MedEd Flashcards
1
Q
what does dyspepsia indicate
A
an upper GI problem
2
Q
what are symptoms of dyspepsia
A
epigastric pain or burning or discomfort early satiety and post-prandial fullness belching bloating nausea
3
Q
A 47 year old man presents to clinic with a 3 month history of epigastric dull abdominal pain. He states that the pain is worse at night and is relieved on eating. On direct questioning, there is no history of weight loss. He is not anaemic. Duodenal ulcer Zollinger-Ellison Syndrome Gastric ulcer Gastro-oesophageal reflux disease Non-ulcer dyspepsia
A
Duodenal ulcer
4
Q
2. A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’. Gastric ulcer Gastric carcinoma Oesophageal carcinoma Gastro-oesophageal reflux disease Barrett’s oesophagus
A
Barrett’s oesophagus
5
Q
3. A 41 year old man is referred to gastroenterology outpatients out patients with a 3 month history of worsening epigastric pain and dyspepsia. Upper GI endoscopy confirms multiple ulcers in the stomach and duodenum. Serum gastrin is elevated. Duodenal ulcer Zollinger-Ellison Syndrome Gastric ulcer Gastric carcinoma Gastro-oesophageal reflux disease
A
Zollinger-Ellison Syndrome
6
Q
4. A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating. On examination there is mild tenderness to palpation of the epigastric region. Duodenal ulcer Zollinger-Ellison Syndrome Gastric ulcer Gastric carcinoma Gastro-oesophageal reflux disease
A
Gastric ulcer
7
Q
what is Zollinger-Ellison Syndrome
A
rare condition in which one or more tumours form in the pancreas or duodenum
these gastrinomas secrete large amounts of gastrin causing increased stomach acid production
8
Q
5. A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth. Zollinger-Ellison Syndrome Gastric ulcer Oesophageal carcinoma Gastro-oesophageal reflux disease Non-ulcer dyspepsia
A
Gastro-oesophageal reflux disease
9
Q
def of peptic ulcer disease
A
a break in the superficial epithelial lining of either the stomach or duodenum
10
Q
what sort of peptic ulcer is more common, gastric or duodenal
A
duodenal
11
Q
what is a common cause of PUD in developing countries
A
h. pylori
12
Q
what is a common cause of PUD in developed countries
A
NSAID use
13
Q
what are the two most important risk factors for PUD
A
h. pylori
NSAIDs
14
Q
how do NSAIDs increase risk of PUD
A
NSAIDs inhibit COX which leads to decreased prostaglandins and this can lead to mucosal damage
15
Q
what are rare associations with PUD
A
increased gastrin (zollinger-ellison)
16
Q
what sort of organism is h.pylori
A
gram-negative flagellate
17
Q
how common is h.pylori
A
very common in developing countries
18
Q
what does h. pylori infection lead to
A
gastritis
peptic ulcers
gastric cancer
19
Q
what sort of pain is PUD associated with
A
recurrent epigastric pain which is a burning and knawing pain
20
Q
what does pain in PUD commonly occur
A
related to eating a meal (dyspepsia)
21
Q
what symptoms are associated with PUD
A
N+V
getting full very quickly
weight loss or anorexia
22
Q
what are the signs of PUD on examination
A
epigastric tenderness
‘pointing sign’
PR blood
23
Q
when does pain from duodenal ulcers occur
A
hours after eating
can wake patients up in the night
24
Q
when does pain from gastric ulcers occur
A
immediately after eating
25
what relieves the pain of duodenal ulcers
eating
| antacids
26
what relieves the pain of gastric ulcers
minimal relief with antacids
27
what is pointing sign
in PUD
| patient can point to site of pain with one finger (specific area of pain)
28
A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating.
You suspect she has a gastric ulcer. What is the most appropriate investigation?
Upper GI endoscopy
Full blood count
Abdominal X-Ray
H.Pylori Breath Test
Trial of Proton Pump inhibitor
H.Pylori Breath Test
29
what are the indications for a h.pylori breath test or antigen test
<55yrs and NO alarm symptoms
30
what are the indications for 2wk UGI endoscopy
>55yrs or alarm (red flag) symptoms or no response to treatment
31
if an ulcer is present after a UGI endoscopy, what must be done
```
1 histology (neoplasia?)
2 h. pylori testing (biopsy urease testing?)
```
32
if a gastric ulcer is present after after a UGI endoscopy and is treated, what must be done as follow up?
repeat endoscopy after 6-8wks to rule out malignancy
33
what are red flag symptoms
```
weight loss
bleeding
anaemia
vomiting
dysphagia
early fullness on eating
```
34
what is the treatment for h.pylori
triple therapy
1PPI
2xantibiotics
for example
1lansoprazole/omeprazole
2xamoxicillin + clarithromycin
35
what is the treatment for PUD if h.pylori negative
PPI or H2 antagonist
36
what complications are associated with PUD
haemorrhage
perforation
malignancy
37
what is GORD
reflux of stomach contents into the oesphagus
38
risk factors for GORD
obesity
smoking
pregnancy
haitus hernia
39
what foods are associated with GORD
large fatty meals
| coffee or alcohol
40
what conditions are associated with GORD
achalasia
41
what symptoms are associated with GORD
burning retrosternal pain related to good
| a sour taste in the mouth
42
what makes GORD better and worse
better - anatacids
| worse - bending or lying flat
43
what are the extra-oesophageal features of GORD
nocturnal asthma
chronic cough
laryngitis (hoarseness)
44
```
A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth.
She has no other significant symptoms and you suspect she has GORD.
What is the most appropriate next step?
UGI endoscopy
Start her on a proton pump inhibitor
Barium Swallow study
Start her on a H2 antagonist
Oesophageal manometry
```
Start her on a proton pump inhibitor
45
what investigations are completed for GORD
a clinical diagnosis generally
| however a trial of PPI is often diagnostic and therapeutic
46
what is the conservative management for GORD
lose weight
avoid precipitants (large fatty meals and coffee and alcohol before bed)
elevate bed for sleeping
stop smoking
47
what is the medical management for GORD
PPIs
48
what is the MOA of PPIs
inhibits H+/K+ ATPase pump
49
what drugs affect oesophageal tone and could lead to GORD
nitrates and CCBs
50
how does GORD lead to oesophageal adenocarcinoma
GORD leads to oesophagitis which leads to barretts this leads to dysplasia and oesophageal adenocarcinoma
51
what changes occur for oesophagitis to turn into barretts oesophagus
squamous to columnar (metaplasia)
52
what history is associated with oesophageal stricture
intermittent progressive dysphagia
53
how should barretts oesophagus be treated
1 surveillance (regular endoscopy + biopsy)
2 treatment
-high grade dysplasia with radiofrequency ablation and PPI
-nodule with endoscopic mucosal resection and PPI or oesophagectomy
54
what is zollinger ellison syndrome
gastrin-secreting tumour of the pancreas
55
what endocrine condition is ZE syndrome associated with
MEN1
56
how does ZE syndrome cause gastric ulcers
increased gastrin from gastrinomas
hypertrophy of the gastric mucosa and stimulation of acid secreteing cells
this leads to damaged mucosa and ulceration
57
how does ZE syndrome cause malabsorption
damage of GI mucosa and inactivation of pancreatic enzymes
58
when should ZE syndrome considered
with multiple ulcers
59
what are symptoms of ZE syndrome
abdominal pain (similar to PUD)
diarrhoea
heartburn
60
what are symptoms of ZE syndrome when associated with MEN1
PPP
pituitary
parathyroid
pancreatic
61
what are the investigations for for ZE syndrome
fasting serum gastrin
| serum calcium
62
what is the management for ZE syndrome
PPIs
| surgical resection
63
what are common DDx for dyspepsia
GORD
PUD
cancer
non-ulcer dyspepsia
64
```
1) A 29 year old woman presents with 2 week history of passing bloody diarrhoea with mucus up to 12 times a day. This is associated with lower abdominal, cramp like pain and malaise. On examination she looks pale and generally unwell and there is some tenderness in the left iliac fossa.
a gastroenteritis
b crohns disease
c IBS
d hyperthyroidism
e UC
```
e UC
65
```
2) A 55 year old woman with diabetes presents with weight loss, diarrhoea and angular stomatitis. Blood tests reveal presence of tTG antibodies.
a hyperthyroidism
b colorectal carcinoma
c IBS
d coeliacs
e CD
```
d coeliacs
66
```
3) A 16 year old boy is brought to paediatric out patients by his mother with a 9 month history of weight loss, abdominal pain and diarrhoea. On examination, he is on the 10th centile for height and weight, having been on the 50th centile previously. tTG antibodies are negative.
a gastroenteritis
b coeliacs
c UC
d hyperthyroidism
e CD
```
CD
67
```
4) A 28 year old medical student returns from his elective in Thailand with a short history of severe lower abdominal cramps and passage of blood diarrhoea.
a gastroenteritis
b pseudomembranous colitis
c UC
d hyperthyroidism
e CD
```
gastroenteritis
68
```
5) A 24 year old woman gives a long history (several years) of intermittent diarrhoea and constipation. She also complains of abdominal bloating and left iliac fossa pain. The pain and bloating are made worse by eating and are relieved by defecation.
a gastroenteritis
b coeliacs
c IBS
d hyperthyroidism
e CD
```
IBS
69
what is IBD
a group of chronic disorders which cause inflammation to the GI tract
70
def of UC
a relapsing and remitting inflammatory disorder of the colonic mucosa
71
how is UC classified
by location
| by severity
72
who does US commonly affect
adolescents or young adults
73
def of CD
a chronic inflammatory condition which may affect any part of the GI tract from mouth to anus
74
who does CD commonly affect
bimodal peak of onset
1 adolescents and young adults
elderly
75
where does UC affect
starts distally and spreads proximally (no further than ileocaecal valve)
mucosa and submucosa
76
where does CD affect
any part of the GI tract from mouth to anus
| transmural
77
what sort of inflammation is typical in UC and CD
UC - continuous
| CD - discontinuous (skip lesions)
78
what does non-caseating granulomas indicate
CD
79
what are symptoms of UC
bloody diarrhoea
tenesmus
diffuse abdomen pain
80
what are symptoms of CD
diarrhoea
steatorhoea (when the ileum is affected)
weight loss and generally more ill than in UC
81
what is p anca associated with
IBD
- positive in UC
- negative in CD
82
what does UC increase risk of
PSC
cholangiocarcinoma
colorectal cancer
83
what are granulomas
collections of immune cells which leads to inflammation
84
what does non-caseating mean
no area of central necrosis
85
what is cobblestone mucosa associated with
CD
86
what is rose thorn appearance associated with
UC
87
what are extra GI features of IBD
mouth ulceration
erythema nodusum
pyoderma gangrenosum
88
what is episcleritis
uncomfortable red eye with no loss of vision
| associated with IBD
89
what is scleritis
painful red eye with no loss of vision
90
what is uveitis
painful red eye with loss of vision
91
what is an acute severe UC attack
12x a day
92
how is IBD diagnosed?
stool sample
| -faecal calprotectin
93
what is coeliacs disease
a chronic autoimmune disease of small intestine which leads to intolerance to dietary gluten
this leads to villous atrophy and malabsorption
94
who does coeliacs commonly affect
infants and middle aged
95
what are symptoms of coeliacs
N+V+D
weight loss
abdominal pain + distension
96
what are signs of coeliacs
aphthous ulcers
angular stomatitis
anaemia with pallor
dermatitis herpetiformis
97
what causes angular stomatitis
B12/iron deficient
98
what antibodies indicate coeliacs
tissue transglutaminase antibodies
anti-endomysial antibody
anti-gliadin
99
what is found on endoscopy and duodenal biopsy
villous atrophy
crypt hyperplasia
intraepithelial WBCs
100
what is the treament for coeliacs
gluten free diet
101
what is gastroenteritis
acute gastrointestinal infection
102
who is at risk of gastroenteritis
young and old
| travellers
103
is bacterial or virla gastroenteritis more common
bacterial
104
what is dysentry
bloody diarrhoea
105
pathology of diarrhoea
toxins or bacteria sticking to gut mucosa
106
pathology of dysentry
pathogens penetrate the intestinal mucosa and epithelial cells are destroyed
this leads to bloody diarrhoea and abdominal pain
107
what pathogen causes diarrhoea and dysentry
campylobacter
c. difficile
salmonella
108
what pathogens cause diarrhoea
s aureus
vibrio cholera
e coli
bacillus cereus
109
what pathogens cause dysentry
haemorrhagic e.coli
entamoeba histolytica
shigella
110
name an antidiarrhoeal
codeine phosphate
111
how is gastroenteritis investigated
stool microscopy and culture
112
how is gastroenteritis treated
oral rehydration therapy
| antibiotics (if systemically unwell, elderly, suppressed)
113
what is IBS
mixed group of abdominal symptoms with no obvious cause
114
who does IBS commonly affect
women>men
| onset in <40yrs
115
which set of criteria is used to diagnose IBS
ROME II/III
116
what are features of ROME II/III
```
chronic (>6months) abdo pain:
-relieved by defaecation
-associated with altered stool form or bowel frequency
and 2 of:
-urgency
-tenesmus
-abdo bloating/distension
-mucuous
-symptoms worse after food
```
117
how is IBS diagnosed
diagnosis of exclusion
118
what are features of colorectal carcinoma history
elderly
| 'red flags'
119
what are features of a pseudomembranous colitis history
c diff infection after recent antibiotic treatment
120
what are infective causes of diarrhoea
gastroenteritis
| pseudomembranous colitis
121
what are inflammatory causes of diarrhoea
IBD
122
what are malignant causes of diarrhoea
colorectal carcinoma
123
what are autoimmune causes of diarrhoea
coeliacs disease
124
what is used to classify severity of UC
Truelove and Witts severity index
125
what are features of a mild UC
<4 bowel movements/day
no blood in stools
ESR <30mm/hr
126
what are features of moderate UC
4-6 bowel movements/day
minimal blood in stools
ESR <30mm/hr
127
what are features of severe UC
```
>6 bowel movements/day
with at least one systemic feature:
-obvious blood in stools
-pyrexia
-HR>90bpm
-anaemia
ESR >30mm/hr
```
128
how is mild and moderate UC flare ups treated with proctitis (inflammation of rectum and anus) or proctosigmoiditis (inflammation of from anus to sigmoid colon)
topical 5-ASA
+/- oral 5-ASA
(to induce remission)
129
give an example of a topical ASA
mesalazine
130
give an example of a oral ASA
sulfasalazine
131
how is mild and moderate UC flare ups treated with left sided and extensive colitis
high dose oral 5-ASA
+/- topical 5-ASA
or oral beclomethasone
(to induce remission)
132
what should be given to mild or moderate UC if no improvement
oral prednisolone
| and if no response to this oral tacrolimus
133
how is severe UC flare ups treated
admit
1 IV corticosteroids + IV fluids
2 consider IV ciclosporin or surgery if no improvement or worsening in 72hrs
(to induce remission)
134
how is remission maintained in proctitis (inflammation of anus and rectum) or proctosigmoiditis (inflammation from anus to sigmoid colon)
topical or oral 5-ASA
| or both
135
how is remission maintained in left sided or extensive colitis
oral 5-ASA
136
when should oral azathioprine or oral mercatopurine be considered
with exacerbations
137
```
1. A 20 year old man presents with diarrhoea. He is passing stool 3 times a day. He is generally well with no fever. After a number of investigations he is diagnosed with Ulcerative Colitis, confined to the rectum. What treatment should be given first?
Oral prednisolone
IV corticosteroid
Oral tacrolimus
Topical 5-ASA
High dose oral 5-ASA
IV ciclosporin
```
Topical 5-ASA
138
```
2. A 20 year old man presents with diarrhoea. He is passing bloody stool 7 times a day. He looks unwell and on examination he is tachycardic and has a fever. After a number of investigations he is diagnosed with Ulcerative Colitis. What treatment should be given first?
Oral prednisolone
IV corticosteroid
Oral tacrolimus
Topical 5-ASA
High dose oral 5-ASA
IV ciclosporin
```
IV corticosteroid
139
does smoking make UC or CD better
UC better
| CD worse
140
what are the medical treaments for inducing remission in active CD
1 corticosteroids
2 5-ASA
3 immunosuppressants (azathioprine or mercaptopurine)
4 infliximab or adalimumab (anti-TNF)
141
what is the medical treatment for maintaining remission in CD
monotherapy with azathioprine or mercaptopurine
142
5-ASA, steroids, immunosuppressants are for which IBD
UC
143
steroids, immunosuppressants, anti-TNF are for which IBD
CD
144
what are the two main functions of the liver
synthetic function
| metabolic function
145
what does the liver synthesise
clotting factors
| albumin
146
what does the liver metabolise
bilirubin
oestrogens
ammonia
147
what happens to the synthetic function of the liver with disease
reduced synthesis of:
clotting factors
albumin
148
what is a sign of reduced clotting factor synthesis
bruising
149
what are signs of reduced albumin synthesis
ascites
| leukonychia
150
what happens to the metabolic function of the liver with disease
reduced breakdown, so increased:
bilirubin
oesotrogen
ammonia
151
what is a sign of increased bilirubin levels
jaundice
152
what are signs of increased oestrogen levels
palmar erythrema
spider naevae
gynaecomastia
153
what are signs of increased ammonia
confusion
| asterixis
154
what are true measures of liver function
bilirubin
albumin
INR (clotting factors or PTT)
155
what are markers of acute liver injury
ALT
AST
ALP
GGT
156
A 19-year-old male is admitted following an alcohol binge. His friends report he has vomited several times and fell over. You notice some bruises on his hands.
Which of the following is likely to be most elevated?
```
AST
ALT
GGT
ALP
All of the above
```
GGT
| raised GGT in isolation is common after recent alcohol consumption
157
A 42-year-old female is admitted with severe RUQ pain that is worse on eating fatty foods. After obtaining her LFTs, you notice a remarkably high ALP.
What is the most likely diagnosis?
```
Viral hepatitis
Alcoholic hepatitis
Short-term alcohol abuse
Biliary tract obstruction
Gilbert’s syndrome
```
Biliary tract obstruction
158
A 45-year-old chronic alcoholic presents with jaundice, bruising and abdominal pain. His stools and urine are of normal colour. His bilirubin and AST are raised.
What other marker is likely to be abnormal?
```
ALT
Albumin
ALP
Haemoglobin
GGT
```
ALT
159
what does a AST:ALT ratio of >2.5:1 indicate
alcoholic liver disease
160
what does a AST:ALT ration of <1:1 indicate
viral hepatitis
161
what causes a rise in ALP
BLIP
Bone
Liver
Intestines
Placenta
162
what are the important markers of liver injury
AST
| ALT
163
what are the important markers of biliary duct injury
ALP
| GGT
164
what does an isolated GGT indicate
acute alcohol intake
165
A 38-year old woman presents with vague, colicky right-sided abdominal pain. She reports it is got worse 6 hours ago after eating an Indian take-out. On examination her sclera appear icteric, and her abdomen is soft and non-tender. Select the investigation needed to confirm her diagnosis:
```
Liver function tests
Ultrasound of the biliary tree
Split bilirubin ratio
ERCP
Liver biopsy
```
Ultrasound of the biliary tree
166
While waiting for her cholecystectomy, the same woman falls more unwell. She feels feverish, has vomited twice and reports that the pain initially felt colicky, but now is constant in her RUQ. She also feels dull pain in her right shoulder. On examination, she displays rebound tenderness in her RUQ and a positive Murphy’s sign. Select the likely diagnosis:
```
Biliary colic
Primary Biliary Cholangitis
Ascending Cholangitis
Acute Cholecystitis
Cholangiocarcinoma
```
Acute Cholecystitis
167
A 48-year old obese man presents to A&E in agony. He is shivering visibly, clutching his right upper quadrant. You notice his hands are yellow and there are excoriations on his arms. His bloods show a raised white cell count and CRP. Select the likely diagnosis:
```
Biliary colic
Primary Sclerosing Cholangitis
Primary Biliary Cholangitis
Viral hepatitis
Ascending Cholangitis
```
Ascending Cholangitis
168
2 hours later, the same man has deteriorated whilst waiting for a hospital bed. His BP is 87/45, HR is 128 and RR is 35. He is drowsy, responding only to pain. Select the likely cause of shock:
```
Septic shock
Hypovolaemic shock due to low albumin
Neurogenic shock
Hypovolaemic shock due to blood loss
Cardiogenic shock
```
Septic shock
169
what are risk factors for gallstones
```
4Fs
Fat
Female
Fertile
Forty
```
170
what is a classical presentation of gallstones
colicky RUQ pain
| worse on eating fatty foods
171
what investigation is gold standard for gallstones
USS of biliary tree
172
what would you see on LFTs with a gallstone
a raised ALP (and GGT)
173
why are women more prone to gallstones
increased oestogen causes an increase in the cholesterol content of the bile, this makes cholesterol gallstone formation much more likely
174
what sort of gallstones show up on AXR
calcium bilirubinate
175
what is the management for a gallstone in the gallbladder
cholecystectomy
176
what is the management for a gallstone in the common bile duct
cholecystectomy
| bile duct clearance
177
how is bile duct clearance completed
ERCP
| US lithotripsy
178
what can a gallstone in the common bile duct progess into
a gallstone in the common bile duct leads to bile stasis
bacteria from the gut can move into the bile ducts
this is ascending cholangitis
179
what can a gallstone in the gallbladder or cystic duct progress into
a combination of bile stasis, inflammation and bacterial infection can lead to acute cholecystitis
180
how does acute cholecystitis present
constant RUQ pain which radiates to the R shoulder and scapula
associated with fever, N+V
181
what sign is indicative of acute cholecystitis
murphys sign
182
what would be found O/E of acute cholecystitis
jaundice (if CBD stone)
rebound tenderness
murphys sign
183
what investigations would be used to diagnose acute cholecystitis
FBC (raised WCCs)
LFTs (raised ALP + GGT)
imaging (USS, CT/MRI)
184
what is the management for acute cholecystitis
cholecystectomy <1wk
185
what is charcots triad associated with
ascending cholangitis
186
what is ascending cholangitis
bacterial infection of the biliary tract due to obstruction
187
what is charcots triad
RUQ pain
jaundice
fevers
188
how does a gallstone in the biliary tract lead to bacterial infection
bile stasis (reduced bile out of the common bile duct) therefore bacterial from the duodenum ascends the biliary tract and causes infection
189
what does reynolds pentad indicate
acute suppurative cholangitis (more severe ascending cholangitis)
which is pus in the biliary ducts
190
what is reynolds pentad
```
RUQ pain
jaundice
fevers
hypotension
confusion
```
191
how does ascending cholangitis become acute suppurative cholangitis
bacteria enters the bloodstream
192
what are the 2 main forms of autoimmune biliary disease
PBC
| PSC
193
what antibody is classic of PBC
AMA
194
what antibody is classic of PSC
pANCA
195
why is primary biliary cholangitis also called primary biliary cirrhosis
autoimmune damage to small bile ducts leads to intrahepatic cholestasis
stasis of bile leads to liver damage
196
how is PBC diagnosed
biopsy
197
how is PSC diagnosed
ERCP
198
what is PBC associated with
RA
thyroid disease
sjogrens
199
what is PSC associated with
UC
200
what is the pathology of PBC
autoimmune damage to small bile ducts which leads to intrahepatic cholestasis
201
what is the pathology of PSC
autoimmune damage to intra and extrahepatic bile ducts which causes inflammation, scarring and narrowing
202
A 53-year old man staggers into A&E having vomited 6 times in 2 hours. He is intoxicated and jaundiced. His friend said his vomit was initially “normal”, but after the first couple of episodes has had fresh blood in it. What is the likely diagnosis?
```
Ruptured oesophageal varices
Mallory-Weiss tear
Ruptured peptic ulcer
Boerhaave syndrome
Oesophagitis
```
Mallory-Weiss tear
203
what is a mallory-weiss tear
tear in the mucosal layer of the oesphagus
204
what is associated with a mallory-weiss tear
common after many episodes of severe vomiting
vomiting always precedes bleeding
205
what does the blood look like in mallory-weiss tear
blood is streaked in vomit
206
where does the tear occur in MW
gastro-oesophageal junction
207
how quickly does a MW tear resolve
1-2days
208
what is boerhaaves syndromes
more severe MWT
| complete rupture of oesphageal wall
209
how is boerhaaves syndrome diagnosed
CXR and CT scan
| -pneumediastinum
210
what are the 2 main causes of oesophageal varices
liver cirrhosis
| chronic alcohol use
211
how does liver cirrhosis cause oesophageal varices
1 decreased clotting factors which increases bleeding risk
| 2 increased extrahepatic blood shunting which leads to portal HTN
212
how does chronic alcohol use lead to oesophageal varices
oesophageal irritation
213
how does oesophageal varices present
PMH of liver cirrhosis +/ chronic alcohol use
| large volume of fresh blood
214
what investigations can confirm oesophageal varices
FBC (macrocytic anaemia)
LFTs (raised GGT from alcohol, low albumin from cirrhosis)
UEs (raised urea)
215
how is oesophageal varices managed
ABCDEFG
IV fluids and reduce portal HTN
endoscopy (band ligation is first line)
216
what is used to reduced portal HTN
terlipressin
217
what is the first line management of oesophageal varices
band ligation
218
how does ruptured peptic ulcer present
PMH of PUD, NSAID use, H.pylori
| a "coffee ground" vomit +/ meleana
219
what investigations confirm ruptured peptic ulcer
decreased BP
220
management of ruptured peptic ulcer
1 endoscopy
-IM adrenaline at site of ulcer
2 omeprazole
3 triple therapy (with H.pylori)
221
A 76-year old retired greengrocer visits her GP with difficulty swallowing solids. She says this has been getting progressively worse over 1 month. There is no coughing, choking or heartburn. She reports food getting “stuck” 2-3 seconds after swallowing. She attributes her weight loss to not eating properly, and also thinks this has caused loose, brown-black stools. Bloods show a microcytic anaemia. Select the likely diagnosis:
```
Stroke
Oesophageal cancer
Pharyngeal pouch
Plummer-Vinson syndrome
Benign stricture
```
Oesophageal cancer
222
what is plummer-vinson syndrome
rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs
223
A 27-year old lawyer presents with a 2-year history of mild dysphagia to both solids and liquids. She has no weight loss. She has symptoms of heartburn and nocturnal cough, but PPIs and bronchodilators haven’t helped. She is systemically well, and her examination is unremarkable. A “bird’s beak” appearance is noted on barium swallow. Select the diagnosis:
```
Achalasia
Benign stricture
Plummer-Vinson syndrome
Oesophageal spasm
Stroke
```
Achalasia
224
A 45-year old man presents with a 6-week history of dysphagia. This is associated with pain in his fingers, with him noting that he sees the colour vary from red, to white, to blue. He also has several red, vascular marks on his face. Select the diagnosis:
```
Plummer-Vinson syndrome
Ortner’s syndrome
Pharyngeal pouch
Limited cutaneous scleroderma
Oesophageal spasm
```
Limited cutaneous scleroderma
225
what are functional causes of high dysphagia
stroke
| parkinsons
226
what are functional causes of low dysphagia
achalasia
oesophageal spasm
CREST
227
what are structural causes of high dysphagia
pharyngeal pouch
228
what are structural causes of low dysphagia
cancer
benign stricture
plummer vinson
ortners syndrome
229
when is a barium swallow indicated
high (functional or structural) or low dysphagia (achalasia)
230
when is endoscopy indicated
first line for low dysphagia
231
when is videofluoroscopy indicated
functional high dysphagia
232
when is manometry indicated
differentiate between motility disorders
233
what cancer commonly occurs in the middle third of the oesphagus
squamous cell carcinoma
234
what cancer commonly occurs in the lower third of the oesophagus
adenocarcinoma
| GORD to oesophagitis to barretts (metaplasia) to adeoncarcinoma (dysplasia
235
how does achalasia lead to dysphagia
absence of ganglion cells in the myenteric plexus (auerbachs plexus)
this causes a failure of relaxation fo the LOS and aperistalsis
236
what sort of dysphagia is oesophageal cancer and achalasia
oesophageal cancer is structural dysphagia
| achalasia is functional dysphagia
237
who does oesophageal cancer commonly affect
elderly
238
who does achalasia commonly affect
young people
239
what investigations are used for oesophageal cancer
OGD
240
what investigations are used for achalasia
```
barium swallow (birds beak)
manometry
```
241
what causes neurological dysphagia
stroke
| parkinsons
242
what symptoms are present with neurological dysphagia
coughing immediately on swallowing
| choking which implies a problem with the swallowing process
243
what are features of pharyngeal pouch
coughing up food
halitosis (bad breath)
gurgling/dysphonia
244
what are features of plummer-vinson syndrome
iron deficiency anaemia (signs of severe IDA such as cheilosis, atrophic glossitiis, koilonychia)
oesophageal webs
dysphagia
245
what are features of limited cutaneous scleroderma
```
CREST
1 calcinosis
2 raynauds
3 esophageal dysmotility
4 sclerodactyly
5 telangiectasia
```
246
what antibodies are associated with limited cutaneous scleroderma
ANA and anti-centromere
247
what is calcinosis
calcium deposits on the skin
248
what is sclerodactyly
abnormal build up of fibrous tissue in the skin can cause the skin to tighten so severely that the fingers curl and lose their mobility
249
```
A 32 year old woman returns from a holiday in India. She started getting diarrhoea after eating at a seafood restaurant on the last night. She is feverish, nauseous and is sore all over. The whites of her eyes are yellow.
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
```
Hepatitis A
250
```
A 29 y/o male comes to the GP with fever, fatigue, joint pain and urticaria-like skin rash. He had unprotected anal sex a month ago. He comes back a week later for a blood test, which shows raised ALT and AST. Now, he complains of feeling sick, RUQ pain and looks a bit yellow.
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
```
Hepatitis B
251
```
A 67 year old man is investigated under the two-week wait for jaundice, tender hepatomegaly, ascites and anorexia. His blood tests show a raised aFP. He mentions that he was diagnosed with hepatitis years ago. What virus(es) are likely?
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
```
Hepatitis B + C
252
```
Which hepatitis virus requires another virus to be present for it to successfully infect?
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
```
Hepatitis D
253
what is the triad of symptoms which applies to all hepatitis
1 fever
2 jaundice
3 raised ALT and AST
254
what are faeco-oral hepatitis'
Hepatitis A + E
| "the vowels which hit your bowels"
255
what are features of hepatitis A
Asymptomatic (usually)
| Acute
256
what are features of hepatitis E
Enteric
Epidemics (water)
Expectant mothers
257
how is hepatitis A spread
when faecal matter containing viral hep A is ingested
258
what is a characteristic history of hepatitis B
```
prodromal symptoms
-non-specific flu like symptoms
-rash
-lymphadenopathy
followed by symptoms of acute infection
-RUQ pain
-N+loss of appetite
-jaundice
```
259
what is the prognosis of hep B
majority recovery
| few develop chronic infection
260
what is the management for acute hep B
supportive
261
what is the management for chronic hep B
peginterferon alpha or tonofovir
262
what is the most common risk factor for developing hepatocellular carcinoma
hepatitis
263
how does hep B increase risk of hepatocellular carcinoma
virus integrates into host chromosome
| acts as an oncogene
264
how does hep C increase risk of hepatocellular carcinoma
causes chronic inflammation
| mutations accumulate
265
what hepatitis must be present for hepatitis D to occur
hepatitis B
266
why does hepatitis D require hepatitis B
hepatitis D enters hepatocytes via hep B surface antigens
267
```
A 41 year old man is brought into A&E by police after being found wandering the streets seemingly confused. He is completely disorientated and is unable to give a history. As part of your neurological assessment, you examine his eyes and notice the following: Which of the following is characteristic of this patient’s condition:
A) High serum caeruloplasmin
B) Low serum copper
C) High serum iron
D) Low total iron binding capacity
E) Low transferrin saturation
```
B) Low serum copper
268
```
A 56-year-old man, diagnosed with emphysema, presents with a one-month history of jaundice and ascites. Your registrar tells you that the man has had breathing problems for the majority of his life.
What is the most likely diagnosis
Sickle Cell Disease
COPD
Epstein-Barr Virus
Idiopathic Pulmonary Fibrosis
Alpha-1 Antitrypsin Deficiency
```
Alpha-1 Antitrypsin Deficiency
269
why is there a low serum copper in wilsons diseases
copper incorporation into caeruloplasmin in hepatocytes and its excretion in bile is impaired
therefore copper is deposited
270
where is copper deposited in wilsons disease
firstly liver
then basal ganglia
eyes
271
what sort of genetic disorder is wilsons disease
autosomal recessive
272
what does wilsons disease present with
1 ataxia
2 tremor
3 dysarthria
273
what is seen in the eyes of wilsons disease patients
kayser fleischer rings
274
what sort of genetic disorder is alpha-1 anti-trypsin deficiency
autosomal recessive
275
what is the pathology of A1AT deficiency
A1AT is genetically mutated leading to it being prevented from release from hepatocytes
this causes a loss of its protective function in the lungs against elastase, leading to emphysema occurs and a build up in the liver leading to destruction an liver disease
276
how does A1AT deficiency normally present
emphysema in a young non-smoker with late onset liver signs
277
what are the stages of liver failure
1 healthy
2 fatty liver
3 liver fibrosis
4 cirrhosis
278
```
A 63-year-old woman stumbles into A+E. She looks unwell with a flushed face. An F1 mentions that when she presented last week, examination of her upper limbs suggested a sensory polyneuropathy.
Cytomegalovirus
Primary Biliary Cirrhosis
Paracetomal Overdose
Alcoholic Liver Disease
Primary Sclerosis Cholangitis
```
Alcoholic Liver Disease
279
```
A 65 year old presents with suspected liver failure. Which of the following tests would NOT be included in a liver screen for liver failure
Alpha-1 Antitrypsin
Caeruloplasmin
HIV Screen
Anti-GBM Antibody
Aspartate Aminotransferase
```
Anti-GBM Antibody
280
A 56-year-old man with a long history of alcohol abuse presents to the emergency department with abdominal pain. On examination he has a distended abdomen with shifting dullness and has a temperature of 38.2°C.
What is the most likely diagnosis?
A Bowel obstruction
B Liver cirrhosis
C Mallory–Weiss syndrome
D Perforated peptic ulcer
E Spontaneous bacterial peritonitis (SBP)
E Spontaneous bacterial peritonitis (SBP)
281
```
A 66-year-old man presents to his GP with increasing weight loss, lethargy and fever over the last 3 months. He has also noticed pale stools and dark urine.
Crigler-Najjar Syndrome
Gilberts Syndrome
Opiate Overdose
Pancreatic Carcinoma
Haemolysis
```
Pancreatic Carcinoma
282
```
A 50-year-old man comes to you because he is worried about his skin which occasionally turns yellow. On further questioning you notice that these episodes are particularly bad during periods of stress or illness. He is otherwise well.
Gilbert’s Syndrome
Hepatic Metastases
Megaloblastic Anaemia
Hepatitis A
Dubin-Johnson Syndrome
```
Gilbert’s Syndrome
283
how is conjugated bilirubin formed
haem is converted to unconjugated bilirubin which is then converted to conjugated bilirubin in the liver by UDP glucuronyltransferase
284
how is bilirubin excreted
as urobilinogen in the urine
| as stercobilin in the stools
285
how does bilirubin cause the yellow colour in our urine
bilirubin is converted to urobilinogen which is converted to urobilin giving the distinct yellow colour
286
how does bilirubin cause the brown colour in our stool
bilirubin is converted to stercobilin
287
what causes jaundice
excess bilirubin
288
what are the causes of jaundice split up into
pre-hepatic
hepatic
post-hepatic
289
aetiology of pre-hepatic jaundice
dysfunctional transport from spleen to liver
290
what sort of bilirubin is increased in pre-hepatic jaundice
unconjugated
291
what are causes of pre-hepatic jaundice
```
1 haemolysis (low Hb, malaria, haemolytic anaemias)
2 inherited disorders of bilirubin metabolism (gilberts)
```
292
aetiology of hepatic jaundice
dysfunctional hepatocytes
| abnormal conjugation/excretion
293
what sort of bilirubin is increased in hepatic jaundice
conjugated or unconjugated
294
what are causes of hepatic jaundice
VADAM
```
Viruses - hep A/B/C/E, EBV, CMV
Alcohol
Drugs - paracetomal, isoniazid, rifampicin
Autoimmune - PBC PSC
Metabolic
```
295
aetiology of post-hepatic jaundice
obstructive jaundice
296
what sort of bilirubin is increased in post-hepatic jaundice
conjugated bilirubin
297
why is there dark urine and pale stools in obstructive jaundice
flow of bilirubin into GI tract is blocked
1 bilirubin is forced into renal system where it is converted to urobilinogen and from there to urobilin (yellow) which in excess causes dark urine
2 less bilirubin in the GI system means less stercobiln (brown) so pale stools
298
what are causes of obstructive jaundice
1 stones in common bile duct (biliary colic)
2 carcinoma at head of pancreas
3 stricture
