Points from Questions

Question 1

Zollinger-Ellison syndrome (ZES) is a condition caused by

Answer 1

Gastrin-secreting tumours form in pancreas and duodenum; called gastrinomas
Secrete large amounts of gastrin that causes hypersecretion of gastric acid leading to ulcer disease.

MEN associated

Presents with abdominal pain, diarrhoea,
gastro-oesophageal reflux disease

Less common WL, GI bleeding, nausea, and vomiting

Question 2

Spleen VS Kidney

Answer 2

Palpable Notch, Dullness on Percussion

Resonant to Percussion
Bilaterally Palpable

Question 3

Diclofenac

Answer 3

Osteoarthritis medication (NSAID's)
Decreases production of stomach protective mucous

Question 4

Bruising is common in?

Answer 4

Cushing’s
Steroid use
Cirrhosis
Haematological Malignancy

Question 5

GAVE - Gastric Antral Vascular Ectasia

Answer 5

Iron deficiency anaemia

dilated small blood vessels in antrum that look like red streaks of watermelon

Question 6

Flapping Tremor

Answer 6

Resp, Hepatic, Renal Failure

Question 7

Acute Pyelonephritis

Answer 7

Severe upper abdominal pain, nausea, vomiting

Serum Amylase Increases

Question 8

Gastric Carcinoma

Answer 8

Indigestion, Loss of apetite (Non-Specific)

Virchows Node

Question 9

Mallory Weiss Tear

Answer 9

Alcohol consumption and excess vomiting

Blood after retching

Question 10

Systemic Sclerosis

Answer 10

Progressive Dysphagia

Incomplete relaxation of LOS - Reflux - Stricture

Question 11

Acute Mesenteric Ischaemia

Answer 11

Triad:
Gastrointestinal Emptying (vomiting, diarrhoea)
Abd Pain,
Cardiac Disease

Question 12

Coeliac Disease

Answer 12

WL, Diarrhoea,
Pale conjuctiva,
Low body Weight

Low Folate,
Endoscopic Small Bowel Biopsy (Atrophy)
Serum Antigliadin Abs

Question 13

Rectal Cancer

Answer 13

Fresh Blood, Mucus, Tenesmus, Diarrhoea

Question 14

Parianal Abscess

Answer 14

Throbbing, Swelling

Question 15

Portal Hypertention

Answer 15

Splenomegaly,
UGI Bleeding (oesophageal varices)
Ascites
Acute/Chronic Encephalopathy

Question 16

Alanine aminotransferase (ALT)

Alkaline phosophatase (ALP)

Aspartate aminotransferase (AST)

γ-Glutamyl transpeptidase

Answer 16

ALT?

ALP enzyme is present in the canalicular and sinusoidal membranes of the liver, as well as bone, intestine and placenta. Cholecystitis

AST present in hepatocytes, brain and myocardium. A rise may occur in hepatitis and myocardial infarction.

γ-GT is a microsomal enzyme, usually raised in association with alcohol excess/cirrhosis/hepatic metastatic disease and may be raised in phenytoin therapy.

Question 17

Right Side Colon Cancer

Answer 17

Present much more insidiously (gradual but harmful) than left-sided tumours,

Asymptomatic iron deficiency anaemia rather than change in bowel habit.

PR bleeding is more suggestive of left-sided lesions, as is large bowel obstruction.

Question 18

bleeding ulcer on the posterior wall of the stomach.

Answer 18

Splenic artery

Question 19

bleeding ulcer in the first part of the duodenum.

Answer 19

Gastroduodenal artery

Question 20

Cystitis

Answer 20

is rare in men and would be associated with symptoms such as urinary frequency, urgency, nocturne and dysuria.

Question 21

Diverticular Disease

Answer 21

A 50-year-old taxi driver has a six-month history of constipation and colicky suprapubic pain that is worse at some times than others, with no discernable pattern. He has had some episodes of diarrhoea and fever.

He drinks little alcohol, and does not smoke, but consumes copious quantities of coffee.

There is some slight tenderness in the suprapubic region, but no other findings on examination.

Question 22

A 55-year-old publican presents with a haematemesis.

His wife provides a history that he has consumed approximately four cans of lager per day together with liberal quantities of spirits for many years. He has tried to stop drinking in the past but failed.

Examination reveals that he is oriented but distressed. His pulse is 120 beats per minute and blood pressure 108/70 mmHg. He has numerous spider naevi over his chest. Abdominal examination reveals a distended abdomen with ascites.

What would you request next for this patient?

Answer 22

Features of chronic liver disease and is now shocked due to haematemesis.

Bleeding oesophageal varices should be top of the differential list and other diagnoses to consider would include peptic ulceration or haemorrhagic gastritis.

Question 23

• A 63-year-old woman complains of diarrhoea, fresh bleeding on defecation, mucus per rectum and tenesmus.

Answer 23

Rectal Carcinoma

Question 24

Hepatomegaly

Answer 24

In alcoholic fatty liver disease

Right heart failure is associated with tender smooth hepatomegaly due to hepatic congestion.

Metastatic liver disease is associated with nodular hepatomegaly.

In primary biliary cirrhosis, asymptomatic patients are discovered on routine examination to have smooth hepatomegaly, a raised serum alkaline phosphatase or autoantibodies. Pruritus is often the earliest symptom, preceding jaundice by a few years.

Question 25

A 62-year-old male with a long history of alcohol abuse presents with acute abdominal pain which radiates through to the back. The following day he is noted to have purplish discolouration in the flanks.

Answer 25

Grey Turner’s Sign

This, like Cullen’s sign, is a representation of intra-abdominal haemorrhage that occurs with aortic dissection and pancreatitis.

Question 26

Murphy’s sign

Answer 26

Characterised by pain on inspiration whilst pressure is applied just below the costal margin in the mid-clavicular line, with pain greater on the right than the same repeated on the left. This is suggestive of acute cholecystitis as the inflamed gallbladder is pushed down during inspiration.

Question 27

Courvoisier’s law

Answer 27

States that in the setting of obstructive jaundice and a palpable gallbladder, gallstones are unlikely to be the cause. This is because patients with gallstones tend to develop a scarred gallbladder that does not allow it to expand enough to be palpable, whereas if a patient has a cholangiocarcinoma (and no gallstones) they can develop high back-pressure in the biliary tree, allowing their gallbladder to expand and become palpable.

Question 28

A 65-year-old male is admitted with two episodes of haemetemesis.

He has a history of ischaemic heart disease (IHD) for which he is taking medication.

Which of the following is the likely cause of his presentation?

Answer 28

The history of IHD is important, as the majority of patients will be receiving aspirin.

Hence the likely cause of the current presentation with haemetemesis is a non-steroidal anti-inflammatory drug (NSAID)-induced peptic ulceration.

He should have an endoscopy and will be commenced on proton pump inhibition.

Question 29

A 45-year-old male presents with fatigue and joint pains. He has a history of type 2 diabetes for which he takes gliclazide and osteoarthritis for which he occasionally takes NSAIDs. On examination he appears slightly pigmented and has two finger breadth hepatomegaly.

Answer 29

Haemochromatosis

This is an autosomal recessive condition associated with excess iron deposition:
Liver - cirrhosis
Joints - Osteoarthritis
Pancreas - diabetes.

Iron deposition in the pituiatary and gonads can also cause hypogonadism. The iron deposition in the skin also results in pigmentation.

Question 30

A 68-year-old male presents with breathlessness and weight loss. He is a smoker of 10 cigarettes daily. On examination he has a raised JVP, two finger breadth pulsatile hepatomegaly and ankle oedema.

Answer 30

Congestive heart failure

This is right sided heart failure probably due to chronic obstructive pulmonary disease (COPD) and is typified by raised JVP, pulsatile hepatomegaly (tricuspid regurgitation) and ankle oedema.

Question 31

A 45-year-old female presents with pruritus and weight loss. She has a history of hypothyroidism which is adequately treated with thyroxine. On examination she appears slightly icteric, has xanthomas around the eyes and has two finger breadth hepatomegaly.

Answer 31

Primary biliary cirrhosis

as this is associated with xanthomas as well as pulmonary fibrosis and other autoimmune disorders.

Question 32

Stimulates acid secretion in the stomach.

Answer 32

Gastrin is secreted from the antrum of the stomach when stimulated by parasympathetic nerves and the presence of amino acids in the stomach.

It stimulates gastric motility, growth and acid secretion, and intestinal motility. The secretion of gastrin is inhibited by acid in stomach and somatostatin.

Question 33

Stimulates bicarbonate secretion from the duodenum, pancreas and liver.

Answer 33

Secretin is secreted from the small intestine when there is acid in the small intestine.

It inhibits gastric motility and acid production, and

Stimulates bicarbonate secretion from the duodenum, pancreas and liver.

Question 34

Stimulates insulin secretion from the pancreas.

Answer 34

GLP-1 is secreted from the small intestine when glucose is present.

It stimulates the pancreas to secrete insulin.

Question 35

Stimulates appetite.

Answer 35

Ghrelin is produced from the fundus of the stomach and is responsible for stimulating appetite.

Question 36

Stimulates enzyme secretion from the pancreas and gall bladder contraction.

Answer 36

CCK is secreted from the small intestine when it contains amino acids and fatty acids.

It inhibits gastric motility and acid production, and

Stimulates pancreatic enzyme secretion and gall bladder contraction and sphincter of Oddi relaxation.

It potentiates secretin’s action on bicarbonate secretion.