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Question

Pharyngeal Pouch: 2 symptoms? Why nocturnal cough? SURG Rx: - 2?

Answer 1

Dysphagia Regurg Regurg of food ==== Excision of pouch Stapling

Answer 2

Sliding - junction into thorax (80%) Rolling - funds of stomach moves into thorax GORD - worse lying flat ``` Bowel sounds in left chest ====== Endoscopy ====== Weight loss Stop smoking ``` ``` Avoid large meals before bed Raised head of bed ======= PPI ======= Insertion of mesh ``` Fundoplication - fundos wrapped around LOS to strengthen it and prevent herniation

Answer 3

Endoscopy Trauma + swallowed sharp foreign body Neck, chest or epigastric pain - EXCRUCIATING Vomiting Subcutaneous emphysema Upper GI bleed Dysphagia ====== CXR CT***** - not endoscopy as it is introducing more foreign pathogens into the mediastinum ===== NG suck of contents NasoJEJUNAL feeding Prophylactic ABs Debridement of mediastinum and T-tube for oesophagocutaneous drainage

Answer 4

5-7 >4 wks GE ==== IBD - especially UC Colorectal cancer ``` Diverticultiis + fistula/abscess ==== Cholera Rotavirus Noravirus ==== Increased gas Offensive smell Floating Hard to flush ``` Pancreatic insufficiency Biliary obstruction ======== Thyrotoxicosis + Addison's ``` Dry mucosa Reduced skin turgor Raised CRT ======== MC+S Ova cysts and parasites C. diff ``` Faecal elastase Faecal calprotectin - done to rule out Stool antigen test - H. pylori can cause D Lactic acid ======= Iron deficiency - Coeliac or CC Alcohol abuse Coeliac and Crohn's Disease Potassium - so hypokalaemia******* Infection, IBD and cancer Thyrotoxicosis Anti-TTG ===== New onset change in bowel habit >55 yrs old + ALARM

Answer 5

Oral rehydration/IV Electrolyte replacement Loperamide - reduces smooth muscle tone stopping D Codeine Probiotics

Answer 6

IBS Anal fissure and stricture Rectal prolapse CC Crohn's stricture Fetus and fibroids ===== Dehydration and low fibre IBS ===== Hypercalcaemia Constipation is worse due to dehydration associated with hypercalcemia. Hypokalaemia - poor nervous control leading to slowing of movement of food ``` Hypothyroidism ====== PD Spinal cord lesion ====== Depression ====== Opiates Iron Diuretics - dehydration ====== Pain meds and muscle relaxants ``` Reduced privacy + having to use a bedpan

Answer 7

PR exam FBC - iron for anaemia ESR/CRP - inflam U&E'S = K+Ca TFT's AXR ===== Increased fibre and fluid BULKING AGENTS****** Stimulant laxatives - fastest Osmotic Laxatives Stool softener

Answer 8

https: //www.youtube.com/watch?v=EEBjuiqEp4w https: //www.youtube.com/watch?v=4bkAH_Z8tmc - better video Soluble fibre - creates gel making stool bulkier but easier to pass - NEEDS TO BE TAKEN WITH PLENTY OF WATER Few days ====== SENNA **** Stimulate bowel movements Cramps ======= Salts and sugar which can't be absorbed = causes water to move into bowel ``` LACTULOSE - hepatic encephalopathy Magnesium sulfate - FASTEST ======= DOCUSATE ****** Enema (basically an oil) Liquid paraffin ``` Anal tissues or painful anal pathology

Answer 9

>35 μmol/L Haemolytic anaemia Impaired conjugation High unconjugated B High levels of urobilinogen - This unconjugated bilirubin isn't water-soluble so can't be excreted in the urine. INTERSTINAL BACTERIA convert some of the extra bilirubin into urobilinogen, some of which is re-absorbed and IS excreted by the kidneys – hence urinary urobilinogen is increased. ====== Normal stool - some conjugation Dark urine - raised unconjugated bilirubin - less urobilinogen High UNconjugated bilirubin ====== L - gallstones ``` M - Cholangiocarcinoma Biliary strictures (PBC, PSC) ``` E - Pan Cancer + Enlarged lymph nodes GS in cystic duct - compresses hepatic duct PBC and PSC Obstetric cholestasis ======= PALE stool + DARK urine Due to build up of BILE SALTS - not bilirubin High CONJUGATED bilirubin Low levels of urobilinogen and high conjugated bilirubin ======= USS MRCP - diagnosis ******* ======= ERCP - stenting, clearance, or sphincterotomy ****** ``` ======= They are at risk of coagulopathy due to impaired absorption of Vit K - it is a fat soluble vitamin (ADEK) ======== IVDU Piercings Tattoos Sexual activity ``` Blood transfusions

Answer 10

Colonic mucosa and submucosa only ``` Inflammation and ulceration ===== Diarrhoea - usually bloody (and mucousy ******) + Cramps ``` Urgency (and Tenesmus (feeling need to pass stool with pain, cramping and strain BUT VERY LITTLE STOOL COMES OUT *****) ``` Infection ===== Uveitis Episcleritis Conjunctivitis ``` Aphthous ulcers Clubbing Erythema nodosum Pyoderma Gangrenosum ``` ARTHRITIS ======= PSC ======= Chronic inflammation leads to thrombocytosis ``` HLA-B27 ======= MC+S Faecal calprotectin C. diff toxin ======= FBC - Hb and haematinics (iron, folate and B12) - patients usually have anaemia Thrombocytosis as well CRP/ESR - inflam U&E's - Hydration, electrolytes LFT's - hepatobilioary disease - PSC RAISED platelets and LOW alb pANCA - same as PSC ======== A - limited flexible sigmoidoscopy with biopsy ******** GOLD STANDARD C - full colonoscopy with biopsy****** ``` Crypt architecture ========= Perforation Gross dilatation Toxic megacolon (>6 cm) ```

Answer 11

Truelove and Witt's severity index Mild to moderate: MESALAZINE***** - maintains remission and reduces flare ups as it reduces inflammation SULPHASALAZINE Prednisolone Can also add PR steroid foams =========== Severe - >6 stools, systemically unwell IV Corticosteroids Ciclosporoin - immunosuppressor Biologics - Infliximab ======= > 2 use of steroids in a yr or severe attack ======= Subtotal colectomy - remove everything but rectum and end ileostomy made Panproctocolectomy with ileostomy (removal of whole large bowel) Ileo-anal pouch anastomosis made after resection of bowel - harder to do though so not preferred

Answer 12

Terminal ileum Younger - tend to be smokers as well ======= Diarrhoea Abdo pain Usually more ACUTE Abscess Fistula Tags RIF - Mass from inflammation on palpation ======== Aphthous ulcers Uveitis Episcleritis Conjunctivitis Clubbing Erythema nodosum Pyoderma Gangrenosum ``` ARTHRITIS ======== Anti-saccharomyces cerevisiae antibodies (ASCA) ======== Dilatation - toxic megacolon Abscess ``` Strictures CT/MRI ======== Skip lesions Cobblestone appearance Transmural disease with granulomas

Answer 13

Cut out smoking Methylprednisolone IV 3 days THEN Prednisolone PO for 2 wks after Azathioprine Biologics ===== 5-ASA - Azathoiprine Immunosuppressors - methotrexate or biologics ======== Loperamide ``` Antispasmodic - Buscopan ===== Diarrhoea Steatorrhoea Electrolyte abnormalities Malnutrition - vitamin deficiencies, weight loss and fatigue ALL due to lack of absorption ====== Panproctocolectomy with ileostomy ======= B12 deficiency - Replace - loss of terminal ileum Loss of bile acids - replace - Ursodeoxycholic acid ```

Answer 14

Rectum - UC Terminal ileum - C Bloody diarrhoea - UC Crampy abdo pain - C Submucosa or mucosa - UC Transmural - C Haemorrhage and toxic megacolon - UC Fistulas, abscesses, obstruction - C

Answer 15

Coeliac Disease Chronic pancreatitis Crohn's Disease Primary biliary cholangitis Ileal resection Biliary obstruction Pancreatic cancer Cystic fibrosis Low iron, B12 and folate Low Vit K Low protein Low Vit D Neuropathy

Answer 16

Autommune response to gluten Cause intestinal damage Diarrhoea (may be bloody) Abdominal pain Bloating Weight loss Steatorrhoea - fat malabsorption Ulcers Angular stomatiis - seen in Fe Anaemia - Fe, B12 + folate Osteoporosis - lack of Ca and + Vit D Oedema - protein ``` Dermatitis Herpatiformis =========== FBC - anaemia (iron, B12) U&E - Ca Albumin - oedema ``` Causes raised ALT Anti-tTG IgA Stay ON gluten ==== DEXA ==== ``` Upper Endoscopy + biopsy **** ===== Life long gluten free diet Remove wheat (bread and pasta), rye and barley) ``` Replace micronutrients

Answer 17

It is never bloody ``` Tenesmus Worse after food Bloating Urgency MUCUS PR**** ========= Hydrogen breath test - H. pylori ``` FBC - anaemia ESR/CRP - rules out IBD TFT's - hyperthyroidism Coeliac antibodies - Anti-TTG to rule out Faecal calprotectin - normal in IBS ``` FOB - shows blood thats not seen - rules out IBD ========= - Regular meals - Good hydration (8 cups per day) - Reduce alc - Max 3 fruit portion per day - AVOID too much fibre especially if insoluble Encourage soluble fibre ========= Antimuscuranic - MEBEVERINE ``` Loparmide Laxative Anti-spasmodic - Hyoscyamine PSYCH - DEPRESSION!!!

Answer 18

Vit C deficiency - Gingivitis - loose teeth and bleeding - Muscle pain and weakness Ascorbic acid Night blinds ===== Macrocytic anaemia Neuropathy Glossitis - inflame of the tongue Rickets in children Osteoporosis Goitre

Answer 19

>25 ``` >35 ===== Hypothyroidism Cushing's Syndrome ===== HTN, stroke etc. ``` T2DM + NAFLD + HTN Obstructive sleep apnoea Gallstones Osteoarthritis ===== Weight loss diet Regular exercise Orilistat Bariatric surgery

Answer 20

Norovirus Adenovirus Rotavirus Salmonella C. diff Shigella E. coli Acute D and/or VOMITING ===== Eating infected poultry Infected poultry, eggs and milk Viral cholera ====== Stool - MC+S ``` FBC (RAISED WBC) U&E (Dehydration) CRP (Inflammatory marker) LFT (Helps with differentials) ===== Oral fluids ``` Anti-emetics Anti-diarrhoeal - loparemide MAKES DYSENTRY WORSE SO ACOID ====== Reactive arthritis Gillian-Barre syndrome - CAMPYLOBACTER

Answer 21

ABs Profuse watery d Abdo pain and tenderness Fever PCR +/- toxin immunoassay****** FBC - raised WBC U&E - AKI due to dehydration

Answer 22

Colicky pain Pain worse on movement Guarding - VOLuntary contraction of abdo muscles when palpated Rigidity - Involuntary contraction of abdo muscles when palpated {Guarding, in contrast, is a voluntary contraction of the abdominal wall musculature to avoid pain. Thus, guarding tends to be generalized over the entire abdomen, whereas rigidity involves only the inflamed area. Guarding can often be overcome by having the patient purposely relax the muscles; rigidity cannot be.} Rebound tenderness ==== Cholangitis Pyelonephritis Intra-abdominal abscess ====== Urine dip - UTI ABG - acid/alk 1. FBC - WBC for infection 2. U&E - dehydration 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - function 5. ESR/CRP - inflammation 6. Lactate - sepsis Beta hCG - ectopic USS Erect CXR AXR CT abdo Due to radiation risk to foetus

Answer 23

1. FBC - WBC for infection 2. U&E - dehydration, raised urea 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - function 5. ESR/CRP - inflammation 6. Lactate - sepsis CT abdo-pelvis ====== Adrenaline, thermal coag or clipping

Answer 24

Nose to ear to the xiphoid pH (should be <5.5) - aspirate some contents CXR: - Crosses carina - Crosses diaphragm - Tip visible beneath D

Answer 25

Colicky visceral pain - umbilical to RIF Pain on movement Guarding Rebound tenderness Fever McBurney's sign - 1/3 of the way between right ASIS and umbilicus is extremely tender **** Rovsing's sign - RIF pain on pressing the LIF ***** Psoas sign - Pain on extending the hip (if retrocaecal appendix) Obturator sign - Pain on flexion and internal rotation of the right hip https://www.youtube.com/watch?v=SkiekzdEtu4 Perforation Peritonitis Abscess formation

Answer 26

1. FBC - WBC for infection 2. U&E - dehydration 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - function 5. ESR/CRP - inflammation 6. Lactate - sepsis USS CT Abdo-pelvis **** ===== Antibiotics IV Appendectomy ===== IV antibiotics and CT-guided drainage

Answer 27

Diverticula present Plus symptoms Small outpouchings of the colonic mucosa and submucosa through the muscular layer ``` Due to high intramural pressures due to LACK OF FIBRE IN DIET ==== Pain Bloating*** Constipation Diarrhoea ``` Can get PR bleeding but not common ====== Guarding PR mucus and blood + diarrhoea Sudden pain and peritonitis ====== Colovaginal and colovesical Strictures Abscess (may be hypochondriac or in splenic flexure Perintotis

Answer 28

1. FBC - WBC for infection 2. U&E - dehydration 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - function 5. ESR/CRP - inflammation 6. Lactate - sepsis Erect CXR - for perforation CT abdo - to diagnose ****** ======== High fibre diet ABs and oral fluids at home Pain relief > 3cm CT-guided aspiration Hartmann's procedure - temporary Hinchey's classification

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