Flashcards in Gastro Deck (146):
Type of oesophageal carcinoma in proximal 2/3 of oesophagus?
Squamous cell carcinoma
Type of oesophageal carcinoma in distal third of oesophagus?
Adenocarcinoma of oesophagus is derived from which pre-malignant condition?
How is Barrett's managed?
Conservative. Pre-malignant - regular OGD screening and biopsy (for malignant change)
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)
How to diagnose hiatus hernia?
OGD / barium swallow
What is achalasia?
Failure of normal peristalsis of oesophagus, LOS doesn't relax and increases in tone (more stiff).
Investigation for achalasia?
What would a BS show - px with achalasia?
Dilated, tapering oesophagus - "bird's beak "
How to manage achalasia?
If no symptoms - conservative
Symptoms? - botox injections, endoscopic LOS dilation + surgery (Heller's myotomy)
GORD risk factors?
Smoking, obesity, caffeine / alcohol intake, pregnancy
How to diagnose GORD?
Oesophageal pH monitoring
Management for GORD?
1. Lifestyle modifications
2. Persist? PPI or H2 antagonists + investigate with OGD
3. Surgery - Nissen fundoplication
Oesophageal web is also known as...
Plummer-Vinson syndrome. (Pre-malignant)
How does oesophageal web commonly present?
Female, iron deficient patient with dysphagia.
How to manage oesophageal web?
Iron replacement and ?endoscopic dilatation
How is oesophageal web diagnosed?
OGD - image
Causes of oesophageal stricture?
Carcinoma, chronic GORD, chemical ingestion
How is oesophageal stricture diagnosed?
Symptoms pharyngeal pouch?
Bad breath, dysphagia, aspiration
Diagnosis of pharyngeal pouch?
Show on barium swallow.
PUD risk factors?
1. H pylori
3. Drugs - NSAIDS, steroids
What type of PUD is painful on eating?
What type of PUD is worse at night / after eating?
How to test H.pylori status in young px with PUD?
H.pylori eradication regime
Acid suppressant (esomeprazole) + 2 Abx (amox + clarythromycin) - 7/7
What type of cancer is gastric carcinoma?
Gastric carcinoma typically affects what?
Pylorus and antrum of stomach.
Causes of upper GI bleed?
1. PUD (36%)
5. Mallory-Weiss tear (boozy bender px)
What bloods for upper GI bleed?
FBC, U&E, LFT, clotting, cross-match (6 units)
Transfuse if <70... Aim for 70-100
Pathophysiology of coeliac's disease?
Gluten intolerance - causes villous atrophy in proximal bowel + malabsorption
Investigation of coeliac?
OGD and jejunal biopsy
Clinical features of coeliac?
Diarrhoea/steatorrhoea, weight loss, malaise, abdo pain, n+v, anaemia
Increased risk of lymphoma
What type of anaemia in coeliac?
macrocytic - due to B12 and folate deficiency
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
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.
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).
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.
Identify px at risk of FURTHER bleeding and mortality. Calculate AFTER endoscopy - more accurate.
Px comes into A&E, haematemesis, coffee ground vomit, maleana.
What to do...
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.
Causes of bloody diarrhoea (4)
IBD (UC + crohns), dysentry, colorectal cancer, ischaemic colitis (thumb-printing on imaging, means inflammation secondary to ischaemia).
Define acute diarrhoea
Onset <4 weeks
Define chronic diarrhoea
Onset >4 weeks
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
Causes of constipation (5)
Obstruction, neuro disorders (decrease motility), drugs (opioids, anticholinergics), IBS, low-fibre diet.
Anywhere between mouth to anus.
Think: Dynamo has a big face now due to Crohn's (mouth) and you think he's shit (anus).
IBD is associated with what antibody (+ rheum condition)?
HLA B27 + Ankylosing Spondylitis.
Which IBD increases risk of colorectal cancer more?
Think: "ultimately cancer"
Histology of Crohn's
(Mouth to anus)
Transmural (whole thickness of bowel)
Non-caeseating granuloma (also in sarcoid)
What part of colon is mostly affected in Crohn's?
Clinical features of Crohn's
Abdo pain - RIF
Fever, malaise, anorexia - acute episodes
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
What extra features of Crohn's crosses over with ankylosing spondylitis?
Extra - arthritis, uveitis, erythema nodosum
Barium follow-through (image small intestine)
Barium enema (large intestine)
Endoscopy - depending on sx +/- biopsy
AXR - cobblestone
UC commonly affects what part of bowel?
Large bowel - rectum mainly.
What is backwash ileitis?
Part of UC when terminal ileum is affected. Usually only rectum.
Histology of UC?
UC = "Ultimately Cancer"
Mucosa and submucosa involved only (transmural is Crohn's)
Ulceration, crypt abscesses, pseudopolyps
UC causes what kind of anaemia?
Iron deficiency - microcytic
Investigations for UC?
Sigmoid/colon -oscopy and biopsy
Barium enema = shows loss of haustra (lead pipe colon)
AXR - toxic megacolon
What extra conditions associate with UC?
Primary sclerosing cholangitis
Type of stool in UC?
Bloody diarrhoea with mucus
Type of stool in Crohn's?
Diarrhoea (might be bloody)
Rx of IBD?
Medical - mesalazine
steroid-sparing - azathiprine
anti-TNF - infliximab
If raised bili, ALT and AST?
If raised bili, ALP and GGT?
Urinalysis for pre-hepatic
Shows no bilirubin but increased urobilinogen
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.
Investigations for obstructive jaundice
1. MRCP +/- ERCP
2. ?CT abdo if no gallstones seen but cancer of pancreas suspected.
Transudate causes of ascites (5)
Thrombosis of portal vein (Budd-Chiari)
- due to increased oncotic pressure in the capillaries which pushes fluid out.
Exudate causes of ascites
Infection (bacterial or TB)
What is liver cirrhosis?
Irreversible liver damage
Histologically defined as - loss of normal liver architecture, fibrosis, nodular regeneration.
Causes of cirrhosis...
Metabollic - haemochromatosis, Wilson's, alpha-1 anti-tripsin
Clinical features of cirrhosis...
Same as chronic liver disease...
Hands - clubbing, leuconychia, dupytren's contracture, palmar erythema
Spider naevi >5, gynaecomastia, axillary hair loss, caput medusae
Ascites, small liver (not palpable), small balls, no pubes.
Investigations for cirrhosis will show what...
Abnormal LFTs, hypoalbuminaemia, abnormal clotting
Liver biopsy - definitive diagnosis
How long before hep can be described as 'chronic'?
Autoimmune hep is associated with which other autoimmune conditions?
Hashimoto's thyroiditis, Sjorgrens, UC
How does autoimmune hep present?
Female, young age, chronic active hep (raised ALT and AST), with insidious onset of stigmata of CLD
What antibodies are present in autoimmune hep?
(anti-liver and kidney microsomal - LKM)
Management of autoimmune hep?
Prednisolone +/- azathioprine
Wilson's disease is accumulation of copper...
In the liver and basal ganglia
CF of Wilson's
Liver disease - hepatitis, cirrhosis
Brain - EPSE
Eyes - Keiser Fleischer rings
How to diagnose Wilson's?
24 hour urine collection - excess copper depo
Treatment for Wilson's?
Wilson's - dominant or recessive?
Haemochromatosis - dominant or recessive?
What happens in Haemochromatosis?
Disorder of iron uptake leading to excess iron deposition.
(HFE chromosome 6)
What skin abnormality is classic of Haemochromatosis?
Also get DM, cardiomyopathy, arthiritis
How does PBC present?
Insidious onset, often asymptomatic at diagnosis or just fatigue.
Clinical features of PBC
Obstructive jaundice (raised bili, raised ALP, raised GGT)
Xanthelasma, hepatomegaly, splenomegaly, skin pigmentation
Can progress to cirrhosis
PBC has what Ig and Ab?
Treatment for PBC
1. Colestyramine - for itching
2. ursodeoxycholic acid
PBC more common in M or F?
F, >40 years
PSC is more common in M or F?
Features of PSC?
Fatigue, pruritis, jaundice, abdo pain, pyrexia
O/E - hepatomegaly, can have features of CLD
What other autoimmune condition is PSC associated with?
What LFTs and Ab in PSC?
LFTs - raised ALP, AST, ALT, Bili, hypergammaglobulinaemia
p-ANCA (like GPA)
What tumour marker is raised in hepatocellular carcinoma?
Consider in px with cirrhosis that suddenly go left...
What is a fistula-in-ano?
Abnormal communicaiton between skin of perineum (around butt hole) and anorectal canal.
How can anal fistula be classified?
According to their site...
What causes anal fistulae? (4)
- Infection of anal glands
- Hidradenitis suppurativa (long term skin condition causing pain and abscesses on skin)
Investigation for anal fistula?
How to manage anal fistula?
rigid sigmoidoscopy - rule out IBD
can examine under anaesthetic - repair, glue
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.
Which bacteria commonly causes perianal abscesses?
What location is most common for perianal abscess?
What condition must you test for in perianal abscess?
What is an anal fissure?
Tear in squamous epithelium of distal anal canal, occurs posteriorly, chronic is >6weeks
How does anal fissure present?
Severe anal pain, fresh rectal bleeding following bowel movements.
No DRE - very painful!!
Classification of haemorrhoids:
External - below dentate line, pain
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.
Features of haemorrhoids
Bright red rectal bleeding
Requires protoscope to view.
Describe blood in bowel cancer?
fresh red blood, weight loss, tiredness, pallor, loss of appetitie
Describe blood in IBD?
fresh red blood, weight loss, tiredness, pallor, loss of appetitie
Describe blood in intestinal ischaemia?
blood mixed in stool, pain on digestion (couple of hours after eating), nausea, vomitting, tachy, constipation
Describe blood in haemorrhoids?
fresh red blood on wiping, feels like grapes hanging out of butt
Describe blood in anal fissure?
SUPER PAINFUL and fresh red blood
Clinical features are...
Inflammation of the GB
RUQ pain - radiates to shoulder tip
Abdo pain = worse on inspiration
US - ?gallstones, or CT is unsure.
What is Murphy's sign?
- 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.
Complications of peritonitis?
Paralytic ileus - absent bowel sounds
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.
Typical presentation of peritonitis
Sudden onset, acute abdo pain
worse on any movement
may begin generalised but then localises (like appendicitis)
Shock, fever, tachy
Investigations of peritonitis
1. Erect CXR
2. Amylase - rule out pancreatitis
3. US/CT to confirm
Causes of acute pancreatitis
Auto - SLE
Hypercalcaemia, hypothermia, hyperlipidemia
Drugs - azathioprine
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
peri-umbilical bruising - pancreatitis
Flank bruising - pancreatitis
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
What scoring systems can be used for pancreatitis?
Glasgow - severity and prognosis
Treatment for acute pancreatitis
1. IV rehydration
3. Drip and suck - prevent abdo distention and therefore aspiration pneumonia
4. prophylactic Abx - cefuroxime, azetreonam
5. Analgesia, pethidine, tramadol
What type of cancer is most pancreatic ca?
Tail - more neuroendocrine
Most common place for pancreatic ca?
Presentation of head of pancreas cancer?
Painless jaundice - obstruction of sphincter of odi
Pancreatic cancer presentation
like pancreatitis - middle then radiates to back
anorexia and nausea
3 symptoms of advanced pancreatic cancer
PE (SOB, chest pain), DM, ascites
What tumour marker is raised in pancreatic cancer
Surgery for head of pancreas cancer?
Whipples - rare
Chronic pancreatitis - caused by?
Features - DM due to pancreatic insufficiency
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.
Genetic disorders associated with colon ca?
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
Screening for colorectal ca
Faecal Occult Blood
Age first invited for one off colonoscopy? - part of screening programme for colon ca
What age invited for FOB home testing kit? How frequently?
60-74 years, every 2 years
Over 75 - ask for tests...
Rectal prolapse first starts as...
Intussusception - intestine slides into intestine like telescope, gets bigger until prolapses out.
Causes of anal prolapse (2)
Constipation, chronic straining
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.