GI & Surgery 3

oelomar's version from 2016-02-27 14:45


Question Answer
What is radiation enteritis and what are its symptoms?Damage to the lining of the intestines caused by radiation therapy. Symptoms include nausea, vomiting, diarrhoea, and abdominal pain.
What are the symptoms of chronic radiation enteritis?Weight loss, muscle fibre atrophy, abdominal pain due to obstruction (main symptom).
Chronic radiation enteritis is diagnosed if symptoms persist for _ months or longer3.
What are the clinical features of bacterial overgrowth in the GI tract?Diarrhoea and steatorrhoea.
Where is iron primarily absorbed in the GI tract?Duodenum.
Where is folate primarily absorbed in the GI tract?Jejunum.
Where are bile acids and vitamin B12 primarily absorbed in the GI tract?Ileum.
What is Whipple’s disease and what does it present with?A rare infectious bacterial disease caused by Tropheryma whipplei (gram positive). It usually presents with arthritis and arthralgia, progressing over years to weight loss and diarrhoea with abdominal pain, and systemic symptoms of fever. Peripheral lymphadenopathy and involvement of the heart, lungs, joints and brain may occur, simulating many neurological conditions.
Whipple’s disease mainly affects females. True or false?False. 90% are male.
How is Whipple’s disease diagnosed?Small bowel biopsy. The characteristic trilaminar (3 laminae) cell wall of T. whipplei can be seen within macrophages. T. whipplei antibodies can be identified by immunohistochemistry. The macrophages are described as “foamy” and are PAS-positive.
What is Whipple’s triad?The clinical presentation of pancreatic insulinomas and consists of symptoms and signs of hypoglycaemia, a low plasma glucose (2.5mmol/L or less) measured at the time of the symptoms, and relief of symptoms with administration of glucose. Whipple’s triad has nothing to do with Whipple’s disease.


Question Answer
What is cryptosporidiosis?A parasitic disease caused by the Cryptosporidium parasite. It affects the intestines and is typically an acute short-term infection of which the main symptom is self-limiting diarrhoea. It can also produce malabsorption.
What is Meckel’s diverticulum?Meckel’s diverticulum is the most common congenital abnormality of the GI tract. The diverticulum projects from the wall of the ileum 60 cm from the ileocaecal valve. It is usually symptomless, but 50% contain gastric mucosa that secretes HCl. Peptic ulcers can occur.
When acute inflammation occurs in Meckel’s diverticulum, from what condition is it clinically indistinguishable?Acute appendicitis.
With regards to Meckel’s diverticulum, what are “the five 2’s”?2 inches long, 2 feet from the ileocaecal valve, 2% of the population, commonly present in first 2 years of life, may have 2 types of epithelia (gastric/pancreatic).
What is the most common cause of acute small intestinal ischaemia?An embolus from the heart in a patient with AF, usually occluding the superior mesenteric artery.
How do patients with acute small intestinal ischaemia present?Sudden abdominal pain and vomiting. The abdomen is usually distended and tender, and bowel sounds are absent. The patient is hypotensive and ill.
What causes chronic small intestinal ischaemia?Atheromatous occlusion of the mesenteric vessels.
What is the characteristic symptom of chronic small intestinal ischaemia?Abdominal pain occurring after food.
What is ischaemic colitis?A medical condition in which inflammation and injury of the large intestine result from inadequate blood supply due to occlusion of the branches of the superior/inferior mesenteric arteries.
What does ischaemic colitis present with?The majority of cases affect the splenic flexure and left colon. It commonly presents with sudden onset of abdominal pain and the passage of bright red blood per rectum, with or without diarrhoea. There may be signs of shock and evidence of underlying cardiovascular disease. On examination the abdomen is distended and tender. A straight abdominal X-ray often shows thumb-printing (a characteristic sign of ischaemic disease) at the site of the splenic flexure.
With regards to radiography, what is thumb-printing?Thumb-printing is a radiographic sign of large bowel wall thickening, usually caused by oedema, related to an infective or inflammatory process (colitis). The normal haustra become thickened at regular intervals appearing like thumbprints projecting into the aerated lumen.
How is ischaemic colitis treated?Most patients settle on symptomatic treatment. A few develop gangrene and perforation and require urgent surgery.


Question Answer
What is intestinal lymphangiectasia and what causes it?Lymphangiectasia is a pathologic dilation of lymph vessels. When it occurs in the intestines, it’s called intestinal lymphangiectasia. The most common cause is congenital malformation of the lymphatics. Secondary lymphangiectasia may be caused by granulomas or cancer causing lymphatic obstruction, or increased central venous pressure causing abnormal lymph drainage.
What are the main features of intestinal lymphangiectasia?Hypoproteinaemia with ankle oedema.
What is abetalipoproteinaemia?This is a rare autosomal recessive disorder that interferes with the normal absorption of fat and fat-soluble vitamins from food. It is due to a failure of apo B-100 synthesis in the liver and apo B-48 in the intestinal cell, so that chylomicrons are not formed. This leads to fat accumulation in the intestinal cells, giving a characteristic histological appearance to the jejunal mucosa.
What are the clinical features of abetalipoproteinaemia?Clinical features include acanthocytosis (spiky red cells owing to membrane abnormalities), a form of retinitis pigmentosa, and mental and neurological abnormalities. The latter can be prevented by vitamin E injections.
What are carcinoid tumours?A tumour of a type occurring in the glands of the intestine (especially the appendix, and also the terminal ileum and rectum) or in the bronchi, and sometimes secreting hormones. Most carcinoids do not secrete hormones or vasoactive compounds, and may present with liver enlargement due to metastases.
What is carcinoid syndrome?This refers to the array of symptoms that occur secondary to carcinoid tumours, and occurs in around 5% of carcinoid tumours, because they secrete high levels of 5-HT. It occurs only when there are liver metastases. The most important clinical finding is flushing of the skin, usually of the head and the upper part of the thorax. Secretory diarrhoea and abdominal cramps are also characteristic features of the syndrome. Cardiac abnormalities are found in 50% of patients and consist of pulmonary stenosis or tricuspid incompetence.
What investigations can be made to diagnose carcinoid tumours?Ultrasound examination confirms the presence of liver secondary deposits. Urine shows a high concentration of 5-hydroxyindoleacetic acid (5-HIAA) which is the major metabolite of 5-HT.
How are carcinoid tumours treated?Treatment is with octreotide and lanreotide. They alleviate the flushing and diarrhoea and can control a carcinoid crisis.
What is octreotide and what is it used for?Octreotide is a peptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of GH, glucagon, and insulin than the natural hormone. It is used for the treatment of growth hormone producing tumours (i.e. acromegaly and gigantism), pituitary tumours that secrete TSH, and diarrhoea and flushing episodes associated with carcinoid syndrome.
What is the prognosis for patients with carcinoid tumours?Most patients survive for 5–10 years after diagnosis.


Question Answer
What is Peutz-Jeghers syndrome?Peutz-Jeghers syndrome, also known as hereditary intestinal polyposis syndrome, is an autosomal dominant genetic disease characterised by the development of benign hamartomatous (a type of benign tumour) polyps in the GI tract and hyperpigmented macules around the mouth (95%), hands (70%), and feet (60%).
How is Peutz-Jeghers syndrome treated?Endoscopic polypectomy.
Is there a link between Peutz-Jeghers syndrome and cancer?Yes. With Peutz-Jeghers syndrome, there is an increased incidence of GI cancers. Non-GI cancers also occur with increased frequency.
What is Crohn’s disease?Crohn’s is a chronic inflammatory GI characterised by transmural granulomatous inflammation. It may affect any part of the gut, but favours the terminal ileum and ascending colon.
What are the intestinal signs/symptoms of Crohn’s disease?The major symptoms are diarrhoea, abdominal pain and weight loss. Constitutional symptoms of malaise, lethargy, anorexia, nausea, vomiting and low-grade fever may be present. Typically people with Crohn's disease have recurrent attacks, with acute exacerbations interspersed with periods of remission or less active disease. The clinical features are very variable and depend partly on the region of the bowel that is affected. Diarrhoea is present in 80% of all cases. Steatorrhoea can be present in small bowel disease. Crohn’s disease can also present as an emergency with acute right iliac fossa pain mimicking appendicitis. Mouth ulcers are also often seen.
With regards to the areas of the bowel affected, how does Crohn’s disease differ from ulcerative colitis?In Crohn’s disease, lesions may be seen anywhere from the mouth to the anus, whereas in ulcerative colitis, inflammation always starts at the rectum and never spreads beyond the ileocaecal valve. In Crohn’s disease, there may be areas of unaffected bowel between areas of active disease (skip lesions), whereas the disease is continuous in ulcerative colitis.
What antibodies are present/absent in Crohn’s disease?Saccharomyces cerevisiae antibody is usually present while pANCA antibody is negative.
What is “Kantor’s string sign”?A radiographic finding which shows severe narrowing of the bowel in which a thin strip of contrast within the lumen looks like a piece of string. This is found in people with Crohn’s disease.
What is the “cobblestone appearance” that can be seen on endoscopy?Longitudinal and circumferential fissures and ulcers separate islands of mucosa, giving it an appearance reminiscent of cobblestones. It is most commonly seen in Crohn’s disease.
How is Crohn’s disease managed?The aim of management is to induce and then maintain a remission (A remission is a temporary end to the medical signs and symptoms of an incurable disease). Cigarette smoking should be stopped. Diarrhoea can be controlled with loperamide.
How is a remission induced in a patient with Crohn’s disease?Prednisolone is first line. Budesonide is an alternative in a subgroup of patients. 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective. Azathioprine or mercaptopurine may be used as an add-on medication to induce remission but is not used as monotherapy. Infliximab can also be used as an add-on treatment.
How is remission maintained in a patient with Crohn’s disease?Azathioprine or mercaptopurine is used first-line to maintain remission. Methotrexate is used second-line. 5-ASA drugs (e.g. mesalazine) should be considered if a patient has had previous surgery.
Can surgery be used in the management/treatment of Crohn’s disease?Consider surgery as an alternative to medical treatment early in the course of the disease for people whose disease is limited to the distal ileum. Strictures are managed with balloon dilation.
What is ulcerative colitis?Ulcerative colitis is a form of inflammatory bowel disease that causes inflammation and ulcers in the colon.
What is the “lead pipe sign”?This is the classical barium enema finding in chronic ulcerative colitis. The organ appears smooth-walled and cylindrical as a result of loss of haustral markings in the diseased section of the colon (haustral markings are the radiological appearance of the haustral folds within the colon).
What are the extragastrointestinal manifestations of IBD?Eyes: Uveitis, episcleritis, conjunctivitis. Joints: Pauciarticular arthropathy, polyarticular arthropathy, arthralgia, ankylosing spondylitis (spine), inflammatory back pain. Skin: erythema nodosum, pyoderma gangrenosum. Liver and biliary tree: Sclerosing cholangitis, fatty liver, chronic hepatitis, cirrhosis, gallstones. Nephrolithiasis. Venous thrombosis.