GI V Flashcards
A 48-year-old woman with chronic pancreatitis due to gallstones is noted to have a macrocytic anaemia. What is the most likely cause of the anaemia? (Please select 1 option) Bone marrow dysfunction Folate deficiency Hyposplenism Hypothyroidism Vitamin B12 deficiency
Vitamin B12 deficiency This is the correct answerThis is the correct answer
Chronic pancreatitis and the resultant pancreatic insufficiency results in the failure of splitting of dietary B12 from R-binders,a reaction that requires trypsin.
This inhibits the binding of intrinsic factor to the vitamin B12 so it is not absorbed.
A 64-year-old female treated with penicillin for a sore throat has presented with profuse diarrhoea. On sigmoidoscopy the mucosa appears a grey white-colour.
Pseudomembranous enterocolitis
Pseudomembranous enterocolitis (antibiotic-associated colitis) is an acute disorder of bacterial overgrowth (usually Clostridium difficle) due to short or long term antibiotic usage.
The condition is commoner after oral rather than intravenous antibiotics.
The hallmark of the condition is the appearance of a grey-white pseudomembrane between inflamed parts of the mucosa. Treatment is with oral metronidazole or vancomycin.
A 38-year-old female has presented with diarrhoea following a recent laparoscopic Nissen’s fundiplication for persistent gastro-oesophageal reflux.
Post-vagotomy
In the past diarrhoea was common following intentional vagotomy for peptic ulcer disease. With the introduction of proton-pump inhibitors this surgery is now rarely performed. Most post-vagotomy diarrhoea results from iatrogenic injury to the vagus during surgery on the stomach or the oesophagus.
The diarrhoea typically fades away over the first few post-operative months and is generally non-capacitating.
A 72-year-old female 10 days post total knee replacement on the orthopaedic ward has started to pass liquid stool having not passed stool for seven days.
Overflow
Spurious (overflow) diarrhoea is a trickling down of liquid faeces through channels in an impacted solid collection in the rectum. The condition is more common in the elderly and in bedridden patients. Unless the condition responds to conservative measures, manual evacuation under anaesthetic is usually required.
A 69-year-old male is seen in outpatients. He reports weight loss of 1 stone over three months but his history is otherwise unremarkable.
On examination his abdomen is soft with no palpable masses. A PR examination is normal.
His blood tests show:
Haemoglobin 8.0 g/dL (12-16)
MCV 70 fL (80-96)
Which of the following is the most appropriate investigation for this patient?
(Please select 1 option)
Abdominal x ray and colonoscopy
CT scan of the abdomen and upper GI endoscopy
Sigmoidoscopy and upper GI endoscopy
Ultrasound scan of abdomen and colonoscopy
Upper GI endoscopy and colonoscopy
Upper GI endoscopy and colonoscopy This is the correct answerThis is the correct answer
This man has weight loss and an unexplained microcytic anaemia.
The likely site of blood loss is from the GI tract in absence of an alternative explanation.
This may be due to an occult GI malignancy and therefore the initial investigations of choice are upper and lower GI endoscopy.
A 56-year-old male presents with generalised fatigue and upper abdominal discomfort with some weight loss over the last six months. He has otherwise been well but admits to consuming 10 units of alcohol per day. On examination you note 2 cm hepatomegaly. Liver function tests show: ALT 140 IU/L (5-35) AST 150 IU/L (1-31) Alkaline Phosphatase 250 IU/L (45-105) MCV 110 fL (80-96) Which of the following is the most likely cause of his presentation? (Please select 1 option) Alcoholic hepatitis Chronic active hepatitis Hepatoma Metastatic liver disease Viral hepatitis
Alcoholic hepatitis is a syndrome of progressive inflammatory liver injury associated with long term heavy intake of ethanol.
Patients who are severely affected present with
Subacute onset of fever Hepatomegaly Leukocytosis Marked impairment of liver function. The liver exhibits
Characteristic centrilobular ballooning necrosis of hepatocytes
Neutrophilic infiltration
Large mitochondria
Mallory hyaline inclusions.
Steatosis (fatty liver) and cirrhosis frequently accompany alcoholic hepatitis.
Which of the following statements regarding jejunal biopsy is correct?
(Please select 1 option)
Electron microscopy is necessary to confirm the presence of villous atrophy
In tropical countries apparently healthy people have a mucosal structure which would be regarded as abnormal in Europe
It can be used to diagnose Whipple’s disease
It is contraindicated over the age of 70 years
Sub-total villous atrophy is diagnostic of gluten-sensitive enteropathy and is not found in other conditions
It can be used to diagnose Whipple’s disease
The villous atrophy may be seen with a magnifying glass.
Apparently healthy people with a mucosal structure that would be regarded as abnormal in Europe would not be ‘healthy’.
There is a group of patients who present with coeliac disease in older age - sometimes in their 90s. They present with iron deficiency anaemia, osteoporosis or weight loss.
Subtotal villous atrophy is seen in a number of conditions other than coeliac disease such as:
Severe tropical sprue Cow's milk/soya sensitivity in children Gastroenteritis Whipple's disease Hypogammaglobulinaemia Neomycin therapy Laxative abuse Norwalk agent.
Normal ranges Bilirubin 0-18 AST 5-45 ALT 5-40 Alkaline phosphatase 30-110 Gamma GT 10-50
A 54-year-old male presents with acute vomiting and upper abdominal pain. He drinks approximately 30 units of alcohol daily. On examination he has a few spider naevi and appears slightly jaundiced. He has two finger breadth hepatomegaly. Results show: Bilirubin 72 µmol/L AST 98 IU/L ALT 120 IU/L Alkaline phosphatase 358 IU/L Gamma GT 450 IU/L
Alcoholic cirrhosis
Normal ranges Bilirubin 0-18 AST 5-45 ALT 5-40 Alkaline phosphatase 30-110 Gamma GT 10-50
A 55-year-old male attends with a three day history of flu-like symptoms and nausea. On examination he has a stuffy nose but is otherwise well. Investigations show: Bilirubin 28 µmol/L AST 22 IU/L ALT 30 IU/L Alkaline phosphatase 75 IU/L Gamma GT 45 IU/L
Gilbert’s syndrome
Liver Function tests (LFTs) are among the most commonly used investigations in clinical medicine. A sound understanding of why they become abnormal and a rational, cost effective approach to their investigation is essential.
Marked elevations of aspartate transminase (AST) and alanine transaminase (ALT) with only modest rises of alkaline phosphatase and gamma glutamyl transferase (GT) suggest hepatitis whereas markedly raised alkaline phosphatase and gamma GT reflect a cholestatic picture.
Gilbert’s disease is an autosomal recessive disorder in most subjects (although autosomal dominant inheritance has been reported). It is associated with benign, mildly symptomatic, non-haemolytic, unconjugated hyperbilirubinaemia. No treatment is required and the typical feature is the isolated elevation of bilirubin often found found completely co-incidentally. The bilirubin may rise in illness or starvation.
The greater than 10-fold elevation of transaminases in the middle aged female suggests a hepatitis and does not appear to be related to alcohol where elevation of alkaline phosphatase and gamma GT would be more pronounced.
The middle aged male with heavy alcohol use has examination and biochemical features which suggest an acute alcoholic hepatitis associated with cirrhosis.
Usually presents with chronic liver disease often in association with neurological features.
Wilson’s disease
This case describes a child with Wilson’s disease also known as hepatolenticular degeneration. It is an autosomal recessive condition characterised by cirrhosis of the liver, degenerative changes of the brain and Kayser-Fleischer rings on the cornea. It is as a result of low caeruloplasmin and high copper excretion.
A 9-month-old baby presents with a sudden onset of abdominal pain and loose stools which have the appearance of red currant jelly.
Intussusception
Intussusception is an invagination of the bowel in to an adjacent segment. It presents as paroxysmal pain occasionally with vomiting and palpation may reveal a sausage shaped mass in the right upper abdomen. A delay in diagnosis results in the child passing blood stained mucus rectally some times known as red currant jelly. Intussusception can sometimes be reduced hydro-statically, if unsuccessful surgery is required.
A 4-day-old infant presents with severe abdominal distension and feculent vomiting
Hirschsprung’s disease
Hirschsprung’s disease is absence of ganglia cells in part or all of the wall of the colon. The child presents with bilious or faeculent vomiting, constipation and distension.
A 5-week-old breast fed baby is admitted with a two week history of vomiting and dehydration. On examination an olive sized mass is palpable.
Pyloric stenosis
Pyloric stenosis is most prevalent amongst first born male and age of onset is usually between 3-6 weeks of age. Babies present with projectile vomiting and examination may reveal visible peristaltic waves and an olive sized mass may be palpable in the upper epigastrium.
A 3-month-old baby boy is admitted with episodic screaming. On examination he is mottled and has a delayed capillary refill time. Palpation of the abdomen reveals a sausage shaped mass.
Intussusception
Intussusception - a segment of bowel becomes telescoped in to an adjacent of bowel often in areas where the bowel is aperistaltic, for example Peyer’s patches, Meckel’s diverticulum, tumour or an area of oedema secondary to Henoch-Schönlein purpura. The child presents with pain, vomiting and signs of shock. A mass may be palpable in the right upper quadrant.
A baby with cystic fibrosis develops vomiting and abdominal distension. A ground glass appearance is seen on plain x ray of abdomen.
Meconium plug syndrome
Meconium plug syndrome is the commonest form of small bowel obstruction and the infant presents with distension, vomiting and constipation. A plain film x ray of abdomen may reveal a ground glass appearance.
A 62-year-old male with a one year history of Type 2 diabetes, presents with weight loss, anorexia and jaundice. On examination he is jaundiced with a palpable gall bladder.
Ca 19-9
Monoclonal antibodies are used to detect serum antigens associated with specific malignancies. These tumour markers are most useful for monitoring response to therapy and detecting early relapse. With the exception of prostate-specific antigen (PSA), tumour markers do not have sufficient sensitivity or specificity for use in screening.
Carcinoembryonic antigen is used to detect relapse of colorectal cancer, and CA 19-9 may be helpful in establishing the nature of pancreatic masses.
Cancer antigen (CA) 27.29 most frequently is used to follow response to therapy in patients with metastatic breast cancer.
PSA is used to screen for prostate cancer, detect recurrence of the malignancy, and evaluate specific syndromes of adenocarcinoma of unknown primary.
