Amir Sam: GI Med/Surg Flashcards Preview

Year 3 Medicine > Amir Sam: GI Med/Surg > Flashcards

Flashcards in Amir Sam: GI Med/Surg Deck (94):
1

Causes of hepatomegaly

3 C's plus infiltration:

Cancer (primary or secondary deposits)

Cirrhosis (early, usually alcoholic- otherwise shrunken)

Cardiac: Congestive cardiac failure OR Constrictive pericarditis

Infiltration: fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases

2

Causes of liver disease

Alcohol

Autoimmune

Drugs

Viruses

Biliary disease (not affecting hepatocytes)

3

Patient with ALT of 300 (high)

Liver cell damage: Alcohol, Autoimmune, Drugs, Viruses

4

Causes of splenomegaly

2 Hs, 2 Is:

H (portal Hypertension- chronic liver disease)

H (Haemotological- cancers, lymphoma)

Infection (UK: IE, Infectious mononucleosis (EBV), TB, brucelosis. Abroad: malaria, schistosomiasis, leishmaniasis)

Inflammation (sarcoidosis)

5

Chronic liver disease signs:

A-J ABCDE in hands:

A: asterixis

B: bruising

C: clubbing

D: Dupuytren's contracture

E: palmar Erythema

 

F: fetor hepaticus (pear drops)

 

G: gynaecomastia

H: hair loss (over chest)

 

I/J: Icterus/Jaundice

6

Causes of abdominal distension

Lots of F's

Flatus (air, obsturction)

Fluid (ascites)

Foetus

Faeces

Fat

7

Casues of Diarrhoea

Infection (colitis)

Inflammation (IBD)

Malignancy

8

Casues of Diarrhoea

Infection (colitis)

Inflammation (IBD)

Malignancy

9

Framework for abdominal pain 2 Q's

Location (9 areas or 4 quadrants)

Character: Intermittent (obstruction), Constant (inflammation)

10

75 year old man

Epigastric pain

Back pain

PR: 130 bpm

BP: 80/50 mmHg

Ruptured Aortic Aneurysm

epigastric pain

back pain

tachycardic and hypotensive (blood loss)

11

Causes of epigastric pain (not stomach/pancreas):

Above, below, left right:

Heart: MI, pericarditis

Aorta: ruptured aortic aneurysm

Liver/gall bladder: cholecystitis, hepatitis

Spleen: splenic rupture

12

Presentation of acute pancreatits

pain

high amylase

13

Pain

High amylase

Acute pancreatitis

14

Chronic pancreatitis

Pain weight loss

loss of exocrine function

loss of endocrine function

Normal amylase

Faecal elastase

15

5 causes of epigastric pain (things there):

2 organs there:

Stomach:

- PEPTIC ULCER (NSAID use)

- GORD (better with antacids)

- Gastritis (retrosternal, alcohol) - malignancy

 

Pancreas:

-Acute pancreatitis (gallstones, alcohol, high amylase)

16

Epigastric pain

High amylase

Acute pancreatitis

17

Chronic pancreatitis

Chronic epigastric pain

weight loss

loss of exocrine function

loss of endocrine function

Normal amylase

Faecal elastase

18

5 causes of epigastric pain (things there):

2 organs there:

Stomach: - PEPTIC ULCER (NSAID use)

- GORD (better with antacids)

- Gastritis (retrosternal, alcohol)

- malignancy

 

Pancreas:

-Acute pancreatitis (gallstones, alcohol, high amylase)

19

50 year old man

history of excess alcohol

chronic epigastric pain

losing weight

On insulin

On creon

chronic pancreatitis (creon is pancreatic enzymes)

20

50 year old man

history of excess alcohol

chronic epigastric pain

losing weight

On insulin On creon

Which investigation?

Fecal elastase (will be low in chronic pancreatitis- measure elastase in stool)

21

50 year old man history of excess alcohol

chronic epigastric pain

losing weight

On insulin On creon

Which investigation?

Fecal elastase (will be low in chronic pancreatitis- measure elastase in stool)

22

Causes of RUQ pain:

Liver: Hepatitis Abscesses Malignancy (HCC)

Gall bladder: Cholecystitis Cholangitis Gallstones

 

Above: Lung (Basal pneumonia)

Left: Stomach/pancreas (peptic ulcer/pancreatitis)

Below: Appendicitis (long appendix- retrocaecal)

Right: Kidney (pyelonephritis)

23

Causes of RUQ pain:

Liver: Hepatitis Abscesses Malignancy (HCC)

Gall bladder: Cholecystitis Cholangitis Gallstones

Above: Lung (Basal pneumonia)

Left: Stomach/pancreas (peptic ulcer/pancreatitis)

Below: Appendicitis (long appendix- retrocaecal)

Right: Kidney (pyelonephritis)

24

Causes of RIF pain:

Bowel:

Appendicitis

Colitis (IBD)

Malignancy (some dull pain- not PC)

Mesenteric adenitis (in children- infective)

 

Gynaecological:

Ectopic pregnancy (pregnancy test- urinary hCG)

Ovarian cyst: rupture, tortion or bleed Pelvic inflammatory disease (PID)

25

Causes of suprapubic pain:

Bladder: Cystitis (inflammation)

Urinary retention (stones, clot, malignancy, neurological, constipation)

26

Causes of LIF pain:

Bowel: Diverticulitis Colitis (IBD) Malignancy

Gynaecological: Ectopic pregnancy (pregnancy test- urinary hCG)

Ovarian cyst: rupture, tortion or bleed

27

5 causes of epigastric pain (things there):

2 organs there:

Stomach: - PEPTIC ULCER (NSAID use)

- GORD (better with antacids)

- Gastritis (retrosternal, alcohol)

- malignancy

 

Pancreas:

-ACUTE PANCREATITIS (gallstones, alcohol, high amylase)

28

Causes of RIF pain:

Bowel:

APPENDICITIS

Colitis (IBD)

Malignancy (some dull pain- not PC)

Mesenteric adenitis (in children- infective)

 

Gynaecological:

Ectopic pregnancy (pregnancy test- urinary hCG)

Ovarian cyst: rupture, tortion or bleed Pelvic inflammatory disease (PID)

29

Causes of suprapubic pain:

Bladder:

Cystitis (inflammation)

Urinary retention (stones, clot, malignancy, neurological, constipation)

30

Causes of LIF pain:

Bowel:

DIVERTICULITIS

Colitis (IBD)

Malignancy

 

Gynaecological:

Ectopic pregnancy (pregnancy test- urinary hCG)

Ovarian cyst: rupture, tortion or bleed

31

Causes of LIF pain:

Bowel:

DIVERTICULITIS

Colitis (IBD)

Malignancy

 

Gynaecological:

Ectopic pregnancy (pregnancy test- urinary hCG)

Ovarian cyst: rupture, tortion or bleed

32

Causes of diffuse abdominal pain:

Obstruction

Infection: peritonitis, gastroenteritis (viral or bacterial)

Inflammation: IBD

Ischaemia: mesenteric ischaemia (clot in a mesenteric artery)

 

Medical causes:

DKA (may be first presentation of T1 diabetes)

Addison's disease (adrenal insufficiency)

Hypercalcaemia

Porphyria (rare)

Lead poisoning (rare)

33

65 year old man AAA repair 2 days ago

Diffuse abdominal pain

PR: 120bpm

RR: 30

Blood tests are likely to show:

A. Normal lactate

B. High amylase

C. High bicarbonate

D. High sodium

E. High Calcium

B. High amylase Amylase can go up in any cause of acute abdomen!! (not specific to pancreatitis) Lactate wont be normal (lactic acidosis will occur as he's sick and hypotensive (tachycardic)) Won't have high bicarb as lactic acidosis (low bicarb) High sodium is very rare (only in diabetes insipidus or people who can't drink) Nothing to suggest high calcium

34

Mesenteric ischaemia: affecting stomach, spleen, liver, gallbladder, duodenum

Coeliac artery

35

Mesenteric ischaemia: Small intestine, right colon

Superior mesenteric artery

36

Mesenteric ischaemia: Left colon

Inferior mesenteric artery

37

55 year old man

Excess ETOH use

Cirrhosis

Confused

Abdominal pain

Abdominal distension

O/E: Ascites, liver flap

 

Consistent with? Investigation?

Spontaneous Bacterial Peritonitis

Ascitic tap: measure neutrophils

 

Microbiology: Gram stain and cell count (urgent cell count to start treatment)

Cytology: malignant cells

Biocheem: protein 

 

If >250 neutrophils/mm3--> Start treatment: ciprofloxacin

38

55 year old man

Excess ETOH use

Cirrhosis

Confused

Abdominal pain

Abdominal distension

O/E: Ascites, liver flap

Which of the following is consistent with SBP:

A. Ascites neut ≥ 25 cells/mm3

B. Ascites neut ≥ 50 cells/mm3

C. Ascites neut ≥ 100 cells/mm3

D. Ascites neut ≥ 250 cells/mm3

E. Ascites neut ≥ 500 cells/mm3

D. Ascites neut ≥ 250 cells/mm3

39

Abdominal distension: Clues of fluid

Ascites: shifting dullness, features of liver disease

40

Abdominal distension: Clues of flatus (gas)

Obstruction:

-N&V

-Not opened bowel

-High-pitched tinkling BS

-Previous surgery (adhesions)

-?Tender irreducible femoral hernia in the groin

41

Difference between ischaemic colitis and mesenteric ischaemia?

Ishcaemic colitis: blockage of small vessels in colon. Presents with bloody diarrhoea.

Colonoscopy- look at mucosa.

 

Mesenteric ischaemia: involves large vessels (coeliac, SMA, IMA). Present with Pain from ischaemia (particularly after eating).

CT angiogram- to find blockage

42

50 year old man

Jaundice

RUQ pain

Dark urine

Pale stool

 

What is the cause of his pale stool?

1. Low biliverdin

2. High unconjugated bilirubin

3. High conjugated bilirubin

4. Low urobilinogen

5. Low stercobilinogen

5. Low stercobilinogen (makes stool brown- so lack makes a pale stool)

Caused by CBD blockage

43

Types of causes of jaundice:

Pre-hepatic: (haemolysis, defective conjugation of bilirubin)

Hepatic: (damage to hepatocytes- 4 causes alcohol, autoimmune, drugs, viruses)

Post-hepatic: CBD obstruction

44

Bilirubin pathway and metabolism:

Normal breakdown of RBCs in spleen --> release of unconjugated bilirubin (from metabolism of haem) ---> conjugated in the liver by Glucuronyltransferase ---> secreted in the bile ---> converted to urobilinogen then stercobilinogen (Brown- makes stool brown) in the gut

45

Pre-hepatic jaundice causes:

Excess haemolysis (Haemolysis) or reduced glucoronidation (Gilbert's disease- deficiency of glucronyltransferase enzyme)

 

Anaemic plus jaundiced (with increased reticulocyte count)--> Haemolysis

46

Jaundiced

Anaemic (low Hb)

Increased reticulocyte count

Haemolysis

47

Hepatic causes of jaundice:

Hepatitis (4 causes)

alcohol, autoimmune, drugs, viruses

 

(leakage of conjugated bilirubin out of hepatocytes into blood- excreted in urine- dark urine)

48

Well man

Isolated increased bilirubin

Jaundice

Possibly starved/dieting

Gilbert's disease

49

Jaundice

Dark urine

Pale stool

Post hepatic jaundice: CBD blockage

Blockage of flow of bile- so leakage of conjugated bilirubin in blood (dark urine)

Low/no stercobilinogen in bowel: pale stool

50

Post hepatic jaundice

Blockage of flow of bile by:

Gallstones in CBD

Stricture

Cancer in head of pancreas

51

Differentiation between post hepatic causes of jaundice (jaudnice, dark urine, pale stool)

Pain

Colicky pain: Gallstones in CBD

Painless: pancreatic Ca

52

Causes of trasudative ascites:

cirrhosis

cardiac failure

nephrotic syndrome

53

Causes of exudative ascites:

Malignancy (abdominal, pelvic, peritoneal mesothelioma)

Infection (TB, pyogenic)

Hepatic vein thrombosis (Budd-Chiari syndrome), portal vein thrombosis

54

50 year old man

Painless

Jaundice

Wt loss

Dark urine

Pale stool

O/E: Thrombophlebitis- tracking nodules 

 

Blood tests most likely to show elevated:

1. ALP, Ca19-9

2. AST, CA 125

3. ALP, alfa-fetoprotein

4. ALT, alfa-fetoprotein

5. ALP, CEA

1. ALP, Ca19-9

 

ALP- sign of obstructive jaundince

Ca19-9 tumour marker for pancreatic cancer (alpha-fetoprotein AFP is HCC marker- hepatic)

Thromboplebitis: Trousseau's sign of malignancy

55

Post hepatic jaundice blood test:

Raised bilirubin

Raised AlkPhos and raised GGT

56

Hepatic jaundice blood test (hepatic damage):

Raised bilirubin

Raised ALT and raised AST

57

Raised ALT, AST (trasnaminases)

Hepatic damage (alcohol, autoimmune, drugs, virus)

58

Raised AlkPhos (ALP) DDx

Obstructive jaundice (raised GGT)

Bone (fracture, bony mets)

Others

59

Raised ALP, Raised GGT

CBD obstruction

60

Bilirubin raised

ALT very raised

ALP raised slightly

Hepatitic jaundice: ALT is more increased than ALP so it is hepatitic not obstructive)

61

Bilirubin raised

ALT very raised

ALP raise slightly

Hepatitic jaundice: ALT is more increased than ALP so it is hepatitic not obstructive)

62

Ca19-9

Pancreatic cancer

63

alpha-fetoprotein (AFP)

Liver cancer (eg- HCC) Also- testicular cancer

64

CA 125

ovarian cancer

65

CA 125

ovarian cancer

66

Causes of bloody diarrhoea:

Bloody diarrhoea (loss of epithelial integrity):

Infective colitis (CHESS)

Inflammatory colitis (young, extra-GI manifestations)

Ishcaemic colitis (elderly)

Diverticulitis

Malignancy

67

Infective causes of bloody diarrhoea

Infective colitis: CHESS

Campylobacter

Haemorrhagic E. coli

Entamoeba histolytica

Salmonella

Shigella

68

Bloody diarrhoea with extra-GI manifestations

Inflammatory colitis

Extra-GI manifestations (arthritis, erythema nodosum, uveitis)

69

Question to differentiate between IBS and IBD

Do you have to get up in the night to go to the toilet (nocturnal

70

Management of Acute GI bleed:

-ABC

-IV access

-Fluids

-G&S, cross-match blood- give blood

-OGD

 

After: IV PPIs (usually peptic ulcer)

 

Variceal blead (caused by portal hypertension): also give Antibiotics for spread of infection (tazocin), Terlipressin (splanchnic constriction)

71

Investigations of acute abdomen (general)

Ix:

Blood: FBC (Hb bleeding, WCC infection), U&Es, LFTs, CRP, clotting, G&S, X-match

Erect CXR (air under diaphragm- perforation)

CT

72

Management of acute abdomen (general):

Nil By Mouth

Fluids

3 A's: 

Analgesics,

Antiemetics,

Antibiotics: Cef and Met

Monitor vitals and urine output

73

Abx for abdominal surgery

cef and met cephalosporin (to cover Gram +ve and -ve) Metronidazole (to cover anaerobes)

74

Antiemetics

Ondansetron, cyclosisne, metorocloparamide,

75

Jaundice: Investigations

Bloods: FBC (Hb) LFTs: raised ALT, AST (hepatitic), raised ALP, GGT (post-hepatic) CRP

Abdominal USS (if raised ALP): after a fast (gallbladder distended and bile-filled so stones visualised better)

76

Dysphagia, weight loss: Investigations

OGD & Biopsy

77

PR bleed, weight loss

Colonoscopy

78

Management of ascites:

-Diuretics (spironolactone +/- furosemide- furosemide only if peripheral oedema)

-Fluid restriction in patients with hyponatraemia

-Ascitic tap: Micro (cell count, infection), Protein, Cytology (tummour cells)

-Monitor weight daily

-Therapeutic paracentesis (with IV human albumin)

 

(Treat for encephalopathy if present)

 

(NB. people with cirrhosis have low kidney perfusion and so triggers RAAS, so high aldosterone. Spironolactone is aldosterone inhibitor)

79

50 year old man

chronic alcoholic liver disease

Ascites

Confused

Management steps:

-Diuretics (spironolactone +/- furosemide- furosemide only if peripheral oedema)

-Fluid restriction in patients with hyponatraemia

-Ascitic tap: Micro (cell count, infection), Protein, Cytology (tummour cells)

-Monitor weight daily

-Therapeutic paracentesis (with IV human albumin)

80

Management of encephalopathy:

Lactulose (10-20ml TDS)

Phosphate enemas

 

Avoid sedation

 

Treat underlying cause (GI bleed or infection):

Treat infections (SBP- tazocin)

Exclude a GI bleed (FBC) Lactulose (reduces transit time in colon- less time for contents to be metabolised by bacteria)

81

Cause of encephalopathy in liver failure:

Bacteria in colon produce toxic metabolites that are removed by the liver

82

Wound infection post op

Erythematous Discharge

83

Anastomotic leak post op

Diffuse abdo tenderness

Guarding, rigidity

Hypotensive/tachycardic

84

Pelvic abscess postappendicectomy

pain, fever, sweats, mucous diarrhoea

85

Perianal abscess: Presentation and treatment

Tender, red swelling Incision & drainage

86

Anal fissure: Presentation and treatment

Rectal pain (defaecation)

Stool coated with blood (not mixed)

Advice on diet (fluids, fibre)

GTN cream

87

Recurrent pain, bloating (improves with defaecation)

Change in the frquency/form of stool

 

No PR bleed, anaemia, wt loss or nocturnal symptoms

Most likely diagnosis:

IBS

But need to exclude coeliac disease first.

88

Recurrent pain, bloating (improves with defaecation)

Change in the frquency/form of stool

Very stressed

 

No PR bleed, anaemia, wt loss or nocturnal symptoms

 

Most likely diagnosis:

IBS

But need to exclude coeliac disease first (coeliac test)

89

IBS treatment:

-Diet & lifestyle modification

-Symptomatic treatment: abdo pain (antispasmodics- buscopan); constipation (laxatives); diarrhoea (anti-diarrhoeals- loperamide)

90

Recurrent pain, bloating (improves with defaecation)

Change in the frquency/form of stool

Very stressed

 

No PR bleed, anaemia, wt loss or nocturnal symptoms

 

Most likely diagnosis:

IBS

But need to exclude coeliac disease first (coeliac test)

Diagnosis of exclusion: need to exclude coeliac, IBD, cancer

91

What does the X-ray show?

Q image thumb

Thumbprinting (thick haustral folds- inflammation). Thickening of the bowel wall.

92

What does this X-ray show?

Q image thumb

Featureless abdo X-ray. Ulcerative Colitis.

93

What does this X-ray show?

Q image thumb

Toxic megacolon (>6cm). Systemic illness

94

Patient presented with diarrhoea. What does this X-ray show? Diagnosis?

Q image thumb

Shows faecal loading (but patient has diarrehoea). Therefore: Overflow (spurious) diarrhoea due to faecal loading.