Gastro

Question 1

Define appendicitis

Answer 1

An acute inflammation of the vermiform appendix, most likely due to obstruction of the lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia).

Question 2

Define Mallory Weiss tear and list its causes

Answer 2

• Longitudinal muscle tear of the oesophagus (distal oesophagus/proximal stomach)
• Caused by violent retching which increases intra-abdominal pressure.
• Also caused by stretching, lifting, stooling and abdominal injury

Question 3

Define haemochromatosis

Answer 3

Mutation in HFE gene (if hereditary) causing increased iron absorption from the GIT, leading to iron overload

Question 4

List signs and symptoms of haemochromatosis

Answer 4

• May be asymptomatic (75%)
• Fatigue
• Weakness
• Lethargy
• Arthralgias
• Hepatomegaly
• Diabetes mellitus (‘bronze diabetes’)
• Impotence in males, loss of libido (due to pituitary dysfunction)
• Skin pigmentation
• Congestive heart failure
• Arrhythmias
• Porphyria cutanea tarda

Question 5

Define wilsons disease

Answer 5

• Liver disease where there is impaired copper secretion into the bile, therefore there is a retention of copper in the body.
• Autosomal recessive ATP7B
• Hepatolenticular degeneration

Question 6

List symptoms and signs of Wilsons disease

Answer 6

• Kayser-Flaischer rings (build up of copper around the cornea, test with slit lamp)
• Neurologic manifestations due to atrophy of the basal ganglia (parkinsonism, dysarthria, tremor, dystonia and polyneuropathy)
• Psychological symptoms (irritability, psychosis, emotional lability, changes in personality and difficulty concentrating)
• GI symptoms are uncommon (bleeding, jaundice, tenderness, spider angioma, gynaecomastia, bruising)

Question 7

Define achalasia and list its causes

Answer 7

• Achalasia is a failure of relaxation of the lower esophageal sphincter due to loss of the myenteric (Auerbach) plexus.

Question 8

How is achalasia investigated and what are the findings on investigation?

Answer 8

• A barium swallow will show a dilated esophagus with an area of distal stenosis.
• Tertiary peristalsis waves
• This is also the characteristic ‘bird’s beak’ sign.
• High resolution manometry is diagnostic. Shows incomplete relaxation of LOS
• CXR shwoing absent gastric air bubble, dilated oesophagus, air fluid level above LOS
• Oesophageal manometry is the gold standard

Question 9

List signs of cirrhosis

Answer 9

• Ascites (shifting dullness)
• Asterixis
• Confusion
• Caput medusae (visible veins from umbilicus due to portal hypertension)
• Splenomegaly due to portal hypertension
• Palmar erythema (increased oestrogen)
• Leukonychia, spider naevi
• Oedema (lower extremity)
• Muscle wasting
• Testicular atrophy

Question 10

Define cirrhosis

Answer 10

Cirrhosis is a condition due to diffuse bridging fibrosis and regenerative nodules that disrupt the normal architecture and function of the liver.

Question 11

Define autoimmune hepatitis

Answer 11

• Immune mediated injury of the liver
• Caused by abhorant HLA II
• Cause fo chronic hepatitis

Question 12

List presentations of autoimmune hepatitis

Answer 12

• Acute hepatitis (fever, fatigue, jaundice, upper right quadrant abdominal pain)
• Amenorrhea
• Epistaxis
• Easy bruising
• Chronic hepatitis
• Cirrhosis

Question 13

Describe epidemiology of autoimmune hepatitis

Answer 13

• 10-17 people per 100000 in europe
• 10000 people in UK
• 3 to 4 times more common in women
• Commonly diagnosed in women age 45, and young women
• 30-50% have another autoimmune condition

Question 14

How is autoimmune hepatitis diagnosed?

Answer 14

• Elevated AST and ALT
• Positive anti-smooth muscle antibody (most specific test)
• Antinuclear antibody
• Antibodies to soluble liver antigen
• Liver/kidney microsomal antigens
• FBC and blood film (mild leukopenia, normochromic anaemia, thrombocytopenia, eosinophilia)
• Liver biopsy

Question 15

Describe presentation of gallstones

Answer 15

• Abdominal pain (right upper quadrant or epigastric)
• Nausea
• Vomiting
• Cholestatic transaminitis

Question 16

Describe the characteristics of inguinal hernias

Answer 16

• Most common hernia
• Medial to inferior epigastric vessels, through hesslebachs triangle is direct (acquired). Indirect hernias are lateral to the inferior epigastric vessels. They pass through both superficial and deep inguinal ring

Question 17

List symptoms of inguinal hernia

Answer 17

• Heaviness or dull discomfort in the groin
• Pain when lifting
• Severe pain may indicate strangulation

Question 18

How are hernias diagnosed?

Answer 18

• Ultrasound and peritoneography are most used

- CT and MRI also reliable

Question 19

How is oral candidiasis treated?

Answer 19

Nystatin oral suspension

Question 20

List symptoms of coelic disease

Answer 20

• Diarrhoea
• Abdominal cramps
• Steatorrhea
• Abdominal distention
• Malabsorption
• Loss of appetite
• Among children, failure to grow normally.
• Fatigue/lethargy
• Recurrent mouth ulcers

Question 21

How is coelic treated?

Answer 21

Lifelong gluten free diet

Question 22

Define coelic disease

Answer 22

• An autoimmune disorder affecting primarily the small intestine that occurs in people who have HLA-DQ2 allele or the HLA-DQ8 allele.
• Reaction to gluten, which are various proteins found in wheat and in other grains such as barley, and rye.

Question 23

Compare LFT in alcoholic and viral hepatits

Answer 23

• Viral ALT>AST

- Alcoholic AST>ALT

Question 24

How does cirrhosis affect thyroid hormones?

Answer 24

• Decreased thyroid binding globulin
• Decreased levels of bound thyroid hormones
• Free thyroid hormones remain the same due to feedback induced decrease in TSH

Question 25

Define chronic pancreatitis

Answer 25

Chronic pancreatitis is a chronic, irreversible, inflammation and/or fibrosis of the pancreas, often characterized by severe pain and progressive endocrine and exocrine insufficiency.

Question 26

List risk factors/aetiology of chronic pancreatitis

Answer 26

- Alcohol induced (70-80%) - Smoking - Autoimmune disease (Sjogrens, IBD, primary biliary cirrhosis) - CF - Haemochromatosis - Genetic abnormalities (SPINK1/PSTI gene) - Drugs (thiazide like diuretics, azathioprine, tetracyclines, oestrogens) - Obstructive causes (gallstones and strictures, cancer)

Question 27

List symptoms of chronic pancreatitis

Answer 27

- Recurrent epigastric pain (deep, severe, dull may radiate to back, intermittent or continuous, relieved by leaning forward, precipitated by eating, associated with nausea and vomiting) - Bloating - Abdominal cramps, flatus - Weight loss - Malnutrition - Steatorrhea - Diabetes mellitus

Question 28

Describe management of chronic pancreatitis

Answer 28

- Fluids - Pain control - Repletion of pancreatic enzymes - Low alcohol low fat diet

Question 29

Define acute pancreatitis

Answer 29

Acute pancreatitis is an acute inflammatory process of the pancreas with varying involvement of local tissues or more remote organ systems.

Question 30

What is the cause of indirect inguinal hernia?

Answer 30

Failure of the tunica vaginalis to fuse

Question 31

List life threatening complications of groin hernias

Answer 31

- Trapping of herniated intestine - Bowel obstruction - Bowel ischaemia

Question 32

What is intrahepatic cholestasis of pregnancy?

Answer 32

- A reversible form of cholestasis affecting some pregnant women in their second or third trimester - Characterised by hepatic dysfunction and pruritus of the skin caused by elevated bile acids in the blood, and bile deposition in the skin

Question 33

Define volvulus

Answer 33

- A subtype of malrotation, in which a loop of bowel is twisted about a focal point along the mesentery attached to the intestinal tract, that may result in a bowel obstruction. - A volvulus is a twisting or axial rotation of a portion of bowel about its mesentery.

Question 34

Describe investigations of volvulus

Answer 34

- Routine bloods - Erect CXR, AXR - Upper gastrointestinal contrast studies - Usually based on barium studies - Some are recommending CT scanning (coffee bean sign in left iliac fossa)

Question 35

List symptoms of gastric volvulus

Answer 35

- Sudden onset severe epigastric pain (colicky) - Abdominal distention - Constipation - Intractable retching without vomiting

Question 36

Define peptic ulcer disease and gastritis

Answer 36

- A peptic ulcer is a break in the lining of the stomach, first part of the small intestine, or occasionally the lower esophagus - Gastritis is inflammation of the stomach lining

Question 37

How does perforation of peptic ulcer present?

Answer 37

- Nausea - Vomiting blood - Bloating - Early satiety - Anaemia

Question 38

List symptoms of acute pancreatitis

Answer 38

- Sudden onset upper abdominal pain (epigastric radiates to back, worsens with movement and alleviated with fetal position) - Nausea - Vomiting

Question 39

Describe diagnosis of Wilsons disease

Answer 39

- Kayser-Fleischer ring - Neuropsyciatric symptoms - LFTs abnormal (raised transferases and bilirubin, or low albumin in failure) - Urinary copper levels (>100 micrograms in 24 hours) - Liver copper levels - Serum ceruloplasmin (low) - Genetic testing - Blood free copper raised but total serum copper decreased - MRI brain showing basal ganglia increased density (panda sign)

Question 40

Name the common complications of cleft lip or palate

Answer 40

- Otitis media - Speech problems - Hearing loss - Feeding problems - Psychosocial problems

Question 41

What is the rigler triad?

Answer 41

Gallstone ileus: - Pneumobilia - Low small bowel obstruction with distended abdomen - Gallstone in terminal ileum

Question 42

List causes of acute pancreatitis

Answer 42

- Idiopathic - GALLSTONES (40%) - ETHANOL (alcohol 35%) - Trauma - Steroids - Mumps - Autoimmune - Scorpion stings - Hyperlipidaemia/hypercalcaemia - ERCP - Drugs

Question 43

Define haemorrhoid

Answer 43

- Haemorrhoids (also known as piles) are abnormally swollen vascular mucosal cushions that are present in the anal canal. - Three vascular mucosal cushions are in the anus to maintain anal continence. These become enlarged in haemorrhouds

Question 44

Compare internal and external haemorrhoids

Answer 44

- Internal above the pectinate line. simple columnar epithelium. Also graded 1-4 based on degree of prolapse (1 no prolapse only bleeds, 2 spntaneously reduce, 3 manual reduction, 4 cannot be reduced) - External inferior to pectinate line, stratified squamous epithelium - Above pectinate line, non-painful but more prone to bleeding - Below pectinate line, painful due to somatic innervation by inferior rectal nerve, but they do not generally bleed

Question 45

What is dermatitis herpetiformis?

Answer 45

- A manifestation of celiac disease - Small vesicles grouped together - No underlying viral cause - Most often lesions are on the forearms, elbows, scalp, knees and back

Question 46

What does the double bubble sign on X ray show?

Answer 46

- Intestinal atresia (lumen of GI tract fails to recanalize between eighth and tenth week of gestation) - Closely associated with down syndrome

Question 47

What is HSP?

Answer 47

- Henoch-Schönlein purpura | - The classic clinical triad of HSP is palpable purpura/petechia migratory arthritis, and abdominal pain

Question 48

Describe the pain in renal colic

Answer 48

- Loin to groin - Starts at the back - Moves down to the suprapubic region and sometimes penis as it irritates the urinary tract

Question 49

What is caput medusa

Answer 49

- Obstruction of vena cava | - Causes superficial veins to distend

Question 50

What is tenesmus?

Answer 50

Sensation of needing to poo when you dont need to, due to irritation of the rectum

Question 51

What is borborygmi?

Answer 51

Loud rumbling of the stomach

Question 52

How is oral thrush characterised?

Answer 52

Pale plaques that can be scraped off the tongue to reveal an erythematous base

Question 53

What is Hirschsprung and how is it diagnosed?

Answer 53

- Failure of the neural crest to fully migrate through the gut to form the enteric nervous system. - The gold standard for diagnosis is biopsy of the distal colon

Question 54

Define crohns disease

Answer 54

- A type of IBD. Transmural granulomatous infection. - Unlike UC, can involve any part of the GI tract from mouth to anus - Skip lesions (areas of normal bowel mucosa between diseased areas) - Moves proximally into ileum - Affects the entire thickness of the colon - May cause fistulae, abscesses and fibrotic strictures - 30 times more likely if a sibling has it

Question 55

List symptoms of Crohns disease

Answer 55

- Fever - Rectal bleeding - Weight loss - Anorexia - Nausea - Vomiting - Malnutrition - Vitamin deficiencies - Abdominal pain (cramp or constant, most commonly right lower quadrant and peri-umbilical regions) - Bowel obstruction (bloating, distention, borborygmi, vomiting)

Question 56

Describe Murphys sign

Answer 56

Where you press on the gallbladder and it makes the patient gasp with pain. Sign of acute cholecystitis

Question 57

Describe blood from different areas of GI

Answer 57

- Melaena is black tarry stools, caused by GI bleeding - Haematemesis when red blood hasnt reached stomach acid, when coffee ground it has - Fresh blood in stools is distal - Altered blood in stalls is proximal - Bright red blood a most commonly not cancer, fissure instead. - Blood smeared on stools due to anal lesion (piles, polyps, fissure) - Blood on toilet paper haemorrhoid or fissure

Question 58

Describe colicky pain

Answer 58

- Occurs in waves when peristalsis occurs | - Crescendo decreascendo

Question 59

List symptoms and signs of bowel obstruction

Answer 59

- Abdominal distension - Flatus absent - Absence of bowel movements - Vomiting (faeculent) - Can see peristalsis - Barbarigmy

Question 60

What is a Blatchford score?

Answer 60

- Stratifies patients presenting to hospital with haematemesis into high and low risk groups to determine who can be managed as outpatient - 0 is low risk, 6 is high risk

Question 61

What is a Rockall score?

Answer 61

- A score to predict the risk of rebleeding and mortality in patients with upper GI haemorrhage - Used to guide urgency of endoscopy

Question 62

List indications for emergency endoscopy

Answer 62

- Unstable patients with severe acute upper GI bleeding immediately after resusitation - Continuing upper GI bleed or Blatchford score of 6 or more - Patients with an aortic graft may require endoscopy to exclude aorto-enteric fistula

Question 63

List investigations performed in haematemesis

Answer 63

- Oesophagogastroduodenoscopy - Erect chest radiograph (perforated peptic ulcer, left sided pleural effusion in boerhaaves perforation) - CT scan of chest-abdomen (all patients with known aortic graft require this to rule out aorto-enteric fistula, provided they are haematologically stable enough)

Question 64

Compare a mallory-weiss tear to a boerhaaves perforation

Answer 64

- Boerhaaves perforation is transmural, surgical emergency with high mortality rate. Presents with severe chest pain after vomiting or consuming a large meal, palpable subcut emphysema at neck, dysphagia. Shock. - Mallory weiss tear is not, small amount of haematemesis after history of vomiting - Both tears to the oesophagus often caused by vomiting

Question 65

What is dupuytrens contracture?

Answer 65

- Thickening of a tendon resulting in contraction of a finger with visible tendon - A sign of liver disease

Question 66

List the different surgical scars in the abdomen and their uses

Answer 66

- Kochers (cholecystectomy) - Left paramedian (colectomy) - Midline (AAA, laprotomy) - Lanz incision (appendectomy) - Groin incision (inguinal hernia) - Pfannensteil (C section, access to bladder)

Question 67

How is a bleeding oesophageal varix due to portal hypertension treated?

Answer 67

- Endoscopic band ligation (use rubber band to ligate the bleeding vessel) - Endoscopic slerotherapy (not first line, can induce necrosis of oesophageal mucosa) - Balloon tamponade (tube passed into the stomach, a balloon at the end is inflated in the stomach to keep the tube in place, a second balloon along the length of the tube is inflated to apply pressure to the bleeding vein and induce haemostasis) - Transjugular intrahepatic portosystemic shunt (pass a catheter down the jugular vein, create a shunt from hepatic vein to portal vein to relieve portal hypertension) - Portiocaval shunt (place a shunt between portal and systemic circulation to bypass the liver and reduce portal hypertension)

Question 68

Describe signs and symptoms of a bleeding peptic ulcer

Answer 68

- Melaena - Haematemesis, coffee ground - History of heart burn/ibuprofen - Pain in epigastric region - Nausea and vomiting - Weight loss

Question 69

Describe investigations for peptic ulcer disease and gastritis

Answer 69

- Urea breath test for H pylori (patients swallow labelled urea, then take a breath sample to look for labelled carbon dioxide in the breath) - Serological tests for IgG - Stool test for H pylori - Endoscopy, to look for ulcer and take a sample to test for H pylori, look at histologically and antibiotic testing - FBC, U and E, faecal occult blood, barium meal test

Question 70

List the main risk factors for peptic ulcers

Answer 70

- H pylori (causes chronic gastritis by provoking an inflammatory response in the gastric epithelium) - Smoking - Alcohol - NSAIDS and aspirin - Blood group O - Hypercalcaemia - Physiological stress - Burns or brain trauma

Question 71

What is an oesophageal varix?

Answer 71

Dilation of the oesophageal veins due to portal venous hypertension (often in patients with cirrhosis)

Question 72

Describe briefly blood clotting and its measurement

Answer 72

- Tissue damage - Intrinsic pathway (APTT - affected by heparin, haemophilias and VWD) - Extrinsic pathway (PT- affected by warfarin, liver disease) - factor X to Factor Xa and Va - Prothrombin to thrombin - Fibrinogen to fibrin

Question 73

Define acute cholangitis

Answer 73

- Ascending bacterial infection of the bilary tract related to choledocholithiasis and bile stasis

Question 74

Describe symptoms of acute cholangitis

Answer 74

Charcot's triad - Right upper quadrant pain - Fever - Jaundice - In severe cases, septic shock and mental confusion

Question 75

List findings on examination in acute cholangitis

Answer 75

- Jaundice - Icterus - Fever - Abdominal pain RUQ - Palpable gallbladder

Question 76

How is acute cholangitis investigated?

Answer 76

- Blood test - Shows leukocytosis, hyperbilirubinaemia and evelated alkaline phosphatase, elevated transaminaise and serum amylase - Blood cultures positive in 50% patients (e.coli, klebsiella, entercoccus and bacteriodes fragilis) - ERCP best first investigation - Consider transabdominal ultrasound

Question 77

How is acute cholangitis managed?

Answer 77

- Broad spectrum IV antibiotics (piperacillin, tazobactam) - Correction of fluid and electrolyte imbalances - Analgesia, oxygen - Biliary decompression (ERCP with or without sphincterotomy and drainage stent first line, percutaneous transhepatic cholangiography second line) - Lithotripsy if stone - Surgical decompression (second line, if risk of morbidity is high)

Question 78

Define rectal prolapse

Answer 78

- A condition in which the rectum loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it inside out. - It is most common in the elderly (especially women) but can occur in all ages, including children.

Question 79

List symptoms of rectal prolapse

Answer 79

- Pain - Rarely bleeding - Seepage - Constipation or incontinence - Mass following defecation - Diminished quality of life

Question 80

List risk factors for rectal prolapse

Answer 80

- Age over 40 - Sex (female) - Multiple deliveries - Medial history of pelvic surgery, chronic constipation, diarrhoea or straining - Anatomical defects - In children from endemic regions, trichuris

Question 81

List signs of rectal prolapse

Answer 81

- Mass of tissue protruding from the rectum | - Unable to contract and relax the anal sphincter completely

Question 82

Define hiatus hernia

Answer 82

- Part of the stomach protrudes through the crura of the diaphragm and into the thoracic cavity. - At risk of ulcer formation - Sliding are protrusion of the gastrooesophageal junction and cardia of the stomach - Paraoesophageal are only the fundus of the stomach

Question 83

List common symptoms of hiatus hernias

Answer 83

- May be asymptomatic - GERD - Epigastric or substernal pain - Postprandial fullness - Nausea - May cause gastric ulcer formation, leading to haematemesis, melena, nausea and epigastric pain worsened after eating fatty foods

Question 84

Describe odonophagia

Answer 84

- Painful swallowing | - May be due to malignancy, more commonly a feature of infection eg. candidiasis

Question 85

List investigations preformed in dyspagia, and their indications

Answer 85

- Barium swallow (for patients who may have a high lesion, and patients who may have achalasia) - Endoscopy (visualisation of luminal and mural lesions, and opportunity to biopsy and treat lesions, used in low dysphagia) - Videofluoroscopy (functional high dyspagia) - Manometry (distinguishing between different types of motility disorders, used when endoscopy is normal)

Question 86

Define barrets oesophagus

Answer 86

Metaplasia of the oesophageal epithelial lining, whereby normal stratified squamous epithelium is replaced by simple columnar epithelium.

Question 87

What are risk factors for barretts oesophagus?

Answer 87

- Family history - Being male - Being white - Age >50 - Chronic heartburn and acid reflux (GORD) - Current or past smoking - Being overweight - Hiatus hernia

Question 88

Describe epidemiology of Barretts oesophagus

Answer 88

- The prevalence ranges from 0.5-2% in the Western world. - Around 10% of patients with GORD will have already developed Barrett’s oesophagus by the time they seek medical attention.

Question 89

Describe symptoms of Barretts oesophagus

Answer 89

- History of GORD (retrosternal chest pain, excessive belching, odynophagia, chronic cough and hoarseness) - Red flag symptoms of potential malignancy (dysphagia, weight loss, early satiety, malaise, loss of appetite, or worsening dyspepsia despite PPI treatment)

Question 90

List signs of barretts oesophagus

Answer 90

Unremarkable on examination

Question 91

Describe diagnosis of barretts oesophagus

Answer 91

- Patients who undergo OGD (gastroscopy) for chronic or resistant GORD (or to exclude malignancy) should have a biopsy taken of the oesophageal epithelium and sent for histological analysis. - At OGD, the oesophagus appears red and velvety in cases of Barrett’s oesophagus, with some preserved pale squamous islands.

Question 92

How is barretts oesophagus managed?

Answer 92

- PPI - Diet advice (avoid acidic foods/ alcohol) - Stop medication eg. NSAIDS - Regular endoscopy due to risk of adenocarcinoma developing (radiofrequency ablation/resection) - Oesophagectomy

Question 93

Describe prognosis of barretts oesophagus

Answer 93

- High grade dysplasia has a high risk of progressing to cancer so should be resected with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). - Adenocarcinomas detected on routine screening for Barrett’s oesophagus are typically early-stage lesions and have a better prognosis than those discovered outside of any screening program.

Question 94

Define GORD

Answer 94

Gastro-intestinal reflux disease (GORD) is a condition characterised by retrosternal, and sometimes epigastric pain, as a result of reflux of the acidic contents of the stomach into the oesophagus.

Question 95

List risk factors for GORD

Answer 95

- Hiatus hernia - Eating certain foods – fat, chocolate, caffeine - Smoking - Obesity - Dysfunction of the lower oesophageal sphincter (LOS) - Alcohol - Helicobacter Pylori - “Stress”

Question 96

Describe epidemiology of GORD

Answer 96

- GORD resulting in heartburn affects 30% of the population - Less common in East Asia - Increases with age

Question 97

List symptoms of GORD

Answer 97

- Dyspepsia – retrosternal chest pain radiating to the jaw back and arms, particularly after eating. May be worse on lying down, usually relieved by antacids and aggravated by drinking alcohol and hot drinks, and by bending over. - Regurgitation of food and acid into the mouth – this generally occurs when the patient is lying flat. - Waterbrash – salivation due to the presence of acid in the oesophagus. - Weight gain – this is a pre-disposing factor – not a symptom. Often a patient will put on a bit of weight, and shortly afterwards, the dysphagia will first present. - Choking at night – as gastric acid irritates the larynx - Dysphagia – this may be present in those people with a stricture. The stricture could be a result of mucosal damage due to reflux - Excess Belching

Question 98

Describe diagnosis of GORD

Answer 98

Generally clinical, based on history and response to antacids (PPI trial 8 weeks). If patients dont respond to initial treatment... - H pylori testing (urea breath test) - Endoscopy - Barium swallow (hiatus hernia/strictures)

Question 99

How is GORD treated?

Answer 99

- Lifestyle changes (weight loss, head of bed elevation, avoid late night eating, chocolate, caffeine, alcohol, spicy foods) - PPI/antacids - Review drugs - If persistant, fundoplication surgery

Question 100

Describe prognosis of GORD

Answer 100

10–15% of people with GORD will develop Barrett's oesophagus, and 1–10% of these will develop oesophageal adenocarcinoma over the next 10–20 years.

Question 101

Define oesophageal cancer

Answer 101

- Tumour of the oesophagus - 4 types -adenocarcinoma, squamous cell carcinoma, leiomyoma and squamous papilloma. - Squamous cell and adenocarcinoma are by far the most common.

Question 102

Describe epidemiology of oesophageal cancer, squamous cell carcinoma

Answer 102

- 2-3 per 100 000 in the UK and USA. Much higher in Asia and the Middle East - Male:Female = 7:1 - Peak age of incidence is 60-70 - 15% - Upper 2/3 of oesophagus

Question 103

List risk factors of oesophageal cancer, squamous cell carcinoma

Answer 103

- Alcohol - Smoking - Dietary nitrosamines (found in mouldy foods) and nitrates - Alfatoxins - Achalasia - Plummer vinson syndrome - Coeliac

Question 104

Describe epidemiology of adenocarcinoma of the oesophagus

Answer 104

- 5 per 100 000 – thus in these regions it is more common than squamous cell carcinoma - Incidence has risen greatly in the last few decades – thought to be related to the increase in obesity (and thus the increase in reflux disease) - Most common presentation is in white, middle-aged males - Lower 2/3 of oesephagus - 80% cancers

Question 105

List risk factors for adenocarcinoma of the oesophagus

Answer 105

- Barrett’s Oesophagus. - Obesity - Smoking - Alcohol - Genetic susceptibility - Age (>45) - Male

Question 106

List signs and symptoms of oesophageal cancer

Answer 106

- Feeling of lump in the throat – not associated with eating - Progressive dysphagia – this is a very characteristic symptom - Regurgitation – may be misinterpreted as vomiting - Weight loss and anorexia - Possible palpable lymph nodes, such as Virchow’s node. - Dyspnoea - Odonophagia (painful swallowing suggesting local invasion) - FLAWS

Question 107

How is oesophageal cancer investigated?

Answer 107

- Endoscopy. Investigation of choice. 90% of oesophageal tumours can be imaged. Biopsy - Barium swallow (rare) – may be used if endoscopy cannot be tolerated - CT/MRI for staging - Rarely laproscopy - Metabolic profile shows volume depletion, hypokalaemia

Question 108

List risk factors of crohns

Answer 108

- White ancestry - Age 15-40 or 60-80 - Family history - Cigarette smoking - High refined sugar diet - Oral contraceptive - Not breastfed - NSAIDs

Question 109

Define gastric cancer

Answer 109

Cancer of the lining of the stomach

Question 110

List causes of gastric cancer

Answer 110

- The most common cause is infection by the bacterium Helicobacter pylori, which accounts for more than 60% of cases. - Other causes include dietary nitrosamines (smoked foods), tobacco smoking, achlorhydria, and chronic gastritis. - Pernicious anaemia - Positive family history

Question 111

List symptoms of gastric cancer

Answer 111

- Presents late - Weight loss - Anorexia - Dyspepsia - Dysphagia - Epigastric pain - Early satiety - Haematemesis (coffee ground) - Meleana

Question 112

List signs on examination of gastric cancer

Answer 112

- Palpable vircows node - Palpable periumbilical lymph nodes - Abdo mass - Hepatomegaly + jaundice

Question 113

Describe epidemiology of gastric cancer

Answer 113

- Over 7000 new stomach cancers are diagnosed each year in the UK - 2 times more common in males - Adenocarcinoma most common - Common in Asia - Age 50-70

Question 114

How is gastric cancer investigated?

Answer 114

- OGD, biopsy all ulcers in multiple locations. - endoscopic ultrasound to examine depth of invasion - CT/MRI for staging - Cytology of peritoneal wash

Question 115

Define hepatocellular carcinoma

Answer 115

The most common type of primary liver cancer

Question 116

List symptoms and signs of hepatocellular carcinoma

Answer 116

- Anorexia - Bloating (ascites) - Weight loss - Peripheral extremity swelling - Hepatomegaly and upper right quadrant tenderness - Ascites

Question 117

List risk factors for hepatocellular carcinoma

Answer 117

- Cirrhosis - Chronic inflammation of the liver caused by hepatitis B or C - Alcohol - Non-alcoholic steatohepatitis - Hemochromatosis - Wilsons - A-1 antitrypsin deficiency - Autoimmune hepatitis - Male

Question 118

Describe epidemiology of hepatocellular carcinoma

Answer 118

- Fifth most common malignancy worldwide - Most common primary liver malignancy in adults - Highest incidence in Southeast Asia and Africa [1] - Peak incidence in the US: 70–75 years - Peak incidence in Africa and Asia: 30–40 years - Affects females more than males

Question 119

Describe investigation of hepatocellular carcinoma

Answer 119

- Raised serum alpha-fetoprotein (AFP - used to screen cirrhosis patients, raised in 80% patients) - Ultrasound (initial test, showing irregular mass boreders, vascular invasion, underlying cirrhosis, also used to screen cirrhosis ts) - Abdominal CT or MRI confirmatory (hypodense lesions, local invasion, irregular mass borders) - Liver biopsy for definitive diagnosis

Question 120

Define gallstones and biliary colic

Answer 120

- Gallstones (cholelithiasis) refers to the formation of hard stones in the gallbladder – a process which typically takes years to occur. - Biliary colic is pain due to gallstones which comes and goes in RUQ

Question 121

Describe epidemiology of gallstones and biliary colic

Answer 121

- More common in women - Cholesterol secretion is a massive factor in gallstone formation – particularly the amount of cholesterol secreted in relation to the concentration of bile salts. Women naturally secrete a higher proportion of cholesterol than men and thus they have a higher incidence of gallstones. - Incidence increases with age - At age 30 – 5% of women and 2% of men have / have had gallstones. Aged 55 – 20% / 10%, age 70, 30% / 20%. - Racial differences: More common in Scandinavia, and Native North and South American Populations.

Question 122

List risk factors for gallstones and biliary colic

Answer 122

- Obesity - Sudden weight loss - Family History - Oestrogen - Female gender - Oral contraceptive pill - Diet (high fat, low fibre) - Increasing age - Diabetes - Crohns 5F- fair, fat, female, fertile, forty

Question 123

List presenting symptoms of gallstones and biliary colic

Answer 123

- Gallstones usually do NOT cause flatulence, dyspepsia, fat intolerance or other vague upper abdominal symptoms, unless they are causing an acute flare-up of biliary colic (see below) or other acute manifestations - Symptomatic gallstones can present as either biliary colic (waves of pain in URQ after fatty meals, nausea and vomiting radiates to scapula), chtis (infection in the biliary tree – an emergency), pancreatitis, or other acute manifestations

Question 124

List signs of gallstones and biliary colic

Answer 124

- Murphys sign (pain when you press down on the gallbladder) - Rebound tenderness - URQ pain

Question 125

Describe investigation of gallstones and biliary colic

Answer 125

- An abdominal ultrasound examination and a blood test to measure liver function tests (LFTs) should be arranged for people suspected of having gallstone disease. - MRCP or EUS may also be used

Question 126

Define viral hepatitis, list the causative agents

Answer 126

- Hepatitis refers to inflammation of the liver and can be due to a number of causes. Viruses cause around half of all cases of hepatitis. - Viral hepatitis is most commonly caused by Hepatitis A, B and C viruses - Other causes include Hepatitis D (associated with hepatitis B virus) and E - Rarely cytomegalovirus, Epstein Barr virus, Adenovirus, HSV (very rare)

Question 127

List risk factors for viral hepatitis

Answer 127

- Those from highly prevalent areas; injecting drug users; sex workers (take a sexual history); those who have been sexually assaulted, sustained a needlestick injury or are HIV positive - At risk patients should be offered the first dose of HBV vaccine also - Injecting drug users and close contacts - Those with multiple sexual partners and sex workers - Those travelling to areas of high prevalence - Household contacts of those with HBV - Those receiving regular blood products - Those with occupational risk - Prison inmates and staff - Infants born to women with chronic HBV - Hep A most commonly rimming - Hep B most commonly vertical (can be both sexually and blood blood) - Hep C most commonly sharing needles (lower risk sexually) - Hep D infects people with hep B (not a full virus) - Hep E most commonly pork (immunocompromised people eg. pregnancy)

Question 128

List symptoms of viral hepatitis

Answer 128

- Fever (often mild), arthralgia and/or rash may appear around 2 weeks before any signs of jaundice, and may resolve when jaundice appears - Nausea and anorexia Acute/ Icteric phase - Nonspecific malaise (can be severe) - Pruritus - Pain/tenderness in the right upper quadrant - Fulminant hepatitis is rare (<1%)

Question 129

List signs on examination of viral hepatitis

Answer 129

- Liver stigmata- spider naevi (chronic), finger clubbing, jaundice, hepatomegaly - In advanced cirrhosis- easy bruising, oedema/ascites, liver flap, encephalopathy (confusion), progressive weight loss, muscle wasting/weakness, jaundice

Question 130

Describe investigations in viral hepatitis

Answer 130

- In acute disease- ALT and AST are usually >1000 (ALT > AST typically) - In chronic disease- ALT and AST are only mildly elevated (<100IU/l) - Hep A elevated IgM, not infective during jaundice. IgM means acute, IgG means chronic - Hep B anti HBe means exposure to live virus, anti HBs is given in vaccines. Can be chronic, often sub-clinical. Core IgM acute - HCV antibody test and RNA test

Question 131

Define primary sclerosing cholangitis

Answer 131

A disease of the bile ducts that causes inflammation and obliterative fibrosis of bile ducts inside and/or outside of the liver.

Question 132

List risk factors and aetiology for primary sclerosing cholangitis

Answer 132

- Narrowing of the bile duct lumen usually occurs throughout the biliary tree. - Less commonly, changes are confined to the intra-hepatic or extra-hepatic ducts but is seldom short enough to resemble a post-traumatic or focal malignant stricture. - Association with inflammatory bowel disease (75 per cent of cases), particularly ulcerative colitis but also Crohn’s disease

Question 133

Describe the epidemiology of primary sclerosing cholangitis

Answer 133

- Prevalence is estimated at 1 to 6 per 100,000. - Mean age at the time of diagnosis is 39 years - 70% of patients are men - Typically occurs in patients with inflammatory bowel disease, but may also occur in association with retroperitoneal or mediastinal fibrosis - Of the 75% of patients with primary sclerosing cholangitis who have inflammatory bowel disease, about 87% have ulcerative colitis and 13% have Crohn's disease

Question 134

List symptoms of primary sclerosing cholangitis

Answer 134

- Progressive fatigue, pruritus and jaundice. - Symptoms associated with chronic liver disease, for example, weight loss, ascites, variceal bleeding and hepatic encephalopathy.

Question 135

List signs of primary sclerosing cholangitis

Answer 135

- Hepatomegaly is found in about 50% of patients | - Less often, there is splenomegaly, hyperpigmentation and xanthomas.

Question 136

Describe investigations performed in primary sclerosing cholangitis

Answer 136

- Raised serum alkaline phosphatase, aspartate aminotransferase and bilirubin - Hypergammaglobulinaemia occurs in one third; IgM levels increased in 50% of cases - Raised hepatic copper levels in nearly 90% of cases - Liver biopsy revealing a fibrous obliterating cholangitis, and loss of interlobular and adjacent septal bile ducts (concentric onion skin fibrosis) - ECRP showing multiple annular strictures, separated by round or slightly dilated duct segments the intrahepatic and extrahepatic bile ducts have a beaded appearance - Raised perinuclear antineutrophil cytoplasmic antibody

Question 137

Describe management of peptic ulcer disease and gastritis

Answer 137

- Lifestyle modification - Assess for stress, anxiety and depression - Reviewing and stopping any drugs which may be exacerbating symptoms - If H pylori positive, PPI prescribed for 2 months then H pylori eradication treatment. Consider H2 receptor antagonist too (triple therapy - PPI, clarithromycin and amoxicillin) - Long term acid suppression therapy should be considered - Annually review if on long term treatment - H pylori negative PPI and H2 antagonist eg. ranitidine

Question 138

List possible complications of peptic ulcer disease

Answer 138

- Haemorrhage (case fatality 5-10%) - Perforation (may cause peritonitis 20% mortality) - Gastric outlet obstruction (strictures and stenosis) - Gastric malignancy (increased risk if H pylori positive) - If posterior duodenal, can infiltrate gastroduodenal artery

Question 139

Describe epidemiology of peptic ulcer disease

Answer 139

- 5-10% lifetime prevalence - Incidence 0.1-0.3% per year - Incidence pf duodenal ulcer peaks at 45-64 years and is 2 times more common in men - Incidence of gastric ulcers increases with age, and is similar in men and women

Question 140

Describe prognosis of peptic ulcer disease and gastritis

Answer 140

- If associated with H pylori, eradication may cure ulcer. - Lifetime gastric ulcer recurrence 60% if H.pylori positive and 5% following eradication - Lifetime duodenal ulcer reccurence 80% if h.pylori positive and 5% following eradication - If associated with NSAIDs, stopping use of drug or co-prescribing with acid suppression reduces risk of occurance - Mortality rate 6-8% - 1 in 10 people with bleeding peptic ulcer will die, and 1 in 4 people with perforated peptic ulcer will die

Question 141

Describe epidemiology of acute pancreatitis

Answer 141

- 13-15 cases per 100000 people worldwide - Most hospitals admit 100 people per year - 80% mild

Question 142

List signs of acute pancreatitis

Answer 142

- Abdominal tenderness - Abdominal distension - Cullens sign (bluish discolouration by umbillicus) or grey turners (bluish flank) due to retroperotineal bleed - Tachycardia and hypotension (shock) - Fever - Jaundice - Ileus - Rigid abdomen

Question 143

List investigations for acute pancreatitis

Answer 143

- Lipase or amylase raised (lipase more specific, rises earlier) - FBC- elevated leukocyte count poor prognosis - ABG for oxygenation - AXR no psoas shadow, increased retroperitoneal fluid, sentinel loop of proximal jejunum from ileus - Erect CXR to exclude perforation - CT standard - US if gallstones and raised AST - Imaging (CT, ultrasound, MRI) - ERCP to check for gallstones, CRP predictor of severe pancreatitis

Question 144

Describe management of acute pancreatitis

Answer 144

- IV fluids (crystalloid), urinary catheter - NJ feeding/ encourage to eat - Oxygen - Pain relief (pethidine 75-100mg/4h IM or morphine - Hourly obs - Antibiotics - Nutritional support - Cholecystectomy if gallstones, ECRP to remove a gallstone - ITU if worsening

Question 145

Describe prognosis of acute pancreatitis

Answer 145

- Mild 1% mortality rate - Severe 10% mortality if sterile and 25% if infected - Average 12% mortality

Question 146

List complications of acute pancreatitis

Answer 146

Early: sepsis, ARDS, renal failure, SIC, shock, hypocalcaemia, raised glucose Long term - Pancreatic necrosis with or without infection - Pseudocyst (thick walled collections of pancreatic fluid, drained percutaneously or using EUS) - Pancreatic abscess drain) - Fustulae (from pancreatic duct to abdominal cavity, pleural cavity or pericardial cavity, close spontaneously) - Pre-hepatic portal hypertension - Acute renal failure - Acute respiratory distress syndrome - Thrombosis causing bowel necrosis - Recurrent oedematous pancreatitis

Question 147

Describe epidemiology of chronic pancreatitis

Answer 147

- 8.3 per 100000 France - 4.45 per 100000 US - India 114-200 per 100000

Question 148

List signs of chronic pancreatitis

Answer 148

- Chronic liver disease - Epigastric tenderness - Jaundice - Abdominal distention (pseudocyst, pancreatic ascites or cancer) - Firm skin nodules due to fat necrosis) - SOB

Question 149

Describe investigations of chronic pancreatitis

Answer 149

- Blood tests (liver function, may be abnormal in liver disease but serum amylase not diagnostic) - Abdominal ultrasonography to exclude other conditions+CT (pancreatitic calcifications) - Stool test for fecal elastase - MRCP, AXR

Question 150

Describe management of chronic pancreatitis

Answer 150

- Stop smoking and alcohol - Analgesia (NSAIDs, paracetamol, weak opiod) - If severe pain, endoscopic therapy to remove stones and dilate strictures, surgery, adjuvant drugs (amitriptyline, gabapentin or pregabalin) - Screen for diabetes, osteoporosis - Refer to dietition - Pancreatic enzyme supplementation (lipase, fat soluble vitamins, insulin) - Corticosteroids if autoimmune chronic - Treat diabetes, hypercalcaemia and hypertriglyceridaemia - Surgery if unremitting, narcotic abuse, low weight (pancreatectomy)

Question 151

List complications of chronic pancreatitis

Answer 151

- Maldigestion and malabsorption. - Diabetes mellitus. - Chronic pain. - Opioid dependency for treatment of chronic pain. - Low-trauma fracture due to an increased risk of osteoporosis due to malabsorption. - Pancreatic calcification. - Pseudocyst formation. - Duodenal or gastric outlet obstruction, gastric varices - Biliary obstruction. - Fistulae. - Pancreatic cancer. - Pseudoaneurysm. - Splenic or portal vein thrombosis.

Question 152

Describe prognosis of chronic pancreatitis

Answer 152

- Chonic pain (stable, worsen or improve over time) - Exocrine insufficiency 91-100% of people after 26-36 years) - Endocrine insufficiency 28-76% - 50 year life expectancy if onset idiopathic around 20 years - 77-80 life expectency if senile idiopathic (50 years plus) - 55-72 year life expectancy if alcoholic - 44 years life expectancy if hereditary

Question 153

List what is looked for in general inspection in abdo exam

Answer 153

- Medical paraphernalia - Tattoos - Distension or scars - Anaemia or jaundice - ASK ABOUT TATTOOS OR BRUISING

Question 154

List what is looked for in inspection of the face in abdo exam

Answer 154

- Central cyanosis - Jaundice - Kaiser flaischer rings - Xanthelasma - Pigmentation - Hydration - Telangectasia - Dentition - Apthious ulcers - Angular stomatitis - Atrophic glossitis - Candidiasis

Question 155

List what is looked for in inspection of the hands and arms in abdo exam

Answer 155

- Clubbing - Palmar erythema - Dupuytrens contracture - Leukonychia and koilonychia - Tatoos - Excoriation - Petichiae - Haemodialysis fistulae

Question 156

Describe epidemiology of Mallory Weiss tears

Answer 156

- 3% to 15% of patients gastrointestinal (GI) bleed. - More common in adults than children (age 30-50) - Males 3 times more affected

Question 157

Describe symptoms of mallory-weiss tear

Answer 157

- Haematemesis after an episode of forceful or recurrent retching, vomiting, coughing, or straining. - Abdominal pain - Melaena - Dizziness and syncope

Question 158

List risk factors for mallory weiss tear

Answer 158

- Excessive alcohol ingestion. - Conditions predisposing to retching and vomiting. (gastroenteritis, bulimia, renal disease, hepatitis, migraine) - Medication such as chemotherapy. - Chronic cough or acute causes of prolonged coughing bouts. (eg. COPD, whooping cough) - Hiatus hernia. During retching or vomiting, the transmural pressure gradient is greater within the hiatus hernia than the rest of the stomach. - Blunt abdominal trauma and cardiopulmonary resuscitation. - Iatrogenic. Tears during upper gastrointestinal instrumentation are uncommon, even with the high incidence of retching during endoscopy. - Ingestion of aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs).

Question 159

Describe investigations of Mallory Weiss tear

Answer 159

- Oesophogastroduodenoscopy - FBC, haematocrit - Blood group serology, group and save - Renal function - ECG

Question 160

Describe management plan of a Mallory Weiss tear

Answer 160

- Ensure patient is stable - Rockall score to stratify risk - Maintain airway, fluid levels, provide oxygen - Usually bleeding stops by itself - IV PPI - Sengsaken blakemore tube - If does not resolve itself, banding or clipping techniques used in endoscopy, or adrenaline injection - Monitor patients for rebleeding

Question 161

List complications of a Mallory Weiss tear

Answer 161

- Vomiting (hypokalaemia and other metabolic disturbance, aspiration pneumonia, perforation and mediastinitis). - Hypovolaemic shock, and death (very rare with good care). - Re-bleeding. (More common in those with shock at presentation, lower haemoglobin levels, multiple transfusions or active bleeding seen at endoscopy.) - Myocardial ischaemia or infarction. - Comorbidities - MI, renal failure, liver failure, diabetic coma - Endoscopy (mediastinitis, aspiration pneumonia, perforation or aggravation of bleeding). - Angiotherapy (organ ischaemia and infarction, aggravation of bleeding).

Question 162

Describe prognosis of mallory weiss tear

Answer 162

- Most patients usually stop bleeding spontaneously and the tears heal rapidly, usually within 48-72 hours. - Bleeding is variable and can range from a few specks or streaks of blood mixed with mucus to large amounts of fresh blood. - Re-bleeding occurs in 8-20% but is more common in those with risk factors - Associated diseases may have a significant effect on prognosis; for example, cirrhosis carries a very poor prognosis

Question 163

Define ulcerative colitis

Answer 163

Ulcerative colitis is a chronic, relapsing-remitting, non-infectious inflammatory disease of the gastrointestinal tract

Question 164

List risk factors for ulcerative colitis

Answer 164

- Family history - Appendicectomy before adulthood is thought to be protective against the development of ulcerative colitis - Non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) may exacerbate ulcerative colitis and increase the risk of disease flare-ups - Smoking appears to be protective against developing ulcerative colitis, as the risk of ulcerative colitis is decreased in smokers (in contrast to Crohn's disease, where smoking increases the risk) - Conversely, smoking cessation may increase the risk of developing ulcerative colitis, and ex-smokers have an approximately 70% greater risk of developing the disease, which is often more extensive and refractory to treatment, compared with people who have never smoked

Question 165

Describe epidemiology of ulcerative colitis

Answer 165

- Most common bowel disease - Within Europe, the highest incidence and prevalence rates are found in Scandinavia and the UK - The incidence of paediatric-onset ulcerative colitis, which represents about 15–20% of all ulcerative colitis cases, ranges from 1–4 per 100,000 per year in most North American and European regions - The prevalence of ulcerative colitis is estimated at 5–500 per 100,000 worldwide - The peak incidence occurs in late adolescence and early adulthood in the second to fourth decades of life, with a small second peak in the fifth decade - Ulcerative colitis affects males and females at approximately equal rates

Question 166

List symptoms of ulcerative colitis

Answer 166

- Bloody diarrhoea persisting for more than 6 weeks, or rectal bleeding, if malignancy is not suspected. - Faecal urgency and/or incontinence. - Nocturnal defecation. - Tenesmus (persistent, painful urge to pass stool even when the rectum is empty). - Abdominal pain, particularly in the left lower quadrant. - Pre-defecation pain, which is relieved on passage of stool. - Non-specific symptoms such as fatigue, malaise, anorexia, or fever (may suggest severe disease). - Weight loss, faltering growth or delayed puberty in children.

Question 167

List signs of ulcerative colitis

Answer 167

- Pallor, clubbing, or aphthous mouth ulcers. - Abdominal distension, tenderness or mass, for example in the left lower quadrant. - Signs of malnutrition or malabsorption — serial weight loss or, in children, faltering growth or delayed puberty. - Eye, skin, or joint signs of extra-intestinal manifestations (pauciarticular arthritis, erythema nodosum, apthous mouth ulcers, episcleritis, metabolic bone disease, ankylosing spondylitis, venous thromboembolism)

Question 168

Describe investigations of ulcerative colitis

Answer 168

- FBC (anaemia) - CRP, ESR (may be raised) - U and E (dehydration) - LFT (low albumin protein losing enteropathy) - Thyroid function tests) - Ferritin, B23 folate and vit D - Coeliac serology - Stool culture to exclude infective gastroenteritis - Fecal calprotectin (inflammation) - Colonoscopy showing continuous inflammation affecting rectum upwards, limited to the mucosa, never goes further than the ileocaecal valve - Monitor bowel due to adenoma risk

Question 169

List complications of ulcerative colitis

Answer 169

- Psychosocial impact - Toxic megacolon (>6cm, systemic upset) - Bowel obstruction or perforation - Intestinal strictures - Fistulas - Anaemia - Malnutrition, delayed puberty in children - Growth failure - Colorectal cancer - Pouchitis (colectomy)

Question 170

Describe management of ulcerative colitis

Answer 170

- Education - Encourage healthy lifestyle - Colorectal cancer surveillance - Monitor child growth and development - Monitor flare ups (inflammatory markers) - Colorectal surgery for stoma - Vaccinations - Aminosalicyclates eg. mesalazine (mild to moderate) - Corticosteroids (induce remission, then return to 5-ASA) - Calcineurin inhibitors - Immunosuppressive drugs (thiopurines - azathioprine and mercaptourine - or methotrexate, if patients need 2 courses of steroids per year) - Anti TNF alpha

Question 171

Describe prognosis of ulcerative collitis

Answer 171

- Slightly increased risk of mortality - 50% in remission at any one time, 90% of people have a relapsing remitting course - Lifetime surgery risk 20-30% - Poor prognosis - severe symptoms at presentation, age less than 50, poor compliance, raised inflammatory markers

Question 172

Describe epidemiology of volvulus

Answer 172

- Malrotation affects 1 in 500 live births - 90% patients diagnosed in first year of life - Most common in the sigmoid colon

Question 173

List risk factors for developing volvulus

Answer 173

- Increasing age - Neuropsychiatric disorders - Resident in a nursing home - Chronic constipation or laxative use - Male gender - Previous abdominal operations

Question 174

List signs of volvulus on examination

Answer 174

- Inability to pass a nasogastric tube | - Tympanic abdomen to percussion

Question 175

Describe irritable bowel syndrome

Answer 175

Irritable bowel syndrome (IBS) is a chronic, relapsing, and often lifelong disorder of the lower gastrointestinal tract, with no discernible structural or biochemical cause.

Question 176

Define functional dyspepsia

Answer 176

- Functional dyspepsia (also known as non-ulcer dyspepsia) refers to people with dyspepsia symptoms and normal findings on endoscopy (gastric or duodenal ulcer, gastric malignancy, or oesophagitis have been excluded) - Dyspepsia is upper GI symptoms present for four or more weeks (upper abdominal pain, discomfort, heartburn, acid reflux, nausea and/or vomiting)

Question 177

Describe epidemiology of IBS

Answer 177

- The global prevalence of IBS in the general population is estimated to be 5–20%. - It most commonly affects young people aged 20–30 years, and the prevalence decreases with increasing age. - It is more common in women than in men

Question 178

Describe epidemiology of functional dyspepsia

Answer 178

- About 40% of the adult population have dyspepsia symptoms each year. - 25% of people will consult their GP to discuss dyspepsia symptoms, and dyspepsia accounts for 1.2–4% of all primary care consultations in the UK - In people with dyspepsia symptoms who undergo endoscopy, 70–80% are diagnosed with functional dyspepsia - Consultations for functional dyspepsia increase with age, and the prevalence is similar in men and women.

Question 179

List risk factors for functional dyspepsia

Answer 179

- Gastroduodenal dysmotility, hypersensitivity to gastric distention, gastric acid secretion abnormalities, and psychosocial factors may be contributory. - Infectious gastroenteritis may also increase the risk of developing subsequent functional dyspepsia. - H pylori may lead to abnormalities in gastroduodenal motility and sensitivity.

Question 180

List mechanisms of IBS

Answer 180

- Visceral hypersensitivity. - Abnormal gastrointestinal immune function. - Changes in colonic microbiota. - Abnormal autonomic activity. - Abnormal central pain processing of afferent gut signals (altered 'brain-gut interactions'). - Abnormal gastrointestinal motility.

Question 181

List risk factors of IBS

Answer 181

- Genetic - Enteric infection (for example, following gastroenteritis) - Gastrointestinal inflammation (for example, secondary to inflammatory bowel disease) - Dietary factors (such as alcohol, caffeine, spicy and fatty foods) — up to 90% of people - Drugs, such as antibiotics - Psychosocial such as associated stress, anxiety and/or depression, PTSD, history of abuse

Question 182

List symptoms and signs of IBS

Answer 182

- Abdominal pain, bloating or change in bowel habit for 6 months + - Pain related to defecation, associated with altered stool frequency or altered stool form or appearance - Straining, urgency or incomplete evacuation - Abdominal bloating - Symptoms worsened by eating - Passage of rectal mucous - Lethargy, nausea, balck pain, headache, bladder symptoms - NO PR bleed, anaemia, weight loss, nocturnal symptoms

Question 183

List symptoms and signs of functional dyspepsia

Answer 183

- Epigastric discomfort - Fullness or bloating - Excessive flatus - Nausea - Fatty food intolerance

Question 184

Describe management of functional dyspepsia

Answer 184

- Offering advice on lifestyle measures that may improve symptoms. - Assessing for stress, anxiety, and depression, and managing these appropriately. - Reviewing and stopping any drugs which may be exacerbating symptoms, if possible and appropriate. - Testing for H pylori - PPI or H2 receptor antagonist if ongoing - Acid suppression therapy with annual review

Question 185

List investigations for functional dyspepsia

Answer 185

- Check for abdominal mass - FBC - Test for H pylori - Endoscopy is symptoms persist despite treatment

Question 186

Describe investigations of IBS

Answer 186

- Diagnosed based on history - Determine effect on daily functioning, look for features of alternative diagnosis - Check weight, BMI, palpate abdomen for massess or tenderness - Rectal exam - FBC, inflammatory markers ESR and CRP, coeliac serology - Diagnosis of exclusion Rome III criteria - at least 3 months with onset at least 6 months previously of recurrent abdo pain or discomfort associated with 2 or more of: - Improvement with defecation and/or - Onset associated with a change in frequency of stool and/or - Onset associated with a change in appearance of stool

Question 187

Describe management of IBS

Answer 187

- Lifestyle advice (eat regular fibrous meals, healthy diet, avoid caffine, lactose, fructose) - If diarrhoea or bloating reduce insoluble fibre and reduce foods which exacerbate symptoms - If constipation advise to try soluble fibre supplements, increase fibre intake gradually, and laxatives if necessary - Anti-diarrhoeals - Increase fluid intake - Identify stress/anxiety/depression (TCA medications) - Increase physical activity - Treat pain with antiplasmotics

Question 188

List complications of IBS

Answer 188

- Mood disorder | - Poor quality of life

Question 189

List complications of functional dyspepsia

Answer 189

If associated with H pylori: - Reduced QOL - Increased risk of peptic ulcer disease

Question 190

Describe prognosis of IBS

Answer 190

- Symptoms fluctuate over years - Symptoms resolve spontaneously in 50% of patients with post-infectious IBS within 6-8 years - Poorer prognosis associated with comorbid anxiety and depression, longer symptom duration and higher somatic scores

Question 191

Describe prognosis of functional dyspepsia

Answer 191

- 70% untreated persistent symptoms - Recurrence 50% - H pylori positive 36% spontaneously improve, 7% eradication therapy improves symptoms - Persists over 3-12 months in 57%

Question 192

Describe classification of internal haemorrhoids

Answer 192

- First degree (Grade 1) — haemorrhoids project into the lumen of the anal canal but do not prolapse. - Second degree (Grade 2) — haemorrhoids protrude beyond the anal canal on straining but spontaneously reduce when straining is stopped. - Third degree (Grade 3) — haemorrhoids protrude outside the anal canal and reduce fully on manual pressure. - Fourth degree (Grade 4) — haemorrhoids protrude outside the anal canal and cannot be reduced.

Question 193

Describe epidemiology of haemorrhoids

Answer 193

- 13-16% population UK - US 4.4% - Peak prevalence between 45-65 years - White people and those of higher socioeconomic status more affected

Question 194

List risks for haemorrhoids

Answer 194

- Constipation. - Straining while trying to pass stools. - Ageing (weakening of the support structures makes haemorrhoids more likely to prolapse). - Conditions that cause raised intra-abdominal pressure (such as pregnancy, childbirth, ascites, or a pelvic mass). - Chronic cough. - Heavy lifting. - Exercising. - Hereditary factors (possibly due to a congenital weakness of the venous walls). - A low fibre diet.

Question 195

List symptoms of haemorrhoids

Answer 195

- Bright red painless rectal bleeding, typically occuring with defecation seen as streaks on the toilet paper or outside the stool - Anal itching or irritation - Feeling of rectal fullness, discomfort, incomplete evacuation - Soiling - Pain (external painless unless thrombosis, internal painless unless strangulated)

Question 196

List signs of haemorrhoids

Answer 196

- Perinium may appear normal if non-prolapsed internal - Macerated perineum from chronic mucus discharge - Bluish soft building vessels covered by mucosa if internal prolapsed - External bluish building of blood vessel - Thrombosed external haemorrhoid purplish, oedematous, tense, tender, subcutaneous perianal mass

Question 197

describe investigations of haemorrhoids

Answer 197

- History and examination - Check for skin tags or other anal pathology - DRE - Protoscopy - Full blood count if signs of anaemia

Question 198

Describe management of haemorrhoids

Answer 198

- Admit people who have lots of pain, or prolapsed internal haemorrhoids, or perianal sepsis - Refer using cancer pathway if cancer suspected - Refer for non-urgent management if 4th or 3rd degree, perianal haematoma, combined internal and external, thrombolised or large skin tags - Ensure stools are soft and easy to pass. Advise adequate dietary fibre and fluid intake - Advise to keep dry and clean - Advise against straining or stool withholding - Offer simple analgesia - avoid NSAIDS and opoids due to constipation, topical steroids (grade 1) - Advise to keep up dietary changes - Secondary care may involve rubber band ligation (grade 2 or 3), injection sclerotherapy, infrared coagulation/photocoagulation, bipolar diathermy, haemorrhoidectomy, stapled haemorrhoidectomy, haemorrhoidal artery ligation - Haemorrhoidectomy for grade 4

Question 199

List complications of haemorrhoids

Answer 199

- Perianal thrombosis. - Incarceration of prolapsing haemorrhoidal tissue — the tissue is unable to be reduced into the anal canal, causing severe pain. - Ulceration — from thrombosis of external haemorrhoids. - Skin tags — from repeated episodes of haemorrhoid dilatation and thrombosis. This causes enlargement of the overlying skin, problems with hygiene, and secondary irritation. - Maceration of the perianal skin — due to mucus discharge. - Ischaemia, thrombosis, or gangrene in fourth degree internal haemorrhoids — progressive venous engorgement and incarceration of the acutely inflamed haemorrhoid lead to thrombosis, infarction, and severe pain. - Anal stenosis. - Perianal or pelvic sepsis (rare). - Anaemia from continuous or excessive bleeding (rare).

Question 200

Describe prognosis of haemorrhoids

Answer 200

- Many symptomatic episodes settle with conservative measures, with low rates of recurrence - Residual or recurrent symptoms are more likely in people with continuing predisposing factors, such as constipation and straining while trying to pass stool - About 10% of people will require surgery to alleviate their symptoms

Question 201

Define diverticular disease, diverticulitis and diverticulosis

Answer 201

- Diverticula are sac-like protrusions of mucosa through the muscular wall of the colon. They are usually multiple, 5–10 mm in diameter, and occur in the sigmoid colon in about 85% of people. - Diverticulosis is a condition where diverticula are present without symptoms. - Diverticular disease is a condition where diverticula cause symptoms, such as intermittent lower abdominal pain, without inflammation and infection. - Diverticulitis is a condition where diverticula become inflamed and infected, typically causing severe lower abdominal pain, fever, general malaise, and occasionally rectal bleeding. (complicated associated with complications)

Question 202

List risk factors for diverticular disease

Answer 202

- Genetic - Low fibre diet - Smoking - Obesity - Drugs (NSAIDs, opiods, corticosteroids) - Age 50-70

Question 203

Describe prevalence of diverticular disease

Answer 203

- Exact prevalence is unknown as most people are asymptomatic - Increasing in developed countries - 75% of people asymptomatic diverticulosis, 25% diverticular disease - Rare before age of 40. 5-10% people age 45+, 80% of people age 85+ - Lifetime risk of acute diverticulitis is 4-25% - 5% complicated disease

Question 204

List symptoms of diverticular disease

Answer 204

- Intermittent abdominal pain in the left lower quadrant. Triggered by eating and relieved by passage of stool - Constipation, diarrhoes, large rectal bleeds - Bloating and passage of mucus rectally

Question 205

List signs of diverticular disease

Answer 205

- Tenderness in left lower quadrant on abdo exam - Guarding, rigitdity, rebound tenderness - If acute, laying still, tachycardia, low--grade pyrexia

Question 206

List symptoms of diverticulitis

Answer 206

- Constant abdominal pain, usually severe staring in hypogastrium before localising in left lower quadrant - Fever - Change in bowel habit with possible rectal bleeding - Nausea, vomiting, dysuria and urinary frequency

Question 207

List signs of diverticulitis

Answer 207

- Tenderness in left lower quadrant | - Palpable abdominal mass or distention on abdominal examination

Question 208

Describe management of diverticular disease

Answer 208

- Urgent admission if significant rectal bleeding. Diverticulosis high fibre diet + primary anastamosis. If diverteiculitis antibiotics, fluids, hartmanns - First presentation of diverticulitis oral abx as outpatient, if elderly/leukocytosis/ immunocompromosed bowel rest and IV ABX and fluids are used - Provide info and support - Reccommend healthy, balance diet containing whole grains, fruits and veg. Gradually increase fibre intake - High fluid intake - Consider bulk forming laxatives if high fibre diet is insufficient - Advise on alagesia (avoid NSAIDS and opiods due to increased risk of perforation) - Review - Barium enema

Question 209

List complications of diverticular disease

Answer 209

Diverticulitis can occur with risk of... - Diverticular haemorrhage 15% of people - 1/3 bleeds require transfusion and 70-80% stops spontaneously - Intra abdominal abscess formation - Perforation and peritonitis - Stricture and fistulae formation (to the bladder commonly) - Intestinal obstruction (from fibrosis and stricture formation) - Abscesses

Question 210

Describe prognosis of diverticular disease

Answer 210

- 10-25% of people with diverticular disease develop diverticulitis - 13.3% of people have a recurance of diverticulitis - 5% of people have complications when followed for 20-30 years - Risk of complications worse during first episode - People who are immunocompromised have a 5 fold increased risk of recurrence - Surgery doesnt eliminate recurrence risk

Question 211

Define anal fissure and its classification

Answer 211

- An anal fissure is a tear or ulcer in the lining of the anal canal, immediately within the anal margin. It is classified as: - Acute — if present for less than 6 weeks. - Chronic — if present for 6 weeks or longer. - Primary — if there is no clear underlying cause. - Secondary — if there is a clear underlying cause.

Question 212

List causes of primary anal fissure

Answer 212

- Ischaemic ulcers associated with spasm of internal anal sphincter resulting in increased anal tone - May occur in response to pain from trauma such as passing hard stools, resulting in reduced blood flow and increased risk of tearing - May be local lack of nitric oxide synthase, a group of enzymes needed for production of nitric oxide

Question 213

List causes of secondary anal fissures

Answer 213

- Constipation (tears of anal mucosa) - IBD - STI (HIV, syphilis, HSV) - Colorectal cancer - Psoriasis and pruritis ani - Anal trauma (previous surgery or anal sex) - Drugs (opiods, nicorandil and chemo) - Pregnancy and childbirth (increased pressure on perineum)

Question 214

Describe epidemiology of anal fissures

Answer 214

- 1 in 350 people - Most common age 15-40, occur at any age - Common in pregnant and post partum women (2nd most common GI complication of pregnancy after haemorrhoids) - Primary uncommon in elderly - Acute significantly more common than chronic

Question 215

List symptoms of anal fissures

Answer 215

- Pain always with defication, severe and sharp on passing stool with deep burning pain afterwards - Bleeding with defication (bright red on stool or paper) - Anal spasm and tearing sensation

Question 216

List signs of anal fissure

Answer 216

- Acute are superficial with well demarcated edges - Chronic are wider and deeper with muscle fibres visible in the base - Primary singular in posterior midline - Secondary irregular outline, multiple, occur laterally - Pain with gentle pressure on anal margin

Question 217

Describe diagnosis of anal fissure

Answer 217

- Take a history + ask about duration of symptoms - Ask about underlying cause (dietary habits, trauma, associated symptoms, family history) - Identify any risks (eg. constipation, cancer, STI, IBD) - Suspect sexual abuse in children - DRE not recommended, may be done under anaesthesia if unclear diagnosis

Question 218

Describe management of anal fissures

Answer 218

- Suspected cancer referral pathway if renal cancer suspected - Or other specialist if other causes suspected - Elderly people refered to surgeon - Manage underlying cause - Ensure stools soft and easy to pass (adequate dietary fibre intake, increase gradually, adequate fluid intake, laxatives) - Manage pain (simple analgesia not opiods due to constipation) - Sitting in shallow warm bath may relieve pain - Topical anaesthetic if extreme pain for use before passing stool - 1 week without improvement prescribe GTN ointment, 2 times a day for 6-8 weeks, or topical diltiazem - Advise against stool withholding and anal hygiene - Butolium toxin injection or surgical sphincterectomy if persistant

Question 219

Describe prognosis of anal fissure

Answer 219

- Primary acute resolve in 6-8 weeks, chronic require intensive treatments eg.surgery - Recurrence common following non-surgical treatment, especially if lifestyle advice not adhered to - Secondary anal fissures dependent on prognosis of underlying cause

Question 220

List complications of anal fissures

Answer 220

- Failure to heal/chronic fissure. - Recurrent fissure. - Anorectal fistula. - Infection and/or abscess. - Faecal impaction (avoidance of defecation to avoid anal pain may worsen constipation and lead to faecal impaction). - Reduced quality of life (especially in people with chronic or recurrent anal fissure).

Question 221

Define gastroenteritis

Answer 221

- Gastroenteritis is a transient disorder due to enteric infection with viruses, bacteria, or parasites. - It is characterized by the sudden onset of diarrhoea, with or without vomiting - Similarly, it can be defined as acute diarrhoeal disease of rapid onset, with or without nausea, vomiting, fever, or abdominal pain - Dysentry is bloody diarhhoea - Persistant diarrhoea is acute onset diarrhoea that lasts 14 days

Question 222

List causes of gastroenteritis

Answer 222

- Feco-oral, foodborne, environmental, airborne - Food poisoning caused by enterotoxins produced by the microorganism - Clostridium perfrigens (inadequate storage and insufficient reheating of contaminated meat dishes or cooked meats) - Bacillus cereus (contaminated cooked foods with inadequate post cooking temperature control) - Staphylococcus aureus (cooked meats and cream) - 40-70% travellers diarrhoea no specific causative agent identified - Norovirus, rotovirus, salmonella, campylobacter, e.coli, yersinia enterolitica, giardia, trichinella

Question 223

List symptoms of gastroenteritis

Answer 223

- Sudden-onset diarrhoea (change of stool consistency to loose or watery stools, usually at least three times in 24 hours); blood or mucus in the stool; faecal urgency. - Nausea or sudden onset of vomiting. - Fever or general malaise. - Abdominal pain or cramps. - Associated headache, myalgia, bloating, flatulence, weight loss, and malabsorption, depending on the underlying cause of infection.

Question 224

Describe diagnosis of gastroenteritis

Answer 224

- Symptoms - Onset, frequency and duration - Severity - Complications - Co-morbid conditions - Occupation - Recent food intake - Exposure to contaminated water - Contact with other infected individuals - Recent foreign travel - PPI/ antibiotic use/ hospital admission - c.difficile - Drugs (diuretic, ACE inhibitors, efficacy affected) - Stool culture and sensitivity testing

Question 225

List signs of gastroenteritis

Answer 225

- Dehydration (general appearance, temp, pulse, BP, breating) - Assess for sepsis - Examine abdomen (tenderness, distention, masses, bowel sounds) - Weight and malnutrition

Question 226

List complications of gastroenteritis

Answer 226

- Dehydration, electrolyte disturbance, kidney injury - Haemorrhagic collitis (E.coli) - Haemolytic uraemic syndrome (children under 5 - AKI, thrombocytopenia, microangiopathic haemolytic anaemia) - Thrombotic thrombocytopaenic purpura - Reactive arthritis and Reiters syndrome - Aortitis, osteomyelitis - Sepsis - Toxic megacolon - Pancreatitis, liver sclerosis, sclerosing cholangitis - Faltering growth - Chronic diarrhoea - IBS - IBD - Lactose intolerance - Guillian barre - Meningitis - Invasive entamoeba infection

Question 227

Describe management of gastroenteritis

Answer 227

- Emergency hospital admission if systemically unwell/ severe dehydration/ complication - Hospital assessment if at risk or unable to manage at home - Liaise with microbiologist if uncertainty about admission or management in travel diarrhoea - Encourage regular fluid intake, oral rehydration salt if at increased risk - Gradually increase usual diet - Not reccomended to use antidiarrhoeal drugs - No antibiotics - Advise on methods to prevent transmission - Stay at home for 48 hours after last episode of vomiting

Question 228

Describe prognosis of gastroenteritis

Answer 228

Symptoms usually resolve within 2 weeks, severe cases several weeks. Self limiting

Question 229

Describe epidemiology of gastroenteritis

Answer 229

- 17 million cases in the UK each year | - Particularly common in summer with outbreaks of zoonotic infections

Question 230

Describe epidemiology of colorectal and anal tumours

Answer 230

Colorectal cancer: - Around 40,000 new colorectal cancers are diagnosed each year in the UK, up to a quarter of these following screening. 3rd most common cancer and 2nd most common cause of cancer death - A full time GP is likely to diagnose approximately one person with colorectal cancer every year. Anal cancer: - Just over 1000 new anal cancers are diagnosed each year in the UK, meaning that a full time GP is likely to diagnose approximately 1–2 people with anal cancer during their career. - Anal cancer occurs in both sexes, though nearly two-thirds occur in women.

Question 231

Define colorectal tumour

Answer 231

A carcinoma of the large intestine or rectum

Question 232

List symptoms of colorectal cancer

Answer 232

- Appetite loss (unexplained) - Deep vein thrombosis - Weight loss (unexplained) - Anal mass or anal ulceration (unexplained) - Anaemia (iron deficiency) - Abdominal pain - Rectal bleeding - Change in bowel habit - Occult blood in faeces - Tenesmus - Fecal incontinence Left sided - tenesmus, bleeding in stools, altered bowel habit, mass PR, obstruction Right sided - iron deficiency anaemia, weight loss, abdo pain

Question 233

List risk factors for colorectal cancer

Answer 233

- Family history - Age - Diet rich in fat and meat, and low in fibre – associated with a Western Lifestyle - IBD – due to high cell trunover - Diabetes - Atherosclerotic disease - Age and family history are the two best predictors for colorectal cancer - Polyps

Question 234

List signs of colorectal cancer

Answer 234

- Cachexia - Abdominal mass - Signs of anaemia (conjunctival pallor /peripheral cyanosis) - Palpable rectal mass - Ascites

Question 235

List investigations for colorectal cancer

Answer 235

- Faecal Occult blood - Guaiac test – for Hb breakdown products. 98% specific, but only 40-80% sensitive - Antibody test – uses antibodies that bind to human blood to test for the presence of blood. - Routine biochemisty – U+E’s, FBC, LFT’s, CRP, ESR - Colonoscopy - Barium enema – in cases where colonoscopy cannot be performed - USS/CT – can asses bowel wall thickness as well as looking for metastatic spread

Question 236

List risk factors for coeliac disease

Answer 236

- Genetic (HLA-DQ2/ more rarely DQ8) - Immune mediated - other autoimmune conditions increase risk - Gluten exposure - GI infections and changes in the gut microbiome - IgA deficiency - T1DM

Question 237

Describe epidemiology of coeliac disease

Answer 237

- Increasing in incidence - 13.8 per 100000 or 1 in 100-300 - Prevalence higher in females than males (1.5:1-2:1) - Peaks in childhood and age 50-60 - Relative risk in first degree relatives 6 times higher

Question 238

List signs of coeliac disease

Answer 238

- Peripheral neuropathy or ataxia - Recurrent miscarriage or subfertility - Enamel defects - Osteomalacia, osteopenia, osteoporosis fragility fractures - Dermatitis herpetiformis - Apthous ulcers - Angular stomatitis - Failure to thrive

Question 239

Describe diagnosis of coeliac

Answer 239

- Blood test while person on coeliac diet (reduced Hb, increased RBCDW, low B12 and ferritin) - Check IgA anti- transglutaminase (MAIN), and total IgA in case of deficiency in IgA production - Check IgA endomysial antibody - Check IgG endomysial, deamidated gliadin peptide or transglutaminase if evidence of IgA deficiency - Duodenal biopsy and look at histology (intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, chronic inflammatory cell infiltrate at lamina propria) - If doubt remains, HLA DQ2/ DQ8 - Bone scan

Question 240

Describe management of coeliac disease

Answer 240

- Gluten free diet (rice, maize, soya, potatoes ok, limited oats in some patients) - Give info - Asess for recurrent symptoms - Assess for nutritional deficiencies - Assess osteoporosis, depression or anxiety - Monitor growth in children - Annual blood monitoring - Dietician, prescription gluten free food - Screen first degree relatives

Question 241

List complications of coeliac disease

Answer 241

- Reduced QOL - Depression, anxiety, eating disorders - Faltering growth and delayed puberty in children - Nutritional deficiencies - Anaemia - Reduced bone density - Hyposplenism or asplenism - Malignancy (lymphoma, gastric, oesophageal, colorectal) - Refractory coeliac disease (persistant symptoms despite diet adherence) - Dermatitis herpetiformis

Question 242

List causes of high bilirubin

Answer 242

- Haemolysis (prehepatic look at FBC and film) - Liver cirrhosis (Hepatic disease - viral hepatitis, alcoholic hepatitis, cirrhosis) - Gallstones (obstructive jaundice, pancreatic cancer) - Gilberts syndrome

Question 243

Describe arrangement of the liver

Answer 243

- Lobules - Central vein - At each corner of the hexagon, there is a triad of bile duct, hepatic portal vein and hepatic artery - Blood goes to the central vein via sinusoids

Question 244

Describe features of gilberts disease

Answer 244

- Recessively inherited - 50% carry the gene - UDP glucuronyl transferase activity reduced, therefore higher level of bilirubin - Elevated bilirubin, higher on fasting, other blood tests normal - Do not do a biopsy - Phenobarb lowers levels

Question 245

How is liver function best tested?

Answer 245

- Prothrombin time most representative, rapidly increases. - Albumin can also be used, but does not change as fast. - Bilirubin - ALT, AST, alkaline phosphatase are the enzymes that leak out - High alkaline phosphatase indicates blockage of bile ducts

Question 246

List test results for liver enzymes and what they indicate

Answer 246

- ALT and AST go up when hepatocytes are damaged. | - Alkaline phosphatase high in obstructive jaundice, ALT and AST normal

Question 247

Describe diagnosis of alcoholic hepatitis

Answer 247

Biopsy shows liver cell damage - Inflammation - Fibrosis - Fatty change (mallorys hyaline, balloon cells, steatosis) - Megamitochondria - Non alcoholic appears the same - High ALT, AST, bilirubin, high MCV. - Check for autoimmune (antibodies), viral hepatitis, lipids+HbA1c fo non-alcoholic

Question 248

List causes of non-alcoholic steatohepatitis

Answer 248

- T2DM | - Obesity

Question 249

Describe treatment of alcoholic hepatitis

Answer 249

- Alcohol cessation - Vitamin B1, thiamine, Vitamin D - 40mg prednisolone for 4 weeks (lille and maddrey score - maddrey score determines whether steroids are needed, lille looks at how well steroids are working). Beforehand check for infection due to risk of sepsis, check diagnosis is correct

Question 250

What is caused by thiamine deficiency?

Answer 250

Beri Beri

Question 251

List signs of portal hypertension

Answer 251

- Splenomegaly - Ascites - Caput medusae (visible veins) - Spontaneous bacterieal peritonitis - Encephalopathy

Question 252

List features of cirrhosis on histology

Answer 252

- Whole liver involved - Nodules of regenerating hepatocytes - Fibrosis - Shunting of blood

Question 253

List causes of cirrhosis

Answer 253

- Fatty liver disease (micronodular) - Hepatitis B and C (macronodular) Others: - Haemochromatosis - Wilsons disease - Primary biliary cholangitis - Primary sclerosing cholangitis

Question 254

What is the additional sign in liver failure not present in cirrhosis?

Answer 254

Flap

Question 255

List sites of porta-systemic anastomoses

Answer 255

- Oesophagus - Lower rectum - Umbilicus - Retro-peritoneum

Question 256

List signs on examination of post hepatic jaundice

Answer 256

- Scratch marks, due to bile salts not entering the gut. Specific to obstructive jaundice - Enlarged gallbladder in pancreatic cancer

Question 257

What is courvoisiers law?

Answer 257

- Palpable gallbladder in a jaundiced patient the cause is a pancreatic cancer. - If gallstones for a long time you have a small and fibrotic gallbladder incapable of being large

Question 258

List signs on examination of autoimmune hepatitis

Answer 258

- Hepatomegaly - Jaundice - Splenomegaly - Spider angioma (chronic liver disease) - Ascites - Encephalopathy - Liver flap - Palmar erythema

Question 259

Describe epidemiology of viral hepatitis

Answer 259

- B and C in particular lead to chronic disease - 325 million people worldwide have hep B and/or C - Hep A uncommon (452 cases UK anually) - Hep B 0.3% of the population chronic infection - Hep C 185 mill hep C - 143000 people with chronic hepatitis. Most common in UK

Question 260

Describe management of viral hepatitis

Answer 260

- 15-45% clear hep C without treatment - Direct acting antivirals - NSAID, opiod, anti-emetic, cream for itch - Hep A admit to hospital - Hep B peginterferon alpha or tenofovir/entefovir - Hep C sofosbuvir, ledipasvir, grazoprevir (directly acting antivirals) - Hep D most need transplant in the end - Hep E ribovarin

Question 261

List complications of viral hepatitis

Answer 261

- Hepatocellular carcinoma (alpha fetoprotein monitoring, though will raise in pregnancy and teratoma) - Hepatic failure - Cirrhosis (fibroscan monitoring) - Chronic hepatitis - Chronic active hepatisis - Hepatic necrosis

Question 262

Describe prognosis of hepatitis

Answer 262

- Hep B usually fully recover, infected children tend to develop long term infection. Never fully clear the virus therefore can reactivate eg. if on chemotherapy, can also get Hep D - Hep A usually passes, can be severe or life threatening - Hep C 1 in 4 people fight off virus, 3 in 4 chronic

Question 263

Define alcoholic hepatitis

Answer 263

Excessive alcohol intake resulting in liver disease, including fatty changes ie. steatosis of the liver

Question 264

Describe epidemiology of alcoholic hepatitis

Answer 264

- 10-30% heavy drinkers develop cirrhosis - 50% fatty liver - 60% of all liver disease

Question 265

List risk factors for alcoholic hepatitis

Answer 265

- Women have higher risk - Obesity - Genetic factors - Race and ethnicity (blacks and hispanics at higher risk) - Binge drinking

Question 266

List symptoms of alcoholic hepatitis

Answer 266

- Weight loss - Loss of body hair - Tremor - Memory loss - Epilepsy - Loss of appetite - Nausea and vomiting - Pruritis - Melena/haematemesis if oesophageal varices

Question 267

List signs of alcoholic hepatitis

Answer 267

- Spider naevi (chronic) - Abdominal distention/ caput medusae - Dupuytrens contracture - Tremor - Gynaecomastia - Testicular atophy - Malnutrition - Ascites - Jaundice - Varices - Liver flap - Tender hepatomegaly

Question 268

List complications of alcoholic hepatitis

Answer 268

- Hepatic encephalopathy (slurred speech, coma) - Oesophageal varices (which can burst and lead to vomiting up blood) - Cirrhosis and liver failure - Kidney failure - Carcinoma

Question 269

Describe prognosis of alcoholic hepatitis

Answer 269

- 30 day mortality when hospitalised is 15% - When hospitalised with severe liver disease, 50% - Mortality rate at 6 months 40% - Most common cause of death is infection leading to sepsis, with 50-90% mortality

Question 270

What is the difference between epigastric pain worse on eating and better on eating?

Answer 270

- Gastric ulcer worse on eating | - Duodenal ulcer better on eating

Question 271

List causes of RUQ pain

Answer 271

- Gall stones - Acute cholecystitis - Ascending cholangitis - Liver hepatitis - Liver abscess Neighbouring - Basal pneumona - Appendicitis (retrocaecal appendix/pregnancy) - Peptic ulcer - Pancreatitis - Pyelonephritis

Question 272

List causes of epigastric pain

Answer 272

- Peptic ulcer - GORD - Pancreatitis (chronic or acute) - Gastritis - Malignancy Neighbouring - MI - AAA - Cholecystitis or hepatitis

Question 273

List causes of flank pain

Answer 273

- Renal stones - Pyelonephritis - Polycystic kidney disease

Question 274

List causes of periumbilical pain

Answer 274

- Appendicitis - Umbilical hernia - AAA

Question 275

List causes of right iliac fossa pain

Answer 275

- Appendicitis - Crohns - Inguinal/femoral hernia (incarcerated) - Mesenteric adenitis - Infectious colitis - Ectopic pregnancy - Ovarian cyst accident - Pelvic inflammatory disease - Testicular torsion

Question 276

List causes of left iliac fossa pain

Answer 276

- Inguinal/femoral hernia (incarcerated) - Infectious colitis - Ectopic pregnancy - Ovarian cyst accident - Pelvic inflammatory disease - Testicular torsion - Diverticulitis - Ulcerative colitis

Question 277

List causes of suprapubic pain

Answer 277

- UTI - Bladder stones - Urinary retention - STI - Endometriosis - Painful periods

Question 278

List causes of diffuse abdominal pain

Answer 278

- Obstruction - Peritonitis - Ischaemic colitis - Gastroenteritis - IBS/D - DKA - Hypercalcaemia - Addisons disease - Porphyria - Lead poisoning

Question 279

Compare presentation of Ulcerative Colitis and Crohns

Answer 279

- PR bleeding UC - Weight loss crohns - Oral ulcers crohns - RIF pain crohns - Rectal pain UC

Question 280

Compare presentation of diverticulitis and diverticular disease

Answer 280

- PR bleeding diverticular disease - LIF pain diverticulitis - Fever diverticulitis

Question 281

List the three factors that exacerbate jaundice in Gilberts

Answer 281

- Fasting - Exercise - Stress

Question 282

Compare causes dysphagia in different presentations

Answer 282

Dysphagia - Oesophageal cancer solids then liquids - Achalasia both solids and liquids - Dysphagia, diarrhoea, FHx autoimmune caused by graves disease - Dysphagia and heartburn caused by GORD (may cause strictures) - Food stuck in mouth and pmhx AF caused by stroke (can't coordinate swallowing) - Odynophagia and weight loss caused by oesophageal cancer

Question 283

Define non-alcoholic steatohepatitis (nash)

Answer 283

A clinico-histopathological entity that includes a spectrum of conditions characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in amounts generally considered harmful to the liver.

Question 284

List risk factors for NASH

Answer 284

- Obesity - Insulin resistance or diabetes - Dyslipidaemia - Hypertension - Metabolic syndrome - Rapid weight loss - Hepatotoxic medications - TPN - Weakly asssociated with wilsons, chronic hepatitis, alpha-1 antitrypsin deficiency

Question 285

Describe epidemiology of NASH

Answer 285

NAFLD - 24-40% of the western world - Majority of cases age 40-60 - Affects both sexes equally - NASH 3% of individuals from developed countries

Question 286

List symptoms of NASH

Answer 286

- Fatigue and malaise - RUQ pain - Pruritis - Rarely haematemesis and melaena

Question 287

List signs of NASH

Answer 287

- Obesity - Hepatosplenomegaly - Jaundice - Spider angioma (chronic liver disease) - Palmar erythema - Nail changes - Dupuytrens contracture - Bruising - Petechiae - Excoriations - Gynaecomastia - Parotid gland enlargement - Testicular atrophy - Alopecia - Caput medusae - Murmur (venous hum in epigastric region) - Peripheral oedema - Ascites - Hypotension - Encephalopathy - Asterixes - Fetor hepaticus (odour of breath)

Question 288

Describe investigations used to diagnose NASH

Answer 288

- AST and ALT mildly elevated. Ratio AST:ALT < 1 - Raised bilirubin - Raised alk phos, gamma glutamyl transferase - FBC anaemia of thrombocytopenia - Mild hyponatraemia, elevated creatinine, urea and glucose - Elevated cholesterol - Increased PT - Low albumin - Liver ultrasound (hyperechoic echotexture, attenuation, vascular blurring) - CT, MRI showing increased liver fat content

Question 289

Describe treatment of NASH

Answer 289

- Weight loss - Treat insulin resistance and diabetes (thiazolinediones) - Treat dyslipidaemia - Vitamin E - Transjugular intrahepatic portosystemic shunt for treating end stage liver failure - Liver transplantation

Question 290

List complications of NASH

Answer 290

- Ascites - Variceal haemorrhage - Portosystemic encephalopathy - Hepatocellular carcinoma - Hepatorenal syndrome - Hepatopolmonary syndrome - Death

Question 291

Describe prognosis of NASH

Answer 291

- Considered to be good - Progress to cirrhosis 9-20% of the time - 1/3 of patients with cirrhosis will die from liver complications - Can reoccur after transplant

Question 292

Describe treatment of hepatic encephalopathy

Answer 292

- Treat predisposing factors and supporting care plus lactulose (first line) - Second line add rifamixin - Phosphate enemas - Avoid sedation - Treat infections and exclude GI bleed

Question 293

Describe epidemiology of appendicitis

Answer 293

- The overall lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females; lifetime risk of appendicectomy is around 12% in males and 23% in females. - The rate of appendicectomy is around 10 per 10,000 cases per year in the US. - Most commonly seen in patients aged between early teens and late 40s. - There is a slight male to female predominance

Question 294

List risk factors for appendicitis

Answer 294

- Low fibre diet - Improved personal hygiene (imbalanced GI microbial flora) - Smoking

Question 295

List symptoms of appendicitis

Answer 295

- Abdominal pain (begins in the umbilical region, moves to the RIF. Constant with intermittent cramps, worse on movement and coughing) - Anorexia - Nausea and vomiting -

Question 296

List signs of appendicitis

Answer 296

- Right lower quadrant tenderness. Mcburneys sign is tenderness at mcburneys point - Tense, rigid abdomen (perforated appendix) - Hypotension and tachycardia (shock or sepsis) - Palpable mass (peri-appendiceal abscess) - Low grade pyrexia - Flushed face and fetor - Reduced bowel sounds (perforated) - Loose stool/constipation - Illiopsoas sign - pain on passive extension of the thigh - Obturator test/copes - flex knee and hip, pain on rotation of the leg - Rosvings sign - pain in left lower quadrant after pressing in right lower quadrant

Question 297

Describe investigations used for appendicitis

Answer 297

- FBC (Leucocytosis with neutrophilia) - CRP (elevated usually) - Abdominal ultrasound (rule out appendicitis if normal appendix, alternative causes of abdominal pain. Diameter over 6mm in appendicitis) - Contrast enhanced abdominal CT (if ultrasound inconclusive, or malignancy or appendicular mass suspected - shows appendix over 6mm, or calcified appendicolith very good) - Exclude UTI with urine dip - Prengnancy test - Group and save - Alvarado score (scoring system for diagnosing appendicitis)

Question 298

Describe treatment of appendicitis

Answer 298

- Nil by mouth for surgery - Paracetamol or opiod - Appendicetomy - Antibiotics if surgery not wanted (amoxicillin + metronidazole) - If complicated, post operative antibiotics - If abscess or phlegmon supportive treatment, appendicectomy and antibiotics. Alternatively can be interval appendicectomy.

Question 299

Describe complications of appendicitis

Answer 299

- Perforation (sepsis/shock) - Peritonitis (exploratory laparotomy) - Appendicular mass - Appendicular abscess (IV antibiotics and CT guided drainage of abscess) - Surgical wound infection

Question 300

Describe prognosis of appendicitis

Answer 300

- Good if treated quickly | - Laproscopic appendicetomy has decreased incidence of overall complications

Question 301

What are the sepsis 6?

Answer 301

- High flow oxygen (aim for sats over 96%. Start with 15ml) - Take blood cultures - Give broad spectrum antibiotics (within 1 hour of recognising the problem) - IV fluid challenges (give fluid bolus aiming to decrease HR and BP) - Measure serum lactate and haemoglobin (venous blood glass, raised lactate indicates ischaemia and therefore severity) - Measure accurate hourly urine output (decreasing output one of the earliest signs of acute renal injury)

Question 302

List characteristics of spider angiomas

Answer 302

- Stable chronic liver disease - Distribution of the SVC - Above the nipple line

Question 303

List hand signs of chronic liver disease

Answer 303

- Asterixis - Bruising - Clubbing - Duputryns contracture - Erythema

Question 304

Describe dukes classifications of colorectal cancer

Answer 304

- Dukes A: tumour is not spread into the muscularis propria - Dukes B: tumour is invading beyond the muscularis propria - Dukes C: Tumour is spread to lymoh nodes - Dukes D: Tumour mets to other organs

Question 305

Describe glasgow criteria for pancreatis

Answer 305

- PaO2 <8kPa - Age over 55 - Neutrophilia - Calcium <2mmol/L - Renal function (urea over 16mmol/L) - Enzymes (LDH and AST high) - Albumin <32g/L serum - Sugar (blood glucose over 10mmol?l)

Question 306

Define intestinal ischaemia

Answer 306

- Ischaemic bowel disease encompasses a heterogeneous group of disorders caused by acute or chronic processes, arising from occlusive or non-occlusive aetiologies, which result in decreased blood flow to the gastrointestinal tract. - 3 main types: acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia (large bowel)

Question 307

Describe epidemiology of bowel ischaemia

Answer 307

- Colonic frequently affects older people with co-morbidities. 4.5-44 cases per 100000 person-years - Acute mesenteric 0.1% of hospital admissions, 1% of patients with acute abdomen - Non-occlusive 20-30% of acute mesenteric, more common over age 80

Question 308

Describe aetiology of bowel ischaemia

Answer 308

Acute mesenteric ischaemia - Small bowel - Superior mesenteric artery thrmbosis (35%) or embolism (35%) - Mesenteric vein thrombosis (5%, youger patients with hypercoagulable state) - Non occlusive disease (20%, poor cardiac output, recent cardiac surgery or renal failure) - Trauma, vasculitis, radiopathy, strangulation Chronic mesenteric ischaemia - Low flow state + atheroma - 95% diffuse atherosclerotic disease in all 3 mesenteric arteries Chronic colonic ischaemia - Low flow in inferior mesenteric artery

Question 309

List risk factors for bowel ischaemia

Answer 309

- Old age - History of smoking - Hypercoagulable states - Atrial fibrillation - Myocardial infarction - Structural heart defects - History of vasculitis - Recent cardiovascular surgery - Shock - Congestive heart failure - Atherosclerosis - Previous ileostomy - Irritable bowel syndrome - Colonic carcinoma - Constipation - Long-term laxative use - Use of vasopressors, digitalis, cocaine

Question 310

List signs and symptoms of acute mesenteric ischaemia

Answer 310

- Acute severe abdominal pain (central, constant or RIF) - No/minimal abdominal signs (degree of illness out of proportion to clinical signs) - Rapid hypovolaemia leading to shock

Question 311

List signs and symptoms of chronic mesenteric ischaemia

Answer 311

- Severe, colicky post-prandial abdominal pain (claudication) - Weight loss - Upper abdo bruit - May be nausea and vomiting, PR bleeding and mal-absorption

Question 312

List signs and symptoms of ischaemic colitis

Answer 312

- Lower left sided abdominal pain | - With or without PR bleeding

Question 313

List investigations for intestinal ischaemia

Answer 313

1st AXR, 2nd CT abdo - FBC (leukocytosis, anaemia) - Chemistry panel including serum lactate (acidosis, uraemia, elevated creatinine and amylasaemia) - Coagulation panel (in case of underlying coagulopathy) - Arterial blood gas/lactate level (acidosis + elevated lactate) - ECG (may demonstrate arrythmia/infarction as a cause) - Erect CXR (for perforation) - Abdominal x-rays (air-fluid level, bowel dilation, bowel wall thickening, pneumatosis) - CT scan with contrast/CT angiogram (occlusion in vasculature, thumb printing sign of oedema/haemorrhage - best test for mesenteric ischaemia) - Sigmoidoscopy or colonoscopy (BEST TEST for ischaemic collitis- mucosal sloughing or friability, petechiae, haemorrhagic nodules, necrosis, gangrene) - Mesenteric angiography - Mesenteric duplex ultrasound - Magnetic resonance angiography- best test for mesenteric ischaemia

Question 314

What is haematochezia?

Answer 314

Bright red blood in stools

Question 315

What is gallstone ileus?

Answer 315

- An uncommon cause of a mechanical small bowel obstruction. - It is a rare complication of chronic cholecystitis and occurs when a gallstone passes through a fistula between the gallbladder and small bowel before becoming impacted at the ileocaecal valve.

Question 316

List investigations and management of booerhaves oesophagus

Answer 316

Investigations - G+S - Contrast oedophagography - CT - OGD Management - NBM - PPI - ABx - Surgery/ endoscopy