o Flashcards
cancer colorectal types
The diagnosis is Familial Adenomatous Polyposis. FAP is an autosomal dominant condition that leads to the formation of hundreds of polyps in the bowel by age 30-40. The gene involved in Familial Adenomatous Polyposis is the APC gene found on chromosome 5.
MLH1 is incorrect. This gene is involved in HNPCC (Lynch syndrome) which is the most common hereditary cause of colorectal cancer. However, multiple polyps are rarely a feature of HNPCC.
MSH2 is incorrect. This gene is also involved in HNPCC (Lynch syndrome). As mentioned above, the colonoscopy findings are more consistent with familial adenomatous polyposis.
most common form of inherited colorectal cancer
HNPCC
HNPCC (Lynch syndrome), an autosomal dominant condition, is the most common form of inherited colon cancer. Around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive. Currently seven mutations have been identified, which affect genes involved in DNA mismatch repair leading to microsatellite instability. The most common genes involved are:
MSH2 (60% of cases)
MLH1 (30%)
hundred of polyps what gene
APC - chromosome 5
coeliac disease cause malabsorption due to
Villous atrophy is the correct answer. Villous atrophy occurs in coeliac disease due to an autoimmune response against gluten which leads to inflammation and destruction of intestinal villi. Histological features of coeliac disease include villous atrophy, crypt hyperplasia and raised intraepithelial lymphocytes.
most common complication of ERCP
Acute pancreatitis
high urea associated with upper or lower go bleed
upper
what drugs can cause drug-induced vitamin B12 deficiency
PPI and metformin
where are femoral and inguinal hernias in comparison to each other
The femoral canal lies just below the inguinal ligament and lateral to the pubic tubercle. Consequently, a femoral hernia will pass below and lateral to the pubic tubercle, whereas an inguinal hernia will be seen above and medial to it. The key landmark for the femoral canal is the femoral vein.
A direct inguinal hernia is caused by a weakness in the posterior wall of the inguinal canal. The abdominal contents (usually just fatty tissue, sometimes with bowel) are forced through this defect and enter the inguinal canal. This means that the contents emerge in the canal medial to the deep ring (as shown).
An indirect inguinal hernia, however, does not pierce the posterior wall. The abdominal contents pass through the deep inguinal ring, passing through the inguinal canal and exiting via the superficial ring.
The principle of this is that if you can place your finger over the deep inguinal ring (just above the mid-point of the inguinal ligament), then you can control an indirect inguinal hernia which has been reduced. If when you press the deep ring, the hernia still protrudes, then the hernia is emerging via a defect in the posterior wall medial to this point and is, therefore, a direct hernia
The location of the neck of the hernia (superior and medial to the pubic tubercle) suggest this is an inguinal hernia as opposed to a femoral hernia which would be inferior and lateral to the pubic tubercle.
A direct inguinal hernia enters the inguinal canal by passing though the posterior wall of the inguinal canal rather than the deep inguinal ring therefore would reappear despite pressure on the deep inguinal ring.
An indirect inguinal hernia enters the inguinal canal through the deep inguinal ring and exits the inguinal canal at the superficial inguinal ring so would not be able to reappear if the deep inguinal ring was occluded.
Bile acid malabsorption can lead to steatorrhoea and Vitamin A, D, E, K malabsorption
test of choice for this and treatment
the test of choice is SeHCAT
bile acid sequestrants e.g. cholestyramine
The hepatobiliary triangle is bordered by the common hepatic duct (medially), the cystic duct (inferiorly) and the inferior edge of the liver (superiorly). This anatomical space is of clinical importance during laparoscopic cholecystectomy for the safe ligation and division of the
cystic duct and cystic artery.
You decide to take an arterial blood gas from the femoral artery. Where should the needle be inserted to gain the sample?
The mid inguinal point is midway between the anterior superior iliac spine and the symphysis pubis
apocrine gland
sweat gland
desmoid tumours associated with what tumour suppressor gene
APC
what score assesses the severity of acute pancreatitis
The Modified Glasgow criteria is used to assess the severity of acute pancreatitis.
A 3-day old neonate with Down’s syndrome has been copiously vomiting while on the ward. The mother had a full term pregnancy with no complications. He has not passed his first bowel motion and the parents are becoming more anxious.
On examination, the abdomen is slightly distended.
What area does the pathology lie within the colon?
and what disease e
The neonate has Hirschsprung disease where there is an absence of ganglion cells in the myenteric nerve plexus (also known as Auerbach’s plexus) resulting in a lack of peristalsis. Features of this condition include nausea and vomiting, bloating, delay in the passage of meconium (first bowel motion). Males and children with Down’s syndrome have a higher risk of this condition.
Hirschsprung’s disease is caused by parasympathetic neuroblasts failing to migrate from the neural crest to the distal colon → developmental failure of the parasympathetic Auerbach and Meissner plexuses
Associations
3 times more common in males
Down’s syndrome
Possible presentations
neonatal period e.g. failure or delay to pass meconium
older children: constipation, abdominal distension
Investigations
abdominal x-ray
rectal biopsy: gold standard for diagnosis
Management
initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon
what artery supplies the lesser and greater curvatures of the stomach
Left gastric artery supplies the proximal lesser curvature of the stomach.
Right gastric artery supplies the distal lesser curvature of the stomach.
Left gastroepiploic artery supplies the proximal greater curvature of the stomach.
Right gastroepiploic artery supplies the distal greater curvature o the stomach.
Short gastric arteries supply the proximal greater curvature of the stomach above the splenic artery.
repair of inguinal hernia
TEP repair
what gene mutation is associated with pancreatic cancer
The KRAS gene mutation is associated with pancreatic cancer
what is a biomarker for colon cancer
CEA is a tumour biomarker for colorectal cancer, rather than a genetic mutation.
most common type of pancreatic cancer
adenocarcinoma
tumour suppressor gene linked to pancreatic cancer
BRCA2
sx of pancreatic cancer
classically painless jaundice
pale stools, dark urine, and pruritus
cholestatic liver function tests
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers
ix fro pancreatic cancer
what sign may be present
US
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
imaging may demonstrate the ‘double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
SAAG means what in the abdomen and what condition
Ascites: a high SAAG gradient (> 11g/L) indicates portal hypertension
Nephrotic syndrome would present with oedema but the vignette will often give you proteinuria and hypoalbuminaemia as well (which is the classic triad in nephrotic syndrome questions). Additionally, the raised liver enzymes and macrocytic anaemia are more in line with liver pathology.
gilbert syndrome pattern of inheritance
autosomal recessive
Right heart failure is associated with a what kind of liver
firm, smooth, tender and pulsatile liver edge
thoracic duct crosses diaphragm
T10
behind oepsahgus
no polyp cancer and polyp cancer what genes
This patient is presenting with hereditary non-polyposis colorectal cancer (HNPCC), which is caused by a mutation in the DNA mismatch repair genes MSH2/MLH1. HNPCC causes a very high likelihood of developing colorectal cancer before and is inherited in an autosomal dominant fashion.
Mutations in APC gene are a cause of familial adenomatous polyposis (FAP). This typically causes a very high number of polyps to develop in the intestine. These polyps are generally benign, but due to their high number, there is an increased risk of a malignant change occurring.
medial to inf epigastric artery what hernia
direct
lateral is indirect - this one goes through deep ring and superficial ring to scortum - most common
hesselbach triangle
inguinal ligament inf
inferior epigastric lat
rectus abdominus medially
what hernia pushes through this
direct hernia - weak floor inguinal canal - only sup ring
SAD PUCKER
A good method for remembering the retroperitoneal structures is: SAD PUCKER
Suprarenal (adrenal) glands
Aorta/inferior vena cava
Duodenum (2nd and 3rd parts)
Pancreas (except tail) Ureters Colon (ascending and descending) Kidneys (o)Esophagus Rectum
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
The azygos vein is routinely divided during an oesophagectomy
A 55-year-old woman presents to her GP concerned about dark, tarry stools she’s been experiencing for the last 4 days. She has a past medical history of hypertension, well controlled with ramipril. Other than ibuprofen, which she is taking for a recent skiing injury, she is on no other regular medication. She mentions in passing that she has lost some weight but she doesn’t have any abdominal pain. She is a none smoker and drinks around 17 units of alcohol per week. On examination, there are no stigmata of chronic liver disease but her conjunctiva appear pale. The GP is concerned and decides to perform several blood tests.
gastric carcinoma or peptic ulcer disease
Gastric Carcinoma would typically present in patients with higher risk (typically male smokers, often with a history of H. pylori infection who are >55 years old) and be accompanied by symptoms of weight loss.
An upper GI bleed can result in blood passing through the digestive tract and forming melaena (dark and tarry stool). Peptic ulcer is a common cause of upper GI bleed especially in patients who have identifiable risk factors such as NSAID use, as is the case in this patient.
what does VIP do
what condition
VIP inhibits acid secretion by stimulating the release of somatostatin
Prolonged diarrhoea, hypokalemia, dehydration and elevated levels of VIP point towards a diagnosis of VIPoma, also known as Verner–Morrison syndrome.
VIP is secreted by the small intestines and pancreas and inhibits acid secretion by stimulating the release of somatostatin. Somatostatin is released from D-cells and inhibits acid release.
what does VIP do
what condition
VIP - Vasoactive intestinal peptide- inhibits acid secretion by stimulating the release of somatostatin
Prolonged diarrhoea, hypokalemia, dehydration and elevated levels of VIP point towards a diagnosis of VIPoma, also known as Verner–Morrison syndrome.
VIP is secreted by the small intestines and pancreas and inhibits acid secretion by stimulating the release of somatostatin. Somatostatin is released from D-cells and inhibits acid release.
A 67-year-old gentleman presents with a swelling in his left groin which is diagnosed as a direct inguinal hernia. Within the inguinal canal, where does the ilioinguinal nerve lie in relation to the spermatic cord?
anterior to the spermatic cord
what is murphes sign
Murphy’s sign is positive in gallbladder inflammation. With the upper border of the examiner’s hand in the right upper quadrant of the abdomen under the rib cage, the patient is asked to inhale. Inhalation causes the gallbladder to descend which catches on the fingers causing pain.
what is cullens sign
Cullen’s sign is suggestive of ectopic pregnancy or acute pancreatitis and describes the bruising around the umbilicus.
what is battles sign
Battles sign describes bruising behind the ear suggesting a basal skull fracture of the posterior cranial fossa.
3 major signs of inflammorty bowel disease
Abdominal pain, Bloating and Change in bowel habit are classic features of irritable bowel syndrome
mallory weise tear
This patient is suffering from a mallory-weiss tear. The clue is in the history of bulimia nervosa. Any episode of repeated forceful vomiting can result in a mallory-weiss tear, which present as painful episodes of haematemesis.
Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics
acute mesenteric ischaemia
Acute mesenteric ischaemia is typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel, for example the superior mesenteric artery. Classically patients have a history of atrial fibrillation.
The abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
Management
immediate laparotomy is usually required, particularly if signs of advanced ischemia e.g. peritonitis or sepsis
poor prognosis, especially if surgery delayed
melena
peptic ulcer most common
how do you measure acute liver failure
Prothrombin has a shorter half-life than albumin, making it a better measure of acute liver failure
what is faecal calprotectin and when is it raised
Faecal calprotectin is a test for intestinal inflammation that has been recommended by NICE as a screening tool for inflammatory bowel disease (IBD). It can also be used to monitor the response to treatment in IBD patients.
In adults, it has a sensitivity of 93% and specificity of 96% for IBD. In children, the specificity falls to around 75%.
In addition to IBD, other causes of a raised faecal calprotectin include: bowel malignancy coeliac disease infectious colitis use of NSAIDs
what do you need to do before prescribing a biologic
Check tuberculosis status before prescribing any biologic
Interferon-gamma release assay - This is the correct answer. Reactivation of TB in an important complication of biologic therapy and an IGRA is a test for TB latency.
when does the external iliac become the femoral artery
External iliac artery becomes the common femoral artery after it passes the inguinal ligament
Which one of the following hepatobiliary disorders are most classically associated with ulcerative colitis?
primary sclerosis cholangitis
3 Fs for the risk factors of developing gallstones:
fat, female, forty.
3 Fs for the risk factors of developing gallstones:
fat, female, forty.
As such, possible differential diagnoses would include that of choledocholithiasis, ascending cholangitis and cholecystitis. However, as this patient displays a positive Murphy’s sign (inspiratory arrest upon palpation of the right upper quadrant), she is more likely to have cholecystitis, as Murphy’s sign is typically negative in choledocholithiasis and ascending cholangitis.
gastrochisis
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord.
no sac round the gut outside
Management
vaginal delivery may be attempted
newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
exomphalos
In exomphalos (also known as an omphalocoele) the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum.
Associations
Beckwith-Wiedemann syndrome - amniocentesis
Down’s syndrome
cardiac and kidney malformations
Management
caesarean section is indicated to reduce the risk of sac rupture
a staged repair may be undertaken as primary closure may be difficult due to lack of space/high intra-abdominal pressure
if this occurs the sacs is allowed to granulate and epithelialise over the coming weeks/months
this forms a ‘shell’
as the infant grows a point will be reached when the sac contents can fit within the abdominal cavity. At this point the shell will be removed and the abdomen closed
what Can a peptic ulcer lead to on X-ray
free air under the diaphragm leading to erect chest x ray
middle colic vein drains what and into what
transverse colon
SMV
The middle colonic vein drains into the SMV, if avulsed during mobilisation then dramatic haemorrhage can occur and be difficult to control.
what is found in the small intestine but not in the large
villi
most common cause of haematuresis especially if taking painkillers
peptic ulcer
what is an anal fissure and symptoms
Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Risk factors
constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
Features
painful, bright red, rectal bleeding
around 90% of anal fissures occur on the posterior midline.
if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease
Mx of anal fissure
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Management of a chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
pathology of indirect hernias
Indirect inguinal hernia occur due to failure of regression of processus vaginalis
A 25-year-old man has an inguinal hernia, which of the following structures must be divided (at open surgery) to gain access to the inguinal canal?
external oblique aponeureissi
Which of the following is most important in providing support to the duodenojejunal flexure?
Ligament of Trietz
A 32-year-old man is undergoing a splenectomy. Division of which of the following will be necessary during the procedure?
During a splenectomy the short gastric vessels which lie within the gastrosplenic ligament will need to be divided. The splenic flexure of the colon may need to be mobilised. However, it will almost never need to be divided, as this is watershed area that would necessitate a formal colonic resection in the event of division.
A 45-year-old women is identified as having a gastric gastro-intestinal stromal tumour. What is the usual cell of origin of these lesions?
GIST’s are derived from the interstitial pacemaker cells of Cajal. This means that they are often located extramucosally and macroscopically, demonstrate little mucosal disruption.
A 55-year-old man undergoes a colonoscopy and a colonic polyp is identified. It has a lobular appearance and is located on a stalk in the sigmoid colon. Which of the processes below best accounts for this disease?
dysplasia
colon - dyslasi a
oesophagus = metaplsia
A 64-year-old man is admitted to the emergency department overnight for a fall and head injury he sustained while walking home. This fall was related to alcohol excess, and this patient is noted to have had a number of previous admissions of a similar nature. The patient’s admission lasts several days, during which his blood sugar levels are consistently high. He is noted to be unkempt. There is no other significant medical history.
What is the likely cause of this patient’s elevated blood glucose levels?
destruction of islet
pancreatitis
. On further questioning the man himself reports that his urine has been getting darker as well as stools becoming paler
decrease in sterobilin
where does the abdominal aorta run between
The abdominal aorta passes from level T12 to level L4
what does terlipressin do
Terlipressin is an analogue of vasopressin. It functions to increase systemic vascular resistance via vasoconstriction and increased renal fluid reabsorption. It therefore serves to increase arterial pressure and combat hypovolaemic hypotension. Terlipressin has a sympathetic stimulating response.
Discuss
Improve
ascites and portla hypertension over what level
Ascites is the pathological build of fluid in the peritoneal space. It usually presents with abdominal swelling, discomfort and shortness of breath. An ascitic tap involves draining a sample of fluid from the peritoneal space and can give information about its protein content. If portal hypertension is present, this will cause an increase in hydrostatic pressure in the portal system. This increase in pressure pushes water into the peritoneal cavity while leaving proteins behind, resulting in a high SAAG. A SAAG value of >11g/L indicates the presence of portal hypertension.
A 42-year-old lady undergoes a difficult cholecystectomy and significant bleeding is occurring. The surgeons place a vascular clamp transversely across the anterior border of the epiploic foramen. Which one of the following structures will be occluded in this manoeuvre?
pringle
p for first one
ch for next too
The portal vein, hepatic artery and common bile duct are occluded.
During liver surgery bleeding may be controlled using a Pringles manoeuvre, this involves placing a vascular clamp across the anterior aspect of the epiploic foramen. Thereby occluding:
Common bile duct
Hepatic artery
Portal vein
first line small bowel obstruction
First-line medical management of small bowel obstruction involves IV fluids and gastric decompression, or ‘drip-and-suck’
A 15-year-old female was admitted 1 week ago to the paediatric unit. She has a past medical history of anorexia nervosa and her body mass index was measured last week at 16kg/m². Although initially uncooperative, over the last few days her insight and willingness to participate with the team had improved. Today she complains of abdominal pain and weakness.
Her bloods reveals the following:
hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
what problem and syndrome
Refeeding syndrome arises in patients due to extended periods of catabolism then abruptly switching to carbohydrate metabolism
Extended period of low calories then high carbohydrate intake
what do you give as prophylactic. fro varicalea bleed
Prophylaxis of variceal haemorrhage
propranolol: reduced rebleeding and mortality compared to placebo
appendix is derived from
midgut
achalasia
narrowing of the oesophagus so can’t swallow- damaged - solid and liquids
Plummer-Vinson syndrome (PVS) is a triad of microcytic hypochromic anaemia (iron deficiency), atrophic glossitis, and oesophageal webs or strictures. Patients usually present with dysphagia to solids, odynophagia and weakness. Its identification and follow-up are considered relevant due to increased risk of
squamous cell carcinoma of the oesophagus
severe vomiting
mallory weiss tears
Mallory-Weiss tears commonly occur after severe bouts of vomiting
this is then followed by the vomiting of a small amount of blood
There is usually little in the way of systemic disturbance or prior symptoms
A 45-year-old man has widespread metastatic adenocarcinoma of the colon. Which one of the following tumour markers is most likely to be elevated?
CEA
Carcinoembryonic antigen is elevated in colonic cancer
