GIT

Question 1

Autoimmune chronic active hepatitis

Answer 1

Risk factors: Female; Genetic predisposition, Autoimmune diseases: thyroiditis, type1DM, ulcerative colitis, coeliac disease, RA, Viruses: measles virus, CMV, hepatitis viruses (A,C,D), and EBV; Drugs: minocycline, methyldopa, nitrofurantoin, diclofenac, atorvastatin, interferon, ezetimibe; Herbal agents: blackcohosh Signs & Symptoms: fatigue; malaise ; lethargy; anorexia; nausea; abdominal discomfort mild pruritus, small joint arthralgia; Fever; Encephalopathy; GI bleeding associated with portal hypertension Examination: Hepatomegaly; Jaundice; Splenomegaly; spider angiomata; ascites Investigations: - LFTs: elevated Aminotransferase levels; - Bilirubin and alkaline phosphatase levels- increased; - serum gamma globulins elevated; - Serum albumin levels - reduced. - Coagulation studies: prothrombin time prolonged.

Question 2

Helicobacter pylori gastritis

Answer 2

• dyspepsia/epigastric discomfort - nausea - vomiting - loss of appetite - no suspicious features of malignancy, ie. GI bleeding, anaemia, early satiety, unexplained weight loss (>10% body weight), progressive dysphagia, odynophagia, or persistent vomiting

Question 3

Hepatitis A

Answer 3

early: - abrupt-onset fever - abdominal pain - malaise, nausea +/- vomiting - headache +/- diarrhoea - +/- upper abdo discomfort late: - dark urine - pale stools - jaundice - hepatomegaly - splenomegaly - marked elevation of serum transaminases (usually >1000 units/L)

Question 4

Hepatitis B

Answer 4

• cirrhosis or liver failure - jaundice - polyarthralgia - transient maculopapular or urticarial rash - multiple sexual partners - men who have sex with men (MSM) - injection drug use - Asian, eastern European, or African ancestry

Question 5

Hepatitis C

Answer 5

• often asymptomatic, detected on screening LFTs - constitutional symptoms (fatigue, myalgia, or arthralgia) - jaundice - ascites - Confusion, altered consciousness, or coma - vasculitis, renal injury

Question 6

Alcoholic hepatitis

Answer 6

• excess alcohol - bruising, leukonychia, clubbing, palmar erythema, spider naevi - Dupuytren contracture - liver enlargement - pale, fatty motions which are difficult to flush away - leucocytosis - raised transaminase levels with AST higher than ALT in a ratio of 2:1, but with neither above 300 IU/dl - elevated bilirubin - hypoalbuminaemia - prolonged prothrombin levels

Question 7

Hirschsprung’s disease

Answer 7

• <12mo - vomiting - explosive passage of liquid and foul stools - abdominal distension - delayed passage of meconium - fever - failure to thrive

Question 8

Hydatid disease (Tapeworm infection)

Answer 8

• living on farm - poor hygiene - eating or handling undercooked meat - eating or handling undercooked fish or crustaceans - ingestion of contaminated water - dog owner - child - anaemia - cough - haemoptysis - allergy manifestations (urticaria or anaphylaxis) - seizures

Question 9

Intussusception

Answer 9

• age 6 to 12 months - male - abdominal pain - vomiting - lethargy/irritability - blood per rectum/currant jelly stool

Question 10

Irritable bowel syndrome

Answer 10

• Hx of physical or sexual abuse - age <50 years - female - previous enteric infection - abdominal discomfort - alteration of bowel habits associated with pain - abdominal bloating or distension - normal examination of abdomen - normal investigations

Question 11

Ascending cholangitis

Answer 11

Risk factors: > 50 years; Hx cholelithiasis; Hx primary or secondary sclerosing cholangitis; stricture of the biliary tree (benign/malignant); injury of bile ducts (e.g. surgery, ERCP, PTC, stent) Signs and Symptoms: RUQ pain and tenderness; Jaundice; Fever (may be absent in over 60 yrs); Nausea and vomiting; Pruritis; Malaise Charcot’s triad (50-75% of cases): fever, RUQ pain and jaundice Reynold’s pentad (~5% of cases): Charcot’s triad plus altered mental state and shock Examination: RUQ tenderness; Jaundice; Fever >38C; Tachycardia; Hypotension; Shock

Question 12

Coeliac disease

Answer 12

Risk factors: FHx of this condition; IgA deficiency; type 1 DM; autoimmune thyroid disease; Down’s syndrome; Sjogren’s syndrome; inflammatory bowel disease; primary biliary cirrhosis Signs and Symptoms: diarrhoea, weight loss, abdominal pain, bloating; fatigue, skin rash (intensely pruritic papulovesicular), recurrent severe aphthous stomatitis, deficiency states (e.g., iron deficiency) or extra-intestinal manifestations (e.g., fatigue, elevated liver enzymes, or infertility).

Question 13

Typhoid Fever (Salmonella typhi)

Answer 13

Clinical Features: Insidious onset, headache prominent, relative bradycardia, dry cough, fever gradually increase in “stepladder” manner over ~4 days, abdominal pain and (early) constipation, diarrhoea (classic pea soup) and rose spots (late), +/- splenomegaly.

Question 14

Strongyloides (Human threadworm)

Answer 14

Clinical Features: Recurrent abdominal pain and swelling, diarrhoea, chronic cough, wheezing, pruritus, dermatitis, urticaria, blood eosinophilia. Classic triad: abdominal pain (low grade) + recurrent diarrhoea + blood eosinophilia High risk: migrants and refugees from tropical developing countries, returned soldiers, former prisoners of war from SE Asia and workers or residents in northern aboriginal communities.

Question 15

Ulcerative Colitis

Answer 15

Clinical Features: Mainly in young adults (15-40yrs), recurrent attacks of loose stools (main system bloody diarrhoea), blood & pus or mucus in stools, High risk factors: Family hx, previous attacks, low fibre diet

Question 16

Volvulus (Most common are sigmoid)

Answer 16

Clinical Features: Abdominal pain, bilious vomiting, infant age <1year, abdominal distension, dark blood in nappy, weight lost, rebound tenderness & guarding, Dx: Abdominal X-ray classic coffee bean sign

Question 17

Wilson’s Disease

Answer 17

Clinical features: Kayser-Fleischer rings, jaundice, sloppy or small handwriting, hx of hepatitis, hx of behavioural abnormalities, tremor, incoordination, signs of liver failure.

Question 18

Pseudomembranous colitis

Answer 18

Risk factors: advanced age, recent hx of antibiotic use, comorbid conditions (immunosuppression, IBD), PPI’s, prolonged hospitalisation, residence in a nursing home Signs and Symptoms: abdominal pain (mild- severe), nausea, mild-severe diarrhoea, fever, nausea & vomiting, and malaise

Question 19

Cholecystitis

Answer 19

Risk factors: cholelithiasis; pregnancy; COCP; elderly; obesity; certain ethnic groups (Northern European and Hispanic); rapid weight loss; and liver transplant, prolonged fasting; diabetes, HIV; hemolytic diseases Signs and Symptoms: Severe, constant RUQ pain and tenderness, right shoulder/ interscapular pain; nausea & vomiting after eating fatty food. May have fever, Mild jaundice, positive Murphy’s sign, gallbladder palpable as a distinct mass (30-40% of cases)

Question 20

Carcinoid syndrome

Answer 20

Risk factors: male, multiple endocrine neoplasia type 1 peptic ulcer disease Signs and Symptoms: Diarrhoea; flushing (triggers stress, tyramine-containing foods (chocolate, bananas, walnuts), and alcohol); telangiectasia; peripheral cyanosis; palpitations; wheezing; and abdominal cramps Examination: pink/red discolouration of face & upper trunk; telangiectasia; hypertrophy facial features; wheeze on respiratory exam; tachycardia, raised JVP, pedal oedema, Right-sided cardiac murmurs (tricuspid regurgitation & pulmonary stenosis) on cardiovascular examination; Abdominal examination may reveal a large tender, pulsatile liver and/or fixed masses

Question 21

Biliary colic

Answer 21

Risk factors: cholelithiasis; pregnancy; COCP; elderly; obesity; certain ethnic groups (Northern European and Hispanic); prolonged fasting; rapid weight loss; and liver transplant, diabetes, HIV; hemolytic diseases Signs and Symptoms: Typical gallbladder 1-5 hours of severe, dull or boring, constant pain, in the epigastrium or RUQ; may radiate to the right scapular region or back. Patients tend to move around to seek relief from the pain. Nausea +/- vomiting, bloating, The onset of pain develops hours after a meal.

Question 22

Bowel cancer

Answer 22

Signs and Symptoms: frequently non-specific late stage diagnosis - fatigue; blood in stools, palpable rectal mass, persisting change in bowel habit, anaemia, anorexia, weight loss, and abdominal pain/bloating/cramping. Examination: may be normal or signs of anaemia, rectal mass, abdominal mass

Question 23

Mesenteric Adenitis

Answer 23

Presents in school age children Diffuse abdominal pain history of recent or current URTI Fever Abdo tenderness not localised to RLQ rhinorrhoea pharyngitis associated lymphadenopathy (usually cervical)

Question 24

Oesophageal Cancer

Answer 24

Key RFs: male, smoker, excessive alcohol intake, GORD and Barrett’s oesophagus, FHx of oesophagus, stomach, oral or pharyngeal Ca, diet low in fruit and veg. Presents with weight loss dysphagia odynophagia hoarseness

Question 25

Acute pancreatitis

Answer 25

Key RFs: gallstones, alcohol, hypertriglyceridaemia, Medications (thiazides, azathioprine, frusemide) ECRP procedure, HIV/AIDS, SLE, Sjogren’s syndrome. Presents with Nausea & vomiting anorexia abdo pain (epigastric radiating to back) tachycardia fever Cullens sign Grey-Turners sign

Question 26

Primary Biliary Cirrhosis

Answer 26

RFs: Female, age 45-60, Fam hx of condition or autoimmune disease, hx of hypercholesterolaemia sx: weight loss and other metabolic features of malabsorption itch fatigue dry eyes and dry mouth jaundice ascites splenomegaly skin pigmentation

Question 27

Peptic Ulcer Disease

Answer 27

Key RFs: Helicobacter pylori infection, NSAID use, smoking, increasing age, Fam hx of condition Presents as: Abdominal pain - chronic or recurrent abdo pain or discomfort centred in upper abdomen abdominal pain (common) Commonly related to eating and is often nocturnal. Pain may be radiate through to back Epigastric tenderness Early satiety Nausea +/- vomiting

Question 28

Pyloric Stenosis

Answer 28

presents in infants 3-6 weeks, M>F Presents with: Non bilious projectile vomiting (soon after feed) Upper abdo mass palpable - ‘olive’ like may see peristaltic waves may see signs of dehydration or failure to thrive.

Question 29

Proctalgia fugax

Answer 29

Episodic sudden, severe pain in the anal canal that lasts only seconds or minutes. May awaken patient from sleep. lasts 3-30 min affects adults, M>F No coccygeal tenderness PR negative

Question 30

Small Bowel Obstruction

Answer 30

Key RFs: Previous abdominal surgery, hernia, Crohn’s disease, foreign body ingestion, appendicitis, intestinal malignancy, intussusception, malrotation, volvulus, intestinal atresia (in neonates) Presents with: Failure to pass flatus or stool Abdominal pain (crampy and intermittent) vomiting Abdominal distension (with tinkling bowel sounds) Abdominal tenderness Peritonitis

Question 31

Infantile Colic

Answer 31

-Baby between 2 and 16 weeks age -Prolong crying (>3 hours) -Inconsolable -At least 3 times a week -Crying worst at around 10/52 age -Especially during late afternoon and early evening -Very characteristic behaviour with flexing legs and clenching fists -Normal physical examination

Question 32

Crohn’s disease

Answer 32

• Recurrent diarrhoea in a young person • Blood and mucus in stools • Colicky abdominal pain • Right iliac fossa pain • Constitutional symptoms (e.g. fever, weight loss, malaise) • Might accompany by perianal disorders (e.g. anal fissure, fistula, ischiorectal abscess), and mouth ulcers

Question 33

Diverticulitis

Answer 33

• Acute or recurrent onset of pain in the left iliac fossa • pain increased with walking and change of position • Irregular bowel habit, usually constipation • Peritoneal sign tenderness, guarding and rebound in LIF • Constitutional signs, ie fever • Maybe LIF mass can be palpated

Question 34

Eosinophilic oesophagitis

Answer 34

• Associated with allergic disorder hayfever and asthma • Dysphagia • Acute bolus food stuck in throat regularly

Question 35

Gastric cancer

Answer 35

• Male to female ratio = 3:1 • Usually asymptomatic early • Recent-onset dyspepsia in middle age • Dyspepsia unresponsive to treatment • Vague fullness or epigastric distension • Anorexia, nausea, ± vomiting • Dysphagia—a late sign • Onset of anaemia

Question 36

Gastroenteritis

Answer 36

1.Self-limiting problem (1-3 days) 2. Abdominal cramps, nausea, vomiting / diarrhoea 3. Usually no acute peritonism 4. Constitutional signs fever, malaise

Question 37

GORD

Answer 37

RF: -FHx of condition -Older age -Hiatus hernia -Obesity Clinical findings: -Heartburn -Acid regurgitation, especially lying down at night -Water brash -dysphagia (uncommon) -bloating/early satiety (uncommon) -laryngitis (uncommon) -globus (uncommon) -enamel erosion (uncommon) -halitosis

Question 38

Giardiasis

Answer 38

RF: -Contaminated water/food -Domestic animals living in or around the house Clinical findings: -Watery malodorous diarrhoea, -Abdominal cramps and distention, flatulence, belching -Intermittent nausea, epigastric discomfort, and anorexia -Low-grade malaise -Weight loss (chronic)

Question 39

Bechet’s syndrome

Answer 39

RF: 20-30yo’s, ethnicity (ME/Asia/mediterr), Family Hx -Oral mucosal ulcers / genital ulcers -erythema nodosum -uveitis -acne arms/legs rare presentation - stroke, pulmonary involvement Ix - +ve pathergy test