GIT Flashcards
A barium swallow shows a lesion in the upper oesophagus. What is the most likely cause? (August 2014)
a. Schatzki ‘A’ ring
b. Vertical shelf
c. Adenocarcinoma
d. Barret oesophagus
Schatzki A ring: smooth ring just above the gastro-oesophageal junction
- Physiological contraction of the muscle - A few cm proximal to the B ring
Schatzki B ring: located at the gastro-oesophageal junction
- Seen in the setting of hiatus hernia - Represents the junction of the squamous and columnar epithelium - Usually 1-3mm in length
Vertical shelf: ?oesophageal web or prominent cricopharyngeus muscle (seen in the proximal oesophagus)
Adenocarcinoma: stricture with an irregular (ulcerated) surface, applecore lesion
Barrett oesophahus: long segment stricture in the mid-lower oesophagus
- Reticular mucosal pattern with thickened folds - Associated with reflux
ANSWER: Unclear. A vertical shelf may refer to oesophageal webs and cricopharyngeal bars which are located in the upper oesophagus.
Which is an association? (March 2015)
a. Oesophageal web with graft vs host disease
b. Oesophageal ring with peripheral neuropathy
c. Corkscrew oesophagus with obesity
Oesophageal webs
- Oesophageal constriction caused by a thin mucosal membrane projecting into the lumen (thoracic oesophagus)
- Most common in middle aged females
- Usually incidental, but can cause dysphagia and food regurgitation if there is severe stenosis
- Typically arise from the anterior wall (never the posterior wall); Can be circumferential; Occasionally multiple
Associations: Plummer-Vinson syndrome GvHD GORD – especially if in the distal oesophagus External beam radiation
Schatzki ring:
- Symptomatically narrow oesophageal B-ring (GOJ)
- Symptoms depend on the degree of narrowing:
• <13mm always symptomatic
• 13-20mm sometimes symptomatic
• >20mm rarely symptomatic
- Occurs in the distal oesophagus and usually occurs with a hiatus hernia
o Associated oesophageal conditions: Hiatus hernia Reflux oesophagitis Oesophageal web Oesophageal diverticulum
ANSWER: Oesophageal webs are associated with GvHD
Which is true regarding the oesophagus? (March 2016)
a. Traction diverticuli affect the mid-oesophagus
b. Schatzki rings affect the mid-oesophagus
ANSWER: Traction diverticuli affect the mid-oesophagus. Schatzki rings affect the lower oesophagus
What organ should not be biopsied with GvHD?
a. Kidney
b. Colon
c. Oesophagus
d. Liver
e. Skin
Graft vs Host disease
- Usually bone marrow or stem cell transplantation
- Initiation of T cell mediated destruction
Main targets:
Host immune cells (as patients are immunosuppressed)
Biliary epithelium (causing jaundice)
Skin (desquamative rash)
Gastrointestinal (GI watery diarrhea and bleeding)
o GvHD in the liver: Acute: • Hepatitis • Chronic vascular inflammation • Intimal proliferation • Bile duct destruction Chronic: • Portal tract inflammation (usually eosinophil mediated) • Bile duct destruction • Fibrosis
ANSWER: The kidney is not centrally involved in GvHD, and therefore should not be biopsied
Which is the least likely option regarding achalasia? (March 2016)
a. Decreased tone in the upper/mid oesophagus
b. Decreased tone in the distal oesophageal sphincter
c. Trypanosoma cruzi is a cause of secondary achalasia
Achalasia
- Failure of organized peristalsis and impaired relaxation of the LOS
- Results in marked dilatation of the oesophagus and food stasis
- Distal segment of narrowing is less than 3.5cm
Classification:
Primary: idiopathic
Secondary: assoc w Chagas disease (Trypanosoma cruzi)
Pathology:
- Loss of peristalsis: Abnormality of the Auerbach plexus (or the vagus nerve or the dorsal motor nucleus)
- Loss of relaxation of the lower oesophageal sphincter:
May be normal tone early in the disease
Complications: Oesophageal carcinoma (5%) Aspiration pneumonia Candida oesophagitis Acute airway obstruction (rare)
DDx:
- Central and peripheral neuropathy
- Scleroderma: GOJ is open, oesophageal dilation is less severe
- Oesophageal malignancy or gastric carcinoma (pseudoachalasia)
- Oesophageal stricture
- Chagas disease (secondary achalasia)
- Anti-Hu antibodies (lung cancer)
- Diffuse oesophageal spasm
- Presbyoesophagus
ANSWER: Decreased tone in the distal oesophagus is the least likely option, as achalasia is characterized by increased tone at the lower oesophageal sphincter
Which is correct regarding Barrett oesophagus? (March 2014)
a. Predisposes to adenocarcinoma
ANSWER: Barrett oesophagus predisposes adenocarcinoma following intestinal metaplasia of the epithelium
What is true of Barrett oesophagitis? (August 2016)
a. Metaplastic columnar epithelium
Barrett oesophagus
o intestinal metaplasia of the oesophagus
o precursor lesion to adenoCa of the oesophagus
Epidemiology:
- 3-15% of patients w GORD
- Mean age at diagnosis – 55
- 37% of patients with scleroderma have Barrett oesophagus
- 30x increased risk of developing oesophageal adenoCa
Pathology:
- progressive metaplasia of the oesophageal stratified squamous epithelium to columnar epithelium
ANSWER: Barrett oesophagus is characterized by metaplastic columnar epithelium
A binge drinker experiences pain on swallowing. A barium study shows a nodular distal oesophagus. (March 2015)
a. Reflux
b. Carcinoma
c. Varices
d. Caustic injury
• Varices should be painless • Barrett’s oesophagus risk factors: - Long standing reflux - Hiatus hernia - Alcohol consumption
ANSWER: Reflux
Which is not considered a risk factor for oesophageal adenocarcinoma and squamous cell carcinoma? (March 2016)
a. Smoking
b. Alcohol
c. Obesity
d. H pylori
e. Hot beverages
- Smoking: risk for SCC and adenocarcinoma
- Alcohol: risk for SCC and adenocarcinoma
- Obesity: risk for adenocarcinoma
- Hot beverages: risk for SCC
ANSWER: H pylori is not a risk factor for oesophageal carcinoma – some studies imply it is protective
Which is not associated with trisomy 21? (August 2014)
a. Pyloric stenosis
b. Imperforate anus
c. Hirschprungs disease
Gastrointestinal associations with T21: o Anal atresia o Coeliac disease o Duodenal atresia o Hirschprung disease o Omphalocoele
ANSWER: Pyloric stenosis is not associated with trisomy 21
Which is false of autoimmune gastritis? (March 2015)
a. Associated with microcytic anaemia
b. Associated with subacute combined degeneration of the cord
c. Associated with carcinoid
d. High gastrin
Atrophic gastritis
- Divided into autoimmune (type A) and non-autoimmune (type B)
Type A (autoimmune):
- Gastric body and fundus atrophy secondary to antiparietal cell antibodies
- Decreased secretion of acid & intrinsic factor -> vitamin B12 deficiency (pernicious anaemia)
o Macrocytic anaemia
o Subacute combined degeneration of the cord
- High serum gastrin
Associations:
• Carcinoid tumours
• 3 times more likely to develop gastric neoplasms
Type B (non-autoimmune) - Gastric antrum atrophy Causes: • Helicobacter pylori (most common) • Alcohol • NSAID use • Bile salt reflux
ANSWER: Autoimmune gastritis is not associated with a microcytic anaemia (associated with a macrocytic anaemia)
What is the most common complication of H. pylori? (September 2013)
a. Duodenal ulcer
b. Gastric ulcer
c. Adenocarcinoma
d. MALT lymphoma
e. Metaplasia
H. pylori causes chronic gastritis which can persist for decades
Complications of H. pylori: o Gastric and duodenal ulcers (10-20%) - H. pylori is responsible for 90% of DU and 70-80% of gastric ulcers o Gastric adenoCa (2%) o Gastric MALT lymphoma (1%)
Metaplasia
o More common in the duodenum
o Meta-analysis suggests incidence from 20-40% in patients w chronic gastritis
ANSWER: Evidence suggests that intestinal metaplasia is the most common complication, secondary to chronic gastritis
Regarding peptic ulcer disease, which is most likely? (March 2014)
a. Greater curvature lesions are associated w NSAIDs
b. Gastric MALToma is associated with …
c. H. pylori has tropism (tendency) towards the duodenal mucosa
d. Duodenal ulcers are more common than gastric ulcers
- 95% of gastric ulcers occur at the lesser curvature of the stomach
- Greater curvature ulcers are more likely to be associated with NSAID use
- DU are more common than stomach ulcers (4:1)
- Duodenal ulcers are almost universally associated with H. pylori infection
- Gastric MALT lymphoma is associated w H. pylori
- In early cases, treatment of H. pylori may lead to regression of the lymphoma
ANSWER: Greater curvature ulcers are associated with NSAID use; H. pylori is almost universally associated with duodenal ulceration. It seems to be more common in gastric mucosa, however but can be present in the abnormal duodenum. MALToma is associated with H. pylori. ?question could be which is false
H. pylori is associated with: (August 2014)
a. Gastric cancer
b. Mantle cell lymphoma
c. Decreased vitamin B12
d. Hyperplastic polyps
e. Duodenal villous atrophy
ANSWER: Gastric cancer is associated with H. pylori (2%). MALT lymphoma is associated in 1%. Hyperplastic polyps are seen in Zollinger-Ellison.
Which is H. pylori not associated with? (March 2017)
a. Gastric cancer/carcinoma
b. Gastric lymphoma
c. GIST
d. Gastric ulcers
e. Gastritis
ANSWER: H. pylori is not associated with GIST
Which is least likely to cause cancer of the stomach? (March 2017)
a. Cronkhite-Canada
b. Peutz-Jegher
c. Hyperplastic polyps
d. Sporadic/fundal gland polyp
e. Atrophic gastritis
ANSWER: Cronkhite-Canada syndrome is least likely to cause cancer of the stomach
Diffuse thickening of the stomach rugae with preservation of the architecture. (August 2016, September 2013)
a. MALT lymphoma
b. Diffuse type adenocarcinoma (Linitis plastica)
c. Intestinal type adenocarcinoma
d. GIST
e. Carcinoid
Mucosa associated lymphoid tissue (MALT) lymphoma
- aka extranodal marginal zone B-cell lymphoma
- Low grade extranodal lymphoma
Epidemiology:
7.5% of non-Hodgkin’s lymphoma
Mean age 60 years
Slight female predominance
Pathology:
- Arise in epithelial tissues where lymphoid cells are usually not found
- Chronic infection/inflammation has been implicated e.g. stomach and H. pylori infection; Sjogren syndrome and salivary gland
- <10% transform to high grade disease
- Can metastasize to other sites or bone marrow
Sites:
• Stomach – most common (33-50%) (H. pylori in 90%)
• Intestine (5%) - Possible association w Coeliacs
• Salivary glands (Sjogren’s)
• Skin
• Thyroid (Hashimoto’s)
• Others: orbit, breast, lung and upper airways, kidney, liver, rectum and prostate
Gastric lymphoma
o Primary or secondary - MALT lymphoma accounts for 60%
o Most common site of extranodal lymphoma (25%
Epidemiology: 6th decade, no gender predilection
Pathology (MALT):
90% association with H. pylori
May spontaneous regress following treatment
- Variable appearance including thickened gastric rugae and linitis plastica
ANSWER: MALT lymphoma
Gastric cancer is most associated with: (August 2016)
a. Bilroth I
b. Bilroth II
c. Roux en y
Risk factors for gastric cancer: o H. pylori infection o Pernicious anaemia o Adenomatous gastric polyps o Atrophic gastritis o Bilroth II partial gastrectomy (for benign disease) - Reflux of bile & pancreatic juices into the stomach is thought to be carcinogenic o Type A blood group
ANSWER: Bilroth II
Regarding GIST, which is true? (March 2014)
a. Stomach GIST are the most maligant
b. Leiomyomas are associated with MEN syndrome
c. Recurrence of GIST is related to the initial size
GIST:
o Most common mesenchymal tumours of the gastrointestinal tract. Responsive to chemotherapy
Pathology:
- Arise from the interstial cells of Cajal
- 95% stain positive for c-KIT – tyrosine kinase growth factor receptor
• Can be targeted with chemotherapy (Glivec/imatinib)
- Smaller lesions and lesions located in the stomach demonstrate less aggressive behaviour
- Round lesions with frequent haemorrhage
- Larger lesions may have central necrosis and cystic degeneration
Associations:
- Carney triad: extra-adrenal paragangliomas, GIST tumours and pulmonary chondroma
- NF1
Locations:
Stomach – 70% (less aggressive behaviour when compared to lesions elsewhere)
Small intestine – 20-25%
Anorectum – 7%
Colon
Oesophagus
Extra-gastrointestinal GISTs – mesentery, omentum and retroperitoneum
Prognosis:
- Tx: en bloc resection & chemoTx
- Local recurrence was more common before the introduction of tyrosine kinase inhibitors
- 50% have metastases at presentation
ANSWER: Considering larger lesions are more aggressive, it could be inferred that local recurrence risk is increased with larger tumours.
Which is true regarding HIV? (March 2015)
a. CMV colitis is associated with apthous ulcers
CMV infection of the GI tract is seen in severely immunocompromised patients e.g. solid organ transplantation and HIV
- Most common gastrointestinal manifestation of AIDS (30% of AIDS patients during their illness)
- CMV oesophagitis, gastritis, enteritis or colitis
o CMV colitis:
Sigmoid colon and rectum are the most commonly involved sites; oesophagus also common
Associated with multiple mucosal ulcerations
Other opportunistic infections in AIDS patients:
o Pneumocystis jiroveci: pneumonia
o Candidiasis (most common fungal infection)
o Atypical mycobacterium
o TB
o Cryptococcus: meningitis
o Toxoplasma: encephalitis (50% of mass lesions in the CNS)
o JC virus: PML
o HSV: mucocutaneous ulcerations in the oral and genital regions
o Cyptosporidium
ANSWER: CMV colitis is associated with apthous ulcers (shallow ulcerations)
What is the second most common cause of GI atresia? (March 2015)
a. Duodenal
b. Ileal
c. Caecal
d. Anal
- Ileal - 1 in 1000
- Anal – 1 in 5000
- Duodenal – 1 in 5000 – 10000
- Caecal – rare
ANSWER: Anal atresia is the second most common
Colonic membranes are associated with: (April 2013, September 2013, August 2016, March 2017)
a. Pseudomembranous colitis and ischaemia
b. Pseudomembranous colitis and ischaemic colitis
c. Inflammatory bowel disease and dysentery
Ischaemic bowel disease
o Mucosal or mural infarction – may follow chronic or acute hypoperfusion
o Transmural infarction – usually follows acute vascular occlusion. All three layers of the wall
Microscopic:
- Atrophy or sloughing of the surface epithelium
- Inflammatory infiltrates usually initially absent in acute ischaemia (Neutrophils recruited within hours of reperfusion)
- Chronic ischaemia is accompanied by fibrous scarring of the lamina propria. Occasionally results in stricture formation
- Bacterial superinfection (acute or chronic ischaemia) can result in pseudomembrane formation secondary to enterotoxin release (Resembles c. diff colitis)
ANSWER: Colonic membranes are associated with pseudomembranous colitis and ischaemic (in the setting of bacterial superinfection)
Which is least likely to cause small bowel ischaemia? (March 2017)
a. Acute myocardial infarction
b. SMA atherosclerosis
c. SMA embolism
d. Polyarteritis nodosa
e. Behcet disease
ANSWER: Behcet disease – causes ulceration of the mucosa, may present with GI bleeding
In severe small bowel ischaemia, which is the most frequent association? (April 2013)
a. Tight atherosclerotic narrowing of the SMA origin
b. Hypotension
c. Aortic dissection
d. Narrowing of the coeliac trunk origin
e. Polyarteritis nodosa
Most common causes of SMA occlusion: o Embolic – 60% o Atherosclerotic – 30% o Dissection o Slow flow/idiopathic
**Robbins: Mucosal or mural infarction is caused by acute or chronic hypoperfusion o Cardiac failure o Shock o Dehydration o Use of vasoconstrictive drugs
Transmural infarction: acute vascular obstruction
o Severe atherosclerosis
o Aortic aneurysm
o Hypercoagulable states
o Oral contraceptive use
o Embolisation: Cardiac vegetations; Aortic atheromas
ANSWER: Atherosclerosis would be the most common. Atherosclerosis is (however) a more common cause of chronic ischaemia.
Abdominal pain in a young women. Stricture found in the mid ileum. What is the most likely underlying cause? (August 2016)
a. Crohn disease
ANSWER: A mid ileal stricture in a young women is most likely due to Crohn disease
Regarding the complications of crohn disease, which is most likely? (March 2014)
a. Adenocarcinoma
Complications of Crohn disease: o Strictures o Adhesions o Fistulae o Perianal abscesses
• Complicating neoplasm (adenocarcinoma) of the large bowel is more common in UC
ANSWER: Adenocarcinoma is more commonly a complication of ulcerative colitis. This may not be the correct response.
What favours a diagnosis of UC over Crohn disease? (March 2016, August 2016, March 2017)
a. Pseudopolyps
Pathology:
- Usually limited to the mucosa and submucosa
• Pseudopolyp formation – islands of spared tissue surrounded by ulcerated mucosa
- Chronic disease assoc w an increased risk of colonic malignancy (1% per year after ten years with the illness)
Associated conditions: Primary sclerosing cholangitis (UC > CD) Moya moya Ankylosing spondylitis Colorectal carcinoma
ANSWER: Pseudopolyps favour a diagnosis of UC over CD
What is most correct regarding ulcerative colitis? (March 2014)
a. Toxic megacolon is more common than in Crohn disease
b. There is non-segmental involvement
ANSWER: Toxic megacolon is more common in UC
What is the most likely cause of pseudomyxoma peritonei? (August 2015)
a. Low grade appendiceal tumour
b. Ovarian cystadenoma
c. Ovarian cystadenocarcinoma
Pseudomyxoma peritonei
o Accumulation of gelatinous ascites secondary to the rupture of a mucinous tumour
o Most commonly occurs secondary to an appendiceal mucocoele
Pathological subtypes:
- Peritoneal adenomucinosis: peritoneal neoplasm composed largely of mucin associated with fibrosis with minimal cytologic atypia and mitoses. Primary tumour is usually an adenoma
• 75% 5 year survival
- Peritoneal mucinous carcinoma: characterized by proliferative epithelium, glands, nests or individual cells with marked cytologic atypia
• primary tumour is a mucinous adenocarcinoma
• 14% 5 year survival
Complications: bowel obstruction
Treatment: resection and intraperitoneal chemotherapy
ANSWER: Low grade appendiceal tumour
What is not associated with FAP? (March 2015)
a. Osteoma
b. Cholangiocarcinoma
c. Duodenal adenoma
d. Papillary thyroid cancer
Pathology:
- 2/3 familial, presents around age 16
- Mutation in the APC tumour suppressor gene (Chromosome 5q)
- 20% sporadic
- Hundred or thousands of colonic adenomatous polyps
• Usually tubular or tubulovillous
• Rectum usually spared
• Less commonly affects the small bowel and stomach
Associations:
- Colorectal carcinoma
• 7% of carriers develop CRC before age 21
• Almost all will develop colorectal cancer before age 35
• Patients are managed with total colectomy
- Hepatoblastoma (400x increased risk)
- Extra-colonic polyps (stomach and duodenum)
o Gardner syndrome: FAP in addition to • Multiple osteomas of the mandible, skull and long bones • Epidermal cysts • Fibromatoses • Desmoid tumours of the mesentery and anterior abdominal wall • Supernumerary teeth • Duodenal tumours/ampullary carcinoma • Papillary thyroid cancer
ANSWER: Cholangiocarcinoma is not associated with FAP
Which is correct regarding FAP? (March 2016)
a. It has autosomal recessive inheritance
b. Adenomas occur in the stomach and duodenum
c. There is a 50% risk of colorectal cancer by age 30
ANSWER: Adenomas occur in the stomach and duodenum
Regarding HNPCC, which is least likely? (March 2014)
a. HNPCC is associated with endometrial cancer
b. HNPCC is associated with small bowel adenocarcinoma
c. HNPCC is associated with urothelial cancer
HNPCC:
o Autosomal dominant inheritance
Associated malignancies: - Colorectal cancer (80% lifetime risk) - Genitourinary tract • Endometrial cancer (30-50% lifetime risk) • Ovarian tumours • Urinary tract cancer - Small bowel cancer (5% lifetime risk) • Duodenum (45%) • Jejunum (29%) • Ileum (12%) - Gastric cancer - CNS tumours (most commonly glioblastoma)
ANSWER: The three options of maligancies are associated with HNPCC. A further possible option included the inheritance type, which is autosomal dominant.
What is the most benign carcinoid? (March 2015)
a. Appendix
b. Stomach
c. Oesophagus
d. Jejunum
e. Rectum
GI tract carcinoid (60-85% of all carcinoid tumours)
o Small bowel – 40%
- Most commonly in the terminal ileum
- Jejunal and ileal carcinoids are often discovered incidentally, but can be large
o Rectum – 22.5%
o Colon – 15%
o Appendix – 10%
- Follow a more benign course, rarely metastasize
- 90-95% 5 year survival
o Stomach – 7.5%
o Pancreas – 7.5%
ANSWER: Appendiceal carcinoid is the most benign
Where is the most aggressive carcinoid? (August 2014)
a. Oesophagus
b. Appendix
c. Stomach
d. Colon
e. Terminal ileum
ANSWER: Carcinoids of the terminal ileum demonstrate the most aggressive behavior.
What is the most common location for small bowel carcinoid? (March 2016, August 2016)
a. Distal ileum
b. Proximal ileum
c. Jejunum
d. Duodenum
ANSWER: Distal ileum
What is the most common location for small bowel adenocarcinoma? (March 2017)
a. Duodenum
b. Proximal jejunum
c. Distal jejunum
d. Proximal ileum
e. Distal ileum
• Most common site duodenum
• Second most common site, proximal jejunum
- Within 30cm of the ligament of Treitz
ANSWER: The duodenum is the most common site for small bowel adenocarcinoma
What is the most likely? (March 2015)
a. Leiomyoma in the duodenum
b. GIST in the rectum
c. Carcinoid in the oesophagus
- 10-20% of leiomyomas in the duodenum
- 3% of GISTs in the rectum
- Oesophageal carcinoid is very rare
ANSWER: Leiomyoma in the duodenum
Which of the following is least associated with GI cancer? (September 2013)
a. Cronkhite-Canada
b. Celiac disease
c. Ulcerative colitis
d. Pernicious anaemia
e. Previous gastrectomy
Cronkhite-Canada
o Hamartomatous polyps in the digestive tract
- Stomach
- Large bowel
- Small bowel (less extensive)
o Clinical: rash, alopecia, watery diarrhoea
o Not associated with malignancy
ANSWER: Cronkhite-Canada syndrome is not associated with malignancy
Which is most associated with colorectal cancer? (March 2017)
a. Crohns disease
b. Ulcerative colitis
c. Coeliac disease
d. Peutz-Jegher
Peutz-Jegher syndrome:
o Rare autosomal dominant syndrome – STK11 tumour suppressor gene
o Presents at a median age of 11
Features:
- Multiple hamartomatous polyps and mucocutaneous hyperpigmentation
- Polyps can initiate intussusception
- Markedly increased risk of several malignancies (40%)
- Sex cord tumours of the testes (from birth)
- Gastric and small intestine tumours (from childhood)
- Colon, pancreatic, breast, lung, ovarian and uterine cancers (from the second and third decades)
Polyps:
-Most common in the small intestine
• May also occur in the stomach and colon
• Rarely can occur in the bladder and lungs
- Large and pedunculated with a lobulated contour
- Arborizing network of connective tissue, smooth muscle, lamina propria and glands lined with normal appearing intestinal epithelium
- Polyps are not considered premalignant
ANSWER: Peutz-Jegher syndrome is most associated with an increased risk of colorectal cancer. UC has a risk of 1% per year after ten years with the disease.
Which is correct regarding coeliac disease? (March 2016)
a. Coeliac disease is associated with a type 4 hypersensitivity reaction against gliadin
b. Villous atrophy with regenerative elongated crypts
c. Associated with MALToma
d. Vitamin B and C deficiencies
e. Malabsorption leads to steatorrhoea
Pathogenesis:
- T cell mediated response against alpha-gliadin (component of gluten) – delayed type hypersensitivity reaction
Morphology:
Flattened villi
Elongated regenerative crypts
Intra-epithelial CD8+ cells
Exuberant lamina propria chronic inflammation
Severity greatest in the proximal intestine
Clinical features:
Infants to middle age
Presents w diarrhea, flatulence, weight loss, anaemia
Dermatitis herpetiformis
Lymphocytic gastritis or colitis
Iron and vitamin deficiencies – more common w the fat soluble vitamins (ADEK)
Increased risk of T cell lymphoma & Sb adenoC
Response to gluten withdrawal
Increase in symptoms in a patient with good diet control should prompt investigation for a small bowel malignancy
ANSWER: Multiple correct answers – delayed hypersensitivity (type IV) reaction, villous atrophy and elongation of regenerative crypts, associated with steatorrhoea
Which is false regarding coeliac disease? (March 2017)
a. Causes MALT lymphoma
ANSWER: Coeliac disease is associated with T cell lymphoma
Which of these is true? (March 2015)
a. Vulval carcinoma predisposes to/has an association with anal cancer
b. Anal melanoma is inherited
Risk factors for anal cancer:
o HPV and other infectious disease including chlamydia, genital warts and HIV
o Women with a history of cervical, vulval or vaginal cellular atypia / in situ / or invasive cancer
o Immune suppression
o Smoking
Anal melanoma:
o Rare and aggressive malignancy
o Usually presents in advanced stages, often with distant metastases
o No known risk factors
o No long-term survivors if stage II or III at diagnosis
- Main Tx surgical excision if found early
ANSWER: Vulval carcinoma predisposes to/has an association with anal cancer
How would anal cancer be staged if there was involvement of ipsilateral iliac or inguinal lymph nodes? (August 2014)
a. I
b. II
c. IIIA
d. IIIB
- Ipsilateral iliac or inguinal nodes are N2
- Contralateral iliac or inguinal nodes are N3
- Both of these confer a stage IIIB diagnosis
ANSWER: Ipsilateral inguinal and iliac nodes confer a stage IIIB diagnosis
A surgeon asks for a Meckel’s scan for a 30 year old having PR bleeding. Which of the following is LEAST correct?
- Over half of symptomatic patients present after the age of 10 years
- Symptomatic patients form only 4% of Meckels, and Meckels are in only 2% of the population
- They are generally 2 – 20 cm from the ileiocaecal value
- They lie on the mesenteric border
- They may contain ectopic pancreatic tissue
- *They lie on the mesenteric border
Concerning oesophageal webs, which of the following is LEAST considered a recognised risk factor/ cause?
- Gastroesophageal reflux
- Graft versus host disease
- Caecal carcinoma
- Sarcoidosis
- Pemphigus
- *Sarcoidosis
Concerning celiac disease, which of the following is most correct?
1) There is an increased incidence of adenocarcinoma and also lymphoma of the small bowel
2) It classically presents as failure to thrive in the initial neonatal period to 3-month period
3) It is the only gut pathology associated with skin lesions
4) Presentation is in childhood, with the adult peak in the early 20s
5) There no association with monosomies / trisomy’s
1) *There is an increased incidence of adenocarcinoma and also lymphoma of the small bowel
Concerning Campylobacter infection which of the following is LEAST correct?
1) Infections are particularly linked to damaged / in adequately sterilized canned foods
2) The majority of infections cause a bloody / watery diarrhoea
3) Unlike Crohn’s disease it does not cause erythema nodosum
4) It can precipitate Guillain Barre syndrome or a reactive arthritis
5) It is characteristically limited to the duodenum and proximal jejunum
4) *It can precipitate Guillain Barre syndrome or a reactive arthritis
A patient has a pancolitis on CT. Which of the following most suggest is it due to antibiotic associated colitis?
1) Presence of a pseudomembranous on colonoscopy/biopsy
2) Presence of Clostridium difficile on stool culture
3) Presence of clostridium difficile toxin on stool sample
4) History of antibiotic use in the preceeding 2 weeks
5) Exclusion of other causative factors
3) *Presence of clostridium difficile toxin on stool sample
Concerning gastrointestinal infections, which of the following is LEAST correct?
1) Immunosuppressed patients with norovirus may have persistent disease/ symptoms for months
2) Rotavirus infection is most often seen in the 3-5 year-olds
3) Rotavirus vaccination can precipitate intussusception
4) Giardiasis is caused by a non-invasive water borne protozoan and most commonly is seen in the duodenum / proximal small bowel.
5) Cryptosporidium can cause self limited diarrhoea infection, most marked in the terminal ileum/ proximal colon but can cause chronic diarrhoea and involve biliary and respiratory tracts in immunosuppressed patients
2) *Rotavirus infection is most often seen in the 3-5 year-olds
Concerning Ulcerative colitis (UC), which of the following is most correct?
1) Rectal sparing (prior to therapy), occurs in only 5 -10% of patients
2) Focal appendiceal or caecal disease may occur with left sided colonic disease (an exception to the usual rule of continuous involvement)
3) The ulceration classically forms deep serpentine ulcers causing mural thickening
4) Extracolonic manifestations are stopped +/- are cured post colectomy
5) A severe initial colitis with no history of proceeding inflammation, is atypical with UC and should suggest another diagnosis
2) *Focal appendiceal or caecal disease may occur with left sided colonic disease (an exception to the usual rule of continuous involvement)
A contrast swallow request states “Long segment Barrett’s oesophagus, recent MI not for endoscopy”. Which of the following is LEAST correct?
- There is a risk of malignancy of 0.2 to 2% per year
- At least 3 cm of oesophagus should be involved
- There is an increased risk of benign structures
- The most common associated malignancy is adenocarcinoma
- The risk of carcinoma is independent of the length of metaplastic change
- *The risk of carcinoma is independent of the length of metaplastic change
A clinical request states, “ Oesophageal cancer; staging”. Which of the following statements is LEAST correct?
- Adenocarcinoma is most common in the mid/upper third, squamous in the lower third
- Overall 5 year survival is up to 75% - 80% for early stage disease.
- When in the distal oesophagus adenocarcinoma may extend into the gastric cardia
- Both adeno and SCC may be plaque like, infiltrative, exophytic or ulcerative masses
- SCC spreads to nodes including cervical, mediastinal / tracheobronchial/ paratracheal and gastric/coeliac, groups depending on tumor location.
- *Adenocarcinoma is most common in the mid/upper third, squamous in the lower third
Concerning chronic gastritis, which of the following is most correct?
- H. Pylori infection / mucosal changes are most severe in the gastric body and fundus
- Autoimmune gastritis accounts for 30 – 35%% of chronic gastritis
- Autoimmune gastritis is associated with a microcytic anaemia
- Hypergastrinemia suggests Zollinger-Ellison syndrome
- An ulcer in the setting of pernicious anaemia should strongly suggest malignancy
- *An ulcer in the setting of pernicious anaemia should strongly suggest malignancy
When staging gastric carcinoma in a 60 year-old female which of the following, is least likely to be due to represent gastric metastatic disease?
- Enlarged periumbilical nodes
- Enlarged solid ovarian masses
- Enlarged supraclavicular nodes
- Enlarged left axillary node
- Enlarged upper right internal mammary node
- *Enlarged upper right internal mammary node
Concerning Gastric neoplasms which of the following is LEAST correct?
- Treatment of H pylori may result in long term remission of gastric lymphoma
- Intestinal-type gastric carcinomas most frequently grow as an ulcerative or exophytic mass rather than a diffuse infiltrative pattern
- Malignant gastric neoplasms are most common in the gastric antrum and on the lesser curve
- Lymphoma accounts for 1 in 20 gastric neoplasms
- Approximately 50% of GIST occur before the age of 40, with gastric GIST the most aggressive.
- *Approximately 50% of GIST occur before the age of 40, with gastric GIST the most aggressive.
Concerning GIST, which of the following statements is LEAST correct?
- Metastasis / recurrence with complete macroscopic resection is rare if less than 5cm for gastric GIST.
- Primary gastric GIST can be up to 30 cm in size and may cause gastric haemorrhage by superficial tumor ulceration
- Most common sites of metastasis of malignant GIST are lung, liver and brain
- Biological behaviour may be difficult to predict by histology
- It is associated with NF-1 and a syndrome with paragangliomas
- *Most common sites of metastasis of malignant GIST are lung, liver and brain
A 70 year old patient has 2 recurrent massive bright / lower GIT bleeds, with no mucosal mass seen on colonoscopy. A bleeding study is performed during a third episode. Which of the following is LEAST correct?
- The history may represent a diverticular bleed
- The history may represent an angiodysplasia-related bleed
- Angiodysplasia is most common in the caecum
- Massive bleeding is not typical of angiodysplasia; a focal submucosal lesion is most likely a small hemangiopericytoma.
- The history suggests a Meckel diverticular related bleed.
- *Massive bleeding is not typical of angiodysplasia; a focal submucosal lesion is most likely a small hemangiopericytoma.
A patient with hepatic metastases has carcinoid syndrome, which of the following statements is most correct?
- The most common site of primary would be in the gut, most commonly small bowel, followed by appendix, stomach, and colorectum
- Carcinoid syndrome is most commonly due to an appendiceal primary
- Within the thorax they are most common in the peripheral lung and thymus
- Midgut carcinoids are more aggressive and can be multiple
- Hindgut carcinoids (e.g. colon distal to splenic flexure only) are usually small/ benign and would be less likely in this setting.
- *Midgut carcinoids are more aggressive and can be multiple
An 8 year boy has a small bowel obstruction due to an intussusception and a history of iron deficient anaemia. Which of the following statements is LEAST correct?
- The age is atypical for intussusception and the history suggests an underlying lesion
- Peutz Jeghers syndrome (PJS) could present like this – perioral/buccal freckling would be characteristic
- PJS have an elevated risk of GI and nonGI malignancy and regular screening should start immediately after diagnosis
- In familial adenomatous polyposis (FAP) the polyps are usually seen later (teenagers) and are confined to the colon
- Sporadic juvenile polyp could present with intussusception but usually at a younger age, and they are most frequently located in the rectum.
- *In familial adenomatous polyposis (FAP) the polyps are usually seen later (teenagers) and are confined to the colon
Concerning colonic carcinomas, which of the following statements is most correct?
1) 75% of colonic carcinomas occur in the rectosigmoid region
2) Carcinomas of the anal canal region show proportionately less hepatic metastases – possibly secondary to non-portal venous drainage
3) In the TNM staging, size cut off are at <3cm, 3-5cm, 5-7cm and >7cm.
4) In the TNM staging system MX designates no metastatic disease.
5) Right side colon carcinomas tend to be low/ flat and more sessile than the left sided counterparts
2) *Carcinomas of the anal canal region show proportionately less hepatic metastases – possibly secondary to non-portal venous drainage
The pathology report of a gallbladder notes “changes of cholesterolosis”. Which of the following statements is most correct?
- This is strongly suggestive of familial hypercholesterolaemia
- It reflects deposition of focal lipid laden macrophages in the gallbladder wall of unknown cause
- It is a response to gallbladder ischemia
- It is strongly suggestive of Gaucher’s disease
- It reflects the extracellular deposition /imbibition of cholesterol crystals from cholesterol stone fragments and “sludge”.
- *It reflects deposition of focal lipid laden macrophages in the gallbladder wall of unknown cause
