Gastroenterology/upper Gi

Front 1

Mouth ulcer - systemic disorders, infection, dermatology

Back 1

Crohn's, ulcerative colitis' coeliac
others: lupus, behcet' neutropenia' Reiter's
ten, erythema multiforme, pemphigus, bullous pemphigoid...
Herpes simplex I / II (fever), cocksackie A, other herpes, syphilis, TB

Front 2

Mouth ulcers - associated drugs

Back 2

Antimalarials, methyldopa, tolbutamide, penicillamine, gold salt

Front 3

Mouth ulcers R/x

Back 3

No specific Rx. Try corticosteroids, chlorhexidine mouthwash etc

Front 4

Leukoplakia cause, ivx, Rx

Back 4

DDx candida
Etoh, smoking, premalignant
always biopsy. Isotretinoin.

Front 5

Glossitis - red, smooth, sore tongue causes

Back 5

Vit B12, folate, iron, nicotinic acid, riboflavin, candida

Front 6

Acute sialadenitis - causes

Back 6

Mumps or bacteria: staph aureus, strept pyogenes, strep pneumonia
sarcoidosis: Heerford syndrome

Front 7

Salivary gland obstruction - sx

Back 7

Painful swelling submandibular gland, palpable stone

Front 8

Parotitis, uveitis, low-grade fever - dx?

Back 8

Heerford syndrome

Front 9

Parotitis, uveitis, low-grade fever, lacrimal gland enlargement. - Dx?

Back 9

Mikulicz syndrome

Front 10

Salivary gland neoplasms how common, what type?

Back 10

3% of all tumors,pleomorphic adenoma most common, 15% malignant transformation

Front 11

Dysphagia - DDx

Back 11

Tonsillitis, neuromuscular: bulbar palsy, myasthenia gravis; motility: achalasia, diffuse spasm, presbyoesophageus, DM, chagas' extrinsic pressure: mediastinal lymphadenopathy, goitre, LA ^ intrnsic lesion: FB, stricture, ring, web, pharyngeal pouch

Front 12

Oesophageal disorders - what Ivx?

Back 12

barium swallow/meal
OGD
Monometry
pH monitoring

Front 13

Hiatus hernia - how common?

Back 13

30% of > 50's

Front 14

Hiatus hernia - diagnostic significance?

Back 14

Not significant symptoms due to reflux

Front 15

What arw the ntireflux mechanismsbod the stomach?

Back 15

LOS = distal 4 cm, intraabdominal part of oesophageus, mucosa folds, contractions of diaphragm ' pinchcock like effect'

Front 16

GORD symptoms

Back 16

Heartburn - positional, worse with hot liquids/alcohol
regurgitation leading to coughing and nocturnal asthma

Front 17

GORD how is the initial mgm?

Back 17

Initial treatment if pt <45 unless alarm sx (dysphagia, wt loss, protracted vomiting, anorexia, haematemesis/malaena)
* barium swallow+water siphon test: severity, hiatus hernia
* 24h manometry and pH study: before considering surg, corelation between sx and episodes of pH <4

Front 18

GORD initial Rx?

Back 18

50% can be mgm c :
risk factor modification, raising head if bed, simple antacids.

Front 19

GORD indications for surgery?

Back 19

Severe reflux, documented with 24h pH monitoring and oesophagitis on OGD failed to be controlled by meds or young that would need long term Rx

Front 20

GORD and established reflux oesophagitis - mgm?

Back 20

Long term PPI and regular OGD surveillance for complications

Front 21

GORD - complcations?

Back 21

* Barret's
* peptic stricture
* adeno Ca

Front 22

Achalasia - what initial investigations? What would they show?

Back 22

CXR - dilated oesophagus, fluid level, no fundal gas
Barium swallow - dilatation, lack of peristalsis, swan neck deformity
OGD - exclude Ca
Manometry, CT scan

Front 23

Achalasia - R/x?

Back 23

first choice: pneumatic dilatation
alternative: botox
elderly: nifedipine 20mg S/L
if medical Rx fails: surgical divisiono

Front 24

Oesophageal diverticulum - what types?

Back 24

pharyngeal pouch (above upper sphincter)
near the middle (traction diverticulum)
above lower sphincter (epiphrenic diverticulum)

Front 25

dysphagia, iron deficiency, glossitis and angular stomatitis - Dx?

Back 25

Plummer-Vinson syndrome

Front 26

What is a Schatzky ring?

Back 26

Narrowing lower end of oesophagus due to ridge of mucosa.

Front 27

Benign stricture - Rx?

Back 27

dilatation, occasionally surgery

Front 28

oesophageal infections in immuncompromised patients - what organisms?

Back 28

candida, herpes, cytomegaly virus

Front 29

Oesophageal rupture - cause? management?

Back 29

violent vomiting (boerhaven syndrome)
CXR (hydropneumothorax), gastrografin surgical repair

Front 30

Oesophageal Ca - commonest location?

Back 30

40% middle (SCC) 45% lower third (AdenoCa)

Front 31

Oesophageal Ca - epidemiology and geographical variation

Back 31

highest incidence in Iran, china, africa.
SCC more common in men
usual age 60 - 70

Front 32

Oesophageal Ca - risk factors for SCC

Back 32

Tobacco, EtOH, Plummer-Vinson, Achalasia, Coeliac, radiotherapy for breast Ca,

Front 33

Oesophageal Ca - risk factors for AdenoCa

Back 33

GORD, Barrett's
Tobacco smoking
Obesity
Radiotherapy for breastCa

Front 34

Major risk factor for Oesophageal Ca?

Back 34

Barrett's
Risk increased 30 - 40 fold.

Front 35

worsening dysphagia, initially for liquids then for solids, weight loss and anorexia - Dx?

Back 35

oesophageal Ca

Front 36

Oesophageal Ca - Ivx?

Back 36

initially OGD or barium swallow
CT/MRI thorax and abdomen: volumem local invasion, lymphnodes
endoscopic USS: depth of tu
PET: sensitivity for distant mets as CT/MRI but specificity higher

Front 37

Oesophageal Ca - Success rate for surgery?

Back 37

80% 5-year survival if Tu not infiltrated outside wall.

Front 38

Oesophageal Ca - Palliative Rx?

Back 38

stent insertion, photo/laser coagulation of tumor, chemoradiation

Front 39

Where is H.pylori found?

Back 39

gastric ANTRUM

Front 40

peptic ulcer - clinical features

Back 40

epigastric pain
DU pain at night and worse when hungry
back pain - suggest penetration

Front 41

peptic ulcer - non-invasive Ivx?

Back 41

* 13C urea breath test - sens 97% specific 96%. Also used to demonstrate eradication after Rx.
* serological: 90% sens/specif.
* stool test sens 97% specif 97% good for control of eradication but need to be off PPI for 1/52

Front 42

how can successful eradication of peptic ulcers been demonstrated?

Back 42

13C breath test

Front 43

peptic ulcer - invasive Ivx?

Back 43

OGD with rapid urease test, culture (abx sensitivities!). Histology: giemsa staining.

Front 44

Suspected peptic ulcer disease - how is the initial mgm?

Back 44

pt <55 with typical sx and H.p positive can be eradicated without further Ivx
unless "alarm symptoms".
older pt. must have OGD and biospy (rule out Ca).

Front 45

Whom to give eradication Rx?

Back 45

All patients with peptic ulcer should have eradication Rx.

Front 46

Should H.p pos patient without ulcer have eradication?

Back 46

controversial

Front 47

How successful is eradication? How frequently does re-infection occur?

Back 47

90% success, reinfection less than 1%

Front 48

Prescribe eradication Rx!

Back 48

PPI + 2 abx for 1 week:
omeprazole 20mg, metronidazole 400mg BD, clarithromycin 500mg BD
OR
omeprazole 20mg, clarithromycin 500mg BD, amoxycillin 1g BD

Front 49

How long is PPI rx in pt with ulcer?

Back 49

eradication + 3-4 weeks PPI

Front 50

peptic ulcer - How can success be measured? How is the follow up?

Back 50

clinically: resolution of symptoms
if symptoms persist, 13C breath test or stool test. In gastric ulcer - re OGD 6/52 to exclude malignancy

Front 51

Complications of peptic ulcer disease?

Back 51

Haemorrage
Perforation
Gastric outlet obstruction
AdenoCa
Gastric B lymphoma (H.p)

Front 52

How many % on NSAIDs develop ulcers? How many have symptoms?

Back 52

50% develop ulcers
5% symptomatic

Front 53

Causes of ulcerative gastropathy?

Back 53

NSAIDS
H.pylori
Alcohol
trauma, severe stress
portal gastropathy (renal or liver disease)

Front 54

Which patients on NSAIDs should receive prophylactic gastroprotective therapy?

Back 54

>65 ye ars
hx of peptic ulcer with complications
on corticosteroids and anticoagulants

Front 55

What problems does a patient with Menetrier's disease get?

Back 55

hyperchlorhydria (needs PPI)
peripheral oedema (protein loss)
premalignant condition

Front 56

How do you manage dyspepsia/indigestin initially?

Back 56

if <45 and no alarm symptoms, serologic test for H.p and PPI/eradication if positive. If remains symptomatic investigate
>45 or alarm symotoms must have OGD to rule out serious pathology.

Front 57

Gastric AdenoCa: Epidemology

Back 57

Japan > USA
age 50 - 70, rare <30

Front 58

Gastric AdenoCa: Risk factors

Back 58

Hp status (class I gastric carcinogen WHO)
diet: high salt, nitrates
achlorhydria
smoking
Blood group A
pernicious anaemia

Front 59

Gastric AdenoCa: Sx

Back 59

epigastric pain (main sx) indistinguishable from ulcer pain!
anorexia, wt loss, nausea
dysphagia (fundal tu)
vomiting (pyloric tumor)

Front 60

Gastric AdenoCa: Metastases

Back 60

peritoneum (ascites), liver, bone, brain, lung

Front 61

Gastric AdenoCa: physical signs to look out for

Back 61

50% palpable mass
virchow's node
dermatomyositis
acantosis nigricans

Front 62

Adeno Ca: Ivx

Back 62

bloods, OGD, CT, USS
CT: limited value assessing local invasion.
endoscopic USS penetration into wall and lymph nodes

Front 63

Adeno Ca: survival rates

Back 63

EGC 90% 5 years
later 50%
only 10% 10 year survival though

Front 64

How should you manage gastric polyps?

Back 64

removal only for adenomatous polyps
usually not premaligant lesions (in the stomach, malignancy arises de novo)

Front 65

Malaena - where is the site of bleeding?

Back 65

above and including the caecum

Front 66

Do corticosteroids cause GI bleed?

Back 66

in usual doses not

Front 67

Do anticoagulants cause GI bleed?

Back 67

not on their own, but can augment

Front 68

Can low dose ASA cause GI bleed?

Back 68

yes it can!

Front 69

GI bleed: How many patients stop bleeding without intervention in 48 hours?

Back 69

85%!

Front 70

GI bleed: When to transfuse?

Back 70

if shocked
if Hb <10 and still bleeding.

Front 71

GI bleed: Mortality

Back 71

age: if <60 mortality <0.1%
>80 mortality 20%

Front 72

GI bleed: when do most rebleeds occur?

Back 72

within 48 hours

Front 73

GI bleed: what can be done to reduce rebleeding rate?

Back 73

intervention at endoscopy
PPI therapy for ulcer pt

Front 74

GI bleed: What patient can be safely discharge early?

Back 74

haemodynamically stable
no stigmata of recent haemorrage on OGD

Front 75

GI bleed: Pt with chronic peptic ulcer - what needs to be doen?

Back 75

H.p status checked and eradicated if found and PPI continued for 4 weeks

Front 76

GI bleed: How to manage Mallory-Weiss tear?

Back 76

usually stops spontaneously. Can be d/c within 24 hours.
severe tears rarly need surgery.

Front 77

GI bleed: overall mortality

Back 77

5-12%

Front 78

Causes of lower GI bleeding - from distal to proximal

Back 78

haemorrhoids (small frequent bleeds)
colitis (crohns, UC)
diverticula
polyps (small frequent bleeds)
Colon Ca
ischaemic colitis
angiodysplasia
meckel's diverticulum

Front 79

iron deficiency in a postmenopausal woman. Source?

Back 79

in all men and postmenopausal women, iron deficiency anaemia due to blood loss is ALWAYS from GI tract and most commonly due to carcinoma.

Front 80

when to use occult blood tests?

Back 80

in premenopausal women
for population screening purposes

Front 81

iron deficiency anaemia due to blood loss. What Ivx?

Back 81

top tail endoscopy in same session
barium enema only if colonoscopy not available
if negative, small bowel follow through next.
enteroscopes if available
capsule endoscopy (90% bleeding sites found in study)

Front 82

Investigations: Small bowel follow through

Back 82

detects gross anatomy (diverticula, strictures, crohn's. dilatation of bowel and cange of folds indicate malabsofption

Front 83

Differential diagnosis of malabsorption

Back 83

coeliac disease
whipples disease
crohn's
dermatitis herpetiformis
tropical sprue
bacterial overgrowth
intestinal resection
radiation enteritis
parasite infestation (e.g giardia)

Front 84

which cereals contain gluten?

Back 84

rye, wheat, barley.

Front 85

Coeliac disease: epidemology

Back 85

any age, but mostly 50-60

Front 86

coeliac disease: clincial features

Back 86

asymptomatic
incidential finding of MCV ^
GI symptoms: diarrhea, steatorrhoe, discomfort, bloating (malabsorption)
mouth ulcers, angular stomatitis

Front 87

coeliac disease: associated diseases

Back 87

autoimmune: IDDM, thyroid, PBC, sjoegren, IBD, ....

Front 88

coeliac disease: Ivx

Back 88

mild moderate anaemia in 50%
folate deficiency almost always present
1. endomysial antibodies if positive endoscopy and biopsy
2. DEXA scan for all patients

Front 89

coeliac disease: treatment and follow up

Back 89

gluten free diet, haematinics.
follow up with serial antibody tests.
if progress suboptimal repeat biopsy
all patients should have pneumococcus vaccine!

Front 90

coeliac disease: complications

Back 90

lymphoma
ulcerative jejunitis
small bowel Ca (rare)

Front 91

bacterial overgrowth - who is at risk?

Back 91

elderly and pt with structural abnormality

Front 92

pathophysiology of bacterial overgrowth

Back 92

bacteriae deconjugate bile salts causing diarrhea and steatorrhoe
bacteria metabolize vit b12 (low)
produce folate (high)

Front 93

how to confirm bacterial overgrowth?

Back 93

hydrogen breath test

Front 94

pathophysiology of ileal resection

Back 94

loss of vit b12 and bile salt resabsorption
bile salts and fatty acids in colon cause diarrhea
increased bile salt production leads to lithogenic bile
increased colonic oxalate reabsorption leads to renal stones.
macrocytosis due to vit b 12 deficiency

Front 95

treatment of illeal resection

Back 95

vit b 12 injections, cholestyramine if diarrhea, low fat diet

Front 96

Whippel's disease - sx

Back 96

M > F
abdo pain, diarrhea
systemic features: fever, weight loss
can affect heart, lung brain.
peripheral lymphadenopathy

Front 97

intestinal TB - presenting sx

Back 97

abdo pain, diarrhea and systemic features: fever, weight loss, anorexia
or presents with acute obstruction or generalised peritonitis

Front 98

intestinal TB DDx

Back 98

consider in asian immigrants
DDx to crohn's and colon Ca

Front 99

intestinal ischaemia - causes

Back 99

1. arterial obstruction
mostly embolic - cardiac arrythmia or aortic disease occluding ostia or vasculitis
(thrombangiits and Takayasu's)
2. venous obstruction
3. non-occlusive: shock, massive reduced cardiac output.

Front 100

acute instinal ischaemia - presenting features

Back 100

hypertensive and ill patient
acute onset abdo pain and vomiting
abdo tenderness, absent bowel sounds

Front 101

what is intestinal lymphagiectasia?

Back 101

dilatation of lymphatics, primary or secondary to malignant obstruction, causing steatorrhoe and low protein with ankle oedema

Front 102

what is abetalipoproteinaemia?

Back 102

rare lack of apo B 100 and apo B 48, so chylomicrones not formed
clinically there is acanthocytosis, retinitis pigmentosa mental and neuro abnormalities preventable by Vit E injections.

Front 103

when does carcinoid syndrome presents?

Back 103

when there are liver mets

Front 104

carcinoid syndrome: clinical features

Back 104

spontaneous bluish-red flushing face and neck, abdo pain, watery diarrhoe.
cardiac: pulm. stenosis or tricuspid regurge
GI: hepatomegaly

Front 105

carcinoid syndrome: Ivx

Back 105

USS (mets), urine for 5-HIAA

Front 106

carcinoid syndrome: treatment

Back 106

somatostatin analogues.

Front 107

What is Peutz-Jeghers syndrome?

Back 107

mucocutaneous pigmentation and gastrointestinal polyps which are hamartomas.

Front 108

Which gene involved in Peutz-Jeghers?

Back 108

LKB1

Front 109

Complications of Peutz-Jeghers?

Back 109

polyps can bleed or obstruct and occasional malignant transformation

Front 110

How to manage Peutz-Jeghers?

Back 110

Individual polypectomy, 2 yearly follow up with Xray and endoscopy.