Gastro for long case Flashcards
Smoking related complications
IHD
Peripheral vascular disease
Berger’s disease of the peripheries
Carcinoma of lung, head and neck, bladder, oesophagous, colon, renal
Osteoporosis in women
Erectile dysfunction in men
Peptic ulcers
Polycythemia
?Tobacco-alcohol amylopia
Side effects of chronic alcoholism
Cognitive impairment
Wernike’s encephalopathy
Poor personal hygiene
Obesity/malnutrition
Midline cerebellar ataxia
Dilated cardiomyopathy
Recurrent pneumonia, TB
Pancreatitis
Cirrhosis, hepatitis
Parotid gland swelling
Carcinoma of the head, neck and esophagous
AF
Dupuytren’s contractures
Poor dentition
Easy bruising
History for chronic alcoholism
Type of alcohol, duration, amount, frequency
Family and coping
CAGE - C-wanting/told to cut down, A-others annoyed by intake, G- guilt, E - morning eye opener
Smoker, IVDU, marijuana
Depression, previous suicide attempts, current suicidal ideation
Occupational stressors
Criminal history - loss of driver’s licence, dangerous activity drinking
Chronic liver disease history
Mode of acquisition -History of Hep B/C, sexual activity, alcohol IVDU
Previous haematemesis and malaena
Prior scopes, ?HCC
Hypogonadism - lack of libido
Swelling of abdomen and ankles
History of haemachromatosis or autoimmune hepatitis
Chronic liver disease exam
Cognitive screen for encephalopathy
Asterixis
Wasting, jaundice, faetor hepaticus
Spider naevi, gynaecomastia
Terry’s nails, Duputren’s contracture, leukonychia
Testicular atrophy
Hyperreflexia (encephalopathy)
Portopulmonary hypertension w/ RHF
Fevers and peritonitis
Oligouria and dehydration
Alcohol examination
Signs of alcohol withdrawal - tremor, tachycardia, anxiety
GI examination ?cirrhosis ?pancreatitis
AF and CCF
Werneke’s
Peripheral neuropathy
Lymphadenopathy (?cancer)
Respiratory exam (?pneumonia)
Complications of IBD
1) Local
2) Liver
3) Haematological
4) Joints
5) Skin
6) Ocular
7) Renal and bone
1) Ulcerative colitis - Toxic megacolon (colon diameter >6cm on AXR), perforation, massive haemorrhage, strictures, carcinoma of colon)
Crohn’s - Anorectal disease (anal fissures/fistulae, pararectal abscess, rectovaginal fistula), terminal ileal obstruction, fistula, toxic megacolon, carcinoma of small and large bowel
2) Fatty liver, primary sclerosing cholangitis, cirrhosis, carcinoma of bile duct, amyloidosis
Crohn’s - gallstones more common, PSC less common
3) Anaemia - chronic disease, iron deficiency, ileal involvement, haemolysis from sulfazalazine or microangiopathy), thromboembolism - antithrombin III deficiency, stasis, dehydration
4) Oligoarthritis (large joints), ankylosing spondylitis
5) Erythema nodosum, pyoderma gangrenosum, aphthus ulcers
6) Uveitis, conjunctivitis, episcleritis
7) Crohn’s - urate and calcium oxalate stones, pyelonephritis, hydronephrosis, amyloidosis; malabsorption from small bowel resection, subsequent osteomalacia
History for IBD
Symptoms of bloody diarrhoea, malaise, fever and weightloss
Colonic - history of fistulae, anal fissures or abscesses, toxic megacolon and resection, strictures and repairs, carcinoma of large bowel
Extracolonic manifestations - Joint pain, back pain, eye pain, RUQ pain, PHx DVT, renal stones, gallstones and colecystectomy, fractures, UTIs and renal infections
Sexual preference, anal trauma, radiation, smoking, alcohol
Meds - NSAIDs, retinoic acid, oral contraceptives
Colonoscopies, investigations, hospital admissions, surgeries
Current treatment - sulfasalazine, 5-ASA, budesonide, metronidazole, immunosuppressants (azathioprine), infliximab or adalimumab
Prior antibiotics possibility of pseudomembranous/c. diff colitis
Employment, living
Issues and management for IBD
Exclude infection - amoebiasis, Shigella/salmonella/Yersinia, Campylobacter, E. coli, 0157:H7, C diff colitis, lymphogranuloma venereum, gonorrhoea and syphilis;
Immunocompromised infection - herpes, CMV, cryptosporidium, isospora belli, TB (can mimic crohn’s disease)
Determine severity -mild (<4motions, minimal blood, afebrile), severe(>6motions, bleeding, febrile, abdominal tenderness), fulminant (>10, distension, fever, tachy); need AXR, ESR, alb, CRP, FBE
LFT, UEC for renal function, liver involvement, iron and folate levels, potassium
Colonoscopy - granulomas 25% in crohn’s disease, crypt abscess formation in UC (avoid barium enema in severe cases)
anti saccharomyces cerevisiae positive and pANCA negative (crohn’s)
IV sterioids in severe UC -/+ cyclosporin (cyclosporin is ineffective in crohn’s), may require surgery for toxic megacolon
Sulfasalazine - to reduce UC relapse rate; topical preparation for proctitis
Steroids do not reduce relapse rates
Azathioprine required for steroid sparing agent if repeated episodes (methotrexate considered only in Crohn’s, ineffective in UC)
Infliximab for refractory cases or fistula (SE: lymphoproliferative disease, TB, demyelination)
Surgery - total colectomy
Other causes of colitis - non IBD
Infections, c. diff colitis
Ischaemic colitis
Radiation
Toxic exposure - peroxideor soapsud enemas, gold induced colitis
Microscopic or collagenous colitis
Lymphocytic colitis
Diversion colitis - colonic loops excluded from faecal stream
Management of colorectal Ca
Investigations - ALP, CTCAP colonoscopy/sigmoidoscopy, transrectal ultrasound, MRI and PET
Follow up colonoscopy 1 month following stenosed carcinoma to look for synchronous tumours; 1 yearly colonoscopies following
Dukes A and B - mucosa/submucosa or muscularis- surgery
Dukes C - lymph node involvement - adjuvant chemotherapy with 5-fluorouracil and leucovorin and oxaliplatin
Dukes D - palliative surgery and/or chemotherapy
Rectal carcinoma may benefit from neo-adjuvant chemotherapy (prior to surgery)
