Gastro - general use this Flashcards
Urgent referal for suspected GI cancer
Dysphagia lasting >3 weeks endoscopy to exclude malignant stricture
- Dysphagia
- Dyspepsia + 1 or more of
Weight loss
Proven anaemia
Pernicious anaemia
Vomiting
Jaundice
Upper abdomnal mass
Barrett’s oesophagus
Known dysplasia, atrophic gastritis, intestinal metaplasia
Peptic ucler surgery >20 years previously
FHx of UGI cancer in >2 first-degree relatives
- Dyspepsia >55 y/o + 1 or more of
Onset of dyspepsia <1 y previously
Continuous symptoms since onset
Indications for endoscopy
- OGD
If pt presents for the first time 55 + there are warning signs or bleeding ulcer or ALARMS
Warning signs - >55 +
- Chronic blood loss
- Persistent vomiting
- Epigastric mass
- Unexplained, persistent, recent onset diarrhoea
- Previous peptic ulcer disease
- Previous gastric surgery
- Pernicious anaemia
- NSAID use
- FHx of gastric carcinoma
ALARMS Anorexia Loss of weight Anaemia (Fe deficiency) Rectal bleeding Melaena/Haematemesis Swallowing difficulty (progressive dysphagia) Suspicious barium meal
Indications for emergency endoscopy
- Unstable patients, severe acute UGI bleeding immediately after resuscitation
- Continuing UGI bleed
- Glasgow-Blatchford score >6 (incl 6)
- Pt w aortic graft to exclude aorto-enteric fistula
- Suspiction of oesohageal varices due to chronic liver disease
Why is constipation common after surgery
- Anaesthesia
- Opioid analgesia
- Electrolyte imbalances (hypokalaemia, hypomagnesaemia)
- Bowel manipulation
How can we reduce the risk of post operative ileus
- Epidural/spinal anaesthesia
- Reduce use of opioids (more local anaesthetics)
- Reduce bowel manipulation during surgery
- Encourage early mobilisation
Differentials for raised INR/PTT
- Liver failure (decreased hepatic production of coagulation factors)
- Vitamin K deficiency
- Cholestasis (decreased vitamin K absorption)
- DIC
What kind of ischaemia does a strangulated hernia/volvulus cause
Ischaemic colitis/Colonic ischaemia(NOT acute/chronic mesenteric ischaemia)
Which hepatitis viruses cause chronic infection?
HBV, HCV, HDV
What does chronic hepatitis infection lead to?
chronic hepatitis
cirrhosis
hepatocellular carcinoma and eventually liver failure
HCC assosciated with HBV, HCV (most commonly with HCV)
Causes of acute pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps/Coxsackie/HIV Autoimmune/Sjogren's syndrome/SLE/Coeliac disease Scorption bites Hyperlipidaemia/hypercalcaemia/hypothermia/hypertriglyceridaemia ERCP Drugs (Sodium valproate, steroids, thiazides, azathioprine)
What is the hepatorenal syndrome?
Kidneys reduce their own blood flow distribution in response to the altered blood flow in the liver which causes extreme vasodilation and therefore decreases MAP
Causes of UGIB
- Oesophageal tumour
- Mallory Weiss tear
- Oesophagitis
- Oesophageal varices
- Gastric carcinoma
- Gastritis
- Gastric ulcer
- Duodenal ulcer
- Angiodysplasia
look at diagram in epigastric pain
What kind of cancer is the most common gastric cancer?
Adenocarcinoma
Colon cancer screening
55 - FlexSig one off bowel scope screening test
60-74 - FOBT home testing kit every 2 years
What kind of jaundice does Gilbert’s cause?
Pre-hepatic
Bilirubin is unconjugated
Which enzyme is affected in Gilbert’s?
UDP glucuronyl transferase
reduced activity –> higher unconjugated blirubin –> tightly bound to albumin –> does not enter urine
What can you use to evaluate liver function
Most representative test for liver function
Albumin
Bilirubin
Clotting factors
Prothrombin time
(clotting factor synthesis affected more quickly than albumin)
Aetiology of appendicitis
Gut organisms invade appendix wall after lumen obstruction
Becomes inflamed + infected
This leads to oedema, ischaemic necrosis and perforation
Infected + faecal matter escape into the peritoneal cavity producing life threatening peritonitis
Lumen can be obstructed by stool, foreign object, faecolith, infective organisms
What is the difference between
diverticulum
diverticulosis
diverticulitis
diverticular disease
- Diverticulum – herniation of mucosa and submucosa through the muscular layer of the colonic wall
- Diverticulosis – presence of diverticulae outpouchings of the colonic mucosa + submucosa through the muscular wall of the large bowel, asymptomatic
- Diverticulitis – acute inflammation and infection of diverticulae
- Diverticular disease - the complications from diverticulosis
Most common site of diverticula
Sigmoid colon
Descending colon
i.e. L hand side
What is the Hinchey classificaiton?
Assessment of periotneal contamination in the context of acute diverticulitis
I pericolic or mesenteric abscess
II walled off pelvic abscess
III perforation with generalised purulent peritonitis
IV generalised faecal peritonitis
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
Hartmann’s procedure Primary anastomosis Colectomy and end-ileostomy formation Delorme’s procedure Whipple’s procedure
Hartmann’s procedure
if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis
Diverticular disease surgical management
Primary anastomosis
- One stage resection of affected bowel + anastomosis
- Proximal loop ileostomy (diverts contents before they pass via primary anastomosis - protects the primary anastomosis)
Hartmann’s procedure - if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis
- Proctosigmoidectomy + Formation of an end colostomy with anorectal stump
- Used when primary anastomosis is not possible due to e.g. inflammation
Delorme’s procedure – rectal prolapse
Whipple’s procedure - ca of head of pancreas
Whipple procedure (pancreaticoduodenectomy) is an operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
How to differentiate bn Inguinal hernias + femoral hernias
o Reduce hernia
o Place finger over femoral canal
o Ask patient to cough
o Inguinal hernia – will reppear, Femoral hernia – will stay reduced
How to differentiate bn direct + indirectInguinal hernias
Reduce the hernia and put your hand over the deep inguinal ring
Get patient to cough - if the hernia reappears then it means it is direct (through the abdominal wall)
if it doesnt reappear it means it’s indirect (through the deep inguinal ring which you are blocking with your hands)
deep inguinal ring:
• Midpoint of inguinal ligament
• 1.5cm above midpoint
• Opening in transversalis fascia
Inguinal vs femoral hernia
Inguinal
Superior and medial to pubic tubercle
Still more common in F than femoral
often contain bowel
Femoral Inferior and lateral to pubic tubercle F>M Higher risk of stangulation than inguinal because it has a narrower neck Often contain omentum
Direct vs indirect inguinal hernia
Direct
Superior and medial to pubic tubercle
Through the abdominal wall
Medial to deep inferior epigastric artery
Through Hesselbach’s triangle
Doesn’t usually extend into scrotum
Cough impulse - will expand outwards (through the defect in the posterior wall of the inguinal canal)
Lower risk of strangulation than indirect hernias
greater tendency for spontaneous reduction
Indirect
More common than direct
Superior and medial to pubic tubercle
Through the deep inguinal ring
Lateral to deep inferior epigastric artery
lateral to Hesselbach’s triangle
More likely to extend into scrotum
Cough impulse - will expand in an inferomedial direction (along the length of the inguinal canal)
Higher risk of strangulation than direct hernias
deep inferior epigastric artery lies medial to the deep inguinal ring
Which is the most common hernia?
Indirect inguinal hernias
Difference bn obstructed + strangulated hernia
Obstructed hernia–refers mainly to hernias containing bowel, where the contents of the hernia are compressed to the extent the the bowel lumen is no longer patent and causes bowel obstruction
Strangulated hernia–the compression around the hernia prevents blood flow into the hernial contents causing ischaemia to the tissues and pain
Pathophysiology of acute pancreatitis
inflammatory condition of the exocrine pancreas in which activated pancreatic enzymes are released and begin to autodigest the gland
Hypercalcaemia
Hypocalcaemia
How do they relate to pancreatitis?
Hypercalcaemia causes pancreatitis
Hypocalcaemia is caused by pancreatitis
Large bowel obstruction commonly due to
Small bowel obstruction commonly due to
large
Malignancy
+ hernias, feacal impaction
small
adhesions, hernias
4 causes of acute mesenteric ischaemia
Arterial emoblism (e.g. AF) Arterial thrombosis (e.g. atheroscleorsis) Venous thrombosis (e.g. hypercoaguable states, malignancy) Non-occlusive disease (e.g. hypotension, cocaine)
Causes of chronic mesenteric ischaemia
- Chronic atherosclerotic disease of the vessels supplying the intestine
- Also known as intestinal angina
- All 3 major mesenteric arteries are involved
Combination of a
Low-flow state (e.g. HF)
Atherosclerotic disease
More common in females
Bacteria that cause bloody diarrhoea (dysentry)
CCHESS Campylobacter Clostrodium difficile Haemorrahgic E coli (E0157) Entoameoba histolytica Salmonella Shigella
Which organism caused the diarrhoea (not bloody)? Clues in hx
- Milk, cheese
- > 70 yo, past C. diff, use of antibiotics, antiperistaltic drugs
- food, 1-6 hours after eating, short lived
- rice water diarrhoea, poor sanitation, shock
- leafy vegetables
- reheated rice, can cause cerebral abscess
- eggs, poultry may present with constipation, multiplies in Payer’s patches of the intestine
- sudden onset diarrhoea a few hours after a wedding reception
- A university student with watery diarrhoea a few days after a barbeque
- Listeria monocytogenes
- C diff
- Staph aureus
- Vibrio cholera
- E. Coli
- Bacillus cereus
- Salmonella
- sudden presentation that lasts less than 24h - because of a toxin in food (food poisoning) - Staph aureus, Bacillus cereus = bacteria that grow on warm food + produce toxins that result in rapid-onset diarrhoea
- campylobacter jejuni
