PM GI Questions Flashcards
Resection of the terminal ileum puts you at increased risk of developing what condtions in the future?
Pernicious anaemia - due to vitamin B12 deficiency.
Gallstones.
Why does tenderness over McBurney’s point indicate appendicitis?
McBurney’s point represents the commonest location of the appendix from the base of the caecum.
What epithelial change occurs in Barrett’s oesophagus?
Squamous to columnar epithelium.
How does the intestinal lining change in coeliacs disease?
Flattening of villi and an increased number of lymphocytes in the lamina propria and surface epithelium. There is also gross crypt hyperplasia.
What is thiamine and where is it absorbed?
Thiamine is a water soluble vitamin and is absorbed in the jejunum.
Where is vitamin D absorbed?
Vitamin D is a fat soluble vitamin and so is absorbed in the duodenum.
Non-caseating granulomas are characteristic of what disease?
Sarcoidosis
How would you describe the pain of a duodenal ulcer?
Epigastric pain is the most common symptom of both gastric and duodenal ulcers. It is characterized by a gnawing or burning sensation and occurs after meals. Duodenal ulcer pain often awakens the patient at night.
How does a hepatic vein thrombosis present?
Ascites, liver enlargement and abdominal pain.
How does diverticulitis present?
Colicky left sided abdominal pain, associated with bloating and flatulence. Fever and leukocytosis. There may be mild iliac fossa tenderness.
How does diverticulitis present?
Colicky left sided abdominal pain, associated with bloating and flatulence. Fever and leukocytosis. There may be mild iliac fossa tenderness.
What is the general presentation of Crohn’s disease?
Feeling generally unwell and nauseous, tenderness in the right iliac fossa and the impression of fullness. THESE EPISODES HAVE HAPPENED SEVERAL TIMES BEFORE - (classic Crohn’s).
A bile pigment produced from the oxidation of heme:
Biliverdin
Sickle cell anaemia can present with what biliary hepatic condition?
Pre-hepatic jaundice.
This component contributes to the dark coloured urine brought about by gallstones obstructing the bile duct:
Conjugated bilirubin
Sodium bicarbonate and water secretion from the ductal cells of the pancreas is stimulated by what?
Secretin
Cherry red benign proliferations of blood vessels observed on the abdomen are known as what?
Campbell de Morgan spots.
Direct inguinal hernia
The abnormal protrusion of the abdominal wall originating above the inguinal ligament and medial to the epigastric vessels.
Headaches, shortness of breath and palpitation are classical symptoms of what?
Headaches, shortness of breath and palpitations are classical symptoms of anaemia. The most common nutritional causes of anaemia are B12, Folate and Iron.
Hesselbach’s triangle?
- what can occur here?
The inguinal triangle (Hesselbach’s triangle) is a region in the anterior abdominal wall. It is alternatively known as the medial inguinal fossa.
A direct inguinal hernia occurs medially to the inferior epigastric vessels (through the inguinal triangle), and an indirect hernia occurs laterally to these vessels.
Metoclopramide
Anti-emetic - commonly used to treat and prevent nausea and vomiting.
Metoclopramide
Anti-emetic - commonly used to treat and prevent nausea and vomiting.
Ileo-colic artery is a branch off what?
SMA
What does the ileo-colic artery supply?
Ascending colon and terminal ileum.
How does biliary colic present?
RUQ pain, positive murphys sign - often presents with pain after eating, particularly after high-fat meals.
How would you differentiate biliary colic vs ascending cholangitis?
In ascending cholangitis the patient may describe a similar history but would likely be more acutely unwell with a fever.
How do duodenal ulcers present?
Duodenal ulcers cause upper abdominal pain which may differ with eating, but the pain tends to be more constant, gnawing and central. If the ulcer bleeds it may also present with haematemesis or melaena.
Metoclopramide contraindications
Metoclopramide should be avoided in children and young adults due to the risk of developing oculogyric crisis.
Contraindicated in parkinsons.
Which clotting factor would be very high in acute liver failure?
In liver failure all clotting factors are low, except for factor VIII which is paradoxically supra-normal. This is because factor VIII is synthesised in endothelial cells throughout the body, unlike the other clotting factors which are synthesised purely in hepatic endothelial cells. Furthermore, whilst activated factor VIII is usually rapidly cleared from the blood stream, good hepatic function is required for this to occur, further leading to increases in circulating factor VIII.
Propanolol
Propranolol - A non-cardioselective β blocker (NSBB) is used for primary and secondary prevention of bleeding in oesophageal varices. They act by causing splanchnic vasoconstriction, reducing portal blood flow.
What makes up the femoral triangle?
SAIL
Sartorius
Adductor longus
Inguinal ligament
Roof of the femoral traingle - fascia latte
What is the clinical relevance of the femoral triangle?
Femoral nerve and its terminal branches pass through the femoral triangle - The nerve enters the femoral triangle by passing beneath the inguinal ligament, just lateral to the femoral artery. The femoral nerve also passes through here.
What is duodenal atresia?
Duodenal atresia is the congenital absence or complete closure of a portion of the lumen of the duodenum. It causes increased levels of amniotic fluid during pregnancy (polyhydramnios) and intestinal obstruction in newborn babies.
Small vs large bowel obstruction.
In small bowel obstruction, the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation. In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer.
Think bowel obstruction when?
Abdominal distension, vomiting, and absolute constipation.
A 64-year-old man has been admitted to the surgical ward for abdominal pain and bleeding per rectum. On the clerking notes it states he has not opened his bowels for five days. Today he has started vomiting and his abdomen is distended.
What is the most likely diagnosis?
Large bowel obstruction
Abdominal distension, vomiting, and absolute constipation - so think bowel obstruction.
Large bowel obstruction presents with constipation before vomiting due to the distal location in the GI tract. His age and bleeding are red flags for colon cancer, which should be investigated by colonoscopy.
Small bowel obstruction - This would cause vomiting earlier on, before constipation. Large bowel obstruction is more likely due to the longer history of constipation and the later onset of vomiting.
What are abdominal adhesions?
Abdominal adhesions are bands of scar-like tissue that form inside your abdomen. The bands form between two or more organs or between organs and the abdominal wall.
How do abdominal adhesions present?
Abdominal adhesions can kink, twist, pull, or compress the intestines and other organs in the abdomen, causing symptoms and complications, such as intestinal obstruction or blockage.
- can lead to small bowel obstruction.
What are the most common causes of large bowel obstruction?
Malignancy
Diverticular disease
Volvulus - when the intestine twists around themselves.
Hematochezia
Hematochezia is the passage of fresh blood per anus, usually in or with stools.
The ascending and descending colons are retroperitoneal.
The ascending and descending colons are retroperitoneal.
Ranitidine
Ranitidine is a competitive antagonist of the H2 receptors on gastric parietal cells
KRAS2 is mutated in almost all cases of what cancer?
KRAS2 is a genetic mutation that will be seen in almost all cases of pancreatic adenocarcinoma.
What is a tumour marker for colorectal cancer?
CEA (carcinoembryonic antigen) is not a genetic mutation but rather the most commonly used tumor marker for colorectal cancer.
Gilbert’s syndrome summary:
This patient has Gilbert’s disease where there is a deficiency in UDP glucuronosyltransferase. This enzyme conjugates bilirubin in the liver. A reduction in this results in a buildup of unconjugated bilirubin which cannot be excreted in the urine resulting in his jaundice. The symptoms become apparent during times of stress but otherwise is not clinically significant.
Wilson’s disease
Wilson disease is an inherited disorder in which excessive amounts of copper accumulate in the body, particularly in the liver, brain, and eyes. The signs and symptoms of Wilson disease usually first appear between the ages of 6 and 45, but they most often begin during the teenage years.
Gold ring in the eyes.
High alpha fetoprotein combined with chronic liver inflammation is usually a sign of what?
Hepatocellular carcinoma
Serum alpha fetoprotein is…
Tumour marker
Which type of hernia becomes apparent on a cough?
Direct inguinal hernia.
H.pylori is gram what + anerobe / aerobe?
Gram negative, oxidase positive, comma-shaped rods aerobe.
What is the treatment for H.pylori infections?
The standard treatment is triple therapy with two antibiotics and one proton-pump inhibitor. Amoxicillin and clarithromycin can be used as the antibiotics, with metronidazole if the patient is allergic to amoxicillin.
The pancreas forms from ventral and dorsal outgrowths of where?
Duodenum
Intussusception
Intussusception is a condition in which one segment of intestine “telescopes” inside of another, causing an intestinal obstruction (blockage).
Can present in young children with red current jelly stools. Child often draws there knees up to their chest.
Pyloric stenosis is associated with projectile vomiting.
Pyloric stenosis is associated with projectile vomiting.
Meckel’s diverticulum
Meckel’s diverticulum is an outpouching or bulge in the lower part of the small intestine. The bulge is congenital (present at birth) and is a leftover of the umbilical cord.
It is useful to remember the rule of 2s. Meckel diverticulum occurs in 2% of the population, 2% are symptomatic, children are usually less than 2 years, affects males twice as often as females, is located 2 feet proximal to the ileocecal valve, is 2 inches long or less, and can have 2 types of the mucosal lining.
How does Meckel’s diverticulum present?
Gastrointestinal bleeding (which can be seen in the stool). Abdominal pain and cramping. Tenderness near the navel (belly button). Obstruction of the bowels, a blockage that keeps the contents of the intestines from passing.
What two structures come together to form the ampulla of Vater?
Common bile duct and pancreatic duct.
Coeliacs disease is sometimes accompanied by what rash?
Sometimes coeliac disease is associated with a vesicular rash, known as dermatitis herpetiformis.
- Dermatitis herpetiformis (DH) is a rare, chronic, autoimmune skin condition characterized by the presence of groups of severely itchy blisters and raised red skin lesions. These are most commonly located on the elbows, knees, buttocks, lower back and scalp.
Cells with hyperchromatic nuclei forming irregular gland-like structures is suggestive of what?
Adenocarcinoma / Adenoma
Transmural inflammation with granulomas and lymphoid aggregates is associated with Crohn’s.
Transmural inflammation with granulomas and lymphoid aggregates is associated with Crohn’s.
How does Omeprazole work?
Omeprazole is a proton pump inhibitor which inhibits H+/K+-ATPase, which is found in parietal cells.
Ranitidine
H2 receptor antagonist - prevents the action of histamine.
What is diphenoxylate and what does it do?
Antidiarrhoeal medication - Diphenoxylate acts on μ-opioid receptors in the GI tract to slow down peristalsis.
Peutz-Jegher’s syndrome - is inherited how and results due to a mutation of what gene.
Peutz-Jeghers syndrome is an autosomal dominant condition (mutation of STK11 on chromosome 19).
What is the main presentation in Peutz-Jegher’s syndrome?
Presents with benign polyps in the colon and stomach - increases risk of cancers growing elsewhere in the body - particularly pancreas breast and lung.
It is also associated with pigmented freckles on the lips, face, palms and soles.
Bell’s palsy is due to paralysis of which nerve?
Facial nerve
Why does Bell’s palsy affect taste?
The chorda tympani branch of the facial nerve innervates the anterior 2/3rds of the tongue. So a facial nerve palsy would cause taste impairment of the anterior tongue.
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.
What is the likely diagnosis?
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.
The inferior rectal nerve branches off what and supplies what?
Inferior rectal artery branches off the internal pudendal artery and supplies the muscle and skin of the anal and urogenital triangle.
The borders of Hesselbach’s / Inguinal Triangle
The inguinal triangle represents an area of potential weakness in the abdominal wall, through which herniation can occur.
The inguinal triangle is located within the inferomedial aspect of the abdominal wall. It has the following boundaries:
Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.
Hernia
A hernia is defined as the protrusion of an organ or fascia through the wall of a cavity that normally contains it.
Direct inguinal hernia?
In a direct inguinal hernia, bowel herniates through a weakness in the inguinal triangle, and enters the inguinal canal. Bowel can then exit the canal via the superficial inguinal ring and form a ‘lump’ in the scrotum or labia majora. Direct hernias are acquired (usually in adulthood), due to weakening in the abdominal musculature.
Achalasia
The lower esophageal sphincter (LES) is a muscular ring that closes off the esophagus from the stomach. If you have achalasia, your LES fails to open up during swallowing, which it’s supposed to do. This leads to a backup of food within your esophagus.
Primary sclerosing cholangitis is linked to what other condition?
Primary sclerosing cholangitis (PSC) is associated with ulcerative colitis (UC). 80% of patients with PSC suffer from UC, and 4% of patients with UC suffer from PSC. The risk of developing colorectal cancer is increased by both UC and PSC.
What is the most common form of pancreatic cancer?
The most common type of pancreatic cancer is ductal adenocarcinoma, with 60% of cancers commonly located in the head of the pancreas
A 65-year-old male with long standing chronic obstructive pulmonary disease (COPD) presents to the emergency department (ED) with shortness of breath over the last 2 hours and wheezing. On examination, he is cyanosed, has a third heart sound present and has widespread wheeze on auscultation. The emergency doctor also notices hepatomegaly which was not present 12 days ago when he was in the ED for a moderative exacerbation of COPD.
Which of the following describes the cause of hepatomegaly?
Cor Pulmonale Malignancy Cirrhosis Left sided heart failure Ascites
Cor Pulmonale: Congestive heart failure can also cause blood to back up into the hepatic veins. These are the veins that help drain blood from the liver. When they back up, the liver will become congested and grow larger. This is called congestive hepatomegaly.
Given the subacute onset of hepatomegaly, it is likely caused by cor pulmonale - right sided heart failure secondary to his COPD. The shortness of breath, third heart sound and cyanosis are in keeping with this complication.
Although left sided heart failure may cause his symptoms, it won’t give rise to hepatomegaly.
Ascites may be a complication of right sided heart failure and portal hypertension but these do not cause hepatomegaly.
Cirrhosis and liver cancer may be a cause of hepatomegaly but is unlikely in this situation given his symptoms that are more in keeping with a cardiorespiratory presentation.
Cor Pulmonale
Enlargement of the right side of the heart.
Where do the ureters run?
Retroperitoneal structure overlying transverse processes L2-L5.
Jaundice starts to appear when bilirubin reaches what concentration in blood?
Jaundice starts to appear when bilirubin reaches an excess of 35umol/l
A 45-year-old women presents to the emergency department complaining of a high fever and pain around the flank area. She also mentions that she has had mild stinging while passing urine for the last 5 days, but she hasn’t passed much urine since she developed a fever yesterday. She has a history of diabetes mellitus type II which has been poorly controlled.
What is the likely diagnosis?
Pyelonephritis:
The woman in the scenario likely has pyelonephritis, secondary to a UTI. Being a diabetic with poorly controlled blood sugars, she is more prone to recurrent UTI.
Which structure is at risk to co-infection in pyelonephritis?
Psoas muscle
The kidneys are retroperitoneal organs so can spread infection to the psoas muscle and cause an abscess. The kidneys are a retroperitoneal structure, and therefore the infection would most likely pass to another organ within that space. The psoas muscle is located posteriorly and can become co-infected alongside a pyelonephritis. In this case, an abscess may form insidiously, with minimal additional symptoms beyond what she is already complaining of. A psoas abscess is best imaged with an MRI abdopelvis.
Michael presents to the Emergency Department with acute severe epigastric pain, nausea and vomiting following a holiday is Spain in which he consumed large amounts of alcohol. On investigation, he has a raised amylase of 500 IU/L and is diagnosed with acute pancreatitis. He is treated and makes a full recovery.
Four weeks later he presents again, complaining of persisting moderately severe abdominal pain and early satiety. An ultrasound of his abdomen shows a fluid filled cavity in the pancreas lined with granulation tissue.
What complication of acute pancreatitis has Michael developed?
Pancreatic cyst Pancreatic tumour Pancreatic pseudocyst Pancreatic abscess Diabetes
Pancreatic pseudo cyst:
A pseudocyst is surrounded in granulation tissue, as opposed to a true cyst which is surrounded with epithelial tissue.
A pancreatic pseudocyst is a complication in 20% of acute pancreatitis cause by alcohol intoxication.
A pancreatic tumour would typically present with obstructive jaundice and symptoms of acute pancreatitis, but would not show a fluid filled cavity on ultrasound.
A pancreatic abscess would present with systemic signs of infection such as fever, rigors, and possibly a palpable tender mass.
Diabetes is a late complication of pancreatitis, however it does not explain the persisting abdominal pain or the fluid filled cavity.
In FAP what is the commonest extra colonic lesion observed in FAP?
Duodenal polyps occur in up to 100% of patients.
Gastric fundal polyps are seen in 50% of patients. Skull osteomas are seen in Gardeners syndrome which is a variant of FAP.
Which antibiotic is classically associated with caused C.diff colitis?
Clindamycin is classically associated with Clostridium difficile colitis.
A 70-year old woman describes colicky left-sided abdominal pain associated with bloating and flatulence. She has a fever and a leukocytosis. There is mild left iliac fossa tenderness. Identify the most likely cause of pain.
Diverticulitis.
With reference to acute pancreatitis what is Grey turners sign?
This is known as Grey Turner’s sign as is evidence of blood pooling in the retroperitoneal space. This happens as the pancreas is a retroperitoneal organ and inflammation can result in blood collecting in this space.
Mnemonic for the Descending abdominal aorta branches from diaphragm to iliacs:
‘Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin’
Phrenic [inferior] Celiac Superior mesenteric Suprarenal [middle] Renal Testicular ['in men' only] Lumbars Inferior mesenteric Sacral
Peutz-Jeghers syndrome
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Although the polyps themselves don’t have malignant potential, around 50% of patients will have died from another gastrointestinal tract cancer by the age of 60 years.
NAVEL mnemonic for the contents of the femoral triangle:
NAVEL can be used to remember the contents of the femoral triangle (lateral to medial): femoral NERVE, femoral ARTERY, femoral VEIN, EMPTY space, LYMPHATICS.
Which gene mutation is associated with pancreatic cancer?
KRAS
What does the anti-emetic metoclopramide do?
Metoclopramide is a dopamine antagonist but also has an agonist effect on peripheral 5HT3 and antagonist effect on muscarinic receptors to promote gastric emptying.
Glucuronic acid does what?
Glucuronic acid is a compound that complexes with bilirubin to enable it to be water soluble (‘conjugated bilirubin’), but does not play a function in synthesis.
UNCONJUGATED > CONJUGATED.
Investigations into hepatocellular carcinoma:
High AFP + chronic liver inflammation = Hepatocellular carcinoma.
What is the biggest risk factor of recurrence in people with Crohns?
Crohns disease is worse in smokers and smoking is an independent risk factor for disease recurrence following resection.
Embryological origin of the appendix?
Foregot, midgut or hindgut?
The appendix is derived from the midgut.
What are the contents of the femoral triangle lateral to medial?
NAVEL can be used to remember the contents of the femoral triangle (lateral to medial): femoral NERVE, femoral ARTERY, femoral VEIN, EMPTY space, LYMPHATICS
How does chronic pancreatitis lead to diabetes?
Chronic pancreatitis can lead to diabetes due to destruction of the islet of Langerhans cells of the pancreas.
What is the biggest risk factor for developing testicular cancer?
Men with a history of undescended testis are 40 times as likely to develop testicular cancer.
Cryptochidism.
Metoclopramide is contraindicated in which neurological condition?
Metoclopramide is contraindicated in Parkinsonism because it is a dopamine antagonist.
KRAS mutation is associated with what cancer?
Pancreatic cancer
Chain of lakes appearance in the pancreas indicates what?
ERCP will show a classic ‘chain of lakes’ appearance of the main pancreatic duct which has become dilated and tortuous in chronic pancreatitis.
Chronic mesenteric ischemia is characterized by what?
Intestinal angina (or chronic mesenteric ischaemia) is classically characterised by a triad of severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit.
By far the most common cause is atherosclerotic disease in arteries supplying the GI tract
Cessation of smoking may trigger an ulcerative colitis flare.
Cessation of smoking may trigger an ulcerative colitis flare.
What do bloods show in cases of autoimmune hepatitis?
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of autoimmune hepatitis.
Raised ALP and ALT
What is the treatment for achalasia?
Achalasia is a disorder of the lower oesophageal sphincter where the opening becomes dysfunctional leading to problems of the passage of food and drink into the stomach. This leads to problems with swallowing and reflux. The dysphagia tends to affect both solids and liquids equally.
Achalasia is treated using a surgical procedure called a Heller cardiomyotomy. This procedure involves cutting of the thick muscle around the lower oesophagus and upper stomach to allow for passage of food and drink.
What is the association between primary sclerosing cholangitis and ulcerative colitis?
Ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC
What are the features of primary sclerosing cholangitis?
Cholestasis Jaundice Pruritus Raised bilirubin + ALP Right upper quadrant pain Fatigue
What is Bloomberg’s sign?
Rebound tenderness - indicative of peritonitis.
What is the most common cause of pneumoperitoneum?
The most common cause is a perforation of the abdominal viscus—most commonly, a perforated ulcer, although a pneumoperitoneum may occur as a result of perforation of any part of the bowel; other causes include a benign ulcer, a tumour, or trauma
What is achalasia?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
Clinical features of achalasia?
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
What is the first line test for diagnosing coeliacs?
Coeliac disease - tissue transglutaminase antibodies are the first-line test.
What antibodies are looked at to investigate B12 deficiency anaemia?
Intrinsic factor antibodies are more useful than gastric parietal cell antibodies when investigating vitamin B12 deficiency, given low specificity of gastric parietal cell antibodies
How can PPI’s affect electrolytes?
PPIs can cause hyponatraemia
A combination of liver and neurological disease points to what?
A combination of liver and neurological disease points towards Wilson’s disease.
What is the screening test for haemochromatosis?
Screening for haemochromatosis
general population: transferrin saturation > ferritin
family members: HFE genetic testing
What is the most important side effect to note of Clindamycin?
Clindamycin treatment is associated with a high risk of Clostridium difficile.
High urea levels can indicate an upper GI bleed versus lower GI bleed.
High urea levels can indicate an upper GI bleed versus lower GI bleed.
Jaundice, abdo pain, pruritus during pregnancy think.
Jaundice following abdominal pain and pruritus during pregnancy think acute fatty liver of pregnancy.
What long term medication should someone who has had a bout of spontanteous bacterial peritonitis be started on?
Patients who have had an episode of SBP require antibiotic prophylaxis.
What triad does Budd chiari syndrome present with?
Budd-Chiari syndrome presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly.
Budd Chiari syndrome
Budd-Chiari syndrome (BCS) is an uncommon disorder characterized by obstruction of hepatic venous outflow. The obstruction may be thrombotic or non-thrombotic anywhere along the venous course from the hepatic venules to junction of the inferior vena cava (IVC) to the right atrium.
How does anaemia present in coeliac disease?
Micro / macro /normo
Coeliac disease commonly presents with anaemia, but it is often a mixed picture. It causes a deficiency in iron, folate and vitamin B12 (although folate deficiency is more common than vitamin B12 deficiency).
Bleeding gums, think scurvy = vitamin what deficiency?
Vit C
What is given to prevent ulcerative colitis flare ups?
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given either oral azathioprine or oral mercaptopurine to maintain remission.
A 40-year-old female presents to her GP with a 6-week history of epigastric pain. This is described as a sharp pain associated with nausea and typically comes on within minutes of eating. Her bowel habit and stools were normal. Physical examination was unremarkable.
Which of the following is the most likely diagnosis?
Gastric ulcers cause pain when, or shortly after, eating.
Summary of Non-alcoholic fatty liver disease:
Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is largely caused by obesity and describes a spectrum of disease ranging from:
steatosis - fat in the liver
steatohepatitis - fat with inflammation, non-alcoholic steatohepatitis (NASH), see below
progressive disease may cause fibrosis and liver cirrhosis
A 52-year-old woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy. What is the single most important step to help prevent the progression of her disease?
Weight loss is the best first line management for NAFLD.
Prophylaxis for oesophageal bleeds?
A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of oesophageal bleeding.
A 38-year-old woman presents with fever, malaise and jaundice. On examination she has moderate hepatomegaly. Laboratory analysis confirms a positive anti-smooth muscle antibody and anti-nuclear antibody. Antimitochondrial antibodies are negative.
What is the most likely diagnosis?
Autoimmune hepatitis
Autoimmune hepatitis occurs most frequently in women and has associations with many other autoimmune diseases. It is often associated with the presence of anti-nuclear and/or anti-smooth muscle antibodies.
Antimitochondrial antibodies are associated with what?
Primary biliary cirrhosis
What causes an itch in jaundice?
Patients presenting with cholestasis may show increased levels of bilirubin. High levels of bilirubin may cause itch.
How is severe alcoholic hepatitis managed?
Corticosteroids are used in the management of severe alcoholic hepatitis.
What is the M rule and what condition is it used for?
Primary biliary cholangitis
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
What is primary biliary cholangitis?
Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman
Dysphagia affecting both solids and liquids from the start think…?
Dysphagia affecting both solids and liquids from the start - think achalasia.
Achalasia
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
A 25-year-old man with ulcerative colitis presents with new onset itching and fatigue. On examination you note that he is jaundiced and tender in the right upper quadrant with significant hepatomegaly. He reports that his ulcerative colitis is well controlled and he has not had a flare in over 6 months. However, he believes he has lost weight despite no change to his diet or exercise.
What is the diagnosis?
Primary sclerosing cholangitis
Which antibody is positive in primary sclerosing cholangitis?
Primary sclerosing cholangitis can have positive p-ANCA.
Management of UC Flares:
Severe flare =
Mild to moderate flare =
Management of UC Flares:
Severe flare = Oral / IV steroids with hospital admission.
Mild to moderate flare = In a mild-moderate flare of distal ulcerative colitis, the first-line treatment is topical (rectal) aminosalicylates, e.g… rectal mesalazine.
What is primary sclerosing cholangitis?
Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts.
How does primary sclerosing cholangitis present?
cholestasis jaundice, pruritus raised bilirubin + ALP right upper quadrant pain fatigue
positive pANCA antibody.
How is Cdiff managed?
Cdiff treatment:
First line: metronidazole
Second line: Oral vancomycin
What is the AST/ALT ratio in alcoholic hepatitis?
The AST/ALT ratio in alcoholic hepatitis is 2:1
What medication is used to maintain remission in Crohn’s?
Azathioprine or mercaptopurine is used first-line to maintain remission in patients with Crohn’s.
What type of oesophageal cancer is associated with GORD / Barrets?
Oesophageal adenocarcinoma is associated with GORD or Barrett’s.
Why is oral vancomycin used to treat Cdif?
Oral vancomycin is not absorbed by the gut. This feature is used to our advantage in Clostridium difficile infection, as it allows direct delivery to the site of infection, without losing any to absorption.
Courvoisier’s sign - relevant to what condition and whats the sign?
Courvoisier’s sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.
HNPCC aka lynch syndrome is associated with what cancers in women?
Endometrial cancer is the second most common association of HNPCC after colorectal cancer.
Alcoholic hepatitis should be treated with what?
Prednisolone
What is Riglers triad and what condition is it found in?
Gallstone ileus: Rigler’s Triad - Air in bile ducts, gallstone visible outside gallbladder and small bowel obstruction.
Budd-Chiari syndrome aka hepatic vein thrombosis presents with what triad of symptoms?
Budd-Chiari syndrome presents with the triad of sudden onset abdominal pain, ascites, and tender hepatomegaly.
RUQ pain- colic
RUQ pain plus fever- cholecystitis
RUQ pain plus fever plus jaundice (charcot triad)- cholangitis
RUQ pain- colic
RUQ pain plus fever- cholecystitis
RUQ pain plus fever plus jaundice (charcot triad)- cholangitis.
Plummer-Vinson syndrome:
A plumber Vincent choked on a rusty iron pipe
i.e. dysphagia (swallowing a pipe), glossitis (red tongue from rust), iron-deficient (iron pipe).
Dysphagia, Glossitis, Iron deficiency anaemia.
Pancreatitis may develop following an ERCP.
Pancreatitis may develop following an ERCP.
Management of C.dif
First-line therapy is oral metronidazole for 10-14 days
If severe or not responding to metronidazole then oral vancomycin may be used.
For life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used.
Management of H.pylori infection:
A proton pump inhibitor + amoxicillin + (clarithromycin OR metronidazole).
If penicillin allergic: a proton pump inhibitor + metronidazole + clarithromycin.
How do you maintain remission of Crohn’s?
Maintaining remission
Stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis).
Azathioprine used first-line to maintain remission.
