Summary of Common Conditions Seen in OSCEs
| Condition | Key points | Management* |
| Oesophageal varices | Due to portosystemic shunting of blood Other shunts:
| Banding Sclerotherapy Balloon tamponade Transjugular intrahepatic portosystemic shunt Portocaval shunt (rare) |
| Peptic ulcer | Pain related to eating:
Weight loss Risk factors:
| Lifestyle interventions Stop NSAIDs and other offending medications if possible Eradicate H. pylori † Reduce acid production (proton pump inhibitor – omeprazole; H2 agonists – ranitidine) |
| Inflammation (oesophagitis, gastritis) | Alcohol Drugs (NSAIDs, corrosive ingestion) Smoking Infection (immunocompromised – HIV) | Address causative issue |
| Mallory–Weiss tear | Longitudinal tear in oesophageal mucosa due to forceful vomiting Alcohol binge Eating disorder | Conservative: most will have stopped bleeding and heal themselves Medical: reduce acid production (proton pump inhibitor), antiemetic (prochloperazine), endoscopy Surgical: few require oversewing of the tear |
| Oesophageal cancer | Risk factors: diet, alcohol, smoking, Barrett’s oesophagus, achalasia, Plummer–Vinson syndrome (iron-deficiency anaemia + postcricoid web + glossitis) Dysphagia Weight loss | Multidisciplinary team Preoperative chemotherapy Surgery Palliation |
| Gastric cancer | Risk factors: pernicious anaemia, smoking, high-nitrate diets – Japan, blood group A Dyspepsia Weight loss Anaemia Vomiting | Multidisciplinary team Partial or total gastrectomy Chemotherapy Palliation |
| Bleeding diathesis | Any bleeding disorder. May be the result of anticoagulation | Treat cause |
| Trauma | ||
| Dieulafoy lesion | Large arteriole in the stomach wall that erodes and bleeds | Endoscopic injection and sclerotherapy |
| Boerhaave’s syndrome | Oesophageal rupture due to vomiting | Surgery |
| Peutz–Jegher syndrome | Dark freckles on the lips, and gastrointestinal polyps that can bleed | Conservative Surgery |
| Osler–Weber–Rendu disease | Autosomal dominant Also known as hereditary haemorrhagic telangiectasia Telangiectasias on skin and mucous membranes | |
| Aorto-enteric fistula | Aortic graft repair + upper/lower gastrointestinal bleed | CT abdomen Endoscopy |
40% of patients referred for upper gastrointestinal endoscopy for haematemesis have no identifiable cause of bleeding.
*Remember that the management of all these conditions begins with resuscitation (airway, breathing and circulation).
†Helicobacter pylori eradication: 7-day regime comprising a proton pump inhibitor (e.g. omeprazole 20 mg twice daily) and two antibiotics (e.g. metronidazole, amoxicillins, clarithromycin). See the BNF for further details.
Hints and Tips for the Exam
Before attempting to practise this station, make sure you have a sound knowledge of the causes of haematemesis, how to differentiate between them and the early management of the condition. The station is likely to be set in an emergency department so remember to address resuscitation first; you can state this on entering the station before beginning the history. One way to give your differential diagnosis for haematemesis is to group by region of bleeding (e.g. oesophageal, gastric, duodenal.
Make Sure It Is Definitely Haematemesis
As always begin with an open question. An important point of call in the history is to delineate whether the patient has experienced haematemesis or haemoptysis. They are similar in presentation but have different differential diagnoses. Be clear and ask whether the patient coughed up (haemoptysis) or vomited the blood.
Aim early on to comfort the patient as vomiting blood is undoubtedly a very worrying symptom. Gaining the patient’s trust early on will make the station smoother and also earn their preference marks. Ask early on whether they have any questions as cancer is a common worry; marks will be awarded for addressing patients′ anxieties. Not addressing the patient’s agenda is a common error in such a station when faced with a possible emergency.
Don’t Forget the Blood in Your Blood Tests!
Students often forget to ‘group and save’ and/or cross-match.
Group and Save (Also Known as ‘Group and Hold’ and ‘Type and Screen’)
- The patient’s blood is tested to determine the ABO type and the rhesus D status. It can also be tested for antibodies to red cells in the serum (e.g. anti-A, anti-B, anti-D or anti-Duffy).
- This test is indicated if a blood transfusion will be necessary in the near future, for example postoperatively.
- The sample is kept in the laboratory for a few days.
- On collection, the bottles should be completely filled and hand-labelled.
Cross-Match
- This is used if there is an imminent need for transfusion.
- The patient’s blood is tested for ABO and antibodies (as in group and save).
- The patient’s blood is tested against the donor sample to assess whether they are compatible.
Risk-Scoring Systems
Know about the risk scoring scales for upper gastrointestinal bleeding and aim to elicit the relevant aspects from the history (see below). If you are able to give a Rockall score in your summary and hence an indication for rebleeding, endoscopy or surgery, this will separate you from other candidates and guide the examiner to question you on this, which you should be prepared for.
The Rockall scoring system was devised to predict the risk of rebleeding in patients presenting with upper gastrointestinal bleeds, and to help estimate mortality. Remember that the greatest risk of rebleeding exists is in the first 48 hours, so bear this in mind when considering whether or not to admit the patient.
A common presentation in this station is of bleeding oesophageal varices due to chronic liver disease. Hence, it is fundamental that you assess possible causes of chronic liver disease (e.g. alcohol, medications, viral hepatitis) in your history. It is important that you are also aware of the Child–Pugh grading system and how to calculate it. This is a score used to grade the severity of liver cirrhosis and the likelihood of variceal bleeding – a score >8 indicates a high risk of bleeding.
You should bear the criteria in mind when you are asked which blood tests you would like to run. The scoring is outlined in the table. Binge drinking is often associated with Mallory–Weiss tears so remember to ask about the patient’s drinking habits (e.g. do they drink ‘binge drink’ on the weekend and not drink on weekdays?, etc.) in addition to how much they drink (with respect to quantity). Do not waste time assessing dependency (i.e. applying a CAGE questionnaire) – this is not the aim of this station.
Rockall Score for Upper Gastrointestinal Bleed
A score >6 may indicate a need for surgery.
Child–Pugh Grading for Cirrhosis and Variceal Bleeding
Kings College Hospital Criteria for Liver Transplantation
| Paracetamol-related | Not paracetamol-related |
|
|
OR all of the below:
| OR three of the criteria listed below:
|
Questions You Could Be Asked
Q. How would you investigate and manage this patient?
Q. What is their Rockall Score? What does it mean?
Q. When would you refer the patient for an endoscopy? How urgently? (Start with the golden phrase: ‘I would consult the local hospital guidelines.’)
Q. Describe the endoscopy procedure.
A. Answers to these questions can be found in the text above.
Other possible topics include:
- Questions related to managing shock (e.g. parameters and appropriate fluids)
- Transfusion reactions
- Liver disease
- Liver transplant (the King’s College Transplant Criteria are included in the text)
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