Gastrointestinal & Hepatobiliary

Reference: Davidson 23rd; P-781

Reference: Davidson 23rd; P-853
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-816

Stem Breakdown:

Abdominal pain, bloody diarrhoea, and tenesmus: These are classic symptoms of ulcerative colitis (UC), which is an inflammatory bowel disease affecting the colon.
Continuous inflammation from the rectum to the sigmoid colon: UC is characterised by continuous inflammation starting in the rectum and extending proximally, often limited to the colon.
Option Analysis:

A) Ulcerative colitis: This is the correct diagnosis. Davidson and Harrison describe ulcerative colitis as a chronic inflammatory condition of the colon characterised by continuous inflammation, starting at the rectum and extending proximally. Bloody diarrhoea, abdominal pain, and tenses are hallmark symptoms. UC is often limited to the mucosa and submucosa of the colon, distinguishing it from Crohn's disease.
B) Crohn’s disease: Crohn's disease can affect any part of the gastrointestinal tract and is characterised by "skip lesions" (areas of normal bowel between inflamed segments). It also often involves transmural (full-thickness) inflammation, which can lead to complications like fistulas and strictures. The continuous inflammation seen in this patient is more typical of UC.
C) Irritable bowel syndrome (IBS): IBS causes abdominal pain and altered bowel habits (diarrhoea or constipation), but it does not cause bloody diarrhoea or visible inflammation on colonoscopy. IBS is a functional gastrointestinal disorder, not an inflammatory disease.
D) Diverticulitis: Diverticulitis presents with localised left lower quadrant pain, fever, and leukocytosis, typically without bloody diarrhoea or continuous inflammation on colonoscopy.

Hepatitis B surface antigen
Hepatitis B surface antigen (HBsAg) is the main indicator of active infection, and a negative test for HBsAg makes HBV infection very unlikely.

Explanation: Chronic gastric ulcer is usually single; 90% are situated on the lesser curve within the antrum or at the junction between body and antral mucosa

Explanation: Chronic hepatitis B infection increases the risk of HCC 100-fold and is the major risk factor worldwide

Reference: Davidson 23rd; P-868
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-783
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-863
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Explanation: Liver imaging is the most revealing investigation

E E Explanation: The most important steps are to make a positive diagnosis and reassure the patient

Reference: Davidson 23rd; P-861
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Acute upper gastrointestinal haemorrhage is the most common gastrointestinal emergency

Reference: Davidson 23rd; P-775
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Explanation: persistent daily vomiting suggests gastric outlet obstruction.

Reference: Davidson 23rd; P-800

Explanation: The most common cause of acute pancreatitis is Gallstones disease

Reference: Davidson 23rd; P-862
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

On liver biopsy, the characteristic early features of PSC are periductal ‘onion skin’ fibrosis and inflammation, with portal oedema and bile ductular proliferation resulting in expansion of the portal tracts (Fig. 24.34). Later, fibrosis spreads, progressing inevitably to biliary cirrhosis; obliterative cholangitis leads to the so-called ‘vanishing bile duct syndrome’.

Reference: Davidson 23rd; P-798
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Left iliac fossa mass
• Sigmoid colon cancer
• Constipation
• Diverticular mass

Reference: Davidson 23rd; P-841
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Explanation: Diarrhoea and weight loss in patients with a normal diet are likely to be caused by malabsorption.

Reference: Davidson 23rd; P-800

:Chronic pancreatitis is most commonly caused by long-term alcohol abuse. Davidson explains that alcohol leads to repeated inflammation and fibrosis of the pancreas, resulting in exocrine and endocrine dysfunction. Harrison highlights that chronic pancreatitis presents with abdominal pain, malabsorption, and diabetes.

Immune-related adverse events should be considered in all patients who present acutely unwell following immunotherapy treatments for cancer. Although the other options are on the differential diagnosis list, severe IRAEs are oncological emergencies, and prompt recognition and management are vital. This is a grade 3 colitis and should be treated with IV methylprednisolone in the first instance. Investigations such as bloods, stool samples, radiological imaging and flexible sigmoidoscopy or colonoscopy are also appropriate.

Explanation: The area most commonly affected is the Ileal or ileocolonic region

Reference: Davidson 23rd; P-838

Reference: Davidson 23rd Fig. 21.52

Reference: Davidson 23rd; P-841

Reference: Davidson 23rd Box 21.37

Reference: Davidson 23rd; P-837

Reference: Davidson 23rd; P-813

Reference: Davidson 23rd; P-802
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-813
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Explanation: Ulcerative colitis is associated with PSC

Reference: Davidson 23rd; P-800

Reference: Davidson 23rd; P-800

Stem Breakdown:

Chronic fatigue, pruritus (itching), and dry eyes: These are common symptoms in cholestatic liver disease, particularly in autoimmune liver conditions.
Isolated elevation in ALP: Alkaline phosphatase elevation suggests cholestasis, where bile flow is impaired, leading to liver dysfunction.
Positive antimitochondrial antibodies (AMA): This is the hallmark serological finding in primary biliary cholangitis (PBC).
Option Analysis:

A) Primary biliary cholangitis (PBC): This is the correct diagnosis. Davidson explains that PBC is an autoimmune disorder characterised by chronic inflammation and destruction of small bile ducts in the liver. The presence of AMA is highly specific for PBC, and ALP is typically elevated due to cholestasis. Harrison notes that PBC often presents with fatigue and pruritus and is associated with other autoimmune conditions like Sjögren's syndrome (dry eyes).
B) Autoimmune hepatitis: Autoimmune hepatitis typically presents with elevated aminotransferases (ALT/AST) and is associated with autoantibodies such as ANA or SMA, not AMA. It does not cause isolated cholestasis.
C) Primary sclerosing cholangitis (PSC): PSC is another cholestatic liver disease, but it is associated with inflammatory bowel disease (usually ulcerative colitis) and typically shows beading of the bile ducts on imaging. AMA is negative in PSC.
D) Hepatitis C: Chronic hepatitis C can cause liver damage, but it usually presents with elevated ALT/AST rather than isolated ALP elevation, and it is not associated with AMA positivity.

Reference: Davidson 23rd; P-798

Reference: Davidson 23rd; P-836(Box-21.75)

Reference: Davidson 23rd; P-858

Reference: Davidson 23rd; P-875
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-825

Reference: Davidson 23rd; P-818

Davidson P852

Ultrasound scanning can confirm the diagnosis, although in the earlier stages the gland may not be grossly swollen. An ultrasound scan is also useful because it may show gallstones, biliary obstruction or pseudocyst formation.

Contrast-enhanced pancreatic CT performed at least 3 days after
admission can be useful in assessing viability of the pancreas if persisting organ failure, sepsis or clinical deterioration is present, since these features may indicate that pancreatic necrosis has occurred.

Reference: Davidson 23rd; P-816

Reference: Davidson 23rd; P-814

Reference: Practical Manual in Clinical Medicine by Professor ABM Abdullah; P-320

Reference: Davidson 23rd Fig. 21.24

Reference: Davidson 23rd; P-841

Clusters of symptoms are used to classify dyspepsia:
•     reflux-like dyspepsia (heartburn-predominant dyspepsia)
•     ulcer-like dyspepsia (epigastric pain relieved by food or antacids)
•     dysmotility-like dyspepsia (nausea, belching, bloating and premature satiety).

Reference: Davidson 23rd; P-864
সলভ ক্লাসের জন্য আলোচনা পোস্ট দেখুন - [আলোচনা পোস্টের লিঙ্ক]

Reference: Davidson 23rd; P-800

Reference: Davidson 23rd; P-799

Explanation: Escherichia coli and various streptococci, particularly Strep. milleri, are the most common organisms

Explanation: Vertical transmission (90%)

Reference: Practical Manual in Clinical Medicine by Professor ABM Abdullah; P-339

Reference: Davidson 23rd; P-801

Stem Breakdown:

Progressive dysphagia to both solids and liquids: This suggests a motility disorder of the oesophagus. In achalasia, there is difficulty with both solids and liquids due to impaired esophageal peristalsis and failure of the lower esophageal sphincter to relax.
Unintentional weight loss: Weight loss is often seen in achalasia due to reduced caloric intake from dysphagia.
Bird-beak appearance on barium swallow: This classic radiological finding is specific for achalasia.
Option Analysis:

A) Achalasia: This is the correct diagnosis. Davidson and Harrison describe achalasia as a motility disorder characterised by the loss of peristalsis in the distal oesophagus and failure of the lower esophageal sphincter to relax. The bird-beak appearance on barium swallow, progressive dysphagia, and weight loss are classic findings.
B) Esophageal cancer: Esophageal cancer often presents with dysphagia and weight loss, but it typically causes dysphagia that starts with solids and progresses to liquids. Additionally, the bird-beak appearance is not associated with cancer.
C) Gastro-oesophageal reflux disease (GERD): GERD causes heartburn, regurgitation, and sometimes dysphagia, but it does not cause a bird-beak appearance or progressive dysphagia to both solids and liquids.
D) Diffuse esophageal spasm: Diffuse esophageal spasm causes intermittent dysphagia and chest pain but does not lead to the bird-beak appearance seen in achalasia.

Reference: Davidson 23rd; P-801