MedEd: GI Med/Surg

Question 1

1. A 41 year old female presents with fever, RUQ pain and nausea. She has icteral sclera and is intensely shaking

A. Diverticulitis
B. Ectopic pregnancy 
C. Ovarian Torsion
D. Ruptured AAA
E. Ureteric colic
F. Cholangitis
G. Splenic rupture
H. Gastric Ulcer 
I. Duodenal Ulcer 
J. Curling’s Ulcer 
K. Zollinger-Ellison syndrome 
L. Oesophageal Varices
M. Cholecystitis

Answer 1

F. Cholangitis

Charcot’s triad: Jaundice, RUQ pain, rigors

41 year old woman (Fat, female, fertile, fourty fair- gallstones)

Fever, nausea (differentiates it from biliary colic- inflammatory component)

Cholangitis: bile duct infection causing RUQ pain, jaundice and rigors

Question 2

Continuous epigastric/RUQ pain
Local peritonism and raised WCC
Fever, N/V

Answer 2

Acute cholecystitis

Follows from stone or sludge impaction in the neck of the gall bladder
No jaundice (as CBD is not blocked- differentiates it from cholangitis)
May be Murphy’s sign positive (inspiration and stop breathing- local peritonism)

Question 3

RUQ pain, radiating to the back

Jaundice

Answer 3

Biliary colic

Symptomatic gallstones obstructing the cystic duct or CBD- jaundice
Pain radiates to back due to diaphragm?

Question 4

2. A 65 year old man presents with severe, acute onset abdominal pain. BP: 90/60,
   HR 150. Upon examination he has an expansile umbilical mass

A. Diverticulitis
B. Ectopic pregnancy 
C. Ovarian Torsion
D. Ruptured AAA
E. Ureteric colic
F. Cholangitis
G. Splenic rupture
H. Gastric Ulcer 
I. Duodenal Ulcer 
J. Curling’s Ulcer 
K. Zollinger-Ellison syndrome 
L. Oesophageal Varices
M. Cholecystitis

Answer 4

D. Ruptured AAA

severe, acute onset pain
Shock (hypotension and tachycardia)- so rupture
expansile umbilical mas
Increased risk of AAA >65 y.o.

Ruptured AAA
Intermittent/continuous abdominal pain
Radiates to back
Expansile abdominal mass
Shock

Screening programme for those >65, treat if >5.5cm across

Question 5

3. A man presents with severe burns to 50% of his body. He is vomiting blood and is pyrexial

A. Diverticulitis
B. Ectopic pregnancy 
C. Ovarian Torsion
D. Ruptured AAA
E. Ureteric colic
F. Cholangitis
G. Splenic rupture
H. Gastric Ulcer 
I. Duodenal Ulcer 
J. Curling’s Ulcer 
K. Zollinger-Ellison syndrome 
L. Oesophageal Varices
M. Cholecystitis

Answer 5

J. Curling’s Ulcer

burns (buzzword)
vomiting blood (GI bleed)
pyrexia (very unwell)

Curling’s ulcer: acute peptic ulcer of gastrum/duodenum
Complication of severe burns (reduced plasma volume–>ischaemia and necrosis of gastric mucosa)

Question 6

5. A man presents with central, burning abdominal pain which presents immediately after meals

A. Diverticulitis
B. Ectopic pregnancy 
C. Ovarian Torsion
D. Ruptured AAA
E. Ureteric colic
F. Cholangitis
G. Splenic rupture
H. Gastric Ulcer 
I. Duodenal Ulcer 
J. Curling’s Ulcer 
K. Zollinger-Ellison syndrome 
L. Oesophageal Varices
M. Cholecystitis

Answer 6

H. Gastric ulcer

Central, burning pain (gastric source)
Post-prandial
Immediately after eating (so gastric- duodenal before meals (hungry) or at night)

Question 7

Differences between Gastric and Duodenal ulcers

Answer 7

Gastric: immediately after meals, relieved by antacids, H. pylori

Duodenal: more common than gastric, epigastric pain before meals or at night (hungry), H. pylori

Question 8

5. A man presents with central, burning abdominal pain which sometimes wakes him up at night and is can be relieved slightly by eating.

A. Diverticulitis
B. Ectopic pregnancy 
C. Ovarian Torsion
D. Ruptured AAA
E. Ureteric colic
F. Cholangitis
G. Splenic rupture
H. Gastric Ulcer 
I. Duodenal Ulcer 
J. Curling’s Ulcer 
K. Zollinger-Ellison syndrome 
L. Oesophageal Varices
M. Cholecystitis

Answer 8

I. Duodenal ulcer

Burning pain suggests ulcer
At night or in between meals (hungry) suggests it is duodenal (gastric is worst immediately after eating)