GI / Liver Flashcards
1
Q
41M. Presents with tiredness, weakness and slight abdominal pain. Yellowing of eyes.
Slightly raised bilirubin, other LFTs normal.
What colour faeces would you expect him to have? Why?
A
Normal urine and normal stool.
He has Gilberts syndrome -> prehepatic jaundice -> raised uncojugated bilirubin -> Normal urine and stool
2
Q
51F. Presents with increasing tiredness (impacting QOL) Scratching forearms - worse at night. No abdo pain but sometimes cramps due to coeliac disease.
LFTs:
- Bilirubin: 75 μmol/l (+++)
- ALT: 60 IU/I (+)
- AST: 92 IU/I (+)
- ALP: 196 IU/I (+++)
- GGT: 108 IU/l (++)
FBC: increase in IgM
Most likely diagnosis and test to perform to confirm?
A
Primary biliary cholangitis.
Blood test for anti-microbial antibodies
3
Q
53M.
Dyspnoea, dark urine, pale stools, yellowing of sclera and pruritis.
Spirometry: FEV1:FVC = 0.68
Abnormal LFTs.
Most likely diagnosis?
A
Αlpha antitrypsin disease
4
Q
A 26-year-old female is brought to the A&E due to Paracetamol poisoning. What’s the mechanism of action of N-acetyl cysteine?
A
Replenishes the supply of glutathione that conjugates NAPQI to ton-toxic compounds.
5
Q
A 46-year old man presents to you with a 2-week history of confusion, malaise and abdominal pain. On examination you locate the pain to the right upper quadrant and notice jaundiced eyes. His temperature is 38.2C.
What is the best investigation to confirm the most likely diagnosis?
A
Ascending cholangitis
Contrast enhanced dynamic CT
6
Q
Most common cause of iatrogenic chronic pancreatitis?
A
Px of ERCP
7
Q
A 52 year-old Swedish male presents to you with fatigue and cholestatic jaundice.
ALP, bilirubin and IgM levels are increased.
Px: ulcerative colitis
Diagnosed with primary sclerosing cholangitis.
Which condition is his risk significantly increased for? What investigation would his annual check involve?
A
Colorectal/biliary system malignancy - colonoscopy
8
Q
Which type of hepatitis virus consists of DNA?
A
Hep B
9
Q
58M.
3 month history of fatigue, weakness, nonspecific abdominal problems and erectile dysfunction. Tachycardia, mood swings.
Bronzing of the skin and hepatomegaly.
Most likely diagnosis and first line investigation?
A
Haemachromatosis
Ferritin blood tests
10
Q
Skip lesions on colonoscopy indicate which IBD?
A
Crohns
11
Q
Which IBD is associated with mouth ulcers?
A
Crohns
12
Q
What is the most appropriate first step to take in the following case:
A 55 YO man referred to a gastroenterology clinic with 6 month history of worsening dyspepsia and epigastric pain. No weight loss or history of dysphagia. No change in his bowel movements. He reports taking ibuprofen for back pain regularly.
A
Refer for upper GI endoscopy within 2 weeks to rule out serious causes before anything else.
13
Q
5M. Underweight, fatigued, intermittent stomach pain, nausea, diarrhoea. Mother has a history of thyroid disease.
Most likely diagnosis and gold standard investigation?
A
Coeliac
Endoscopic intestinal biopsy
14
Q
What is a pharyngeal pouch and what symptoms can it cause?
A
A posteromedial herniation of the oesophagus between the thyropharyngeus and cricopharyngeus muscles.
Symptoms: difficulty swallowing, regurgitation ,aspiration. Chronic cough but no resp symptoms. Bad breath. Midline throat lump that gurgles on palpation
15
Q
What kind of anaemia can colorectal cause?
A
Iron deficiency anaemia
16
Q
Likely finding on colonoscopy / biopsy with UC?
A
- crypt abscesses
- goblet cell depletion
- inflammation limited to the mucosa
- continuous inflammation (i.e. not skin lesions)
17
Q
What is diverticulosis?
A
Asymptomatic diverticula
18
Q
What is diverticulitis?
A
Inflammation of diverticulum - outpourings of the large intestine
19
Q
What is diverticular disease?
A
Diverticula causing symptoms
20
Q
What is diverticular stricture?
A
A complication of diverticulitis
21
Q
Where is Virchow’s node?
A
Supraclavicular area
22
Q
What dietary supplementation is required post ileo-caecal resection?
A
Vitamin B12
23
Q
Describe Marsh 1
A
Only intraepithelial lymphocytes and NO crypt hyperplasia
24
Q
Describe marsh 2
A
intraepithelial lymphocytes and crypt hyperplasia
25
Describe marsh 3a
intraepithelial lymphocytes and partial/mild villus atrophy
26
Describe marsh 3b
intraepithelial lymphocytes and subtotal/moderate villus atrophy
27
Describe marsh 3c
intraepithelial lymphocytes and total villus atrophy
28
42M. 2mnth history epigastric pain, weight loss. Relief from antacids. No vomiting or loose stools. Endoscopy and biopsy show inflammation.
Most likely diagnosis?
H.pylori gastritis
29
How do you distinguish between small and large bowel obstruction from pt history?
Vomiting before constipation? = small bowel
Constipation before vomiting? = large bowel
30
What is the first line investigation for coeliac disease?
Blood test for coeliac antibodies: IgA and TTG
31
What is the GS investigation for coeliac?
Duodenal biopsy
32
What is the name of the bowel cancer screen?
Faecal immunochemical test (FIT)
33
What is the GS investigation for acute diverticulitis?
CRP
34
Give 6 red flag symptoms of oesophageal cancer
- weight loss
- bleeding
- anorexia
- lymphadenopathy
- vomiting
- progressive dysphasia
35
Give 3 symptoms of GORD
- heartburn
- increased belching
- food regurgitation
- increased salivation
- chronic cough
36
Give 2 causes of GORD
- hiatus hernia
- lower oesophageal sphincter hypotension
- para oesophageal hiatus
- abdominal obesity
37
Give 2 possible complications of GORd
Barrett’s oesophagus, peptic stricture
38
Give 2 causes of IBS
- psychological stress
- depression
- anxiety
- trauma
- eating disorders
39
Give 2 non intestinal symptoms of IBS
- painful periods
- change in urinary frequency
- back pain
- joint hyper mobility
- fatigue
40
Name 2 DD for IBS
- coeliac disease
- lactose intolerance
- bile acid malabsorption
- IBD
- colorectal cancer
41
What is the diagnostic criteria for IBS?
Rome III criteria
42
What class of drugs are used to manage IBS?
Anticholinergics
43
Give 2 DD of biliary colic
Pancreatitis, renal colic
44
What are the 2 types of biliary colic?
Cholesterol biliary colic / gallstone
Bile pigment biliary colic / gallstone
45
Risk factors for biliary colic
Female, obese, fertile, smoking
46
How is biliary colic diagnosed?
Abdominal US
47
Give 2 treatment options for biliary colic
Stone dissolution
Shock wave lithotripsy
Laparoscopic cholecystectomy
48
Presentation: severe epicanthic pain radiating to the back, binge drinking, history of gallstones.
Most likely diagnosis and first line investigation?
Acute pancreatitis
Serum amylase
49
What are the first line and GS treatments for autoimmune hepatitis?
1st line = Prednisolone
GS = Prednisolone AND Azithioprine
50
Peritonitis causative organism - gram positive, coagulase positive
Staphylococcus aureus
51
Peritonitis causative organism
Gram negative bacteria, lactose fermenter (pink on MacConkey agar)
Klebsiella pneumoniae, E.coli
52
Define primary sclerosing cholangitis
A rare, chronic, cholestatic liver disorder characterised by multi focal biliary strictures and progressive liver disease.
53
How does primary sclerosing cholangitis present?
Insidious onset, presents with jaundice, pruritis, fatigue, ±IBS symptoms
54
What kind of cancer is associated with primary sclerosing cholangitis?
CHolangiocarcinoma
55
What type of jaundice is seen in primary sclerosing cholangitis and what colour urine and stool ?
Post hepatic jaundice, therefore raised conjugated bilirubin, therefore dark urine and pale stool
56
First line treatment for alcohol withdrawal?
Chlordiazepoxide
57
What is the most common cause of liver cirrhosis?
Chronic alcohol abuse
58
Give a complication of ascites
Bacterial peritonitis
59
Give 4 RFs for developing a hernia
- lifting heavy weights
- previous abdominal surgery
- chronic cough
- straining while defacating
60
What causes median accurate ligament syndrome (MALS)?
Compression of the coeliac artery
61
50F. Recurrent RUQ pain, 20 min episodes after meals especially with fatty food. No fever/chill, episodes always resolve. Px hyperlipidaemia, morbid obesity, poly cystic ovarian disease.
Most likely diagnosis?
Gallstones
62
List 5 causes of hepatocellular cancer
Alcoholic liver disease,
Non alcoholic fatty liver disease,
Viral hepatitis,
Autoimmune hepatitis,
Wilsons disease,
Haemochromatosis
63
List as many causes of pancreatitis as you can
IGETSMASHED is the mnemonic to learn for this.
• Idiopathic
• Gallstones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpion venom/spider bite
• Hyperlipidaemia, hypothermia, hypercalcaemia
• ERCP
• Drugs
64
Explain the Pathophysiology behind hepatitis
- hepatitis is inflammation of the liver
- something causes liver injury which activated the inflammatory response, causing infiltration of inflammatory cells and liver cell necrosis
- if chronic, this causes progressive fibrosis and cirrhosis, and therefore chronic liver disease
- causes of the initial injury include infection (bacterial/virus/parasite), medication, alcohol, autoimmune etc
65
Treatment of ruptured appendix -> peritonitis
Urgent appendectomy and clean the cavity
IV antibiotics for several days, then oral antibiotics for 2-4ths
66
You see a 31-year-old male patient in your clinic who has been diagnosed with Wilson’s disease. Name 2 signs you might expect to see and what causes them?
- Keyser-Fleischer rings due to copper deposits in the iris
- Neurological signs due to copper deposits in the CNS
67
A 43 -year-old female patient presents in A and E with fever, RUQ pain, jaundice, hypotension, confusion. What is the name of this presentation and what is the most likely diagnosis?
Charcots Triad
Ascending cholangitis
68
A 51-year-old female patient presents with in your clinic and you diagnose her with PBC. What clinical features might you expect to see?
• Pruritus, with or without jaundice is the most common presenting complaint
• Hepatosplenomegaly
• Xanthelasma
• Raised serum alkaline phosphatase or autoantibodies
• Steatorrhea
• Malabsorption of fat-soluble vitamins
69
Treatment for paracetamol overdose?
N-acetyl-cysteine AND activated charcoal within 1 hr of ingested substance
70
Name 4 abnormal results expected in ruptured oesophageal varices
- anaemia
- raised bilirubin
- low albumin
- raised AST/ATL/ALP
- increased prothrombin time
71
2 conditions that cause bronze skin pigmentation
- Haemochromatosis
- Addisons disease
72
4 signs or symptoms of hepatitis
- fever
- RUQ pain
- headache
- jaundice
- nausea/vomiting
73
What is Morpheys sign and which condition gives a positive murpheys sign?
Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive
74
Name 2 signs that appear on the abdomen as colour changes during acute pancreatitis
-Grey Turners sign (flank brushing)
- Cullens sign (bruising around the umbilicus)
75
Name the types of diarrhoea
- secretory
- osmotic
- exudative
- inflammatory
- dysentery
76
What symptoms would indicate inflammatory diarrhoea?
Severe diarrhoea (very watery), blood in stool, fever, abdominal pain, tenesmus
77
List 3 symptoms of small bowel obstruction
- abdominal distension
- vomiting/nausea
- constipation
- intermittent abdominal pain
78
What abdo radiograph finding would confirm diagnosis of small bowel obstruction?
Dilated jejunum and/or ileum, Absence of gas in bowel distal to the obstruction
79
Describe the supportive management of small bowel obstruction
‘Drip and suck’ management
- make the pt nil by mouth
- insert a nano gastric tube to decompress to bowel
- start IV fluids to correct electrolyte imbalance
- urinary catheter and fluid balance
- analgesia as required
- anti emetics
80
List 3 causes of gastritis
Helicobacter pylori infection,
Non-steroidal anti-inflammatory drugs (NSAIDs),
alcohol abuse,
Bile reflux,
Autoimmune-related,
Mucosal ischaemia,
Bacterial invasion of the gastric wall.
81
What investigation would be done if infective gastritis is suspected?
- helicobacter pylori urea breath test
- helicobacter Pylori faecal antigen test
82
Name 3 clinical features of haemorrhoids
- bright red bleeding i.e. fresh blood on toilet paper and outside of stool
- discomfort / pain when defacating
- pruritis ani
- mucus discharge
83
What are haemorrhoids?
Swelling and inflammation of veins in the rectum and anus
84
Describe the two types of haemorrhoids
Internal haemorrhoids: arise internally, are painless, can prolapse, covered in mucus
External haemorrhoids: form at the anal opening, painful, covered with skin
85
Give the non surgical and surgical treatment options for haemorrhoids
Non surgical: stool softeners, high fibre diet, adequate fluid intake, topical analgesia, topical hydrocortisone
Surgical: band ligation, haemorrhoidectomy, sclerotherapy
86
GORD, non pharmacological management options
- weight loss
- healthy eating
- smoking cessation
- eat smaller meals
- eat evening meal several hours before going to bed
- reduce alcohol consumption
87
Describe the macroscopic features of Crohns
Affects any part of the GI tract (from mouth to anus)
Skip lesions
Cobblestone mucosa
88
Describe the microscopic features of Crohns
Transmural inflammation
Granuloma
Goblet cells present
89
List 5 causes of acute diarrhoea
- bacterial e.g. salmonella
- viral e.g. rotavirus
- food allergy
- anxiety
- constipation w overflow
90
Give 2 examples of antibodies that if raised cause suspicion for coeliac
IgA-tTG, IgA-EMA
91
List 5 RFs for colorectal carcinoma
- increasing age
- alcohol
- smoking
- low fibre diet
- UC / Crohn’s disease
- family history
- PMH cancer
92
Name 3 non invasive tests for H.pylori infection
- C-urea breath test
- blood / serological testing / IgG antibody detection
- stool antigen test
93
List 4 potential complications of diverticulitis
- large bowel perforation -> peritonitis
- fistula formation to the bladder or vagina
- large bowel obstruction
- bleeding, possibly large volumes
- mucosal inflammation
94
What is the first line drug used to treat haematemesis from ruptured oesophageal varices?
If this drug if contraindication what drug should be used instead?
IV Terlipressin (vasodilator, controls variceal bleeding)
If contraindicated (e.g. IHD) then IV somatostatin should be used
95
List 3 DD for acute appendicitis
- ectopic pregnancy
- UTI
- diverticulitis
- perforated ulcer
96
What is the function of the gallbladder ?
Store and concentrate bile
97
What are the majority of gallstones made from?
Cholesterol
98
What is gallstone ileus?
Impaction of the gallstone in the small intestine
99
How are Mallory Weiss tears usually treated?
Endoscopic haemostasis
100
3 most common causes of pancreatitis?
- gallstones
- alcohol
- trauma
101
What blood test result is sensitive and specific for pancreatitis?
Raised serum lipase
102
What is the name of the scoring system that is used to predict the severity of pancreatitis?
Modified Glasgow criteria
103
What might be found on surgical exploration of post abdominal surgery necrotising fasciitis?
- grey, necrotic tissue
- lack of arterial bleeding
- thromboses vessels
- ‘dishwater’ pus
- lack of resistance to dissection
- non-contracting muscles
104
Name a highly sensitive investigation for intestinal inflammation
Faecal calprotectin
105
Give 2 extraintestinal signs of inflammatory bowel disease
Clubbing
Aphthous ulcers
Iritis
Conjunctivitis
Episcleritis
Arthritis
Erythema nodosum
Fatty liver changes
Perianal disorders e.g. skin tags, fistulae, etc.
106
Inherited colon cancer; what is the pattern of inheritance?
Autosomal dominant
107
What is the commonest dermatological manifestation of IDB?
Erythema nodosum
108
List 4 causes of raised bilirubin in urine
- common bile duct stone
- hepatocelluar carcinoma
- pancreatic cancer
- viral hepatitis
109
What is the pathogenesis of epigastric pain caused by NSAIDs
NSAIDs cause a reduction in mucus and bicarbonate secretion in the stomach causing epigastric pain after eating
110
Where is the remnant of the viteline duct?
What pathology is it associated with?
In the distal ileum
Associated with Meckel’s diverticulum
111
Describe the ABG results of metabolic acidosis
- low pH
- normal O2/CO2
- low bicarbonate
112
What does the anion gap tell you about metabolic acidosis?
High anion gap = more acid being produced/ingested eg diabetic ketoacidosis
Low anion gap = loss of bicarbonate causing acidosis eg diarrhoea
113
What part of the bowel is most likely to perforate during obstruction?
Caecum
114
Where does UC most commonly start?
Rectum
115
Where does Crohn’s most commonly affect?
Ileum
116
Where does coeliac most commonly affect?
Duodenum
117
What type of hernia is a hernia below the pubic tubercle most likely to be?
Femoral hernia
118
What is Reynold’s pentad?
CHarcots triad (upper abdo pain, fever, jaundice) + shock (hypotension, tachycardia) + altered GCS
119
What is ascending cholangitis most commonly caused by?
E.coli
120
Describe the acute management steps of a ruptured oesophageal varices
- ABCDE management (including fluid replacement, maybe balloon tamponade to stop bleeding)
- Terlipressin (ADH analogue, for hypovolaemia)
- prophylactic antibiotics
121
What is the difference between exudate ascites and transudate ascites? Give an example of each
Exudate = higher protein content. Caused by peritonitis
Transudate = lower protein content. Caused by budd-chiari, heart failure, liver cirrhosis, portal hypertension)
122
Give 2 causes of iron overload
- hereditary Haemochromatosis
- repeated blood transfusions
123
What two results may be shown in a blood test that can help confirm the diagnosis of appendicitis?
Raised C-reactive protein
Raised white cell count / neutrophils / leukocytes
124
List 8 signs of appendicitis
- fever
- abdominal pain
- vomiting
- anorexia
- nausea
- constipation
- tachycardia
- guarding
- rebound tenderness
- pain on movement
125
How do you treat delirium tremens in wernickes encephalopathy?
Chlorodiazepoxide and lorazepam
126
What is the triad of wernickes encephalopathy?
- confusion
- ataxia
- opthalmoplegia
127
Give 5 signs of liver failure, other than ascites
- spider naevi
- clubbing
- jaundice
- palmar erythema
- bruising
- oedema
- anorexia
128
Give 3 complications of alcoholic liver disease
- hepatocellular carcinoma
- oesophageal varices
- portal hypertension
129
Explain why liver failure leads to ascites
Low albumin levels cause oncotic pressure to be lower than hydrostatic pressure, causing fluid to leak into the abdominal cavity
Portal hypertension
130
What is the name given to green/brown rings around the cornea in Wilsons disease?
Kayser-Fleischer rings
131
Haemachromatosis: what gene is affected, what inheritance pattern?
HFE gene (homeostatic iron regulator)
Autosomal recessive
132
Give 2 signs of haemachromatosis
Bronze skin pigmentation
Hepatomegaly
133
Give 3 symptoms of Haemochromatosis
- fatigue
- arthralgia
- erectile dysfunction
134
Describe the vomit in peptic ulcer
‘Coffee ground’ haematemesis
135
GI cancer red flags
- unexplained weight loss
- melena (blood in stool)
- family history of bowel or ovarian cancer
- change in bowel habit and over age 50
- nocturnal symptoms
- anaemia
- raised inflammatory markers
