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Flashcards in Gastro Deck (146):
1

Type of oesophageal carcinoma in proximal 2/3 of oesophagus?

Squamous cell carcinoma

2

Type of oesophageal carcinoma in distal third of oesophagus?

Adenocarcinoma

3

Adenocarcinoma of oesophagus is derived from which pre-malignant condition?

Barrett's Oesophagus

4

How is Barrett's managed?

Conservative. Pre-malignant - regular OGD screening and biopsy (for malignant change)

5

Types of hiatus hernia?

1. Sliding - OG junction AND stomach pass through opening (3/4)

2. Rolling - OG junction remains below opening (only cardia of stomach passes through)

6

How to diagnose hiatus hernia?

OGD / barium swallow

7

What is achalasia?

Failure of normal peristalsis of oesophagus, LOS doesn't relax and increases in tone (more stiff).

8

Investigation for achalasia?

Barium swallow

9

What would a BS show - px with achalasia?

Dilated, tapering oesophagus - "bird's beak "

10

How to manage achalasia?

If no symptoms - conservative
Symptoms? - botox injections, endoscopic LOS dilation + surgery (Heller's myotomy)

11

GORD risk factors?

Smoking, obesity, caffeine / alcohol intake, pregnancy

12

How to diagnose GORD?

Oesophageal pH monitoring

13

Management for GORD?

1. Lifestyle modifications
2. Persist? PPI or H2 antagonists + investigate with OGD
3. Surgery - Nissen fundoplication

14

Oesophageal web is also known as...

Plummer-Vinson syndrome. (Pre-malignant)

15

How does oesophageal web commonly present?

Female, iron deficient patient with dysphagia.

16

How to manage oesophageal web?

Iron replacement and ?endoscopic dilatation

17

How is oesophageal web diagnosed?

OGD - image

18

Causes of oesophageal stricture?

Carcinoma, chronic GORD, chemical ingestion

19

How is oesophageal stricture diagnosed?

Barium swallow

20

Symptoms pharyngeal pouch?

Bad breath, dysphagia, aspiration

21

Diagnosis of pharyngeal pouch?

Show on barium swallow.

22

PUD risk factors?

1. H pylori
2. Smoking
3. Drugs - NSAIDS, steroids
4. Stress

23

What type of PUD is painful on eating?

Gastric ulcer

24

What type of PUD is worse at night / after eating?

Duodenal ulcer

25

How to test H.pylori status in young px with PUD?

H.pylori breath-test

26

H.pylori eradication regime

Acid suppressant (esomeprazole) + 2 Abx (amox + clarythromycin) - 7/7

27

What type of cancer is gastric carcinoma?

Adenocarcinoma

28

Gastric carcinoma typically affects what?

Pylorus and antrum of stomach.

29

Causes of upper GI bleed?

1. PUD (36%)
2. Varices
3. Oesophagitis
4. Malignancy
5. Mallory-Weiss tear (boozy bender px)

30

What bloods for upper GI bleed?

FBC, U&E, LFT, clotting, cross-match (6 units)
Transfuse if <70... Aim for 70-100

31

Pathophysiology of coeliac's disease?

Gluten intolerance - causes villous atrophy in proximal bowel + malabsorption

32

Coeliac antibody?

HLA B8
anti-TTG

33

Investigation of coeliac?

OGD and jejunal biopsy

34

Clinical features of coeliac?

Diarrhoea/steatorrhoea, weight loss, malaise, abdo pain, n+v, anaemia

Increased risk of lymphoma
Dermatitis herpetiformis
Peripheral neuropathy

35

What type of anaemia in coeliac?

macrocytic - due to B12 and folate deficiency

36

What can cause hiatus hernia?

Triggers - coughing, vomiting, straining while having a bowel movement, sudden physical exertion and pregnancy

Age, tobacco use and obesity ?contribute

37

ABCDE management of upper GI bleed?

A - secure airway, oropharyngeal if unconscious (otherwise nasopharyngeal)

B - sats, RR, auscultate lungs (aspirated? reduced air entry and crackles in right base), sit px up, give 15L O2 NRB

C - HR, BP, pallor, ?JVP, temperature of peripheries, cap-refill (bad if >2), ?feel pulse

2 14-16G cannulas, Bloods (FBC, U+E, LFT, clotting, cross-match (6 units), group and save), monitor fluid balance (want 1ml/kg/hr), ?catheter

Fluid resus? Blood transfusion <7?

D - AVPU, CBG

E - PR (malaena), stigmata of chronic liver disease (spider neavi, caput madusa, ascites), bruising (?coagulopathy), bleeding from other sites?

Unstable? = IMMEDIATE endoscopy after you make them stable. Stable px with UGIB - within 24hrs.

38

Suspected GI bleed due to varices?

1. Terlepressin - vasoconstriction of the splenic artery, reducing blood pressure in the portal system, give and then stop once homeostasis, CONSULTANT DECISION.

2. Prophylactic abx (?suspected/confirmed) - Ciprofloxacin 1g, BD, 7/7

3. PPI (don't give before endoscopy if px no variceal bleed).

39

Blatchford score?

Identify low risk px, NO ENDOSCOPY.
0-1 = low risk, can be managed in the community
Urea, Hb, BP, (maleana, syncope, tachy, liver or cardiac disease)


Patient comes into A&E, says vomitting blood, dark stool, fresh red blood etc - ensure they are stable, take history, do obs, take bloods, PR - calculate Blatchford score, between 0-1? Girl bye.

40

Rockall score?

Identify px at risk of FURTHER bleeding and mortality. Calculate AFTER endoscopy - more accurate.

41

Px comes into A&E, haematemesis, coffee ground vomit, maleana.

What to do...

1. ABCDE
2. History - colour, consistency of vom, previous incidents, ?maleana, ?boozy bender, ?heartburn/GORD, ?PUD - pain after eating or lying down, ?liver disease, ?alcohol.
3. Bloods - FBC, U+E, LFT, clotting, cross-match (6units), G&S.
4. Work out Blatchford score
5. If >1 send for endoscopy within 24 hours. Immediately after if unstable px made stable. <1 can be managed in community.
6. Come back from endoscopy, calculate Rockwell score.

42

Causes of bloody diarrhoea (4)

IBD (UC + crohns), dysentry, colorectal cancer, ischaemic colitis (thumb-printing on imaging, means inflammation secondary to ischaemia).

43

Define acute diarrhoea

Onset <4 weeks

44

Define chronic diarrhoea

Onset >4 weeks

45

How to assess px with acute diarrhoea?

1. Frequency and severity
2. RED FLAG SX (blood in stool, recent hospital stay or abx, persistent vomitting, weight loss, ?painless/watery (risk of dehydration).
3. Underlying infection? - fever, contact with ill, dodgy food, travel abroad. Or stress? New meds?
4. Hydration status
5. ?PR

46

Causes of constipation (5)

Obstruction, neuro disorders (decrease motility), drugs (opioids, anticholinergics), IBS, low-fibre diet.

47

Crohns affects...

Anywhere between mouth to anus.

Think: Dynamo has a big face now due to Crohn's (mouth) and you think he's shit (anus).

48

IBD is associated with what antibody (+ rheum condition)?

HLA B27 + Ankylosing Spondylitis.

49

Which IBD increases risk of colorectal cancer more?

UC

Think: "ultimately cancer"

50

Histology of Crohn's

(Mouth to anus)
Transmural (whole thickness of bowel)
Non-caeseating granuloma (also in sarcoid)
Skip lesions

51

What part of colon is mostly affected in Crohn's?

Terminal ileum

52

Clinical features of Crohn's

Abdo pain - RIF
Weight loss
Diarrhoea (?bloody)
Fever, malaise, anorexia - acute episodes
Apthous ulcers
Perianal skin tags, fistulas, abscess
Malabsorption - vit b12 due to terminal ileum disease
Anaemia - due to iron (micro) or b12 deficiency (macro)

Extra - clubbing, arthritis, uveitis, erythema nodosum

53

What extra features of Crohn's crosses over with ankylosing spondylitis?

Extra - arthritis, uveitis, erythema nodosum

54

Investigate Crohn's?

Barium follow-through (image small intestine)
Barium enema (large intestine)
Endoscopy - depending on sx +/- biopsy
AXR - cobblestone

55

UC commonly affects what part of bowel?

Large bowel - rectum mainly.

56

What is backwash ileitis?

Part of UC when terminal ileum is affected. Usually only rectum.

57

Histology of UC?

UC = "Ultimately Cancer"

Mucosa and submucosa involved only (transmural is Crohn's)
Ulceration, crypt abscesses, pseudopolyps

58

UC causes what kind of anaemia?

Iron deficiency - microcytic

59

Investigations for UC?

Sigmoid/colon -oscopy and biopsy
Barium enema = shows loss of haustra (lead pipe colon)
AXR - toxic megacolon

60

What extra conditions associate with UC?

Pyoderma gangrenosum
Primary sclerosing cholangitis

61

Type of stool in UC?

Bloody diarrhoea with mucus

62

Type of stool in Crohn's?

Diarrhoea (might be bloody)

63

Rx of IBD?

Medical - mesalazine
prednisolone
steroid-sparing - azathiprine
anti-TNF - infliximab

64

If raised bili, ALT and AST?

Hepatic jaundice

65

If raised bili, ALP and GGT?

Obstructive jaundice

66

Urinalysis for pre-hepatic

Shows no bilirubin but increased urobilinogen

67

Hepatic liver screen consists of what...

viral serology (A-E, CMV, EBV), serum ferritin/iron (?haemochromatosis), copper/caeruloplasmin (Wilson's), Ab (ANA, anti-mitochondrial, anti-SM), liver biopsy.

68

Investigations for obstructive jaundice

1. MRCP +/- ERCP
2. ?CT abdo if no gallstones seen but cancer of pancreas suspected.

69

Transudate causes of ascites (5)

Portal HTN
Right-sided HF
IVC obstruction
Nephrotic syndrome
Thrombosis of portal vein (Budd-Chiari)

"PRINT"
- due to increased oncotic pressure in the capillaries which pushes fluid out.

70

Exudate causes of ascites

Infection (bacterial or TB)
Malignancy
Pancreatitis

>35 protein

71

What is liver cirrhosis?

Irreversible liver damage
Histologically defined as - loss of normal liver architecture, fibrosis, nodular regeneration.

72

Causes of cirrhosis...

Alcohol
Hep A,B,C
Autoimmune hep
Metabollic - haemochromatosis, Wilson's, alpha-1 anti-tripsin
PBC

73

Clinical features of cirrhosis...

Same as chronic liver disease...

Jaundice
Hands - clubbing, leuconychia, dupytren's contracture, palmar erythema
Asterixis
Spider naevi >5, gynaecomastia, axillary hair loss, caput medusae
Ascites, small liver (not palpable), small balls, no pubes.

74

Investigations for cirrhosis will show what...

Abnormal LFTs, hypoalbuminaemia, abnormal clotting
Liver biopsy - definitive diagnosis

75

How long before hep can be described as 'chronic'?

6 months

76

Autoimmune hep is associated with which other autoimmune conditions?

Hashimoto's thyroiditis, Sjorgrens, UC

77

How does autoimmune hep present?

Female, young age, chronic active hep (raised ALT and AST), with insidious onset of stigmata of CLD

78

What antibodies are present in autoimmune hep?

ANA
anti-SM
(anti-liver and kidney microsomal - LKM)

79

Management of autoimmune hep?

Prednisolone +/- azathioprine
Rx complications
?transplant

80

Wilson's disease is accumulation of copper...

In the liver and basal ganglia

81

CF of Wilson's

Liver disease - hepatitis, cirrhosis
Brain - EPSE
Eyes - Keiser Fleischer rings

82

How to diagnose Wilson's?

24 hour urine collection - excess copper depo

83

Treatment for Wilson's?

Penicillamine

84

Wilson's - dominant or recessive?

Autosomal recessive

85

Haemochromatosis - dominant or recessive?

Autosomal recessive

86

What happens in Haemochromatosis?

Disorder of iron uptake leading to excess iron deposition.

(HFE chromosome 6)

87

What skin abnormality is classic of Haemochromatosis?

Bronze pigmentation
Also get DM, cardiomyopathy, arthiritis

88

How does PBC present?

Autoimmune.
Insidious onset, often asymptomatic at diagnosis or just fatigue.

89

Clinical features of PBC

Obstructive jaundice (raised bili, raised ALP, raised GGT)
Pruritis
Xanthelasma, hepatomegaly, splenomegaly, skin pigmentation
Can progress to cirrhosis

90

PBC has what Ig and Ab?

IgM
Anti-mitochondrial (95%)

91

Treatment for PBC

1. Colestyramine - for itching
2. ursodeoxycholic acid

92

PBC more common in M or F?

F, >40 years

93

PSC is more common in M or F?

M

94

Features of PSC?

Fatigue, pruritis, jaundice, abdo pain, pyrexia

O/E - hepatomegaly, can have features of CLD

95

What other autoimmune condition is PSC associated with?

UC

96

What LFTs and Ab in PSC?

LFTs - raised ALP, AST, ALT, Bili, hypergammaglobulinaemia
p-ANCA (like GPA)

97

What tumour marker is raised in hepatocellular carcinoma?

serum alpha-featoprotein

Consider in px with cirrhosis that suddenly go left...

98

What is a fistula-in-ano?

Abnormal communicaiton between skin of perineum (around butt hole) and anorectal canal.

99

How can anal fistula be classified?

According to their site...
Inter-
trans-
supra-
extrasphincteric-

100

What causes anal fistulae? (4)

- Infection of anal glands
- Hidradenitis suppurativa (long term skin condition causing pain and abscesses on skin)
- IBD
- Malignancy

101

Investigation for anal fistula?

MRI

102

How to manage anal fistula?

Drain abscess
rigid sigmoidoscopy - rule out IBD
can examine under anaesthetic - repair, glue

103

What is Goodsall's rule?

If external opening lies between 3 and 9 o'clock, the internal opening will lie anteriorly in anal canal.

If external is posterior then internal will be in the midline, posteriorly.

104

Which bacteria commonly causes perianal abscesses?

E.coli
Enterococcus
Bacteroides

105

What location is most common for perianal abscess?

Perianal 60%

106

What condition must you test for in perianal abscess?

DM

107

What is an anal fissure?

Tear in squamous epithelium of distal anal canal, occurs posteriorly, chronic is >6weeks

108

How does anal fissure present?

Severe anal pain, fresh rectal bleeding following bowel movements.

No DRE - very painful!!

109

Classification of haemorrhoids:
External
Internal

External - below dentate line, pain
Internal
1st degree = bleed when poo but no prolapse
2nd = prolapse when poo but spontaneously goes back up
3rd = prolapse with poo, need to manually shove back up
4th = always there.

110

Features of haemorrhoids

Bright red rectal bleeding
prolapse
mucus discharge

Requires protoscope to view.

111

Describe blood in bowel cancer?

fresh red blood, weight loss, tiredness, pallor, loss of appetitie

112

Describe blood in IBD?

fresh red blood, weight loss, tiredness, pallor, loss of appetitie

113

Describe blood in intestinal ischaemia?

blood mixed in stool, pain on digestion (couple of hours after eating), nausea, vomitting, tachy, constipation

114

Describe blood in haemorrhoids?

fresh red blood on wiping, feels like grapes hanging out of butt

115

Describe blood in anal fissure?

SUPER PAINFUL and fresh red blood

116

Cholecystitis is...

Clinical features are...

Diagnosed via...

Inflammation of the GB

RUQ pain - radiates to shoulder tip
Abdo pain = worse on inspiration

US - ?gallstones, or CT is unsure.

117

What is Murphy's sign?

For cholecystitis
- press on patient left side of tummy
- ask px to take deep breath in
- if inflamed = PAIN as GB moves down to touch your hand.

118

Complications of peritonitis?

Intestinal dilation
Paralytic ileus - absent bowel sounds

119

Causes of peritonitis (5)

- Organ rupture - ectopic, trauma = gram negative bacteria - e.coli
- Complication of surgery - external bugs enter abdo = staph. aureus
- Spontaneous bacterial peritonitis - occurs in kids and liver disease
- Leakage of sterile blood, bile urine. Will defo become infected in 2 days.
- TB sometimes causes.

120

Typical presentation of peritonitis

Sudden onset, acute abdo pain
worse on any movement
may begin generalised but then localises (like appendicitis)
Shock, fever, tachy
Washboard rigidity

121

Investigations of peritonitis

1. Erect CXR
2. Amylase - rule out pancreatitis
3. US/CT to confirm

122

Causes of acute pancreatitis

Gallstones
Ethanol (alcohol)

Trauma
Steroids
Mumps
Auto - SLE
Scorpion sting
Hypercalcaemia, hypothermia, hyperlipidemia
ERCP
Drugs - azathioprine

123

How does acute pancreatitis present?

Pain starting in epigastrium
Nausea and vomitting
Inflammation spreads - refers to back

Widespread abdo tenderness and guarding
absent bowel sounds

124

Cullen's sign

peri-umbilical bruising - pancreatitis

125

Grey-Turner's sign

Flank bruising - pancreatitis

126

How to diagnose pancreatitis?

1. Bloods - raised amylase
2. CXR - rule out perf, ?gallstones
3. US - find gallstones, show swelling/necrosis
4. Contrast spiral CT - show extent of necrosis
5. MRI (MRCP) - damage and find stones
6. ERCP

127

What scoring systems can be used for pancreatitis?

Apache
Glasgow - severity and prognosis

128

Treatment for acute pancreatitis

1. IV rehydration
2. NBM
3. Drip and suck - prevent abdo distention and therefore aspiration pneumonia
4. prophylactic Abx - cefuroxime, azetreonam
5. Analgesia, pethidine, tramadol

129

What type of cancer is most pancreatic ca?

exocrine, adenocarcinoma

Tail - more neuroendocrine

130

Most common place for pancreatic ca?

Head

131

Presentation of head of pancreas cancer?

Painless jaundice - obstruction of sphincter of odi

132

Pancreatic cancer presentation

Super late
like pancreatitis - middle then radiates to back
anorexia and nausea
cachexia
obstructive jaundice
itching

133

3 symptoms of advanced pancreatic cancer

PE (SOB, chest pain), DM, ascites

134

What tumour marker is raised in pancreatic cancer

CA19-9

135

Surgery for head of pancreas cancer?

Whipples - rare

136

Chronic pancreatitis - caused by?

ALCOHOL
Hyperparathyroidism, CF

Features - DM due to pancreatic insufficiency

137

What will ERCP and Xray show for chronic pancreatitis?

ERCP - distorted ducts due to scar tissue from bare inflammation

Xray - show calcified pancreas from fat necrosis.

138

Genetic disorders associated with colon ca?

FAP
HNPCC

139

Red flag symptoms for colorectal ca

- Palpable rectal mass
- IDA in men
- IDA in non-menstruating women
- Rectal bleeding and change of bowel habit 6weeks+ in px >40 years
- Rectal bleeding 6weeks+ in px >50 years

140

Screening for colorectal ca

Faecal Occult Blood

141

Age first invited for one off colonoscopy? - part of screening programme for colon ca

55 years

142

What age invited for FOB home testing kit? How frequently?

60-74 years, every 2 years

Over 75 - ask for tests...

143

Rectal prolapse first starts as...

Intussusception - intestine slides into intestine like telescope, gets bigger until prolapses out.

144

Causes of anal prolapse (2)

Constipation, chronic straining

145

What is Solitary Rectal Ulcer Syndrome?

SRUS = occurs from chronic straining, on wall of rectum, causes inflammation, shouldn't be treated if asymptomatic, can have slight bleeding and mucus when pooing.

Take laxatives m8.

146

Tenesmus?

Feeling of stool in the rectum due to intussusception.