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GASTROENTEROLOGY > (1) > Flashcards

(1) Flashcards

1
Q

History:

Lower GI symptoms - 4 domains

Upper GI symptoms - 5 domains

Systemic symptoms - 5

Systemic symptom for cholestasis

Systemic symptom for encephalopathy

A

Stool - D/C, Melaena, Steathorrhoea
PR bleeding
Abdo pain
Bloating/abdominal distention

Jaundice (Could also have itch) 
Ulcers 
N&V - VCC - Haematemesis
Reflux
Dysphagia/Odynophagia
Anorexia 
Weight loss (malignancy/malabsorption) 
Nausea
Fatigue 
Fever

Pruritus

Confusion

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2
Q

History:

Abdominal pain locations:

What do the following pain locations suggest the differential is:

RIF - 3
LIF - 2
Epi - 2
RUQ - 2
Flank pain - 2
Suprapubic
A

RIF pain (appendicitis, Crohn’s disease, ectopic pregnancy)

LIF (diverticulitis, ectopic pregnancy)

Epigastric (oesophagitis and gastritis)

RUQ pain (cholecystitis and hepatitis)

Flank pain (renal colic and pyelonephritis)

Suprapubic pain (urinary tract infection)

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3
Q

History:

Travel history:

What to ask about? - 4

A

Area of travel: note areas with a high prevalence of specific diseases (e.g. malaria, campylobacter, shigella, giardia).

Diet: ask the patient if they recently ate any high-risk food in these areas (e.g. salmonella).

Insect bites: ask if the patient noticed any insect bites (e.g. mosquito bites preceding malarial symptoms).

Contact with contaminated water: ask the patient if they ingested water which may have been contaminated (e.g. swimming in contaminated water).

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4
Q

History:

PMH - What should you not forget to ask about?

DHx - GI side effects of the following meds:

  • Aspirin
  • Nsaids
  • St john’s wart
  • Opiates - 2
  • Penicillin
  • Ondansetron

SHx:

  • Risk of smoking - 2
  • Risk of alcohol - 2
  • Risk of IVDU
  • ASK ABOUT DIET!!!!!!!!!!!!!!!!!
A

Procedures such as endoscopy and colonoscopy

A - worsen GI bleeding
N - gastric/duodenal ulcer
JW - can alter clearance of prescribed meds

O - constipation, nausea
P - hepatitis
O - constipation

GI malignancy (oesophageal and oral cancers) + Crohn’s Disease

GI malignancy (oesophageal and oral cancers) + hepatitis/cirrhosis

Hep B

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5
Q

Examination:

What do the following indicate (also what are they called):

  • Clubbing - 3
  • White area on nails
  • Spoon shaped nails

Signs of CLD from hands? - 2

Flapping tremor? - 2

Spider naevi?

Eyes:

  • 2 main things to look for?
  • Hyperlipidaemia - 2
  • Wilsons - 1

Mouth:

  • Low iron - 1
  • Low B12

DONT FORGET LYMPH NODES

A

ALD - raised oestrogen - SPECIFICALLY ALCOHOL (>3)

IBD
Cirrhosis
Coeliac

Leukonychia - low albumin

Koilonychia - iron

Palmar erythema
Dupuytren’s contracture

Hepatic encephalopathy
Hypercapnia

Jaundice + anaemia

Xanthelasma + Corneal arcus

Angular stomatitis
Atrophic glossitis

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6
Q

Examination:

Caput medusae?

Palpation:

  • Hepatomegaly - 3
  • Splenomegaly - 2
  • Tender kidneys - 2
  • Palpable kidneys - 1
  • How would you know it is a AAA?

Percussion:
- Why percuss?

Auscultation - where do you listen for the following:

  • AAA
  • Renal arteries

What do they following suggest?

  • No BS - 2
  • Tinkling/high pitched BS

What 4(men)/5(women) exams do you say you will order or do after the examination?

A

Pulsatile, EXPANSILE mass

Dilation of epigastric vein
Portal HTN

Liver disease
Congestive HF (Right sided)
Cancer

Cirrhosis and other liver diseases
Infection

UTI/stones

Hydronephrosis - retention?

Organomegaly + ascites (shifting dullness)

3cm above umbilicus

3cm either side of a point 3 cm above umbilicus

So 3x3 basically

Paralytic ileus/peritonitis

Obstruction 
=======
Hernial orifices
PR/DRE 
External genitalia 
Urine dipstick

Pregnancy

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7
Q

DR Exam:

What 3 things may be seen?

What do you test for before advancing finger?

Once finger in, what do you get them to do?

If mass found, what 2 things should be recorded?
How would you know its stool?

What is felt with:

  • BPH
  • Cancer

What to do when you take finger out?

A

Lesions
External piles
Fistula

Sensation

Squeeze finger - weakness

Distance from anus + % of circumference

Stool moves and tends to be soft

Firm, nodular enlargement

Ill defined ——

Blood!!!!

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8
Q

BMI and Mouth Ulcers:

Underweight?
Overweight?
Obese?

Leukoplakia - what is it?
Candidiasis - associated with? 
Aphthous ulcers:
- 2 GI diseases that cause
- CON RX - 2
- MED Rx - 2

Gingivitis:
- Vit deficiency?

A

O > 30

UW - <18.5

OW >25

Oral mucosal white patch (pre-malignant)

Coeliac and Crohn’s = PAINFUL ULCERS

Soft toothbrush
Avoid acidic food

Antimicrobial mouthwash
Topical steroids and analgesia

=======

Vit C deficiency

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9
Q

GI Imaging:

Endoscopy:

  • What can be done to look at the jejunum?
  • How many wks to stop PPI?
  • How long should they fast?
  • Anaesthesia? - 2

2 types of lower GI endoscopy?

  • What 3 therapeutic procedures can be done?
  • What can be done for blood in stool?
  • What has been done in the end?
  • When should it not be done? - 2
  • What given for a clear view?
  • What drug is used for sedation? - M

Stops anticoags/platelets for procedures with high bleeding risk!

2 indications for a AXR?

A

Topical anaesthesia/IV sedation

Enteroscopy

2 wks

6 hrs - same for LOWER a

Sigmoidoscopy (splenic flexure)
Colonoscopy (terminal ileum)

Polypectomy
Stenting - for blockage
Decompression - twisting of bowel

Perforation
Diverticuitis - increases risk of perforation

Enema - clears bowel

Midazolam

Bowel obstruction - also do erect CXR for pneumoperitoneum

Foreign body

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10
Q

Dysphagia:

Within lumen:

  • Infectious causes - 4
  • Other causes?
  • Pre-cancerous

Within muscle:

  • Caused by GORD?
  • 2 type of oesophageal strictures?
  • LOS closure?
  • Also oesophageal spasm

Extramural:

  • Type of hernia
  • Congenital
  • Compressive process

Neurological causes - 5

A

Polyp

Candidiasis
Pharyngtiis
Retropharyngeal abscess
Oesophagitis***

Foreign body

Benign strictures

Oesophageal web (linked to iron deficiency anaemia) 
Oesophageal ring

Rolling hiatus hernia

Pharyngeal pouch

Malignancy

Stroke 
MG
MS
MND
PD
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11
Q

Dysphagia:

What do the following features suggest:

OATES:

O:

  • Both solid and liquids from start
  • Solids then liquids
  • Difficulty initiating movement

A:

  • Bulge or gurgle in neck
  • Cough on lying down - 2
  • Heart burn
  • Odynophagia - 3

T:

  • Intermittent
  • Constant/worsening
  • Both

E:

S ……

You may wish to do a neurological exam if indicated

A

Neuro - bulbar palsy

Spasm

Malignancy

Achalasia

Pharyngeal pouch

Achalasia + PP

Motility issue - MG, pharyngeal issue

Stricture - benign or malignant

GORD
======
Ulcer 
Oesophageal spasm 
Oesophagitis
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12
Q

Dysphagia:

Inv:

Bloods - 2

Imaging:

  • Gold standard?
  • For pharyngeal pouch
  • Gold standard for dysmotility?

Oesophageal spasm:
- 2 main symptoms?

How to Rx oesophageal stricture?****

A

Oesophageal manometry

FBC + U&E (anaemia and dehydration)

Upper GI endoscopy +/- biopsy

Barium /contrast swallow

Intermittent dysphagia
Chest pain

ENDOSCOPIC BALLOON DILATATION

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13
Q

N&V:

Appearance:

  • Coffee grounds
  • Recognisable food
  • Faeculent

Timing:

  • Morning - 2
  • Post-prandial
  • Vomiting relieving pain
  • Preceded by loud gurgling

Other causes:

  • Infection
  • Acute upper GI - 2
  • Occurs more distally
  • Malignancy
  • Ulcer

Non-GI causes - look at main cuecards

A

Thicker and foul-smelling - distal bowel obstruction

Upper GI bleeding

Gastric stasis

Pregnancy
Raised ICP

Gastric stasis/gastroparesis - happens in DM and pyloric sphincter closure

Peptic ulcer

GE

Acute cholecystitis or pancreatitis

Gastric cancer

PUD

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14
Q

N&V:

Inv:

  • What is seen on ABG?
  • Imaging and why?
  • What is persistent vomiting/blood?

1 Rx?

A

Endoscopy

Metabolic alkalosis

AXR - bowel obstruction

Anti-emetics

Monitor electrolytes and fluid balance

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15
Q

Anti-emetics:

(1) Anti-histamines:
- 2 examples
- Type of side-effects it has

(2) Anti-dopaminergic (METACLOPAMIDE):
- Side effects - 3
(DOMPERIDONE)
- What type of patient is this safe to use in?

(3) Anti-serotonergics:
- 1 example
- Main GI side effect

SE for all anti-emetics

Sniffing isopropyl alcohol swabs for rapid relief!

A

Constipation

Cyclazine
Promethazine

Anti-cholinergic effects

Confusion
Dyskinesia + Parkinsonism**
========
Parkinson Disease
====
Ondansetron - also used in reflux - H1 receptor blocker

Sedation

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16
Q

Dyspepsia:

3 symptoms it comes alongside?

You can get functional dyspepsia!

Causes:
Most common cause
Oesophageal - 3
Gastric - 2

A

Fullness
Belching
Nausea

=====
PUD

GORD
Oesophagitis
Oesophageal cancer

Gastritis
Gastric cancer

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17
Q

PUD:

DUO>GAS

Main cause of DU?

Main cause of GU? - 2

Other causes:

  • Lifestyle -2
  • Med?

S+S:

  • Burning, epigastric pain/tenderness
  • Timing?
  • Which type if relieved by food?
  • 2 signs of a bleeding ulcer?

Inv:

Bed:
2 test for H. Pylori?
Instructions to patient?

Bloods - 1 and why?

Imaging - Endoscopy with biopsy - what further test can be done after biopsy?

A

Steroids

H. Pylori - gastric acid hypersecretion

H. Pylori - damage of epithelial tight junctions
NSAID’s

Smoking + Alcohol

GU (1-3 hrs after food)
DU (4-5 hrs after - so more likely to wake you up in the night

DU - as food buffers acid - REMEMBER - acid hypersecretion is the cause of this

Haematemesis 
Melena 
=======
13C urea breath test *******
Stool antigen test ********

Stop PPI 2 wks before

FBC - anaemia

Rapid urease test - biopsy place into medium with urea - changes colour if positive

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18
Q

PUD:

Prevention for long term steroids

Alternative to NSAID’s

Management of dyspepsia:

  • Review meds and lifestyle changes - CON
  • How do you know it is more PUD > GORD?

MED:
H. pylori - Triple therapy given? **
What if they are negative?

SURG:
- For severe disease

2 complications of PUD?

A

Mneumonic - CAMP to remember all the drugs used

Prophylactic PPIs

COX2 inhibitors - celecoxib

Epigastric pain greater in PUD 
====
7 days of PPI - can keep for months 
\+ 
1 wk of Amoxicillin
\+ 
1 wk of Clarithromycin or Metronidazole

1-2 months PPI (lansoprazole)

Bleed
Perforation or penetration (fistula)

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19
Q

PUD:

Perforated ulcer:

  • 3 features?
  • Imaging and why?

Management:

  • Initial management
  • SURG - how is it repaired?

Gastritis very similar to PUD but without an actual ulcer - it is a precursor so a useful differential

A

Epigastric pain
Shock
Peritonitis

Erect CXR - pneumoperitoneum
CT can also be used!

Drip and suck (IV and empty stomach)

Peritoneal washout
Surgical repair with patch of omentum

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20
Q

GORD Causes:

Medical:

  • Hiatus hernia - 2 types and which one is more common?
  • Infection?
  • Oesophageal dysmotility?
  • DM

Lifestyle - 3?

Meds:

  • 2 BP tablets
  • Also anticholinergics + COCP
  • Pain meds?

Heartburn pain:

  • Character
  • Pain better/worse after food
  • What makes it worse?
  • Relieving meds?

Other symptoms in GORD - 5

A

NSAIDs

SLIDING - cardia of stomach moves up *******
Rolling - funds moves up

H. pylori - gastric acid hypersecretion

Systemic sclerosis

Delayed gastric emptying 
======
Obesity + overeating
Alc
Smoking - Nicotine products can weaken your LES, increasing your symptoms.
======
BB + CCB - slows motility

Burning pain

Worse after eating

Bending forward makes it worse

Antacids 
=====
Cough
Hoarseness - due to acid affecting vocal cords 
Nocturnal asthma 
Belching 
Acid brash (acid regurg)
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21
Q

GORD:

What can be done to diagnose it clinically?

INV:

Endoscopy:*******

  • Indicated if ALARM signs - what are they?
  • 3 things seen?
  • PPI?
  • What can be done if endoscopy not diagnostic?

Management:

CON - USUALLY DONE FIRST:

  • Lifestyle - 2
  • Eating habits - 4

MED:

  • 1st line med with 2 examples?
  • What should be done if still symptomatic after meds?
  • Alternative to PPI

Complications of GORD - 4

A

24 hr pH monitoring in oesophagus (<4 diagnostic)

Clinical - after trial with PPI

Anaemia - bleeding 
Loss of weight 
Anorexia 
Recent onset/progressive sym
Melaena/haematemesis

Swallowing difficulty - Dysphagia

Oesophagitis
Barret’s
Oesophageal cancer

Lose weight + exercise
Reduce Alc and S

Reduce spicy and fatty foods
Small regular meals
No food < 3 hrs before bed
Raise the bed head

PPI 1-2 months - Lansoprazole /Omeprazole

Test for H. pylori 
=====
H2 blockers - famotidine/ranitidine 
=====
Oesophagatiis 
Oesophageal ulcers 
Benign oesophageal strictures (peptic stricture) 
Barrett's oesophagus
22
Q

Upper GI bleed:

Causes:

  • Common causes?
  • Inflammation - 3
  • Vomiting
  • UPPER GI CANCER **

Other causes:

Varices:
- Cause
Rx:
- MED - 1 - reduce BP 
- SURG - 1

Portal HTN:

  • Pre-hepatic cause?
  • Hepatic —?
  • Post-hepatic —? - 2

S+S:

  • 2 sites of pain
  • Vomit
  • Stool
  • If severe?
A

Mallory-Weiss tear

PUD - alcohol can also be a cause for an ulcer

Oesophagitis
Gastritis
Duodenitis

CLD

BB

Endoscopic banding/sclerotherapy (Sclerotherapy is a form of treatment where a doctor injects medicine into blood vessels or lymph vessels that causes them to shrink).

Thrombosis

Cirrhosis

Epigastric
Diffuse abdo pain

Red if ACTIVE
Coffee-ground if SETTLED

Melaena - black and foul smelling - also caused by Fe and cancer

SHOCK**

23
Q

Upper GI Bleed:

INV:
Bed - OBS 
Bloods - 5 and why?
Imaging - 2?
What is the GOLD standarrd imaging for diagnosis?

RISK ASSESSMENT:

  • Score to stratify upper GI bleeding patients who are “low-risk” and candidates for outpatient management.
  • Score to assess severity?

MEDICALRx:

  • ABCDE if unstable - what may need to be given if needed - 3
  • Instructions for patient?

Oesophageal variceal bleed:

  1. Main drug given until haemostasis reached?
  2. What can be added if it is due to portal HTN?
  3. What should you not forget?

Gastric variceal bleed
4. N-Butyl cyanoacrylate - why?

Non-variceal bleed - 1 drug that is used in this?

SURGICAL Rx:

Oesophageal variceal bleed:

  • 1st line
  • 2nd line if 1st line unsuccessful

Gastric variceal bleed:
- 1st line

Non-variceal bleed:
- Endoscopy - what do they do? - 3

You can only continue aspirin after an acute bleed which has been resolved!

A

Endoscopy (if not acute, then within 24 hrs)

FBC - rule out anaemia 
LFT's 
Coag 
U&E - raised urea 
Group and save + crossmatch - surgery

Erect CXR + AXR
CT abdo-chest

Blatchford score - Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.

Rockall score (used pre-endoscopy)
Complete rockall score (post-endoscopy to determine severity)
======
O2 + fluids + transfusion (FFP, PCC for those on warfarin)

NIL BY MOUTH

Terlipressin - vasoconstrictor - stop after haemostasis

Somatostatin - diminishes flow to portal system

Prophylactic AB - due to risk of infection

Gastric varices - basically a glue

========
PPI IV - decrease the rate of further bleeding and need for surgery in such patients.
========
Band ligation

TIPS - connects portal vein and hepatic vein
========
Clipping
Thermal coag + adrenaline
Fibrin or thrombin + adrenaline

24
Q

Achalasia:

Get fluid regurg but what else may it cause?

INV:

  • Gold standard imaging + sign seen?
  • How to measure of LOS?

MED Rx:

  • 1st line - Cardiac drug for given for relaxation?
  • 2nd line

SURG Rx:

  • 1st line to dilate LOS?
  • 2nd line?
A

Oesophageal manometry

Aspiration pneumonia

Upper GI endoscopy

Bird peak sign**

CCB - nifedipine

1st - Endoscopic dilatation of LOS

2nd - Cardiomyotomy

25
Q

Pharyngeal Pouch:

2 symptoms?

Why nocturnal cough?

SURG Rx:
- 2?

A

Regurg of food

Dysphagia
Regurg

Excision of pouch
Stapling

26
Q

Hiatus hernia:

Define sliding and rolling?

Main symptom?

Other signs:

  • Vomiting
  • Weight loss
  • Bleeding (due to ulceration)
  • Hiccups/palpitations

One sign on examination?

GOLD standard INV?

CON Rx

  • Lifestyle - 2?
  • Eating habits - 2?

MED Rx - 1

SURG Rx - 2 types?

A

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

27
Q

Oesophageal perforation:

Iatrogenic cause?

2 other causes?

Mackler’s triad?

GI symptoms - 2

INV:

  • Initial imaging?
  • GOLD STANDARD?

Management:

  • How to feed?
  • If perf, what should not be forgotten?
  • SURG Rx? - don’t need to know - refer to cardiothoracic and get surgeon
A

CT***** - not endoscopy as it is introducing more foreign pathogens into the mediastinum

Endoscopy

Trauma + swallowed sharp foreign body

Neck, chest or epigastric pain - EXCRUCIATING
Vomiting
Subcutaneous emphysema

Upper GI bleed
Dysphagia
======
CXR

NG suck of contents
NasoJEJUNAL feeding

Prophylactic ABs

Debridement of mediastinum and T-tube for oesophagocutaneous drainage

28
Q

Diarrhoea (> 3 stools per day)

Bristol stool chart - score?

When is it chronic?

Cause of Acute D?

Bloody diarrhoea - 2 causes?

Pussy diarrhoea - 2 causes?

Explosive diarrhoea - causasive pathegen - 3

Steatorrhoea - 4 signs? - 2 causes?

GI:
- Endocrine causes? - 2

3 signs of dehydration?

INV BEDSIDE - Stool - 4

  • 2 things you look for/do for stool samples?
  • What specific pathogen can be looked for?
  • What is used to look for chronic pancreatitis?
  • For IBD and IBS?
  • Test for H. pylori causing D?
  • For lactose intolerance?

INV - BLOODs - 5:

(1) FBC - what do the following suggest?
- Low mcv
- High mcv
- low B12

(2) U&E:
- What electrolyte is expected to fall with D?
* *******

(3) ESR/CRP - 3 causes of rise
(4) TFT’s - why?
(5) EXTRA for bloods - Coeliac serology?

INV (Initial):
- When is 2WW done?

A

GE

5-7

> 4 wks

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

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

29
Q

Diarrhoea - Management:

Most self-resolve.

Rx - 2 therapeutic interventions?

What 2 meds can help?

What is done for AB diarrhoea?

A

Oral rehydration/IV
Electrolyte replacement

Loperamide - reduces smooth muscle tone stopping D
Codeine

Probiotics

30
Q

Constipation (<3 a wk):

What does alternating with D suggest?

Causes - BOWEL:

  • 2 anal causes
  • Rectum - 1
  • Neoplasm
  • How can Crohn’s cause it?
  • Extraluminal - 2
  • BOWEL OBSTRUCTION IS AN OBVIOUS CAUSE!

Causes - DIETARY - 2?

Causes - FUNCTIONAL - 1

Causes - METABOLIC:
- 2 electrolyte imbalances and why?

Causes - ENDOCRINE - 1

Causes - NEUROLOGICAL - 2

Causes - PSYCH - 1

Causes - DRUGS - 3

Why post-operatively? - 2

Why hospital? - 2

A

Fetus and fibroids

IBS

Anal fissure and stricture

Rectal prolapse

CC

Crohn’s stricture

Dehydration and low fibre

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

31
Q

Constipation:

INV - BEDSIDE - 1

INV - BLOODS - 4 and why?

INV - IMAGING - 1 - not usually done

CON Rx - 2

MED Rx:

  • 4 types of laxatives
  • What is the main type?
  • Which one is the fastest?
A

AXR

PR exam

FBC - iron for anaemia
ESR/CRP - inflam
U&E’S = K+Ca
TFT’s

Increased fibre and fluid

BULKING AGENTS****
Stimulant laxatives - fastest
Osmotic Laxatives
Stool softener

32
Q

Constipation:

Bulking agents:

  • MOA
  • Onset?

Stimulant L:

  • Examples? - 2
  • MOA?
  • SE - 1?

Osmotic L:

  • MOA
  • Main example?

Stool softeners:

  • 3 examples?
  • Softens stool to allow easier passage. When may it then be indicated?
A

Few days

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

SENNA **

Stimulate bowel movements

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

33
Q

Jaundice:

Say/draw out bilirubin cycle!!!

Over what level leads to jaundice?

PRE-HEPATIC:

  • Causes? - 1
  • Gilbert’s syndrome - what is it?
  • What is raised in bloods and urine?
  • Stool and urine normal

HEPATIC (liver dysfunction):

  • Stool?
  • Urine?
  • What is raised in bloods?

OBSTRUCTIVE:

Cause:

  • Luminal - 1
  • Mural - 2
  • Extra-mural - 2
  • Mirizzi’s syndrome?
  • Autoimmune - 2
  • Pregnancy - 1

Features:

  • Stool?
  • Urine?
  • Why do they itch?
  • Bloods?
  • Urine - what is high and what is low?

INV for obstructive:

  • 1st line imaging?
  • GOLD STANDARD imaging?

Management for obstructive:

MED Rx:
- Done according to needs to patient - e.g. IV fluids

SURG Rx:
- GOLD STANDARD Rx

Complication:
- Why is IV Vit K given?

History:

  • What would you ask about for Hep B? - 4
  • What recent Rx would you ask about? - 1
A

Obstetric cholestasis

> 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

PALE stool + DARK urine

Due to build up of BILE SALTS - not bilirubin

High CONJUGATED bilirubin

USS

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

34
Q

UC:

Transmural or mucous only?

2 features if severe?

S+S - INTESTINAL:

  • 2 main symptoms?
  • 2 rectal symptoms?

UC attacks - Trigger?

Same as Crohn’s:

S+S - NON-INTESTINAL:

  • Eyes - 3
  • Mouth - 1
  • Hands - 1
  • Shin’s - 1
  • Leg - 1

What is the most common non-GI sign?

What autoimmune disease of liver can it cause?

Why are they at an increased risk of VTE?

Risk factors - linked gene?

INV - BEDSIDE - STOOL - 3

  • To rule out infection?
  • Marker for inflammation?
  • Pathogen that cause D?

INV - BLOODS - 4 and why?

  • What does inflam do to platelets and albumin?
  • Autoantibody?

INV - IMAGING - ENDOSCOPY:

  • What is done if acute and if chronic?
  • What is seen on endoscopy?

AXR - why? - 3

A

HLA-B27

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

MC+S

Faecal calprotectin

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

A - limited flexible sigmoidoscopy with biopsy ** GOLD STANDARD

C - full colonoscopy with biopsy****

Crypt architecture 
=========
Perforation
Gross dilatation 
Toxic megacolon (>6 cm)
35
Q

UC - Management:

Score used to assess severity?

CON Rx - Patient education

MED Rx - Mild to moderate:

  • 1st line is 5-aminosalicylic acid (5-ASA) for distal disease - give 2 examples? - M, S
  • Whats added if more proximal?

MED Rx - Severe:

  • What is severe?
  • 1st line med?
  • 2nd line to induce remission - 2nd line for refractory disease

MED Rx - Remission:
- After how many attacks are immunosuppressors (azathioprine) needed?

SURG Rx:

  • Type done in acute cases?
  • MAIN SURGICAL Rx?
  • What is a J pouch?
A

Can also add PR steroid foams

Truelove and Witt’s severity index

Mild to moderate:

MESALAZINE***** - maintains remission and reduces flare ups as it reduces inflammation
SULPHASALAZINE

Prednisolone

Severe - >6 stools, systemically unwell

IV Corticosteroids

Ciclosporoin - immunosuppressor

> # 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

36
Q

Crohn’s:

Main place affected?

This is transmural - granulomatous inflammation

Younger or older?

S+S:

  • 2 main
  • Other features are weight loss, fever and fatigue.
  • Is it more chronic/acute than UC?
  • Perianal signs? - 3
  • What may be found on examination?
Same as UC:
S+S - Non-GI:
- Mouth - 1
- Eyes - 3 - same as UC 
- Nail - 1
- Shin's - 1
- Leg - 1

What is the most common non-GI sign?

INV - BEDSIDE - same as UC

INV - BLOODS - same as UC
- Antibody associated with Crohn’s?

INV - IMAGING:

  • AXR - 2 features you could find?
  • Barium enema - what will it show?
  • What imaging for more detailed look at disease extent?

FOR DIAGNOSIS - INV - COLONOSCOPY - 2 KEY signs?*******

What will biopsy show?

A

Younger - tend to be smokers as well

Terminal ileum

Diarrhoea
Abdo pain

Usually more ACUTE

Abscess
Fistula
Tags

Aphthous ulcers

Uveitis
Episcleritis
Conjunctivitis

Clubbing

Erythema nodosum

Pyoderma Gangrenosum

ARTHRITIS 
========
Anti-saccharomyces cerevisiae antibodies (ASCA)
========
Dilatation - toxic megacolon
Abscess

Strictures

Skip lesions
Cobblestone appearance

Transmural disease with granulomas

37
Q

Crohns - Management:

CON Rx - 1

MED Rx to induce remission - 1 drug - REMEMBER - Crohn’s tends to be more acute

2 Drugs that can be added for refractory disease?

MED Rx for maintaining remission:

  • 1st line
  • 2nd line

MED Rx for symptomatic relief:

  • For diarrhoea?
  • For cramping?

SURG Rx - Small bowel:
- Can get short gut syndrome - 4 effects?

SURG Rx - Large bowel:
- MAIN SURGICAL Rx?

Complication of surgery:
- 2 effects of (disease or) removal of terminal ileum and how to solve them?

A

Immunosuppressors - methotrexate or biologics

Cut out smoking

Methylprednisolone IV 3 days
THEN
Prednisolone PO for 2 wks after

Azathioprine
Biologics
=====
5-ASA - Azathoiprine

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
38
Q

Crohns vs UC:

Where does it tend to affect?

Main symptom

Thickness of inflammation

Complications - 2

Also go through stomas deck!

A

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

39
Q

GI Malabsorption:

3 causes?

3 causes of low bile?

2 causes of pancreatic insufficiency?

What deficiencies would cause:

  • Anaemia
  • Bleeding disorder
  • Oedema
  • Metabolic bone disease
  • Neurological feature
A

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

40
Q

Coeliac Disease:

Define?

4 GI symptoms?
Stool?
Mouth? - 2
Due to malabsorption? - 3
Skin?

ASK ABOUT AUTOIMMUNE DISEASES

INV - BLOODS - 3 and why?

  • Why LFT’s?
  • Autoantibody?
  • What must the patient do to make sure bloods are accurate?

INV for osteoporosis?

What is done for diagnosis?**

Rx - 2

A

Stay ON gluten

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

DEXA
====

Upper Endoscopy + biopsy ****
=====
Life long gluten free diet 
Remove wheat (bread and pasta), rye and barley)

Replace micronutrients

41
Q

IBS:

What is the main difference in the stool between IBS and IBD

List a few symptoms?

INV - BEDSIDE - 2

INV - Bloods - 3 and why?

  • What test can be used to differentiate between IBS and IBD?
  • To rule out coeliac
  • How can you make sure there is no blood?

CON Rx - Dietary - list a few

Low FODMAP diet also used if severe!

MED RX for symptomatic relief:

  • For bloating
  • For diarrhoea
  • For constipation
  • For cramps

What is another cause of iBS that shouldn’t be forgotten about?

A

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!!!

42
Q

Nutritional Disorders:

Scurvy:
- Cause?

S+S:

  • Gum?
  • Muscle?
  • Also get anorexia, cachexia and halitosis
  • Rx? - A

Vit A def - causes?

Vit B12 deficiency - 3 signs

Vit D def - 2

Iodine def leading to?

A

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

43
Q

Obesity:

BMI for overweight and obese

2 endocrine causes?

Health risk:

  • CVD
  • Metabolic syndrome - 3
  • Resp
  • GI
  • Bone

Management:
1, 2, 3 and 4th line?

A

Osteoarthritis

> 25

>35 
=====
Hypothyroidism 
Cushing's Syndrome 
=====
HTN, stroke etc.

T2DM + NAFLD + HTN

Obstructive sleep apnoea

Gallstones

Weight loss diet

Regular exercise

Orilistat

Bariatric surgery

44
Q

Gastroenteritis:

Viral - name?
Bacterial - name?

2 symptoms?

Campylobacter - how do you usually catch it?

Salmonella - how do you usually catch it?

Profuse water D - cause?

INV - Bedside - 1

INV - BLOODS - 4 and why?
D+V can be a feature of sepsis and many other infections - CNS, urinary, appendicitis

CON Rx - 1

MED Rx - inpatient - 2

Complications:

  • Joint
  • Neuro
A

Acute D and/or VOMITING

Norovirus
Adenovirus
Rotavirus

Salmonella
C. diff
Shigella
E. coli

Eating infected poultry

Infected poultry, eggs and milk

Stool - MC+S

FBC (RAISED WBC) 
U&E (Dehydration) 
CRP (Inflammatory marker) 
LFT (Helps with differentials)
=====
Oral fluids

Anti-emetics
Anti-diarrhoeal - loparemide

Reactive arthritis
Gillian-Barre syndrome - CAMPYLOBACTER

45
Q

C.diff:

Iatrogenic cause?

S+S:

  • Diarrhoea?
  • 2 more?

INV - BEDSIDE - what can be done to confirm from a stool sample? *****

INV - BLOODS - 2

Rx with specific AB’s

A

ABs

Profuse watery d

Abdo pain and tenderness
Fever

PCR +/- toxin immunoassay****

FBC - raised WBC
U&E - AKI due to dehydration

46
Q

Acute abdomen and surgical emergencies:

Types of pain in obstruction?

Peritonitis:

  • What makes pain worse?
  • 3 other features?

What do rigors suggest? - 3

INV - BEDSIDE - 2 and why?

INV - BLOODS - 6 and why?

For women?

INV - IMAGING - 4?

When should an exploratory laparotomy be considered?

A

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

47
Q

Acute abdomen and surgical emergencies:

Lower GI bleed:

INV - BLOODS - 6 and why?

INV - IMAGING - 1

INV - Special test - COLONOSCOPY:
- How may haemostasis be achieved? ***

A

CT abdo-pelvis

  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

Adrenaline, thermal coag or clipping

48
Q

Nasogastric the placement:

How to determine length?

Confirmation:

  • 1st line
  • CXR - 3 signs
A

Nose to ear to the xiphoid

pH (should be <5.5) - aspirate some contents

CXR:

  • Crosses carina
  • Crosses diaphragm
  • Tip visible beneath D
49
Q

Appendicitis:

Pain:

  • Character
  • Radiation

What indicates peritonitis? - 3

What indicates abscess?

4 signs on examination and define?

3 complication if untreated?

A

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

50
Q

Appendicitis:

INV - BEDSIDE - OBS

INV - BLOOD - 6 and why?

INV - IMAGING - 2

MED Rx - 1

SURG - Rx - 1

Management of complications:
- Abscess

A

Appendectomy

  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

IV antibiotics and CT-guided drainage

51
Q

Diverticular Disease:

Difference between diverticulosis and diverticular disease

What is it?

Cause?

Non-specific symptoms of diverticular disease - 4

Diverticulitis:

  • LIF pain - what else may be seen?
  • Stool? - 2
  • Anorexia and N&V as well
  • Signs of perf?

Complications:

  • 2 types of fistula?
  • Cause of bowel obstruction
  • 2 complications of perf?
A

Can get PR bleeding but not common

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

Guarding

PR mucus and blood + diarrhoea

Colovaginal and colovesical

Strictures

Abscess (may be hypochondriac or in splenic flexure
Perintotis

52
Q

Diverticular disease:

INV - BLOODS - 6 and why?

INV - IMAGING - 2 and why?

Management:

CON Rx - 1 - uncomplicated
MED Rx - 3 - uncomplicated at home

SURG Rx:

  • Over how many cm’s is an abscess drained?
  • How is it drained?
  • What procedure is done for severe disease?
  • What classification is used to classify colonic perforation due to diverticular disease and therefore guides management?
A
  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

GASTROENTEROLOGY (54 decks)

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