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gastro Flashcards

1
Q

what signs does vomiting during bowel obstruction show on a VBG

A

Hypochloraemia
Hypokalaemia
metabolic alkalosis

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2
Q

what signs does strangulation during bowel obstruction show on a VBG

A

metabolic alkalosis (lactic alkalosis)

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3
Q

clinical features suggesting strangulation in bowel obstruction

A

pyrexia
tachycardia
pain from colicky to constant
peritonism
raised CRP
leucocytosis
absent or reduced bowel sounds

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4
Q

most common causes of small bowel obstruction

A

adhesions
neoplasia
incarcerated hernia
crohns disease

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5
Q

bowel obstruction supportive management

A

NBM
large bore cannula
IV fluid resus
IV antiemetics
IV analgesia
correction of electrolyte imbalances
NG tube for decompression
urinary catheter

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6
Q

bowel obstructive conservative management for faecal impaction

A

stool evacuation

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7
Q

bowel obstructive conservative management for volvulus

A

rigid sigmoidoscopic decompression

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8
Q

indications for surgical management of BO

A

haemodynamic instability
sepsis
complete BO with ischaemia
complete loop obstruction
persistent obstruction of more than 2 days despite conservative treatment

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9
Q

describe the presentation of a perforated peptic ulcer

A

sudden diffuse or epigastric pain
referred shoulder pain
history of NSAIDs/steroids/recurrent epigastric pain

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10
Q

describe the presentation of a perforated diverticulum

A

LLQ pain
constipation

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11
Q

describe the presentation of a perforated appendix

A

migratory pain
anorexia
gradual worsening RLQ pain

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12
Q

describe the presentation of a perforated malignancy

A

change in bowel habits
weight loss
anorexia
PR bleeding

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13
Q

what would a VBG of GI perforation show

A

lactic acidosis

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14
Q

what would an FBC of GI perforation show

A

neutrophilic leukocytosis

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15
Q

what would a CXR/AXR show for GI perforation

A

CXR: pneumoperitoneum (free air under diaphragm)
AXR: pneumoperitoneum, free GI contents, mesenteric fat stranding

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16
Q

surgical management of GI perforation with generalised peritonitis +/- sepsis

A

explorative laparotomy/laparoscopy
upper GI (eg perforated ulcer): closure of perforation - maybe with omental patch
lower GI: resection with anastomosis and temporary stoma (to divert pressure away whilst the anastomosis heals)
obtain some intrabdomninal fluid for MC&S
do peritoneal lavage

if appendicitis do appendicectomy
if malignancy take biopsies

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17
Q

bowel ischaemia risk factors

A

age >65
cardiac arrhythmias mainly AF
atherosclerosis
vasculitis
sickle cell disease
hypercoagulation/thrombophilia
profound shock causing hypotension

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18
Q

imaging for acute appendix

A

CT - gold standard
USS - women and children
MRI - pregnant women if USS is inconclusive

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19
Q

specific clinical signs for appendicitis

A

McBurnerys sign: pain in RLQ

Blumbergs sign: rebound tenderness in RIF

Rovsing sign: pain in RLQ upon deep palpation of LLQ

Psoas sign: pain in RLQ upon flexion of right hip against resistance

Obturator sign: pain in RLQ upon passive internal rotation of the hip and flexion of knee and hip

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20
Q

steps of a laproscopic appendicectomy

A

place 3 trocars
explore RIF and identify appendix
elevate appendix
divide mesoappendix
secure base with endoloops
divide appendix
remove appendix and place in a plastic retrieval bag
do pelvic irrigation + haemostasis
remove tracers and close wound

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21
Q

2 most common causes of SBO

A

previous abdominal operation (adhesions)
external strangulated hernia (incarcerated hernia)

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22
Q

sign of LBO due to volvulus on AXR

A

bent inner tube sign / coffee bean sign

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23
Q

if you have a LBO caused by volvulus and leave it until there is necrosis/cannot salvage by rigid sigmoidoscopic decompression, what surgery do you do

A

explorative laparotomy + sigmoid colectomy + end colostomy

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24
Q

you think a pt has acute mesenteric ischaemia, what imaging should you order

A

CT Abdomen and pelvis with contrast

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25
how to restore blood flow in embolic acute mesenteric ischemia
embolectomy of superior mesenteric artery
26
how to restore blood flow in thrombotic acute mesenteric ischemia
aterial bypass of superior mesenteric artery
27
brief outline of causes of acute mesenteric ischamia
arterial - embolism - thrombosis - non occlusive venous - superior mesenteric vein thrombosis
28
in which patients is SMV thrombosis more likely to occur
patients with portal hypertension portal pyaemia/pyelophlebitis sickle cell disease
29
which conditions does portal pyaemia/pyelophlebitis increase the risk of
intra abdominal sepsis due to - appendicitis - diverticulitis
30
what does portal pyaemia show on CT scan
air in SMV and intrahepatic portal venous system
31
4 major phyla of bacteria in the microbiota
bacteroidetes, firmicutes, actinobacteria, proteobacteria
32
what is the bacterial toxin TMAO linked with
atherosclerosis
33
what is the bacterial toxin 4-EPS linked with
autism
34
what is the bacterial toxin AHR ligand linked with
asthma, MS, rehumatoid arthiritis
35
what is an increase or decrease in SCFA's linked with
increase: psychiatric syndromes, stess decrease: IBD
36
describe the composition of a MALT and where its found
in submucosa lymphoid mass: aggregated lymphoid follicles surrounded by HEVs
37
give examples of organised GALTs
peyers patches (small intestine) caecal patches (large intestine) isolated lymphoid follicles mesenteric lymph nodes (encapsulated)
38
give examples of non organised GALTs
intraepithelial lymphocytes lamina propria lymphocytes
39
describe the composition of peyers patches
aggregated lymphoid follicles consisting of naive T and B cells surrounded by a FAE (follicle associated epithelium)
40
what 3 things does the FAE not have
no microvilli no goblet cells no secretary IgA
41
what are M cells and where are they found
Microfold cells found in the FAE surrounding peyers patches have IgA receptors to take in IgA antigen complexes
42
other than by M cells how else can antigens be captured
dendritic cells
43
formation of secretory IgA
plasma cells secrete dimeric IgA in submucosa dimeric IgA binds to poly-Ig receptor receptor and dimeric IgA are taken upon into a vacuole within the epithelial cell and undergo enzymatic cleavage are released onto the other side into lumen as secretory IgA
43
formation of secretory IgA
plasma cells secrete dimeric IgA in submucosa dimeric IgA binds to poly-Ig receptor receptor and dimeric iGA are taken upon into a vacuole within the epithelial cell and undergo enzymatic cleavage are released onto the other side into lumen as secretory IgA
44
describe the process of lymphocyte homing and circulation
B and T cells undergo antigen presentation and activation in peyers patch They then move to mesenteric lymph node where they undergo lymphocyte proliferation then move into thoracic duct and then into circulation once in circulation, can either go to peripheral immune systems eg MALTs, BALTs, skin OR go back to lamina propria
45
explain how T cells move from HEVs into lamina propria
alpha 4 beta 7 integrin on T cell binds two MAdCAM-1 on HEV this activates the T cell and allows them to move into the lamina propria
46
3 vaccines for cholera
dukoral inactivated oral
47
treatment for cholera
oral rehydration
48
vaccine for rotavirus
live attenuated vaccine: Rotarix
49
most common rotavirus type in humans
Type A
50
most common cause of diarrhoea in infants and children
rotavirus
51
rotavirus treatment
oral rehydration therapy
52
what type of virus is noravirus
RNA virus
53
diagnosis for norovirus
sample PCR
54
treatment for campylobacter
no treatment usually required possibly need azithromycin
55
most common cause of food poisoning
campylobacter
56
what type of bacteria is e coli
gram negative intestinal bacteria
57
management for C diff
isolate pt (as very contagious) stop current abx give vancomycin and metronidazole if get lots of recurrence can do faecal microbiota transplantation
58
raised CRP + WCC new onset diarrhoea with generalised tenderness Differential diagnoses?
infectious and non infectious diarrhoea
59
common causes of non infectious diarrhoea
ischaemic colitis microscopic colitis Abx side effect coeliac disease post infectious IBS IBD
60
common causes of infectious diarrhoea
clostridium difficile clostridium perfringens klebsiella oxytoca salmonella spp
61
3 different disease categories of C diff infection
non severe disease (WCC<15, creatinine<150) severe disease (WCC>15, creatinine>150) fulminant colitis --> Hypotension, shock, toxic megacolon, ileus
62
what does toxic megacolon look like on X-ray
dark and distended bowel
63
treatment for non severe disease of C diff
vancomycin fidaxomicin metronidazole FMT (faceal microbiota transplantation)
64
what is pseudomembranous colitis
associated with C diff infection severe colonic disease formation of yellow white plaques which form pseudomembranes on mucosa
65
describe mild UC
4 BM a day mild symptoms no systemic toxicity normal CRP and ESR
66
describe moderate UC
>4 BM a day mild symptoms mild anaemia mild systemic toxicity nutrition maintained and no weight loss
67
describe severe UC
>6 BM a day severe symptoms systemic toxicity raised CRP and ESR significant anaemia weight loss
68
which scan would you do to check gall bladder/pancreas
MRI
69
what must you alway include in the management plan for a severely vomiting patient
NG tube
70
what scan do you do to check for gall stones
MRCP (MR cholangiopancreatography)
71
what is a common cause of 4 quadrant tenderness peritonitis
perforation - leakage of contents irritates peritoneum
72
describe the types of muscles of the oesophagus
top 1/3 - skeletal/striated middle 1/3 - mixture of skeletal and smooth bottom 1/3 - smooth
73
what surrounds the LOS
diaphragm - phrenoesophageal ligament
74
describe the phases of swallowing
phase 0: oral phase - food bolus prepared by saliva and chewing phase 1: pharyngeal phase - pharyngeal muscles guid bolus to the UOS, which opens by reflex. LOS opens by receptive relaxation reflex (vasovagal reflex) phase 2: upper oesophageal phase - UOS closes, superior circular muscles contract, inferior circular muscles dilate, sequential contraction of longitudinal muscles phase 3: lower oesophageal phase - LOS opens as bolus passes through
75
what is oesophageal pressure measured by
manometry
76
resting LOS pressure
20 mmHg
77
what is LOS resting pressure determined by
inhibitory NCNA neurones of myenteric plexus (non cholinergic non adrenergic)
78
pressure of peristaltic waves of oesophagus
40 mmHg
79
regurgitation vs reflux
regurgitation: return of oesophageal contents from above an obstruction reflux: passive return of gastroduodenal contents to the mouth
80
pain on swallowing
odynophagia
81
causes of achalasia (hyper motility of oesophagus)
due to loss of inhibitory ganglions of Aurebachs myenteric plexus and decreased activity of inhibitory NCNA neurones primary: unkown secondary: chagas disease protozoa infection oesophagitis
82
risks of achalasia
dramatically increases risk of oesophageal cancer
83
pathophysiology model of achalasia
genetic predisposition environmental tigger immune infiltrates extracellular turnover, fibrosis, wound repair loss of immune tolerance apoptosis of neurones humoural response myenteric plexus abnormalities
84
features of achalasia
higher LOS pressure receptive relaxation reflex is too late dilation of distal oesophagus as food gets stuck in peristaltic waves can stop
85
achalasia treatment
pneumatic dilatation hellers myotomy with Dor fundoplication
86
risk of hellers myotomy + dors fundoplication
oesophageal and gastruc perforation division of vagus nerve splenic injury

BRS 1b (10 decks)

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