gastro Flashcards
(107 cards)
1
Q
investigations for diverticular disease
A
FBC → ↑WCC, ↑CRP, microcytic anaemia
Erect CXR → exclude pneumoperitoneum caused by perforation
Barium enema → sawtooth appearance of lumen (investigation of choice)
USS → assess bowel wall thickness, rule out other differentials
CT abdomen
Colonoscopy
2
Q
indications for end ileostomy
A
permanent: panproctocolectomy for UC or FAP
temporary: emergency bowel resection for intra-abdominal sepsis, haemorrhage
3
Q
indications for end colostomy
A
permanent: abdominoperineal resection for cancer involving anal sphincter
temporary: Hartmann’s (diverticulitis / bowel obstruction from cancer)
4
Q
Hartmann’s procedure definition + indications
A
proctosigmoidectomy (rectosigmoid resection) → temporary end colostomy
emergency surgery when immediate anastomosis not possible for:
• Inflammation e.g. diverticulitis
• Colorectal cancer → obstruction / perforation
5
Q
causes of abdominal distension
A
fat fluid: ascites fetus flatus: IBS, bowel obstruction faeces
6
Q
causes of small bowel obstruction
A
adhesions
hernia
intra-abdominal masses e.g. lymphoma
7
Q
causes of large bowel obstruction
A
colorectal cancer
volvulus
strictures e.g. from diverticular disease
8
Q
bowel obstruction management
A
ABCDE
drip + suck (NBM + NGT decompression + IV fluids)
analgesia
definitive:
SBO → gastrograffin follow-through
laparotomy → bowel resection if: no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
9
Q
indications for laparotomy in bowel obstruction
A
no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis
10
Q
SMA supplies which parts of bowel?
A
distal duodenum → splenic flexure
11
Q
IMA supplies which parts of bowel?
A
splenic flexure → rectum
12
Q
indications for loop ileostomy
A
anterior resection (rectosigmoid resection) + anastomosis for colon cancer / Crohn’s
13
Q
indications for loop colostomy
A
relief of Sx of obstruction (no resection)
rare
14
Q
Kocher’s incision: where + for what surg
A
L subcostal → open cholecystectomy
R subcostal → splenectomy / distal pancreatectomy
15
Q
McBurney’s / Gridiron incision: where + for what surg
A
RIF (2/3 between umbilicus + ASIS) → open appendicectomy
16
Q
indications for midline laparotomy
A
emergency: Hartmann’s (obstruction, perforation, trauma), ruptured AAA
elective: colectomy, vascular bypass, AAA repair
17
Q
Mercedes Benz incision: where + for what surg
A
subcostal margins + midline → hepatobiliary surgery: liver transplant/resection, Whipple procedure (pancreatic cancer)
18
Q
rooftop incision: where + for what surg
A
subcostal margins (similar to mercedes benz but w/o midline) → upper GI surg: oesophagectomy, gastrectomy
19
Q
Rutherford Morrison / hockey stick / J-shaped incision: where + for what surg
A
LIF / RIF (more commonly L) → renal transplant
20
Q
Pfannenstiel incision: where + for what surg
A
low transverse incision → gynaecological procedures: C-sections / lower urinary tract procedures: radical cystectomy / prostatectomy
21
Q
flank incision for what surg
A
nephrectomy: renal cell carcinoma, PKD
22
Q
inguinal incision for what surg
A
hernia repair
vertical incision = for vascular access
23
Q
Lanz incision: where + for what surg
A
transverse @ McBurney’s point → open appendicectomy (reduced scarring)
24
Q
stoma complications
A
immediate: operative complications (pain, infection, bleeding)
early: high output stoma, retraction, ischaemia/necrosis, parastomal abscess
late: parastomal hernia, prolapse, obstruction (strictures / stenosis)
25
causes of ascites
high albumin gradient (>11g/L): cirrhosis, portal HTN, cardiac failure
low albumin gradient (<11g/L): infection (peritonitis, TB), inflammation (nephrotic syn, pancreatitis), malignancy
26
causes of hepatomegaly
cirrhosis
malignancy: primary / mets
congestion: cardiac failure, constrictive pericarditis
infection: hepatitis
haematological: leukaemia, lymphoma, myeloproliferative disorders (sickle cell, myelofibrosis)
infiltration: sarcoidosis, amyloidosis, haemochromatosis
27
anterior resection: definition, indications, results in?
rectosigmoid resection
can be low or high
for rectal cancer not involving rectal sphincter
anorectal anastomosis (if healthy rectum) / temporary loop ileostomy / end colostomy
28
abdominoperineal resection: definition, indications, results in?
resection of sigmoid + rectum + anal sphincter
for malignancy involving anal sphincter
permanent end colostomy
29
panproctocolectomy: definition, indications, results in?
resection of entire colon + rectum
for UC / FAP
permanent end ileostomy / J pouch
30
complications IBD
toxic megacolon
malabsorption → gallstones, vit B12 deficiency
fistula, abcesses, strictures
malignancy: colon / PSC → cholangiocarcinoma
31
extra-abdominal signs IBD
derm: pyoderma gangrenosum, erythema nodosum, clubbing
eye: iritis, conjunctivitis
hepato-pancreato-biliary: gallstones, PSC → cholangiocarcinoma
32
histology in UC vs Crohn's
ulcerative colitis: crypt abscesses
| crohn's: non-caesating granulomas
33
definition fistula
abnormal connection between two epithelial surfaces
34
definition hernia
protrusion of viscous / part of viscous through defect of its containing cavity into an abnormal position
35
indirect vs direct inguinal hernias
direct (20%) via Hesselbach's triangle (weakness in posterior wall of inguinal canal)
↑intra-abdominal pressure
indirect (80%): through deep ring and out through superficial
patent processus vaginalis
complications more common
more difficult to reduce
differentiate: occlude deep ring + ask patient to cough
36
induction of remission ulcerative colitis
```
mild-mod:
proctitis / proctosigmoiditis: rectal 5ASA
after 4wks: + oral 5-ASA
then add oral / rectal corticosteroid
extensive: rectal 5ASA + oral 5ASA
severe: admission
IV corticosteroids
+ ciclosporin / consider surg
```
37
causes chronic liver disease
```
alcohol
non-alcoholic fatty liver disease
infection: hepatitis
autoimmune: hepatitis, PSC, PBC
vascular: Budd-Chiari,
infiltrative: sarcoidosis, amyloidosis, haemochromatosis
```
38
causes of portal HTN
pre-hepatic: portal / splenic vein thrombosis
external compression (malignancy)
hepatic: cirrhosis (most common)
post-hepatic: budd-chiari, congestive heart failure, constrictive pericarditis
39
presentation portal HTN
```
ascites
splenomegaly
oesophageal varices (melaena, haematemesis)
caput medusae
worsening of haemorrhoids
```
40
management oesophageal varices
```
ABCDE
IV fluids
terlipressin (reduces portal pressure)
endoscopic band ligation
can treat portal HTN with TIPS (transjugular intrahepatic portosystemic shunt): hepatic to portal vein
```
41
management ascites
monitor weight
diuretics: spironolactone (+ furosemide if required)
fluid + salt restriction
therapeutic paracentesis (+ albumin infusion for large volume paracentesis)
TIPS (transjugular intrahepatic portosystemic shunt) for portal HTN
42
causes of splenomegaly
portal HTN
haem: leukaemia, lymphoma, myelofibrosis, haemolytic anaemia, sickle cell
infection: TB, malaria, HIV
inflammatory: Felty's
43
definition + causes of massive splenomegaly
```
reaches midline / iliac crest / > 1500g
CML
myelofibrosis
leishmaniasis
malaria
EBV
```
44
signs of decompensated liver disease
JAB:
jaundice
asterixes, ascites, altered consciousness (encephalopathy)
bruising
45
causes of dysphagia
obstruction: cancer, mallory-weiss tear
oesphageal dysmotility: achalasia, systemic sclerosis, stroke, MND, myaesthenia gravis
other: pharyngeal pouch
46
causes of tender hepatomegaly
hepatitis
| rapid liver enlargement: budd-chiari, R heart failure
47
indications for splenectomy
emergency: rupture / trauma → uncontrolled bleeding
elective: haem (hypersplenism): ITP, TTP, AIHA, hereditary spherocytosis
oncological: leukaemia, lymphoma
48
causes of pancreatitis
```
most common: gallstones, alcohol
trauma
steroids
mumps
autoimmune
scorpion bites
hypercalcaemia
ERCP
drugs: furosemide, thiazides, azathioprine
```
49
scoring system for pancreatitis
```
glasgow score (severity)
pao2 ↓
age > 55
neuts ↑
calcium ↓
renal function: ↑urea
enzymes: AST, ALT, LDH
albumin ↓
sugar: glucose ↑
```
50
signs on examination pancreatitis
```
epigastric tenderness
grey-turner's sign: flank bruising
cullen's sign: periumbilical bruising
fox's sign: inguinal ligament bruising
signs of hypocalcaemia: trousseau's (carpopedal spasm on BP cuff inflation) / chvostek's sign (facial nerve tap induces spasm)
```
51
investigations pancreatitis
bloods: FBC, CRP, U&Es, LFTs, amylase / lipase (normal in chronic), low Ca, faecal elastase reduced in chronic
imaging: abdo USS
AXR / erect CXR to rule out other causes
CT in chronic / diagnostic uncertainty for acute
ERCP: can remove gallstones
52
management acute pancreatitis
ABCDE
IV fluids + oxygen if low sats
analgesia
antiemetics
nutritional support: consider NGT + TPN, vitamin supplementation
treat cause: if gallstones cholecystectomy / ERCP if not fit for surgery
53
complications pancreatitis
```
acute:
necrotising pancreatitis (high risk mortality)
sepsis
pseudocysts
chronic:
pseudocysts
exocrine sufficiency + malabsorption
diabetes
pancreatic cancer
```
54
management chronic pancreatitis
cons: reduce alcohol
med: analgesia, creon, insulin for diabetes
surg: ERCP (sphincterotomy, stone extraction, stricture stenting) / cholecystectomy for gallstones
lateral pancreaticojejunal drainage
resection / opening of pancreatic duct
55
severity classification for diverticular disease
hinchley classification
1. paracolonic abscess
2. pelvic abscess
3. purulent peritonitis
4. faecal peritonitis
56
diverticular disease acute management
```
ABCDE
IV fluids
analgesia
oral / IV ABx if diverticulitis
surg:
bleeding → colonscopy + endoscopic haemostasis (adrenaline injection, cauterisation)
complications → Hartmann's
```
57
pathophysiology behind toxic megacolon
non-obstructive colonic dilatation due to myenteric plexus swelling (loss of bowel tone + motility)
58
gastrointestinal causes of clubbing
IBD
liver cirrhosis
coeliac disease
cancers: GI lymphoma, oesophageal carcinoma
59
causes of spider naevi
liver disease (>3)
pregnancy
COCP
60
prevention of oesophageal bleeding
propranolol
61
liver cirrhosis severity score
child-pugh
62
ulcerative colitis severity score
truelove + witt's criteria:
mild: < 4 stools / day, some blood
mod: 4-6 stools / day, mod blood
severe: > 6 stools / day, systemic features (fever, high ESR, tachycardia)
63
maintenance Tx for ulcerative colitis
following mild-mod flare: rectal 5-ASA +/- oral 5-ASA
| severe flare OR > 2 flares / year: oral azathioprine / mercaptopurine
64
maintenance Tx for Crohn's
1. azathioprine / mercaptopurine
| 2. methotrexate
65
induction of remission Crohn's
1. glucocorticoids (or 5-ASA or budesonide)
| 2. add azathioprine / mercaptopurine / methotrexate
66
features of peutz jeghers
autosomal dominant
pigmented freckling of lips, face, palms, soles
hamartous polyps in GIT
small bowel obstruction e.g. intususseption
increased risk of malignancy: colorectal, pancreatic, breast
67
causes budd-chiari
hepatic venous outflow obstruction
primary: hypercoagulable states (myeloproliferative, anti-phospholipid, COCP), stenosis
secondary: external compression (malignancy, trauma, abscess, cyst)
68
classification of intestinal ischaemia
1. acute mesenteric ischaemia: SMA (distal duodenum → splenic flexure)
2. chronic mesenteric ischaemia: all 3 gut arteries (SMA, IMA + coeliac trunk)
3. ischaemic colitis: IMA (splenic flexure → rectum)
69
indications for liver transplant
```
liver failure due to:
alcoholic / non-alcoholic liver disease
viral hepatitis (chronic B+C)
autoimmune hepatitis
malignancy: HCC
drug induced: paracetamol overdose
budd-chiari
infiltration: haemochromatosis, amyloidosis
```
70
complications liver transplant
immediate: pain, infection, bleeding, acute rejection
late: vascular / biliary anastomosic problems, immunosuppression (infection, malignancy)
71
types of liver transplant
1. cadaveric (more common)
| 2. partial live donor transplantation (L / R lobe)
72
complications of liver disease
portal HTN
hepatocellular carcinoma
hepatic encephalopathy (toxins not removed from blood e.g. ammonia)
coagulopathy
73
management liver cirrhosis
supportive / symptomatic until liver transplant
cons: diet, reduce alcohol, avoid hepatotoxic drugs (e.g. NSAIDs), monitor for complications
med:
treat cause (e.g. protease inhibitors ± ribavirin for hep C)
treat symptoms / complications (e.g. diuretics, fluid restriction, tap for ascites)
74
severity scoring for cirrhosis
```
child-turcotte-pugh score
encephalopathy
ascites
bilirubin
albumin
prothrombin time
```
75
severity scoring for cirrhosis
```
child-turcotte-pugh score
encephalopathy
ascites
bilirubin
albumin
prothrombin time
```
76
types of gallstones
cholesterol (80%)
bilirubin
mixed
77
investigations gallstones
bloods: FBC, CRP, U+Es, LFTs
imaging: abdo USS (1st line)
ERCP if choledocholithiasis (common bile duct stone) → diagnostic + therapeutic
78
management gallstones
asymptomatic: observation
elective cholecystectomy if: gallstones > 3cm, porcelain gallbladder, gallstone in CBD
symptomatic (cholelithiasis): elective cholecystectomy
```
gallstone in CBD (choledocholithiasis):
ERCP w biliary sphincterotomy + stone extraction
OR cholecystectomy
other surgical options:
extra-corporeal shockwave lithotripsy
biliary stent
papillary balloon dilatation
laparopscopic CBD exploration
```
79
complications gallstones
```
ascending cholangitis
cholecystitis
pancreatitis
sepsis
gallstone ileus
```
80
causes of jaundice
pre-hepatic: haemolysis (autoimmune, sickle cell. malaria), Gilbert's
hepatic: viral hepatitis, alcohol, drugs (paracetamol, isoniazid, rifampicin)
post-hepatic: obstructive (gallstones, pancreatic cancer)
81
PBC vs PSC
PBC: autoimmune damage (AMA +ve) to intrahepatic bile ducts → cholestasis
PSC: fibrosis → stenosis of bile ducts (intra + extrahepatic) → cholestasis
82
complications of PBC
liver cirrhosis + failure
osteomalacia + osteoporosis
risk of hepatocellular carcinoma
83
PBC associations
autoimmune conditions:
rheumatoid, systemic sclerosis, sjogren's
thyroid disease
84
complications of PSC
liver cirrhosis + failure
| risk of cholangiocarcinoma + colorectal carcinoma
85
PSC associations
IBD esp ulcerative colitis
| HIV
86
definition of achalasia
1. oesophageal aperistalsis
2. failure of relaxation of lower oesophageal sphincter
due to loss of ganglion cells in myenteric plexus
87
presentation of achalasia
```
dysphagia (fluid + solids)
posturing to aid swallowing
regurgitation (+ cough + risk of aspiration pneumonia)
retrosternal pain / pressure
weight loss
```
88
how does a lateral pancreaticojejunostomy work
jejunum divided and proximal end anastomosed to pancreas to allow drainage
jejuno-jejunostomy restores continuity of GI tract
89
differentiating Sx of small + large bowel obstruction
SBO: early vomiting, late constipation, high-pitched tinkling bowel sounds, central more frequent abdo pain
LBO: late vomiting, early constipation, lower less frequent abdo pain, empty rectum on PR
90
definitive management of volvulus
caecal volvulus: usually requires surgery (R hemicolectomy)
| sigmoid volvulus: decompression w rigid sigmoidoscopy + rectal tube insertion
91
typical presentation acute cholangitis
```
charcot's triad:
1. fever
2. RUQ pain (radiating to back)
3. jaundice (+ itching, pale stools, dark urine)
raynaud's pentad:
4. hypotension
5. confusion
```
92
management acute cholangitis
```
ABCDE
IV fluids + analgesia + anti-emetics
broad-spectrum ABx
definitive:
therapeutic ERCP after 24-48hrs (to relieve obstruction)
other options:
shockwave lithotripsy
cholecystectomy
```
93
types of hiatus hernia
1. sliding: Z-line moves above diaphragm
| 2. rolling: fundus of stomach herniates above diaphragm w Z-line maintined below
94
types of oesophageal carcinoma
upper 2/3: squamous cell carcinoma
| lower 1/3: adenocarcinoma
95
management achalasia
medical: CCBs, nitrates (isosorbide dinitrate)
surgical:
pneumatic (balloon) dilatation (older pts)
Heller cardiomyotomy (laparoscopic incision of LOS muscle, younger pts)
2nd line: endoscopic botox injection
last line: gastrostomy
96
types of autoimmune hepatitis
type I: most common
anti-SMA (smooth muscle), ANA (anti-nuclear Ab)
type II: ALKM1-Ab (anti-liver/kidney microsomal type 1), younger pts w other autoimmune conditions
type III: soluble liver-kidney Ag, older pts
97
complications coeliac disease
```
dermatitis herpetiformis
malabsorption:
folate / B12 / iron deficiency
vitamin D deficiency → osteomalacia
malignancy: small-bowel cancer, EATL
hyposplenism
```
98
DDx RUQ pain
duodenal ulcer
hepatitis, liver abscess
gallstones, cholangitis, cholecystitis
99
DDx LUQ pain
splenic rupture / infarct
100
DDx epigastric pain
GORD
gastric ulcer
pancreatitis
101
DDx umbilical pain
early appendicitis
ruptured AAA
IBD
102
DDx hypochondrial pain
renal colic
pyelonephritis
hydronephrosis
103
DDx RLQ pain
IBD
late appendicitis
gynae: ectopic pregnancy, ovarian cyst / torsion
104
DDx LLQ pain
diverticulitis
IBD
faecal impaction
gynae: ectopic pregnancy, ovarian cyst / torsion
105
DDx suprapubic pain
cystitis
UTI
urinary retention
106
investigations liver cirrhosis
bloods: FBC, CRP, LFTs, U&Es, clotting, hepatitis serology, aFP (for HCC)
diagnostic:
fibroscan (transient elastography): best
acoustic radiation force impulse imaging
liver biopsy
monitor for complications:
USS / CT / MRI
OGD → varices
107
tumour markers cholangiocarcinoma
CEA
Ca19-9
Ca125
