gastroentrology PT 1 2016 modif

Session Progress0 Responses Correct: 298 Responses Incorrect: 298 Responses Total: 0% Responses - % Correct: Blog https://www.pastest.com/blog About Pastest https://www.pastest.com/about

Trang 1

What is the best-fit diagnosis?

Explanation

Irritable bowel syndrome

Irritable bowel syndrome has a female to male preponderance of 2:1 and frequently occurs inpatients with underlying problems of anxiety Examination and investigations are invariablynormal Any history of weight loss, bleeding, onset > 40 years of age or faecal incontinencewould not fit with this picture, however, and these features should trigger other investigations

if the basic examination/investigations are unremarkable

Trang 2

Session Progress

0 Responses Correct:

298 Responses Incorrect:

298 Responses Total:

0% Responses - % Correct:

Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us)Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help)

Trang 3

A 48-year-old publican presents with acute-onset confusion and a mild fever On examination

he has signs of chronic liver disease and ascites and is generally tender over his abdomen.Blood tests reveal mildly raised aspartate aminotrasferase (AST) and alanine

aminotransferase (ALT) levels and a bilirubin of 186 μmol/l His creatinine is 145 μmol/l Hisinternational normalised ratio (INR) is 2 and he has a mixed-picture anaemia with a

haemoglobin of 9.8 g/dl, low platelets and an elevated neutrophil count Ascitic tap revealsfluid with a polymorphonuclear cell count of > 250/mm

What is the most likely diagnosis?

Explanation

Spontaneous bacterial peritonitis

This man clearly has alcoholic cirrhosis, which is decompensated with ascites The ascites hasbecome infected and spontaneous bacterial peritonitis has developed Diagnosis is made onthe basis of a white count of > 250 cells/mm , the presence of bacteria on Gram staining and

a positive ascitic fluid culture Pathogens are usually Gram negative, and include Escherichia coli, Klebsiella pneumoniae and enterococci The treatment of choice includes

piperacillin/tazobactam for severe disease, although ciprofloxacin or ofloxacin might be used

Trang 4

Session Progress

Trang 5

An 82-year-old woman is admitted from a nursing home with profuse diarrhoea She was

discharged 2 weeks earlier from the orthopaedic ward, where she was treated for a fracturedhip There was some evidence of osteomyelitis during that admission and she was treated

with clindamycin and discharged on tablets On examination she is drowsy and dehydrated,with lower abdominal tenderness She soils the bed with watery diarrhoea during the

examination Blood tests confirm pre-renal failure

What is the most likely diagnosis?

Explanation

Pseudomembranous colitis

Pseudomembranous colitis can occur in up to 10% of patients who have received a course ofclindamycin In addition, it is thought that many nursing-home residents show chronic

carriage of Clostridium difficile (the causative pathogen) Sigmoidoscopy will usually reveal

raised, white-yellow exudative plaques adherent to the colonic mucosa (the

pseudomembrane) The diagnosis is made by the presence of clostridium toxin in the stool.Treatment is with oral metronidazole or vancomycin for 10–14 days, accompanied by

appropriate rehydration therapy The mortality rate is as high as 10% in the elderly

Salmonellosis would not be impossible here but the osteomyelitis associated with this tends

to affect the long bones and typically occurs in patients with sickle cell disease

Trang 6

Session Progress

Trang 7

Irritable bowel syndrome

Irritable bowel syndrome is a functional disorder of the alimentary tract that is characterised

by altered bowel function, constipation and diarrhoea, with or without abdominal pain,

nausea and vomiting, with no significant physical, laboratory or histological findings

Anaemia, occult blood in the stool, weight loss or nocturnal symptoms cannot be attributed

to irritable bowel syndrome A diet high in soluble fibre can be useful in some patients andothers seem to gain benefit from excluding dairy foods

Characterised by nocturnal diarrhoea

Trang 8

Trang 9

Crohn’s disease can involve any segment in the alimentary canal but distal ileum involvement

is characteristic The inflammatory process involves all layers of the bowel with the formation

of non-caseating granulomas, ulcers and fistulae Discontinuity of the inflammatory processacross the bowel (skip lesions) is also characteristic

Ulcerative colitis

In ulcerative colitis there is diffuse, continuous involvement of the colon with proctitis as anearly feature in 90% of cases The inflammation is confined to the mucosa and lamina propriawith crypt abscess formation Ileal involvement is not a common feature of ulcerative colitisbut the distal segment of the ileum can be involved in the inflammatory process from

adjacent inflamed colonic segment (backwash ileitis)

Table of pathological findings;

Crohn's Disease Ulcerative colitis

Transmural inflammation Mucosa and submucosa only involved

Mucosal ulcers (in 30% only) Inflammatory cell infiltrate

Trang 10

Difficulty: AveragePeer Responses

Session Progress

Trang 11

Gastric acid secretion

In the stomach, parietal cell acid secretion is stimulated by one of the three principal

mediators: gastrin, acetylcholine and histamine

Several hormones in the small intestine inhibit gastrin and gastric acid secretion in vivo.Resection of the small bowel leads to the removal of this inhibition and gastric acid

hypersecretion results (Large-bowel resection has no effect on gastric acid secretion.)Systemic mastocytosis is associated with increased histamine production

In pernicious anaemia, gastrin levels are elevated in the presence of mucosal atrophy inthe body of the stomach; acid production is therefore reduced

Steroid therapy and Cushing syndrome have been associated with peptic ulcer disease;

it has not been demonstrated that this possible relationship is due to gastric acid

hypersecretion, however

Vasoactive intestinal polypeptide (VIP) inhibits gastric acid secretion and achlorhydria

is a feature of VIP-secreting tumours

Trang 12

Session Progress

Trang 13

Unlike amoebic liver abscess, the symptoms of pyogenic abscess are those of a

systemic febrile illness lasting for only days to weeks and multiple abscesses are usuallyidentified on ultrasound examination of the liver

A raised white cell count and other acute-phase reactants are common in both

conditions

A solitary abscess in the right lobe of the liver is typical of amoebic liver abscess

A history of chronic diarrhoea might be elicited in patients with amoebic liver abscess

A history of recent biliary colic and fever is much more suggestive of cholecystitis

Patient usually aged over 60

Trang 14

Session Progress

Trang 15

Associations of Helicobacter pylori infection

Consequences of Helicobacter pylori infection include duodenal and gastric ulcer and their

complications (eg bleeding and perforation), atrophic gastritis, gastric cancer and associated lymphoid tissue (MALT) lymphoma Epidemiological studies have shown that 95%

mucosa-of low-grade gastric MALT lymphomas are associated with H pylori, and these lymphomas have been shown to arise from B-cell clones at the site of H pylori gastritis Eradication of H pylori can produce clinical and histological remission of these tumours in 70–80% of cases,

but treated patients must be followed closely for residual or recurrent lymphoma

Patients with a variety of upper gastrointestinal symptoms that have been called ‘non-ulcer

dyspepsia’ may or may not be infected with H pylori; at present, however, there is no

generally recognised association of non-ulcer dyspepsia with H pylori infection.

Several mechanisms operate in the pathogenesis of reflux oesophagitis but there is no

recognised association with H pylori infection More recently, it has also become evident that individuals without H pylori are at greater risk for gastroesophageal reflux disease and its

sequelae, Barrett’s oesophagus and adenocarcinoma of the oesophagus Achalasia of the

cardia is a motility disorder leading to failure of relaxation of the lower end of the

oesophagus and is not associated with H pylori infection Coeliac disease is a malabsorption

syndrome due to gluten sensitivity; it is an autoimmnune disorder and is not associated with

Trang 16

Session Progress

Trang 17

Alcoholic liver disease

Alcoholic liver diseases include acute alcoholic hepatitis, chronic active hepatitis and

alcoholic cirrhosis

Alcoholic liver disease is the most common cause of cirrhosis in developed countries.Women are more susceptible to alcohol-related liver disease than men, even when

consumption is corrected for body weight

Unlike viral hepatitis, alcoholic hepatitis is associated with a reversed AST:ALT ratio of2:1

Transferrin saturation and serum ferritin are commonly increased in alcoholic liver

disease and minor degrees of iron overload are common

Alcoholic hepatitis and alcoholic fatty infiltration are reversible with abstinence and

Trang 18

Session Progress

Trang 19

This test distinguishes between malabsorption due to small-intestinal diseases and

malabsorption due to pancreatic exocrine insufficiency A 5-hour urinary excretion of 5 g orgreater is normal following the oral administration of 25 g of D-xylose to a well-hydrated

subject

Decreased xylose absorption and excretion are found:

In patients with damage to the proximal small intestine

When there is bacterial overgrowth in the small intestine (the bacteria catabolise the

xylose)

Patients with pancreatic steatorrhoea usually have normal xylose absorption Abnormal

results might be encountered in renal failure, in the elderly and in patients with ascites due to

an excretion defect rather than malabsorption

Trang 20

Session Progress

Trang 21

The liver receives approximately 1500 ml of blood each minute, two-thirds of which is

provided by the portal vein Portal hypertension is present when the wedged hepatic vein

pressure is more than 5 mmHg higher than the inferior vena cava pressure Because the veins

in the portal system lack valves, increased resistance to flow at any point between the

splanchnic venules and the heart will increase the pressure in all vessels on the intestine site

of the obstruction This is manifest clinically by the development of porto-systemic collaterals(oesophageal varices), splenomegaly and/or ascites

Spider telangiectases, jaundice, hepatomegaly and gynaecomastia are manifestations of

abnormal liver cell function

Trang 22

Trang 23

You are asked by a GP to review a 16-year-old girl who appears tremulous, with some

evidence of ataxia She also has dysarthria, which has developed over time Otherwise sheappears relatively well You carry out some screening tests: the alanine aminotransferase

(ALT) is elevated, the serum caeruloplasmin is low and there is increased urinary copper

neurological symptoms (as in this case), symptoms of chronic cirrhosis, or occasionally withpsychiatric disorders such as depression or obsessive-compulsive disorder

Diagnosis and treatment

The diagnosis is based on abnormal liver function tests, increased urinary copper excretionand decreased serum caeruloplasmin Liver biopsy at an early stage might reveal focal

necrosis and hepatic steatosis Late biopsy reveals cirrhosis The liver copper content is

usually more than five times the upper limit of normal Wilson’s disease is treated with

penicillamine, which acts as a copper chelator

Trang 24

Session Progress

Trang 25

obvious signs of chronic liver disease as well as nystagmus and cerebellar ataxia He

appeared very confused Investigations showed an abnormal alanine aminotransferase (ALT),mildly raised bilirubin levels and an alkaline phosphatase level just above the upper limit ofnormal His full blood count and glucose are normal

Which diagnosis fits best with this clinical picture?

Explanation

Wernicke’s encephalopathy

This neurological picture, with no localising signs but in the presence of signs of chronic liverdisease, is likely to be related to Wernicke’s encephalopathy The precipitating cause in thiscase is probably chronic liver disease secondary to alcohol abuse If there had been a history

of head injury, subdural haematoma would have been an alternative diagnosis Computed

tomography often reveals evidence of cerebral atrophy secondary to chronic alcoholism inpatients with Wernicke’s encephalopathy

Management is 100 mg thiamine, intravenously or intramuscularly, followed by oral thiaminereplacement to correct the thiamine deficiency Untreated, this condition can become

Trang 26

Session Progress

Trang 27

10 g fat/24 hours There is a mixed-picture anaemia, hypocalcaemia, hypokalaemia and

decreased serum albumin Antigliadin and anti-endomysial antibodies are negative A bowel follow-through study reveals evidence of mucosal oedema

small-Which diagnosis fits best with this clinical picture?

Explanation

Whipple’s disease

Coeliac disease is a possibility with such a history, but negative antigliadin and

anti-endomysial antibodies make this possibility remote Whipple’s disease is a very uncommoncondition, occurring slightly more commonly in men and peaking in the 30–60-year age

group

Diagnosis of Whipple’s disease is based on biopsy of the small-intestinal lamina propria,

which reveals infiltration by periodic acid–Schiff- (PAS-) positive macrophages containing

Gram-positive bacilli The causative organism of Whipple’s disease is the bacterium

Trang 28

Session Progress

Trang 29

myalgia, headaches and cough for some days Apparently, just after returning to the UK therewas a history of diarrhoea On examination you notice some faint rose spots, which blanch, onher chest Blood testing reveals neutropenia You send blood, stool and urine samples for

culture

Explanation

Typhoid fever

Typhoid fever can have an incubation period of anything from a few days to a few weeks

Diarrhoea or constipation is common at the outset of the illness, but often settles Later

symptoms include fever, malaise, headache, cough, anorexia, sore throat and the

characteristic maculopapular rose spots, which blanch on pressure Laboratory testing mightreveal raised transaminases, and neutropenia is common Multiple blood, stool and urine

cultures are sometimes needed to identify the causative organism, Salmonella typhi.

Acute treatment is with a 14-day course of ciprofloxacin Chronic carriage is possible, and up

to a 4-week course of ciprofloxacin may be required in this case The disease is rare in thiscountry, but it occurs more commonly in parts of the world where there is poor hygiene

Trang 30

Session Progress

Trang 31

You are asked to review a nursing-home resident who has generalised inflammation of his

oropharynx and is finding it difficult to eat His past history of note includes the use of a

steroid inhaler for chronic obstructive pulmonary disease On examination there are areas oferythema and a number of white plaques accompanied by some white, curd-like material

Explanation

Oral thrush

This man is in a nursing home and is using a steroid inhaler for his chronic obstructive

pulmonary disease It is likely that he also has inadequate oral hygiene and a Candida

infection has taken hold The best treatment is to encourage mouth-swilling after using theinhaler and a nystatin mouthwash to get rid of the acute infection It is worth noting that

dentures can harbour Candida spp., so they should be soaked overnight in a dilute nystatin

solution Resistant infections can be treated with a short course of fluconazole

Trang 32

Trang 33

What is the most likely clinical diagnosis in this case?

Explanation

Giardiasis

Giardiasis is caused by the protozoal parasite Giardia lamblia and is transmitted by poor

hygiene practices Giardia infection occurs more commonly in families with X-linked

agammaglobulinaemia and in sexually active homosexual men

Trang 34

Session Progress

Trang 35

of haemolysis (the haptoglobins are normal) No intervention is required and the jaundice

usually subsides over the course of a few days

Trang 36

Trang 37

which might be associated with asthma and chronic bronchospasm.

The occasional sticking of food does, however, flag a warning signal and confirms the needfor diagnostic endoscopy Heartburn is known to occur in up to 60% of adult Lifestyle advice,including alcohol avoidance and giving up smoking, is important, but proton-pump inhibitorsare highly effective in symptom relief

Severe long-term reflux disease can result in Barrett’s oesophagus (columnisation of the

oesophageal squamous epithelium), which is known to predispose to oesophageal carcinoma.People with Barrett’s oesophagus should undergo surveillance endoscopy at least once every

Trang 38

Session Progress

Trang 39

episodes of vomiting blood He feels there is an epigastric mass Investigations have revealed

a microcytic anaemia and abnormal liver enzymes Her past history, which might be of

importance, includes excess consumption of sherry and spirits, and a 30 pack-year smokinghistory

Explanation

Gastric carcinoma

The annual incidence of gastric carcinoma in the Western world is around 7/100,000 In

Japan, the incidence is much higher at around 80/100,000, and it is thought to be

diet-related Most gastric cancers (35%) occur in the antrum There is a slight male preponderance(3:2) and the disease is more common in the over-65 age group Metastasis at presentation ofgastric carcinoma is common, with the liver the commonest site of metastasis Around 5% ofgastric tumours are gastric lymphomas

Risk factors for gastric carcinoma include:

Chronic Helicobacter pylori infection

Trang 40

Difficulty: AveragePeer Responses

Session Progress

Định dạng
Số trang	619
Dung lượng	3,27 MB