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Gastro/ GI Surg Flashcards

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1
Q

GI causes of clubbing

A

Uncommon:

Cirrhosis (especially biliary cirrhosis)
Inflammatory bowel disease
Coeliac disease

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2
Q

Management of anal fissure

A

Conservative: high fibre diet/ lactulose to allow to heal

Medical: steroid/LA suppositories before opening bowels - GTN ointment to relieve anal muscle spasm pain

Surgical

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3
Q

Management of haemorrhoids

A

Conservative

Medical: steroid/ LA ointment or suppository

Surgery

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4
Q

In what % is a cause of UGIB not found on endoscopy?

A

20%

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5
Q

2 most common causes of UGIB

A

PUD and varices

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6
Q

how much more common in UGIB compared with pr bleeding

A

x4

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7
Q

how does UGIB present?

A

haematemesis
coffee-ground vomit
melaena
haematochezia

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8
Q

What to look for on examination of UGIB?

A

Signs of shock
Hydration
Anaemia
Signs of tumours, eg lymphadenopathy

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9
Q

What clinical findings are suggestive of Boerhaave’s?

A

s/c emphysema

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10
Q

Ix for UGIB

A

Endoscopy:
immediately after resus if severe acute
everyone else within 24h

FBC (seially every 4-6h to check Hb trend)
Cross-match (usually 4-6 units)
Coagulation profile
LFTs
U&Es
Ca: detect hyperparathyroidism and monitor effects of blood transfusion
Gastrin: rule out gastrinoma

CXR: identify aspiration pneumonia, pleural effusion, perforated oesophagus
Erect + supine AXR: perforated viscus and ileus
Consider other imaging

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11
Q

Who should be considered for hospital admission for UGIB?

Name of scores

A

60 years+
witnessed fresh blood/ suspected continued bleeding
haemodynamic disturbance
liver disease or known varices

Blatchford score: first assessment
Rockall: after endoscopy

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12
Q

Mx options for oesophageal varices

A

Terlipressin
Prophylactic abx
Band ligation

if uncontrolled, consider balloon tamponade and TIPS

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13
Q

Most important factor in managing bleeding PUD

A

H.pylori eradication

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14
Q

With rectal bleeding, who to refer for flexi sig and who to refer for colonoscopy?

A

colonoscopy if suspicion of malignancy
virtual colonoscopy is NICE-approved

flexi sig for younger patients with concern about pathology other than haemorrhoids

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15
Q

Who should be referred under 2WW cancer pathway (bowel ca)?

A

Age 40+ with unexplained weight loss and abdo pain

Age 50+ with unexplained rectal bleeding

Age 60+ with iron-deficiency anaemia or change in bowel habit

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16
Q

Causes of acute oesophagitis

A

Immunocompromised
HSV/ CMV (ulceration more common in lower bowel)
Deliberate/ accidental swallowing corrosive substances

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17
Q

Complications of chronic oesophagitis

A

Fibrosis/ strictures
Ulcers may haemorrhage or perforate
Barrett’s oesophagus

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18
Q

What is achalasia?

How does it show on imaging?

A

Loss of coordinated peristalsis of the lower oesophagus and spasm of LOS - preventing passage of contents into stomach
Bird beak

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19
Q

Describe two types hiatus hernia

A

Sliding: gastro-oesophageal jct slides through hiatus and sits above diaphragm (more common)

Rolling (para-oesophageal): part of fundus rolls up next to oesophagus - usually requires surgical correction to avoid strangulation

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20
Q

How does Boerhaave syndrome differ from MW tear?

A

Transmural oesophageal rupture (vs tear at gastro-oesophageal jct)

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21
Q

Medications that must be taken with sufficient water to avoid GORD

A

NSAIDs and bisphosphonates

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22
Q

What is relationship between GORD and H.pylori?

A

None

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23
Q

Who should be referred on 2WW for upper GI cancer?

A

Dysphagia

Dyspepsia + alarms
Dyspepsia (over 50) + symptoms persistent/ within last 1 year
Dyspepsia + clinical finding or risk factors

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24
Q

Pharmacological mx GORD

A

Trial 1 month PPI

consider if on drugs that slower motility/ exacerbate

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25
Mechanisms contributing to/ causing hiatus hernia
Widening of diaphragmatic hiatus Pulling up of stomach (oesophageal shortening) Pushing up of stomach (intra-abdominal pressure)
26
Presentation of sliding hiatus hernia
Asymptomatic Or: heartburn, reflux, difficulty swallowing
27
Presentation of para-oesophageal hernia
Asymptomatic Or: chest pain, epigastric pain, fullness, nausea, potentially sx of obstruction
28
Usual surgical procedure for hiatus hernia
``` laparoscopic fundoplication (although PPIs preferred mx) ```
29
Histology of oesophageal ca (and Barrett's)
Barrett's = columnar metaplasia SCC (esp with smoking + alcohol, Barrett's is precursor), AC (now much-increased)
30
Causes of acute gastritis
Almost always: drugs (esp aspirin), alcohol
31
Name of gastritis caused by shock, severe burns, toxic substances
Acute erosive gastritis
32
What causes autoimmune chronic gastritis
``` Pernicous anaemia (autoimmune gastritis + macrocytic anaemia) Against parietal cells and IF ```
33
Shape of H.pylori
Gram neg spiral-shaped bacillus
34
Transmission of H.pylori
oral-oral, faecal-oral
35
What is reactive gastritis? How does it present?
Regurg of duodenal contents into stomach through pylorus | Dyspepsia, biliary vomiting
36
What causes reactive gastritis?
Irritants: NSAIDs, alcohol, biliary reflux | or when motility is compromised
37
What causes acute peptic ulcer disease?
Same as acute gastitis
38
Most common: gastric ulcers or duodenal?
Duodenal (x2-3) - clasically exacerbated by hunger
39
Peptic ulceration is rare without...
H.pylori (95% duodenal, 80% gastric) | or NSAID use
40
How can H.pylori be tested?
Urea breath test or stool antigen test
41
Eradication of H.pylori therapy
7-day course: PPI + 2 abx (amoxicillin or clarithromycin or metronidazole)
42
Usual mx gastric ca
Surgery | 5 year prognosis (15%)
43
General pattern for LFTs
Pre-hepatic: bilirubin raised Intrahepatic: bilirubin raised + AST/ ALT raised Posthepatic: Bilirubin raised + ALP raised
44
Why is acute pancreatitis so dangerous?
Releases exocrine enzymes
45
Most common causes of acute pancreatitis?
Gallbladder disease (blocked bile duct causing back pressure in pancreatic duct) Excess alcohol
46
Classic presentation of acute pancreatitis
Severe upper abdo pain: sudden onset with vomiting Sometimes more L-sided, sometimes encircles abdo. Often penetrates to the back. Dehydrated ``` Maybe jaundice (esp common bile duct obstruction) Maybe Cullen's/ Grey Turner's ``` Hypoxia is characteristic Pain steadily decreases over 72h
47
Best test for acute pancreatitis
Lipase
48
Ix acute pancreatitis
Bloods: FBC, U&Es, LFTs, lipase, glucose, CRP, calcium (in chronic pancreatitis - lipase often normal) Imaging: plain erect AXR Consider USS for gallstones
49
Scoring systems for acute pancreatitis
Glasgow Prognostic Score Ranson's score (similar, involves criteria on admission)
50
Mx acute pancreatitis
Fluids + pain relief (pethidine or buprenorphine/ +/- IV benzos) (IV abx if significant necrosis - mx in ITU/ HDU)
51
Why is morphine relatively contraindicated in acute pancreatitis?
Possible spasm of sphincter of Oddi
52
Abdominal complications of acute pancreatitis
Pancreatic necrosis (raising CRP) Acute fluid collections (usually spontaneously resolve) Pancreatic abscess (needs surgical drainage) Pseudo-cyst (pancreatic juice in a wall of fibrous/ granulation tissue): can rupture/ haemorrhage
53
Presentation of chronic pancreatitis
``` Epigastric pain radiating into the back (can be severe: may need opiates) N&V Decreased appetite Exocrine dysfunction Endocrine dysfunction ```
54
What is Courvoisier's sign?
palpable bladder + painless jaundice usually pancreatic ca (only in about 25%)
55
How might pain be treated in palliative care of pancreatic ca?
Coeliac plexus block
56
Tumour marker for pancreatic ca
CA19-9
57
What is hydrogen test for?
Bacterial overgrowth in gut
58
Dermatological manifestation of coeliac
Dermatitis herpetiformis
59
Who should be screened for coeliac
unexplained neuro sx, metabolic bone disorder...lots of others
60
Types of diarrhoea
Osmotic Secretory Rapid transit
61
Most common source of bacterial food poisoning in UK
Campylobacter
62
Hepatic complication related to UC
Primary sclerosing cholangitis (5%)
63
Transmission of C.difficile?
Faeco-oral | Spores on surfaces
64
Appearance of C.diff
Gram-positive rods REPORTABLE
65
How long after abx therapy does C.diff usually present?
5-10 days | sometimes no abx exposure
66
Rovsing's sign
Touch L, pain in R
67
Initial ix for IBD
FBC, U&Es, LFTs, CRP, stool culture + microscopy, faecal calprotectin For UC: also iron studies, B12 and folate
68
Initial ix for IBS
FBC, CRP, coeliac screen, CA-125, faecal calprotectin
69
Why do hernias become irreducible?
Hernia enlarges. Fibrous adhesions form.
70
Types of inguinal hernia
INDIRECT: 80% - protrusion through internal inguinal ring (usually failure of inguinal canal to close properly) - runs LATERALLY to inferior epigastric vessels DIRECT: hernia protrudes directly through weakness in posterior wall of inguinal canal - more common in elderly, v rare in kids - runs MEDIALLY to inferior epigastric vessels
71
Presentation of femoral hernia
Bump lateral and inferior to pubic tubercle | All should be repaired electively, as soon as possible
72
Define ileus
Non-mechanical intestinal obstruction
73
Causes of small bowel obstruction
Adhesions (75%), strangulated hernia, malignancy (usually caecal), volvulus
74
Causes of large bowel obstruction
Colorectal malignancy, tumours often advanced
75
Initial ix intestinal obstruction
FBC, U&Es, group + cross-match | erect AXR
76
Proper name for small bowel ischaemia
Mesenteric ischaemia (vs ischaemic colitis) - more acute
77
Causes of bowel ischaemia
arterial throboembolism, non-occlusive ischaemia (hypoperfusion, vasospasm), venous thrombosis
78
Where are diverticula most commonly found?
Sigmoid and descending colon | but can be anywhere in GI tract
79
Main histology of colorectal ca
adenocarcinomas
80
Causes and signs of prehepatic jaundice
Haemolysis Ineffective erythropoiesis Gilbert's Increased unconjugated billi in serum. None in urine: insoluble
81
Causes and signs of hepatic (mixed) jaundice
``` Hepatitis Cirrhosis Autoimmune disease Weil's disease (bacterial infection spread from rat urine) Wilson's ``` Increased clotting time Increased ALT and AST - hepatocellular damage
82
Causes and signs of post-hepatic jaundice
``` Pancreatitis Primary billiary cirrhosis Gallstones Drugs Ca obstructing bile duct ``` Dark urine, pale stools, itching Gamma-GT and AP increase (damage to biliary tree)
83
Antibodies is primary biliary cirrhosis
antii-mitochondrial antibodies
84
Why are those with Crohn's susceptible to gallstones?
Malabsorption of bile salts from the terminal ileum - can't deal with cholesterol
85
Innervation of gallbladder
T5-9
86
Charcot's triad
Ascending cholangitis: | upper RUQ pain - fever (usually with rigors) - jaundice
87
Bacteria in ascending cholangitis
gut bugs: e coli, klebsiella etc
88
Why is gallstone ileus a misnomer?
ileus characterised by cessation of normal peristalsis - if a gallstone obstructs the bowel there is vigorous peristalsis in attempt to remove it
89
Ix for ascending cholangitis
``` FBC U&Es LFTs Blood cultures amylase ``` USS
90
Range of alcoholic liver disease What is equivalent for NAFLD?
Fatty liver Alcoholic hepatitis Alcoholic cirrhosis NAFLD NASH (non-alcoholic steatohepatitis) cirrhosis
91
Mx auto-immune hepatitis
Pred and immunosuppress given indefinitely | transplantation if ineffective
92
Most common cause of hepatitis worldwide?
Hep B
93
Transmission of hep B
Sexual Vertical Blood-to-blood (inc transfusion)
94
Hepatitis D only present in whom?
Those with hep B
95
Inheritance pattern of Wilson's disease
autosomal recessive
96
Ix Wilson's
low serum caeruloplasmin
97
3 classes of liver failure
Fulminant hepatic failure (within 8 wks) Late-onset hepatic failure (under 6 months) Chronic decompensated hepatic failure (6 months+)
98
Pre-hepatic causes of portal HTN
Portal vein thrombosis AV fistula Increased splenic bloodflow
99
Hepatic causes of portal HTN
Cirrhosis
100
Post-hepatic causes HTN
Budd-Chiari (hepatic vein obstruction)
101
How does portal HTN led to pancytopenia?
Splenomegaly/ hypersplenism
102
Should someone with hepatic encephalopathy reduce protein intake?
nah
103
Role of neomycin in hepatic encephalopathy
Reduces nitrogen-producing bacteria
104
What is bile duct cancer called?
cholangiocarcinoma
105
A focal lesion in liver of someone with cirrhosis is highly likely to be what?
HCC
106
Jaundice + pain suggests...
Gallstones
107
Specific ix for autoimmune hepatitis
Immunoglobulins IgG if acute IgM if chronic
108
Infective causes of hepatomegaly
``` Viral hep EBV CMV Malaria Helminths ```
109
Congestive/ vascular causes of hepatomegaly
RVF/ CCF Constrictive pericarditis Budd-Chiari synrome
110
Autoimmune causes of hepatomegaly
autoimmune liver disease!
111
Haematological causes of hepatomegaly
``` thalasseaemia SCD other haemolytic anaemia myeloma leukaemia ```
112
Tumours and infiltrative causes of hepatomegaly
all!
113
Metabolic causes of hepatomegaly
haemochromatosis Wilson's porphyria NAFLD
114
Toxic-related causes of hepatomegaly
alcoholic liver disease | drug-induced hepatitis
115
Low WCC in liver disease suggests
viral hep
116
What do ALT and AST show?
hepatocellular damage | ALT more specific for liver, AST is also skeletal/ cardiac
117
What does ALP show?
From bile ducts - cholestasis | also bone
118
Steps for presenting AXR | 11 steps + finish
1. Pt details/ indication/ presenting complaint 2. Projection (usually AP) 3. Technical adequacy: should show whole abdomen, hemidiaphragms to pubis symphysis 4. Obvious abnormalities 5. BOWEL Large (has partial haustra): start at rectum a) bowel diameter (~6 cm, except caecum) b) bowel wall thickness Small bowel (has full width valvulae conniventes) a) bowel diameter (~3 cm) b) bowel wall thickness 6. Pneumoperitoneum? 7. Liver, gallbladder, spleen 8. Urinary tract 9. Major vasculature 10. Skeleton 11. Iatrogenic abnormalities END: Request previous imaging, suggest ddx and ix
119
Only indications for AXR
acute abdo ?obstruction | acute exacerbation IBD/ similar ?megacolon
120
Causes of pneumperitoneum
perf recent laparotomy intra-abdo infection with gas-forming bug
121
What analgesia is given for gastroscopy?
``` LA spray (back of throat) or lozenge sedative ```
122
Practical steps in explaining gastroscopy
Lie on side mouth guard filled with air (might make you belch!) takes ~10 mins but expect to be in hosp about 2 hours
123
What preparation is needed for gastroscopy?
no food 4-6 hours, sips water | Someone to take home, if sedative
124
What is MRCP?
uses MRI to produce images of liver, gallbladder, bile ducts, pancreas with contrast
125
What is ERCP?
Endoscope + x-rays to look at bile duct and pancreatic duct | can remove gallstones, take biopsies
126
Who is invited to bowel screening?
55+ (some areas - one-off flexi sig) 60-74 home FOB test every 2 years 75+ call to opt-in
127
How far does flexi sig go? Colonoscopy?
Splenic flexure, ileo-caecal valve
128
What happens during CT colonoscopy?
Usually contrast swallowed | tube in bum to fill a little with gas
129
What is an ileo-anal pouch?
new rectum following colectomy to store poop
130
where does colostomy sit/ ileostomy
c: LIF - flush with skin i: RIF - spout
131
how to remove surgical drains?
2 cm per day, slowly allowing to heal | may cause discomfort, may need analgesia
132
What causes reactive bleeding?
Bleeding within 24h op | Pt usually hypotensive and relatively vasoconstricted. When BP rises, bleeding can occur
133
what is dumping syndrome
complication of gastrectomy fullness (even after eating small amounts cramps, pain, N&V, severe diarrhoea, autonomic quickly dumps into small intestine
134
dysphagia: OGD or barium swallow?
OGD if solids only | barium if liquids too
135
what gives a corkscrew oesophagus appearance on barium swallow?
diffuse oesophageal spasm
136
What is mirizzi syndrome?
Gallstones become impacted - obstructive jaundice ensues
137
what is pellagra? sx?
Dermatitis, diarrhoea, dementia/delusions, leading to death | niacin (b3) deficiency
138
when should alginates be given?
2 hours after meds so not to cause absorption problems
139
examples of dopamine-receptor anti-emitics. when are these best? when should not be given?
metoclopramide, domperidone pro-kinetic risk of EPSE (kids, young adults). not in perf or GI obstruction
140
examples of histamine-receptor anti-emitics. when are these best? when should not be given?
cyclizine, promethazine N&V, esp vertigo/ motion sickness anticholinergic side-effects so no BPH, also hepatic encephalopathy
141
examples serotonin-receptor anti-emetics. when best?
ondansetron, best following chemo/ GA | causes prlonged QT

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