Gastro 3 Flashcards
(139 cards)
1
Q
Define cholecystectomy
A
Surgical procedure to remove the gallbladder, uses laproscopic surgery (using a camera and tools through small incisions in the abdomen). May also have an open cholecystectomy
2
Q
List indications for cholecystectomy
A
- Gallstones (bladder, bile duct)
- Cholecystitis
- Large gallbladder polyps
- Pancreaitis due to gallstones
3
Q
List complications of cholecystectomy
A
- Bile duct leak (abdo pain, N and V, ERCP to manage)
- Bleeding
- Infection
- Injury to nearby structures (perforation)
- Anaesthesia risks (blood clots and pneumonia)
4
Q
Define colonoscopy
A
- Imaging of the rectum, colon, and terminal ileum with a fibre-optic instrument
- Also can be used therapeutically, and to take biopsies
5
Q
List indications for colonoscopy
A
- Screening or surveillance for colon cancer/ evaluating symptoms of colon cancer
- Iron deficiency anaemia/ lower GI bleed
- IBD evaluation (change in bowel habit, rectal bleed)
- Evaluating imaging abnormalities
- Therapeutic indications - stricture dilatation, stent placement, colonic decompression, foreign body removal
6
Q
List possible complications of colonoscopy
A
- Sedation: cardiopulmonary complications
- Bowel prep: fluid and electrolyte disturbances, nausea, vomiting, bloading, aspiration, oesophageal tears
- Bleeding following polypectomy
- Perforation
- Post-polypectomy syndrome (fever, abdo tenderness, leukocytosis 5 days after)
- Infection
- Gas explosion
7
Q
Define ERCP
A
- Endoscopic retrograde cholangiopancreatograpy
- An endoscopic technique where an endoscope is guided into the duodenum, allowing imaging and usage of instruments into the bile and pancreatic ducts.
- Involves injection of the contrast medium
8
Q
List indications for ERCP
A
- Choledocholithiasis
- Biliary structure
- Pancreatic or biliary cancer (palliation of biliary obstruction where surgery not indicated)
- Tissue sampling in patients with pancreatic or biliary cancer
- Ampullary cancer diagnosis
- Investigate biliary pancreatitis
- Sphincterectomy (sphincter of Oddi dysfunction type 1)
9
Q
List complications of ERCP
A
- Perforation, bleeding, pancreatitis, infection
- Cardiopulmonary problems (aspiration, hypoxaemia, dysrhythmia)
- Contrast allergy
- Pseudocyst formation, stent occlusion
10
Q
Define endoscopy
A
- Visualisation of the oropharynx, oesophagus, stomach, proximal duodenum
- Real time assessment and interpretation of the findings
- Used for tissue sampling and some management
11
Q
List diagnostic indications of endoscopy
A
- Upper GI symptoms (pain, nausea, persisting despite management/ over 50/ weight loss, dysphagia, odynophagia, recurrent GORD)
- Upper GI bleeding (active or recent)
- Investigate abnormal imaging
- Caustic injections
- Screening Barretts oeseophagus
- Assess varices in pts with portal hypertension
12
Q
List the therapeutic indications of endoscopy
A
- Bleeding lesions
- Prophylactic banding of varices
- Removal of foreign bodies
- Place feeding tubes/ drainage tubes
- Removal of polyps
- Dilate stenotic lesions
- Manage achalasia
- Palliation of stenosing neoplasma
- Manage strictures
13
Q
List complications of endoscopy
A
- Cardiopulmonary complications due to sedation
- Hetaemoglobinaemia (topical anesthetics)
- Bleeding
- Perforation
- Infection
14
Q
Define parenteral feeding
A
- IV administration of nutrients.
- TPN is where it is the only source of nutrition
- Uses central lines for over 2 weeks duration, and lines are inly used for nutrition not drugs
15
Q
List indications for parenteral feeding
A
Considered for all patients who are malnourished or at risk of being malnourished with a non-functioning or inacessible GI tract
16
Q
List complications of parenteral feeding
A
- Re-feeding syndrome (electrolyte disturbances with profound hypophosphataemia - rhabdomyolysis, cardiac failure, hypotension, resp failure, arrythmias)
- Pneumothorax or haemothorax, arrythmias, cardiac tamponade
- Thrombosis, PE, pneural or pericardial effusion, bacterial endocarditis
- Infection
- Liver and gallbladder dysfunction
- Hyperglycaemia
17
Q
Define enteral feeding
A
- Delivery of nutritionally complete feed directly into the stomach, duodenum, or jejunum
- May use standard or pre-digested feeds (used in pancreatic insufficiency or IBD)
- NG tubes depend on adequate gastric emptying, easily displaced
- NJ tubes reduce GORD
- PEG tubes are inserted through stomach wall surgically
- Percutaneous jejunostomy tubes used in patients at risk of reflux, inserted through the stomach into the jejunum
18
Q
List indications for enteral feeding
A
- Malnourished patients or those at risk of malnutrition who have a functional GI tract but are unable to maintain adequate or safe oral intake
- Children (eg. Cystic fibrosis, neuromuscular disorders)
- Critically ill patients
- Postoperative patients with limited oral intake
- Early post-pyloric feeding
- Patients with severe pancreatitis
- PEG tubes in stroke, MND, parkinsons, oesophageal cancer.
19
Q
List complications of enteral feeding
A
NG
- Nasopharyngeal erosions, abscesses, sinusitis
- Perforation, bronchial insertion or intracranial insertion
- Oesophagitis, ulceration or strictures
- GORD and aspiration
Percutaneous gastrostomy or jejunostomy
- Endoscopy related complications + bowel perforation and abdominal wall or intraperitoneal bleeding
- Post insertion stoma site infections, peritonitis, peristomal leaks, septicaemia, dislodgement and gastrocolic fistula formation
20
Q
Define haemorrhoidectomy
A
- Surgery to remove internal or external haemorrhoids that are extensive or severe
- CLosed commonly used for internal haemorrhoids, use complete wound closure with a dissolvable suture
- Open leaves incision open
- Stapled used if prolapsing, lifts tissue back to the normal position in the anal canal
21
Q
List indications for haemorrhoidectomy
A
- Symptomatic grade III, IV, or mixed internal and external haemorrhoids
- Additional anorectal conditions that require surgery
- Strangulated internal haemorrhoids
- Thrombosed external haemorrhoids
- Patients cant tolerate or fail minimally invasive procedures
22
Q
List complications of haemorrhoidectomy
A
Closed/open
- Pain
- Bleeding
- UTI/ urinary retention
- Fecal impaction
- Infection, wound breakdown
- Fecal incontinence and anal stricture/stenosis
- Open reduces risk of infection
Stapled
- Higher rate of recurrence
23
Q
Define liver cysts
A
- Hepatic cysts may be solitary or hydatid (echinococcal).
- May also be multiple in polycystic liver disease
- Fluid filled growths in the liver, within a membranous cavity
24
Q
Describe epidemiology of hepatic cysts
A
- Often found incidentally
- More common over 40, slightly more common in women
25
Describe aetiology of hepatic cysts
- Congenital (polycystic liver disease, simple)
- Polycystic liver disease associated with PRKCSH and SEC63 or PKD1 and PKD2
- TN
- Abscesses (bacterial, parasitic (e. histolytica) or fungal)
- Neoplastic - cystadenomas and cystadenocarcinoma
- Amoebic - E hystolytica
- Hydatid due to tapeworms (echinococcus), hand to mouth transmission or fecal contaminated food
- Pyogenic s aureaus or E coli (kids vs adults)
26
List symptoms and signs of hepatic cysts
- Usually asymptomatic
- Large cysts may cause dull abdo pain in teh RUQ, bloating and early satiety
- Very large may be palpable
- Hydatid cysts asymptomatic for many years, or can present with pain. May rupture causing jaundice and cholangitis (if biliary tree) or into the peritoneal cavity, causing sepsis.
- If abscess - swinging fever, night sweats, N and V, anorexia and weight loss, cough and dyspnoea
27
List investigations for hepatic cysts
- Ultrasonography (anechoic round lesion with dorsal acoustic enhancement. Daughter cysts within a tuck walled main cavity in echinococcosis)
- CT well delimited lesion with no contrast enhancement, or abscess visualised
- FBC in echinococcosis shows eosinophilia, leukopenia, thrombocytopaenia. LFT abnormal
- Screen renal function for polycystic kidney disease
- ELISA for echinococcosis
- CA19-9 raised in neoplastic cysts
- Blood culture if abscess suspected
28
Define nasogastric tube insertion
- Insertion of a tube through the nose into the stomach for the purpose of enteral nutrition
- Inserted while the patient is sitting upright, first lubricate the tip of the NG tube then numb the patients throat.
- Aspirate gastric contents and check pH for correct placement, then use CXR to ensure correct
29
List indications for nasogastric tube insertion
- Evaluate upper GI bleed (volume of blood)/ removal of gastric contents (drip and suck in obstruction, removing toxic material)
- Feeding patients at risk of malnutrition with inadequate/ unsafe oral intake and a functional, accessible GI tract
- Delivery of medications to the stomach, and radiographic contrast
30
List complications of nasogastric tube placement
- Gagging or vomiting
- Tissue trauma (nasal, oropharyngeal or upper GI tract)
- Oesophageal perforation
- Incorrect placement leading to resp tree intubation
31
Define perineal abscess and fistulae
- Abscesses are the acute manifestation of a purulent infection in the perirectal area. They are pus-filled cavities
- Fistulae are the chronic manifestation of these infections. These are connections between an abscess and the anal canal or perianal skin
32
Describe epidemiology of perineal abscess and fistulae
- Male to female 2:1
- Mean age 40 (20-60)
- 100000 people per year in the US
- 50% of patients with an anorectal abscess develop fistulas
33
Describe aetiology of perineal abscess and fistulae
- Flow obstruction and infection of the anal crypt glands (90% of cases)
- IBD, more commonly Crohns
- Acute infections of the GI (diverticulitis, acute appendicitis)
- Radiation induced proctitis
- Iatrogenic (eg. post haemorrhoidectomy
- Foreign body
- Malignancy (colorectal cancer)
34
List types of perineal abscesses and fistulas
Abscesses
- Perianal (does not transverse the external sphincter)
- Ischiorectal (below the levator ani muscle)
- Intersphincteric abscessess between the internal and external sphincters
- Supralevator (above levator ani)
Fistulas
- Intersphincteric (Park's type 1)
- Transsphincteric (parks type II)
- Suprasphincteric (type III)
- Extrasphincteric (type IV)
- Subcutaneous, subanodermal, submucosal
35
List symptoms and signs of perineal abscess and fistula
- Dull perianal discomfort and pruritis
- Erythematous, subcutaneous mass near the anus
- Perirectal - bloody, purulent or mucoid drainage through rectum, or via fistula
- Pain exacerbated with sitting and defecation (fistula)
- DRE: fluctuant indurated mass, pain with pressure (abscess)
36
Describe investigations for perineal abscesses and fistula
- CT/MRI or anal ultrasonography for deeper abscesses
- Endoscopy
- Fistula probe (with methylene blue)
37
Describe management of perineal abscesses and fistulae
Abscesses
- Early surgical incision and drainage
- Post op sitz baths, analgesics and stool softeners
Fistulae
- Fistulotomy (cutting along the whole length of the fistula to open it), endoanal advancement flap and LIFT
- Seton placement for 8-12 weeks (for adequate drainage and healing)
- Possible fibrin glue or fistula plug (provides a scaffold, dissolves over a few weeks)
- Antibiotics and immunosuppressants for pts with crohns
38
Describe prognosis of perineal abscess and fistula
- 50% abscesses become fistula/ recur
| - Fistulostomy success rate 92-97%
39
List complications of perineal abscesses and fistula
- Recurrence
| - Incontinence (inability to control stool - after division of the anal sphincter muscle)
40
List risks for C diff
- Advanced age
- Immunosuppression
- Antibiotic use (amoxicillins, cephalosporins, cirogloxacin)
- Hospitalisations
- PPI
- GIT manipulation
41
List symptoms and signs of C diff infection
Asymptomatic
- 3-5% of pts
- 25-35% hospitalised pts
Mild-moderate
- Watery diarrhoea, usually not bloody
- Abdo cramping
- No significant abnormalities on colonoscopy
Severe
- High volume diarrhoea with blood
- Moderate-severe abdo pain
- Fever, malaise, leukocytes
- Patchy and moderate colitis on colonoscopy
Pseudomembranous colitis
- Severe diarrhoea that may be bloody
- Abdo pain and tenderness
- Fever
- Pseudomembranes on colonoscopy
42
List complications of pseudomembranous colitis
- Perforation
- Sepsis
- Death
43
Define open abdo surgery (inc. laparotomy)
- Laparotomy is a procedure which involves making one large incision in the abdomen, under general anaesthesia
- Midline (middle - standard)
- Paramedian (vertical to the side of the midline, for acess to the kidneys/adrenal)
- Transverse (horizontal, less damage to muscle)
- Pfannensteil (pelvic)
- Subcostal (upper abdo, gallbladder, liver or spleen)
- Rooftop (chevron - subcostal on each side)
44
List indications for open abdo surgery (inc. laparotomy)
- Diagnosing abdo conditions (exploratory laparotomy - to identify source of bleeding or trauma)
- Appendectomy
- C section, hysterectomy
- Inguinal hernia repair
- Abdo injuries
- Peritonitis due to perforation
- Infection in the abdomen
- Cancer
45
List complications of open abdo surgery (inc. laparotomy)
- Infection
- DVT/PE
- Scarring
- Adhesions (may cause small bowel obstruction, infertility)
- Bleeding
- Shock
- Resp failure/ cardiac insufficiency during surgery
- Ileus
46
Define laparoscopic abdo surgery
- A surgical procedure where a small incision is made using a trocar and then CO2 is pumped into the abdomen, to allow for a better view
- A laproscope is used to image the abdomen.
- Multiple port sites are made
- The pneumoperitoneum is then evacuated, and port sites are sutured
47
List indications for laparoscopic abdominal surgery
- Cholecystectomy, appendectomy, hernia repair, bowel resection
- Gynaecological surgery (hysterectomy, oophorecotomy)
- Urological (nephrectomy, pyleoplasty)
- DIagnostic laparoscopy (visualisation and biopsy of suspicious areas, collection of peritoneal fluid)
- Used in: Acute abdo pain with negative imagine, abdo trauma with negative imaging, staging of cancers and to determine resectability of cancers
48
List complications of laparoscopic abdominal surgery
- Injury to adjacent organs
- Aspiration of gastric contents
- Intra abdo pressure over 20mmHg can cause decreased lung volume, compression of the IVC and therefore decreased cardiac output, compression of renal arteries, tachycardia due to increased systemic vascular resistance and release of catecholamines)
- Pneumothorax, pneumomediastinum
- Subcutaneous emphysema
- Hypercapnea and respiratory acidosis
- Venous air embolism
- Post op - shoulder pain, atelectasis, DVT, icisional hernia, port site mets
49
Define vitamin A, B, C, D, E, K deficiency
- Vitamins ADEK are fat soluble, from the diet. Some vit K synthesised from intestinal bacteria
- Vitamins B1-12 and C are water soluble, from the diet and intestinal flora (B7,9,12)
- Deficiency is where you dont have enough of these vitamins to meet your bodies needs
50
Describe aetiology of vitamin ADEK deficiency
- Malnutrition
- Steatorrhoea (coeliac, CF)
- Bile acid deficiency (cholestasis, bile acid malabsorption)
- Medications or supplements (Orlistat, mineral oil)
- Genetic disorders (eg. hereditary rickets)
51
Describe aetiology of vitamin B and C deficiency
- Restricted diet (vegan)
- Malabsorption disorder (gastritis, following gastric resection)
- Congenital disorders (hartnup disease)
52
List sources, absorption, storage and excretion of vitamin A
- Carotinoid - activated to retinal and retinoic acid
- Sources: kale, spinach, carrots (beta carotine), or in storage form in liver, kidney, fish, eggs, and butter
- Transported by cellular retinoic acid binding protein and retinal binding protein
- Stored in hepatic cells in the perisinusoidal space in the form of retinyl ester
- Excreted via bile and urine
53
List functions of vitamin A
- Component of rhodopsin as 11 cis retinal
- Gene transcription (cell growth, differentiation, apoptosis, reproduction and embryoni development)
- Tissue maintenance and cell differentiation
- Antioxident
54
List signs and symptoms of vitamin A deficiency
- Ocular manifestations
- Night blindness (nyctalopia)
- Retinopathy
- Xerophthalmia
- Keratomalacia
- Bitot spots: gray, triangular, dry patches on the bulbar conjunctiva, covered by a layer with a foamy appearance (caused by squamous cell metaplasia and keratinization of the conjunctiva)
- Keratinizing squamous metaplasia of the bladder (pearl-like plaques on cystoscopy)
- Xerosis cutis
- Immunosuppression: Vitamin A deficiency increases the risk of a measles infection taking a severe course.
- Poor growth
55
Describe epidemiology of vitamin A deficiency
- Severe in refugee settlements, globally affects 100-140 million children
- Clinical common in southeast asia and sub-saharan africa (95% of deaths related to vit A deficiency happened here)
- Rare in the UK
56
Describe investigations for vitamin A deficiency
- Serum retinol binding protein (less costly)
- Retinol (1-3mcmol/l)
- Zinc level
- Iron studies
- FBC (anaemia and infection)
- LFT, U and E
- X rays in children
57
Describe management of vitamin A deficiency
- Subclinical - consumption of vitamin A rich foods
| - Oral vitamin A supplements
58
Describe prognosis of vitamin A deficiency
- Good if treated when subclinical, poor morbidity once blindness has progressed
- If mild early eye signs, vision can be healed completely
- n developing world, mortality in ifants is up to 50%
- Only 40% of patients with corneal xeropthalmia are alive one year later
59
List complications of vitamin A deficiency
- Blindness
- Mortality
- Severe infection
60
List sources, absorption, storage, excretion of B1 (thiamine)
- Thiamine pyrophosphate is activated
- Found in whole grain cereals, yeast, pork, legumes
- Mainly bound to blood cells
- Resporption via thiaine transporter 2
61
List functions of vitamin B1 (thiamine)
- PCofactor for several enzymes in carbohydrate and amino acid metabolism
62
List symptosm and signs of B1 deficiency (thiamine)
- Beriberi (inadequate thiamine uptake due to manlnutrition, heavy drinking, or increased demand)
- Dry causes peripheral neuropathy, muscle wasting, paralysis, confusion
- Wet causes cariomegaly, oedema, high output cardiac failure
- Infantile: cardiomegaly, tachycaria, cyanosis, aseptic meningitis
- Wenicke encephalopathy
- Leigh syndrome
63
Describe investigations for vitamin B1 deficiency (thiamine)
- Erythrocyte thiamine pyrophosphate reduced
- ABG metabolic acidosis
- Lactte elevated
- TFT
- Consider MRI brain
- Adminstering B1 causes increased RBC transketolase activity
64
List risk factors for B1 deficiency
- Chronic alcohol excess
- Malnutrition
- Staple diet of polished rice
- Refeeding/total parenteral nutrition
- GI surgery
- Magnesium deficiency
- Recurrent vomiting/chronic diarrhoea
- AIDS
- Cancer and chemotherapy
- Thiaminase- and thiamine antagonist-containing diet
65
Describe epidemiology of vitamin B1 deficiency
- Wenickes encephalopathy 0.1-10% europe and US
- In infants, extremely rare in western world
- Beriberi occurs in eat Asian countries due to thiamine depleted rice (58-66% prevalence)
66
Describe management of vitamin B1 deficiency
- IV thiamine with magnesium, potassium and/or phosphate replacement
- Oral thiamine if in the community with alcohol withdrawal
67
List complications of B1 deficiency
- Low output cardiac failure with thiamine replacement (CV support until myocardium recovers)
- Anaphylaxis from thiamine replacement
- Korsakoffs psychosis
68
Describe prognosis of B1 deficiency
- Wernickes encephalopathy 20% patients will die
| - Wet beriberi can recover in 24 hours with IV thiamine and dry beri beri can take weeks to months
69
List sources, excretion and transport of vit B2
- Meat, fish, eggs, milk, green veg, yeast
- 2 active formsn - FMN and FAD
- Cleaved to riboflavin in the intestine
- Trnasported via albumin and immunoglobulins
70
List functions of vit B2
- COfactors used in redox reactions
| - Eg. TCA cycle, glutathione reductase
71
List causes of vit B2 deficiency
- Malnutrition
- Restricted diet
- Increased demand (pregnancy, lactation)
72
List signs and symptoms of B2 deficiency
- Corneal vascularization
- Cheilitis, glossitis, stomatitis, pharyngitis
- Seborrheic dermatitis
73
Describe investigations for B2 deficiency
- Normocytic normochromic anemia
- Erythrocyte glutathione reducase assay and activity coefficient (in presence and absence of FAD)
- Therapeutic trial
- Urinary excretion of riboflavin
74
Describe epidemiology of B2 deficiency
- Uncommon in the developed world
| - More common in developing countries - up to 50% have mild deficiency
75
Describe management of B2 deficiency
- High dose riboflavin supplements, usually taken by mouth
76
List complications of B2 deficiency
- If beginning in infants, can cause difficulty chewing or swallowing leading to aspiration
- Respiratory problems due to paralysis of the diaphragm
- Hearing loss
77
List sources, activation and metabolism of vit B3
- Niacin/nicotinic acid
- NAD, NADP
- Cerals, meat, seeds, legumes
- Derived from tryptophan, synthesis requires B2 and B6
- Passive resorption in the intestine
78
List signs and symptoms of vit B3 deficiency
- Glossitis
- Pellagra(triad of dermatitis, dementia and diarrhoea)
- Characteristic detmatitis (circuar rash on neck, C3 and 4, hyperpigmented skin lesions in sun exposed areas)
- Diarrhoea and vomiting
- Neurologic symptoms (dementia, hallucinations, anxiety, insomnia, encephalopathy)
79
Describe epidemiology of vit B3 deficincy
- Sporadic cases in the US
- Chronic seasonal endemic cases in deccan plateau in India
- Outbreaks in Malawi, Mozambique, Angolia, Zimbabwe and Nepal
- Chronic alcohol use the commonest cause in the Western World
- Most common age 20-50
80
List complications/ prognosis of vit B3 deficiency
- Peripheral neuropathy, encephalopathy
- Carcinogenesis
- Untreated pellagra results in death from multiorgan failure
- Symptoms resolve after 2 weeks of treatment
81
List investigations for vit B3 deficiency
- Serum tryptophan
- Urinary N-methylnictinamide (low)
- Urinary N-methyl-2-pyridone-5-carboxamide (low)
- Skin biopsy is the confirmatory diagnostic test (oedema, capillary dilatation, dermal fibrosis)
- Photosensitivity testing (confirmatory - blistering, erythema, swelling)
- FBC
- Albumin, protein, LFTs
82
Describe management of vit B3 deficiency
- Low dose nicotinamide
| - If symptomatic, nicotinamide + other B vitamins
83
List the sources, transport, and activation of vitamin B5
| + epidemiology of B5 deficiency
- Pantothenic acid
- Sources: liver, kidney, egg yolks, broccoli, milk
- Transported in blood bound to proteins
- Rare
84
List functions of vitamin B5
- Essential component of coenzyme A
- Cofactor in activation of carboxylic acids
- Cofactor for fatty acid, cholesterol and acetylcholine synthesis
85
List features of B5 deficiency
- Adrenal insufficiency (may lead to paraesthesias and dysthesias)
- Alopecia
- Dermatitis
- Enteritis
86
List the sources, metabolism and transport of B6
- Pyridoxine. Active form is pyridoxal phosphate
- Cleaved by phosphorylases and resorbed by the intestine
- Transported free in the blood and bound to albumin
- Sources: nuts, whole grains, vegetables, yeast, meat (esp. liver and poultry)
87
List functions of B6
- Coenzyme involved in transamination, decarboxylation, amino acid metabolism, glycogenolysis
- Synthesis of heme, histamine, niacin, gluthathione, crystathionine, neurotransmitters
88
List causes of B6 deficiency
- Malnutrition
- Heavy drinking
- Chronic renal failure
- Chronic hepatitis
- Drug interactions (isoniazid and oral contraceptives)
89
List signs and symtposms of B6 deficiency
- Cheilosis, glossitis, stomatitis
- Sideroblastic anaemia
- Irri`tability, seizures, peripheral neuropathy
- Depression, confusion, weakened immune function
90
Describe epidemiology of B6 deficiency
- 1.5% in canada
- Suboptimal B6 statius 10.9%
- BMI (-ve) , south asian ethnicity (-ve) and use of supplements (+ve) were significant predictors
91
List sources, resorption and transport of B7
- Biotin
- Plants (soy products, nuts), animal producs (liver, egg yolk, dairy)
- Small amounts from intestinal flora
- Resorbed actively in the intestine
- Mainly free in the blood
92
List functions of B7
- Coenzyme for various carboxylase enzyme complexes, which all add a 1-carbon group
- Fatty acid synthesis
- Gluconeogenesis
- Fatty acid reduction
93
Describe epidemiology of B7 deficiency
- Rare
| - 1 in 11000 have biotinase deficiency, higher in hispanic population
94
List causes of B7 deficiency
- Malnutrition
- Prolongued antibiotic use
- Excessive consumption of raw egg white (contains avidin which avoids biotin resorption)
95
List signs and symptoms of B7 deficiency
- Dermatitis
- Conjunctivitis
- Enteritis
- Alopecia
- Myalgia
- Neuro (lethargy, depression, hallucinations, paraesthesia)
96
List complications of B7 deficiency
- Seizures
- Muscle weakness
- Ataxia
- Developmental delay
- Problems with vision and hearing
97
Describe investigations + management for B7 deficiency
- Test biotinase in the blood
- Tested in babies, can test fluid in the womb
- Treated with oral biotin
98
List sources, resorption and transport of vitamin C
- Absorbic acid
- Fruits and veg
- Passive resorption in the oral mucosa, active resorption in the intestine
- Transported mostly freely in the blood
99
List functions of vitamin C
- Antioxidant: ascorbate and dehydroascorbate form a redox system
- Promotes intestinal iron resorption
- Coenzyme for important enzymatic reactions (carnitine, collagen, noradrenaline, peptide hormones)
100
Describe epidemiology of vitamin C deficiency
- Rare
- 13% US population vitamin C deficient
- 3% canada and UK
- Epidemics in Africa and Afghanistan, though small scale
101
List signs and symptoms of vitamin C deficiency
Scurvy: clinical manifestation of vitamin C deficiency, which leads to impaired collagen synthesis and easily damaged connective tissue
- Follicular hyperkeratosis, perifollicular hemorrhage, coiled “corkscrew” hair
- Subperiosteal hemorrhage
- Gingivitis, swollen gums
- Mucosal bleeding, easy bruising, petechiae
- Impaired wound healing
- Arthralgia, hemarthrosis
Signs of anemia (fatigue, paleness)
- Normocytic anemia: decreased iron absorption in the small intestine
- Macrocytic anemia: decreased conversion of folate into its active metabolite
Poor immune response
102
List risks for vit C deficiency
- Famine and refugee populations
- Alcohol use disorder
- Infants taking only cow's milk
- End stage renal disease and/or haemodialysis dependence
- Smoking
- Surgery
- Sepsis
- HIV
- Critical illness
- Acute respiratory distress syndrome
- Pancreatitis
- Elderly
103
List investigations for vitamin C deficiency
- FBC and blood smear (anaemia)
- Serum ascorbic acid, leukocyte ascorbic acid
- Whole blood ascorbic acid
- Xray (knee and wrist to exclude conditions mimicking scurvy. shows Pelkans sign and Frankels sign)
104
Describe management of vitamin C deficiency
Oral replacement
105
List complications of vit C deficiency
- Intracerebral haemorrhage
- Endocardial haemorrhage
- Neck pain
- Back pain
106
Describe prognosis of vit C deficiency
- Within day most signs and symptoms improve
| - If not treated, high risk of death
107
Describe epidemiology of vitamin D deficiency
- Most common nutritional deficiency worldwide in children and adults
- More than 40% of adults over 50 in the US and europe
108
Describe aetiology of vitamin D deficiency
- Lack of sunlight
- Ageing
- Inadequate dietary intake
- Malabsorption syndromes
- CKD
109
List signs and symptoms of vitamin D deficiency
Rickets
- Bowing of the legs
- Difficulty walking
- Widening of the ends of the long bones
- Delayed tooth eruption and caries
- Chest wall deformity
- Head sweating
- Rachitic rosary
- Frontal bossing
Osteomalacia
- Bone discomfort
- Weaknes
- Tenderness
- Waddling gait
- Fatigue and malaise
Hypocalcaemia: cramps, weakness, spasm, numbness, tetany, seizures, chovseks and trousseaus sign
110
List investigations for vit d deficiency
- Serum 25 hydroxy vit D
- Alk phos (elevated or normal)
- Ca
- Phosphate
- Radiographs (cupping, splaying, fraying of the metaphysis, loosers zone)
- PTH
111
Describe management of vitamin D deficiency
- Vit D (ergocalciferol or cholecalciferol)
- Sun exposure
- Calcium carbonate
- Active vit D analogue (alphacalciferol) if imapired metabolism
112
List complications of vit D deficiency
- Osteopenia and osteoporosis
- Falls and fractures
- Treatment related toxicity (hypercalcaemia and hyperphosphataemia)
113
Describe prognosis of vit D deficiency
- Asymptomatic corrects vit D in 2-3 months
| - Symptomatic takes 6 months to return to normal in rickets, and 1-2 years in adults.
114
List functions of vitamin E
- Tocopherol
- Antioxient which prevents free radical damage
- Inhibition of platelet aggregation, cell proliferation, enzyme inhibition
115
List signs and symptoms of vitamin E deficiency
- Neurologic dysfunction
- Dedecreased proprioception and vibration sensation, ataxia
- Hyporeflexia
- Limited upward gaze
- VIsual field defect
- Muscle weakness
116
List investigations for vitamin E deficiency
- Hemolytic anemia; : deficiency results in increased fragility of erythrocytes and membrane breakdown
- Acanthocytosis
- Measure serum alpha-tocopherol or ratio of serum alpha-tocopherol to serum lipids
117
Describe epidemiology of vitamin E deficiency
- Extremely rare, commonly due to irregularities in fat absorption or metabolism
- 0.1% in the US
118
List complications of vitamin E defiiency
- Blindness
- Dementia
- Cardiac arrhythmias
- Interactions with anticoagulants, and simbastatin and niacin (reduce HDL)
119
Describe management of vitamin E deficiency
- Address underlying cause, then vit E supplementation (leafy veg, whole grains, nuts, seeds, vegetable oils, fortified cereals)
120
Describe prognosis of vitamin E deficiency
- Symptoms may worsen if untreated
| - Once treated, most symptoms resolve quickly
121
Define hartmanns procedure
Sigmoid colectomy with end colostomy
122
List different antibody testing results in HepB testing and what they mean
- HBsAg, anti-HBs, anti-HBc = susceptible
- Anti-HBs only positive = vaccination
- Past infection anti-HBs and anti HBc (IgG) positive
- Acute infection HbsAg positive, anti-HBc IgM positive
- Chronic infection HBsAg positive, anti-HBc IgG positive
123
List common secondary tumours in the liver
Mets from
- Bowel
- Breast
- Oesophagus
- Stomach
- Pancreas
124
Describe cholangiocarcinoma and its risks
- Adenocarcinoma of the bile duct epithelium
- RF: PSC, worm infections, cirrhosis, hisor of
- Intra or extra hepatic ducts, or gallbladder
- Same symptoms, signs and investigations as pancreatic cancer (abdo USS, biopsy)
125
Describe epidemiology of rectal prolapse
- More common in older patients
- Especially women with multiple childbirths (women over 50 6 times more likely than men)
- 2.5 cases per 100000
126
List investigations for rectal prolapse
- Visualise, ask patient to bear down to visualise
- Anal manometry
- Colonoscopy
- MRI
127
Describe epidemiology of crohns disease
- Ashkenazi jews
| - Peak age 15-40 and age 60-80
128
Which form of IBD is associated with ankylosing spondylitis?
Ulcerative colitis
129
Describe presentation of a subphrenic abscess
- Tachycardia and pyrexia on
examination
- Hiccupping due to irritation of the diaphragm
- Subphrenic abscesses are the most common
intra-abdominal abscess.
130
Describe Zolliger Ellison syndrome and when it is suspected
- Gastrinoma (secretes gastrin, increased stomach acid producton, peptic ulcers)
- NET, associated with MEN1
- Consider if: hypercalcaemia (suggests MEN1 cause), no response to management where risk factors absent
- Measure fasting serum gastrin level
131
Describe pseudoobstruction
- Dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction
- Most common in the elderly
- Causes: electrolyte imbalance, opioids, CCB, anti-depressants, recent surgery or trauma, neuro disease
- Most common in the caecum and ascending colon
132
Describe whipple's procedure
- Surgery to remove thehead of pancreas, duodenum, proximal jejunum, gal bladder, common bile duct and distal stomach
- Pancreatic tumour, cyst, bile duct cancer, and NETs are all indications
133
Describe Budd Chiari syndrome
- Obstruction of hepatic venous outflow
- May be thrombotic or non thrombotic
- Presents with abdo pain, ascites, enlarged liver due to build up of blood, cramp in the legs and feet, itching
- Associated with polycythaemia vera, thrombophilic conditions (factor V lieden), pregnancy, OCP use, vena cava abnormalities
134
Define hepatic adenoma
A benign liver tumour associated with oral contraceptives and pregnancy
135
Describe investigations for diverticular disease
- FBC showing polymorpholeukocytosis in older patients (diverticulitis)
- CRP (raised)
- CT abdo (to confirm acute disease, ideally with IV contrast)
- Blood culture (if signs of systemic sepsis)
- Abdo x ray (if acute suspected, pneumoperitoneum, ileus)
- Abdo ultrasound/MRI (if CT cant be used)
- CXR (if perforation suspected)
- Colonoscopy (to diagnose diverticular disease, may be used in acute bleeding for accurate diagnosis)
136
Describe zenker diverticulum
- Zenker diverticulum is an outpouching of the posterior
esophageal wall immediately proximal to the upper esophageal sphincter.
- It is usually diagnosed with a barium swallow study, often combined with a dynamic continuous fluoroscopy.
- Cricopharyngeal myotomy and diverticulectomy have been the mainstay approach to patients who are good surgical candidates.
137
Describe investigation for C diff
- FBC
- Stool PCR
- Stool immunoassay for glutamate dehydrogenase
- ELISA on stool sample for toxins a and b
- Stool culture is the gold standard- but it is slow and laboured
- Abdo x ray
138
Describe cholestatic hepatitis
- Cholestasis predominant injury ALP and GGT raised, AST and ALT mildly raised
- Often following antibiotics and other medications
139
What level of bilirubin causes visible jaundice
35umol/l
