GIT Mock Flashcards
A 55 year old man with dyspepsia undergoes an upper GI endoscopy. An irregular erythematous area is seen to protrude proximally from the gastro-oesophageal junction. Apart from specialised intestinal metaplasia, which of the following cell types should also be present for a diagnosis of Barretts oesophagus to be made?
Goblet cell Neutrophil Lymphocytes Epithelial cells Macrophages
Goblet cells need to be present for a diagnosis of Barrett’s oesophagus to be made.
A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited. What is the best course of action?
Endoscopic surveillance at 3 monthly intervals Photodynamic therapy Nissens fundoplication Oesophagectomy External beam radiotherapy
Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected.
OESOPHAGECTOMY
A 23 year old lady presents with a posteriorly sited fissure in ano. Treatment with stool softeners and topical GTN has failed to improve matters. Which of the following would be the most appropriate next management step?
Lords procedure Injection of botulinum toxin Lateral internal sphincterotomy Endoanal advancement flap Surgical division of the external anal sphincter
The next most appropriate management option when GTN or other topical nitrates has failed is to consider botulinum toxin injection. In males a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive this may predispose to delayed increased risk of sphincter dysfunction. Division of the external sphincter will result in faecal incontinence and is not a justified treatment for fissure.
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?
10% 30% 2% 50% 25%
Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.
A 43 year old male has been troubled with symptoms of post defecation bleeding for many years. On examination, he has large prolapsed haemorroids, colonoscopy shows no other disease. What is the best course of action?
Injection with 20% phenol Injection with 80% phenol Rubber band ligation Excisional haemorrhoidectomy Haemorrhoidal artery ligation
Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where phenol is used, low concentration phenol in oil is the correct agent, the 80% phenolic solution above is used to ablate the nail bed in toe nail surgery! Either way, phenol does not work for haemorrhoidal disease in general.
Which of the following is not an extraintestinal feature of Crohns disease?
Iritis Clubbing Aphthous ulcers Erythema multiforme Pyoderma gangrenosum
ERYTHEMA
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing
A 55 year old man is found to have an anal cancer. His staging investigations show a T2 lesion with no metastatic disease. What is the most appropriate treatment?
Radical abdominoperineal excision of the anus and rectum Radical chemoradiotherapy Excision proctectomy External beam irradiation alone Chemotherapy alone
Combined chemoradiotherapy is the standard treatment for anal cancer
First line treatment for anal cancer (which is very different from rectal cancer) is radical chemoradiotherapy.
An 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver. What is the best course of action?
Arrange a PET CT scan
Arrange an endoscopic ultrasound
Assess fitness for liver resection prior to oesophagectomy
Assess fitness for oesophagectomy followed by liver resection
Insertion of metallic stent
T
he presence of distant disease in the context of oesophageal cancer renders him incurable. Further staging is not needed and surgery is not an option. Palliation is the preferred option and a metallic stent will achieve this.
A 53 year old man has a 1cm polyp identified and completely removed during a colonoscopy. Histology confirms a low grade adenoma. What is the correct follow up?
Suggest participation in bowel cancer screening but no further routine endoscopy
Repeat endoscopy in 5 years.
Repeat endoscopy in 3 years.
Segmental resection of the affected area.
Barium enema at 5 years.
In the UK, the guidance has now changed and patients like this are managed expectantly with suggestion that they participate in bowel cancer screening programmes.
A 25 year old man complains of passing painless bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani. The underlying cause is likely to be amenable by treatment from which of the following modalities?
Topical GTN Topical diltiazem Rubber band ligation Injection sclerotherapy Lateral internal sphincterotomy
Rubber banding
The history of one of the haemorrhoidal bleeding. The recent HUBLE trial showed equivalence of banding vs HALO for haemorrhoids. Rubber band ligation has a 30% failure rate but is generally easy and well tolerated. Painful PR bleeding is more suggestive of a fissure which is treated with nitrates or surgery.
A 21 year old man presents with a 5 week history of painful bright red bleeding that typically occurs post defecation and is noted on the toilet paper. External inspection of the anal canal shows a small skin tag at the six o’clock position. The patient declines internal palpation. What is the most likely underlying diagnosis?
Fissure in ano Fistula in ano Haemorrhoidal disease Solitary rectal ulcer Internal rectal prolapse
Painful bright red rectal bleeding is usually due to a fissure
The presence of pain and the sentinel tag suggests a posterior fissure in ano.
The cell of origin in virtually all pancreatic carcinomas is which of the following?
The acinar cells The islet beta cells The islet alpha cells The interstitial fibroblasts The ductular epithelium
Over 90% of pancreatic carcinomas are adenocarcinomas and are thus of ductular epithelial origin.
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Vagus nerve Azygos vein Right inferior lobar bronchus Phrenic nerve Pericardiophrenic artery
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
A 68 year old man presents with iron deficiency anaemia. Which of these sites is most likely to require a biopsy in order to identify the underlying cause?
Duodenum Ileum Antrum Jejunum Right colon
In older adults, colorectal cancer is a major cause of iron deficiency anaemia and the right colon is the major site of occult blood loss. For this reason, colonic imaging is the first line investigation in such cases.
During a colonoscopy, a patient is found to have a colonic cancer in the caecum and a 1cm polyp (which looks adenomatous) in the sigmoid colon. What is the correct management of the sigmoid polyp?
Undertake a snare polypectomy
Leave in situ until the cancer has been resected
Perform a hot biopsy
Perform a cold biopsy
Resect the sigmoid at the same time as the cancer resection
Dysplasia and cancer are not the same disease. All colonic adenomas are dysplastic. Adenomas greater than 2cm may harbor foci of malignancy within them. However, many have dysplastic cells only. These do not require segmental resection.
When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding.
In summary, do NOT remove polyps until after the cancer has been resected.
During a colonoscopy, a patient is found to have a colonic cancer in the caecum and a 1cm polyp (which looks adenomatous) in the sigmoid colon. What is the correct management of the sigmoid polyp?
Undertake a snare polypectomy
Leave in situ until the cancer has been resected
Perform a hot biopsy
Perform a cold biopsy
Resect the sigmoid at the same time as the cancer resection
Dysplasia and cancer are not the same disease. All colonic adenomas are dysplastic. Adenomas greater than 2cm may harbor foci of malignancy within them. However, many have dysplastic cells only. These do not require segmental resection.
When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding.
In summary, do NOT remove polyps until after the cancer has been resected.
A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis?
Haemorrhoids Rectal cancer Ulcerative colitis Solitary rectal ulcer syndrome Fissure in ano
Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.
A 1 year old child has been unwell with a sore throat and fever for several days. He progresses to develop periumbilical abdominal discomfort and passes diarrhoea. The paediatricians call you because the ultrasound has shown a ‘target sign’ on the right side of the abdomen. What is the best initial course of action
Obtain intravenous access, administer fluids and antibiotics Undertake urgent fluoroscopic reduction Undertake urgent hydrostatic reduction Undertake a colonoscopy Undertake a laparotomy
Always ensure that children with intussusception are resuscitated first. Administration of antibiotics is also important. This should precede any intervention
A 1 year old child has been unwell with a sore throat and fever for several days. He progresses to develop periumbilical abdominal discomfort and passes diarrhoea. The paediatricians call you because the ultrasound has shown a ‘target sign’ on the right side of the abdomen. What is the best initial course of action
Obtain intravenous access, administer fluids and antibiotics Undertake urgent fluoroscopic reduction Undertake urgent hydrostatic reduction Undertake a colonoscopy Undertake a laparotomy
Always ensure that children with intussusception are resuscitated first. Administration of antibiotics is also important. This should precede any intervention
An 82 year old lady is taken to theatre for a common bile duct exploration. She has a stone impacted at the distal aspect of the common bile duct and despite best efforts it proves impossible to remove it. What is the best course of action?
Close the bile duct over a T Tube and arrange for a stent to be placed Undertake a choledochoduodenostomy Arrange for a repeat ERCP Construct a hepaticojejunostomy Bypass the gallbladder onto the jejunum
If a stone cannot be removed at surgery then the chances of succeeding at ERCP are slim. In this case, its probably best to bypass the distal bile duct and a choledochoduodenostomy is the best way of achieving this. There are long term risks of cholangitis which are less of a concern in older patients.
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination, he has some right iliac fossa tenderness and is febrile. What is the most likely cause?
Appendicitis Irritable bowel syndrome Inflammatory bowel disease Infective gastroenteritis Meckels diverticulum
The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckels can bleed and cause inflammation, they seldom cause marked weight loss.
A 34 year old woman presents with recurrent peptic ulceration. She is on proton pump inhibitors and previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing?
Secretin Cholecystokinin Gastrin Amylase Histamine
It is likely that this patient has an MEN I type gastrinoma (female, young age). As such, the serum gastrin levels are likely to be elevated.
Which of the following strategies is not employed in the management of acutely bleeding oesophageal varices?
Endoscopic sclerotherapy Intravenous vasopressin Intravenous beta blockers Endoscopic rubber band ligation of varices Insertion of Sengstaken Blakemore tube
Intravenous beta blockers are not typically used to manage an acute event, their value lies in prophylaxis by lowering portal venous pressure.
A 65 year old lady is admitted with large bowel obstruction. On investigation with CT, she is found to have a tumour of the mid rectum with no evidence of metastatic disease. What is the most appropriate course of action?
Formation of a loop colostomy Laparotomy and Hartmanns procedure Pan proctocolectomy and end ileostomy Low anterior resection and covering loop ileostomy Low anterior resection and end colostomy
Avoid emergency resections in large bowel obstruction due to rectal cancer
This patient has presented with large bowel obstruction. However, in the case of rectal cancer, she is incompletely staged as ability to completely resect the lesion can only be determined with MRI scanning and this information is not provided. Even if the lesion were resectable, in the emergency setting, it is often safer to undertake a simple procedure such as a loop colostomy and then complete surgery at a later date. A low anterior resection and loop ileostomy in this situation would almost certainly leak (and for the reasons outlined above, may be incomplete).
