to monitor eradication)
Blood/serological testing / IgG antibody detection
- detects IgG antibodies (not useful for confirming eradication or presence of current infection as IgG takes 1 year to fall by 50% even after treatment)
Stool antigen test
- immunoassay using monoclonal antibodies for detection of H.pylori

However, if the patient was over 55 or had any ALARM Symptoms (symptoms that may indicate malignancy), then an endoscopy with biopsy should be done. The biopsies taken can also be assessed for H.pylori using the histology, cultures and biopsy urease tests.

Question 35

Risks for peptic ulcer? And how to prevent?

Answer 35

Heavy drinking
SOME long-term drug use (NSAIDs, steroids, SSRIs) - prescribe a PPI to take as preventative medication when using these drugs

Question 36

Duodenal v gastic ulcer?

Answer 36

Duodenal ulcers are relieved by eating and are more common than gastric ulcers.
Gastric ulcers are worsened by eating and are commonly associated with NSAID use.

Question 37

RED FLAG ALARM symptoms for GI CANCER?

Answer 37

Anaemia (iron deficiency)
Unexplained weight Loss
Anorexia
Recent onset/progressive symptoms
Evidence of GI bleeding e.g. Melaena (dark tar like black stools) or haematemesis
Swallowing difficulty - dysphagia
Upper abdominal mass & persistent vomiting

Question 38

Haematemesis.
Drinking a lot of alcohol recently, over the last couple of weeks.
The blood appeared after vomiting and retching multiple times that night.
Haemodynamically stable and has no fever.

Most likely diagnosis?

Answer 38

Mallory-Weiss tear

Question 39

What is a Mallory-Weiss tear?

Answer 39

Linear mucosal tears that occur in the oesophagus after sudden increases in intra-abdominal pressure.
The tear often follows a bout of coughing or retching or vomiting and is classically seen after alcoholic ‘dry heaves’. It can also occur in those with eating disorders who regularly make themselves vomit.
Most of the bleeds are minor, stop spontaneously and heal in 24hrs.