Final Professional Examination

(FPE)
Dr Duncan Loft
Gastroenterology

Contents
Clinical
Written

Contents, Clinical

Abdominal Examination
Gastro Patient Scenarios
Interactive
Will not cover:
Hepatology, Jaundice
Cross-over with Surgery
The examination procedure
I dont know the exam questions!

Contents, Written
Best one of five
MCQ
Extended matching questions

Physical Examination
Gastroenterology

History
Presenting complaint
History of presenting complaint
Include system review gastroenterology

Past Medical History (TI resection, TB)

Drugs (NSAIDS) & Allergies
Social: Alcohol, smoking
Family History, (Peptic ulcer, IBD, Coeliac
disease)

Physical Examination

Hands
Eyes & downwards (may avoid mouth exam)
Lymphadenopathy
Abdomen

Inspection (Distension)
Palpation (Liver, spleen)
Percussion (Liver & spleen before palpation. Ascites)
Auscultation (Bowel sounds, bruits)

Requirement for PR.

Gastroenterology Patient
Scenarios

Possible cases 1

Dysphagia
Chronic epigastric pain
Acute GI haemorrhage?
Jaundice
Hepatomegaly
Ascites
Chronic diarrhoea
Altered bowel habit

Possible cases 2

Rectal bleeding
Generalised Abdominal pain
RIF pain
Weight loss
Anaemia
Constipation

Gastroenterology Diagnoses

Peptic ulcer
appendicitis
ulcerative colitis & Crohns disease
cholecystitis and gall stones
oesophageal varices
carcinoma of oesophagus and colon
oesophageal ulcer, Barretts oesophagus
adenomatous polyp

Case scenarios.
A few pearls
I dont know what will feature!

Abdominal examination
Mass
Fluid
Chronic conditions
Chronic liver disease, leukaemia, myelofibrosis
Polycystic kidney

Splenomegaly
Very large
Chronic myeloid leukaemia
Myelofibrosis
Malaria, gauchers

Moderate
Hodgkins. Chronic lymphatic leukaemia
Cirrhosis

Slightly
Glandular fever, hepatitis, SBE, amyloid,
sarcoid.

Hepatomegaly
Common
Heart failure,
Metastases
Cirrhosis

Others
Infections: glandular fever, hepatitis
Leukaemia, lymphoma
Tumours: hepatoma
Amyloid, sarcoid
PBC, Haemochromatosis

Ascites

Malignant (ovarian)
Portal hypertension
CCF
Nephrotic & other low albumin states
TB

Exudate >30g/l protein.

Cytology. Microscopy & culture.

Dysphagia
Common causes
Oesophago-gastric carcinoma
Peptic stricture

Less common
Achalasia
External pressure

Neurological
Bulbar palsies

Dysphagia
Oesophageal
Strictures

High oropharyngeal
Neurological, pharyngeal pouch

Dysphagia
History
History:

Pain (odynophagia)
Previous oesophagitis
Length history (Malignant, 3 months)
Solids or liquids (achalasia)
Recurrent pneumonia (achalasia)

Dysphagia
On examination

Mouth
Observe swallowing
Neck (lymphadenopathy)
Abdomen (Carcinoma)

Dysphagia
Investigation
Always:
Gastroscopy
FBC (Plummer-Vinson syndrome)

Sometimes
Barium swallow
pH Manometry
Naso-laryngoscopy (oropharyngeal dysphagia)
CT chest (extrinsic compression)

Diarrhoea
Infections. Rota, Norovirus. Salmonella,
Shigella, Campylobacter, C.diff.
(Unlikely in exams)

Non-infectious.
Drugs: Antibiotics. Laxatives.
Carcinoma
Inflammatory bowel disease
Malabsorption (Coeliac), thyrotoxicosis,
diabetes
Irritable bowel syndrome

Diarrhoea. History
Acute

Isolated or recurrent
Food
Contacts
Others affected

Chronic Diarrhoea. History

Duration (>2-4 weeks, chronic. <3 months,
sinister)
Appetite, weight loss, pain, blood &
mucus. Constipation. Drugs.
Family History
Wake at night
Previous surgery
Travel
Antibiotics

Chronic diarrhoea
Extra-intestinal manifestations
Arthritis
Skin Erythema nodosum, pyoderma
gangrenosum, dermatitis herpetiformis
Iritis, episcleritis, uveitis

Diarrhoea. Examination.

Dehydration
Weight loss, anaemia,
Clubbing (Crohns. Malabsorption)
Mass (Carcinoma. Crohns)
Distension, tender, pyrexia (Toxic
dilatation)
PR critical, but not in exam.

Diarrhoea, Blood tests

Anaemia
Macrocytosis
Albumin, CRP, ESR
Renal function. Hypokalaemia
TSH
Transglutaminase IgA antibody

Diarrhoea. Investigations
Acute
Stool, C&S, microscopy, C.diff.

Chronic (> 2-4 weeks)

Flex sigmoidoscopy (Beware in acute colitis)
And biopsy

Established Chronic diarrhoea- colonoscopy

Abdo XRAY

Diarrhoea, does & donts.

Barium enema NO
CT pneumocolon (virtual colonoscopy)
OK. Generally inferior
Bowel prep. Beware renal function
Avoid anti-diarrhoeals
Barrier nurse
C.diff & norovirus
Remember small bowel & pancreas

Colitis. Assessment of severity

Stool frequency (> 6 / day)

Blood
Abdo pain & distension
Pulse >100. BP < 100. Pyrerxia
Bloods
Albumin
ESR, CRP, WCC, Hb, platelets

AXR (Dilatation)

Epigastric pain.

Functional dyspepsia
Gastro-oesophageal reflux disease (GORD)
Duodenal ulcer
Gastric ulcer
Gall stones
Gastric or pancreatic cancer
Chronic pancreatitis

Epigastric pain. History

Length of history
Long, benign disease
Short but persistent, may be more sinister

Nocturnal symptoms
Antacids & Omeprazole
Alarm features
Weight loss, vomiting, bleeding, anaemia,
Jaundice

Epigastric pain. Investigation

Bloods
FBC (anaemia)
LFT (Gall stones or malignancy)
Amylase (pancreas)

Gastroscopy
Alarm features, urgent

Abdo Ultrasound
If negative consider CT abdo

Chronic Abdominal pain

Colonic
Irritable bowel syndrome
Colon cancer
Diverticular stricture

Pancreatic
Gynaecological
Renal

Chronic abdominal pain

History
Nocturnal symptoms
Length of history
Colonic symptoms
Altered bowel habit
Rectal Bleeding

Sinister symptoms
Anorexia, weight loss

Related to menstruationn

Chronic abdominal pain.

Investigations
Bloods
FBC (Anaemia)
U&E (Renal
Urine dipstix (Renal)
LFT (Albumin, metastases)

Colonoscopy
Abdo Ultrasound
Second-line CT Abdo

Summary 1
Wash hands
Listen, be attentive
Look as though the patient is more
important than your exam
Look practised
Dont be tempted to take short-cut

Summary 2
You are unlikely to fail if you have the
wrong diagnosis or interpretation
You are more Likely to fail if you look
unpractised

Contents, Written
Best one of five
MCQ
Extended matching questions

Best one of five

Likeliest cause of Jaundice in 24 yr-old?
1. Ca head of pancreas
2. Antibiotics (eg sulphonamide)
3. Malaria
4. Iron-deficiency anaemia
5. Epstein-Barr Virus

Best one of five

Likeliest cause of Jaundice in 24 yr-old?
1. Ca head of pancreas
2. Antibiotics (eg sulphonamide)
3. Malaria
4. Iron-deficiency anaemia
5. Epstein-Barr Virus

MCQ
These are true in pseudomembranous colitis:
1. Diagnosis based on presence of clostridium dificile in
stool
2. Best treated with intravenous vancomycin
3. Risk of disease increased by intravenous
cephalosporins
4. May result in bloody diarrhoea
5. Causal bacterium is a normal commensal gut
organism

MCQ
These are true in pseudomembranous colitis:
1. Diagnosis based on presence of clostridium dificile in
stool
2. Best treated with intravenous vancomycin
3. Risk of disease increased by intravenous
cephalosporins
4. May result in bloody diarrhoea
5. Causal bacterium is a normal commensal gut
organism

Extended matching questions

Theme: abdo pain
76 yr. post-prandial abdo pain, mild diarrhoea
PMH: Angina, diabetes. Smoker. Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Extended matching questions

Theme: abdo pain
76 yr. post-prandial abdo pain, mild diarrhoea
PMH: Angina, diabetes. Smoker. Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Extended matching questions

Theme: abdo pain
32 yr old. Abdo pain, nausea, weight loss. O/E:
mouth ulcers. Tender bruise-like lesions on shins.
Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Extended matching questions

Theme: abdo pain
32 yr old. Abdo pain, nausea, weight loss. O/E:
mouth ulcers. Tender bruise-like lesions on shins.
Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Extended matching questions

Theme: abdo pain
47 yr old. LIF pain, intermittent, relieved by
defaecation. Bloating, alt constipation or diarrhoea.
Weight gain. Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Extended matching questions

Theme: abdo pain
47 yr old. LIF pain, intermittent, relieved by
defaecation. Bloating, alt constipation or diarrhoea.
Weight gain. Likely cause?
1.
2.
3.
4.
5.
6.
7.

Sigmoid volvulus
Acute appendicitis
Cholecystitis
Duodenal ulcer
Bowel ischaemia
Diverticulosis
Crohns

8. Irritable bowel
syndrome
9. Acute pancreatitis
10. Colon cancer
11. Carcinoid syndrome
12. Ovarian Cysts
13. Ectopic pregnancy

Best one of five

Characteristic finding in Barretts oesophagus
1. Goblet cells
2. Transitional cell metaplasia of
oesophageal mucosa
3. Increased risk oesophageal squamous cell
carcinoma
4. Villous formation
5. Dysplasia

Best one of five

Characteristic finding in Barretts oesophagus
1. Goblet cells
2. Transitional cell metaplasia of
oesophageal mucosa
3. Increased risk oesophageal squamous cell
carcinoma
4. Villous formation
5. Dysplasia

MCQ
Causes of acute pancreatitis
1. Gallstones
2. Prednisolone
3. Thyroxine
4. Coxsackie infection
5. Hyperlipidaemia

MCQ
Causes of acute pancreatitis
1. Gallstones
2. Prednisolone
3. Thyroxine
4. Coxsackie infection
5. Hyperlipidaemia

Summary, Written paper

Read instructions
Time per question
Go through paper first answers you know
are correct
Then educated guess
No wild guess
Look for obvious incorrect. Always and
never are rarely correct