General Surgery - Upper GI

Question 1

Causes of ACUTE upper GI bleeding?

Answer 1

• Peptic ulcer (duodenal and gastric).
• Mallory Weiss tear.
• Chronic liver disease (oesophageal varices).
• Gastric carcinoma.
• Following PCI (anti-thrombotics e.g.heparin, fondaparinux) in those who are also on anti-platelets (e.g. clopidogrel, ticagrelor).

Question 2

Signs of acute upper GI bleeding?

Answer 2

• Haematemesis.
• Malaena.
• Shock (tachycardia, pallor, cold peripheries, low BP).

Question 3

Causes of vomiting?

Answer 3

• Any GI disease.
• Infection (flu, norovirus, pertussis, UTI).
• CNS disease (raised ICP, vestibular disturbance e.g. motion sickness, migraine).
• Metabolic (uraemia, hypercalcaemia).

Question 4

Conditions associated with early morning nausea and vomiting?

Answer 4

• Pregnancy.
• Alcohol dependence.
• Metabolic disorders e.g. uraemia.

Question 5

Vomiting is regulated by?

Answer 5

• Central neural control centres located in the lateral reticular formation of the medulla.

Question 6

Central neural control centres which regulate vomiting are stimulated by?

Answer 6

• Chemoreceptor trigger zones in the floor of the fourth ventricle.
• Vagal afferents from gut.

Question 7

What can directly stimulate central trigger zones responsible for stimulating the central neural control centres which regulate vomiting?

Answer 7

• Luminal toxins.
• Inflammation.
• Mechanical obstruction.

Question 8

Proctalgia fugax is?

Answer 8

Severe, deep rectal pain of sudden onset but short duration.

Question 9

Causes of mouth ulcers?

Answer 9

• Idiopathic aphthous ulceration (most common),
• GI disease (e.g. IBD, coeliac).
  Infection (e.g. HSV, HIV, Coxsackie, candidiasis, syphilis, TB).
• Systemic disease (e.g. reactive arthritis, Behcet syndrome, SLE).
• Trauma (e.g. dentures).
• Neoplasia (e.g. SCC).
• Drugs (e.g. erythema multiforme major, toxic epidermal necrolysis, chemotherapy, antimalarials).
• Skin disease (e.g. pemphigoid, pemphigus, lichen planus).

Question 10

Causes of dry mouth?

Answer 10

• Sjogren’s.
• Drugs (e.g. anti-muscarinics, anti-parkinsonian, lithium, tricyclics, MAOIs).
• Radiotherapy.
• Psychogenic.
• Dehydration.

Question 11

Causes of sialadenitis (salivary gland infection)?

Answer 11

• Viral e.g. mumps.

- Bacterial e.g. staphylococcus, streptococcus.

Question 12

What kind of neoplasms affect the salivary glands?

Answer 12

• Pleomorphic adenoma.

(15% become malignant and can cause CN VII lower motor neurone signs).

Question 13

HIV is associated with oral manifestations of which diseases?

Answer 13

• Candidiasis (with erythema &/or white exudates).
• Oral hairy leucoplakia.
• Kaposi’s sarcoma.
• Non-Hodgkin’s lymphoma.
• Necrotising ulcerative gingivitis.
• Necrotising ulcerative periodontitis.

Question 14

With regards to oesophageal mucosal defence mechanisms, the mucus and unstirred water layer trap what & why?

Answer 14

• Bicarbonate.

- Weak buffering mechanism.

Question 15

What is the role of epithelium in oesophageal mucosal defence?

Answer 15

• Limit diffusion of H+ into cells.

(Apical cell membranes and junctional complexes between cells limit H+ diffusion into cells). In oesophagitis, junctional complexes are damaged > increased H+ diffusion > cellular damage).

Question 16

When will stitches normally be removed following a laparoscopic cholecystectomy and by whom?

Answer 16

If required, 5-7 days post op by patient’s practice nurse.

Question 17

When can a patient return to work following a laparoscopic cholecystectomy?

Answer 17

Some time off is required - 2 weeks sick note will be provided upon discharge. Further time off can be requested from GP.

Question 18

When can a patient drive following a laparoscopic cholecystectomy?

Answer 18

Not until after at least 24 hours and must be able to safely perform an emergency stop.

Question 19

When should a patient seek medical attention following discharge after a laparoscopic cholecystectomy?

Answer 19

• Severe pain uncontrolled by medication.
• Pain complicated by symptoms such as vomiting.
• Pain from a site other than operation sites, ribs or shoulders.
• Large amounts of blood stained fluid discharge from wounds.
• Fever or chills.

Question 20

Gastric acid is stimulated by?

Answer 20

• Acetylcholine.
• Gastrin.
• Histamine.

Question 21

Gastric acid is inhibited by?

Answer 21

• Somatostatin.
• Secretin.
• Cholecystokinin.

Question 22

Gastric acid is composed of?

Answer 22

• Hydrochloric acid.
• Potassium chloride.
• Sodium chloride.

Question 23

Describe the cephalic phase of gastric acid secretion.

Answer 23

Gastric acid produced before food enters the stomach - triggered by sight, smell, thought, tasted of food acting via vagus nerve.

Question 24

Describe the gastric phase of gastric acid secretion.

Answer 24

Initiated by food in stomach (particularly protein-rich food). Due to G cell stimulation > gastrin release.

Question 25

Describe the intestinal phase of gastric acid secretion.

Answer 25

Luminal distension + presence of amino acids + food in duodenum > stimulates acid production.

Question 26

Describe Zollinger-Ellison syndrome.

Answer 26

Gastrinoma(s) form in pancreas or dudodenum. These are neuroendocrine tumours which secrete gastrin.

Question 27

Signs of Zollinger-Ellison syndrome.

Answer 27

- Excess gastrin production can lead to increased gastric acid production. - Multiple, severe gastric ulcers.

Question 28

Very elevated ALP in the presence of jaundice indicates?

Answer 28

Extrahepatic obstruction - typically due to common bile duct stone or carcinoma of the head of the pancreas.

Question 29

High levels of AST suggest?

Answer 29

Intra-hepatic disease. | - AST is a marker of liver cell damage.

Question 30

Common causes of intra-hepatic cholestasis?

Answer 30

Drugs, alcohol, infective hepatitis, liver lesions.

Question 31

High AST + jaundice indicates?

Answer 31

Intrahepatic cholestasis.