Gastro + Surgery Flashcards
(177 cards)
1
Q
STOMATITIS
Causes
A
Inflammation of oral cavity
Non-infective: Crohn’s, Behcet’s, coeliac, normal population
Infective: herpetic, oral candidiasis (NB uncommon in DM)
2
Q
Causes of glossitis
Different appearances
A
Stomatitis (various causes), deficiencies (esp B vitamins, folic acid)
Acute: tongue is beefy-red, raw, painful
Chronic: tongue appears moist and unduly clean
3
Q
What is Chagas’ disease?
A
Infection by Trypanosoma cruzi - cause of secondary achalasia due to destruction of myenteric plexus
(S America)
4
Q
Difference between urea breath test and CLO test?
A
CLO is invasive: you add biopsy to kit
5
Q
Most commonly prescribed prophylaxis for gut surgery?
A
Co-amoxiclav
6
Q
Define Zollinger-Ellison syndrome
A
A gastrin-secreting tumour of the pancreatic G cells, resulting in gastric gland hyperplasia and gastric hypersecretion
Common to have multiple peptic ulcers and diarrhoea
7
Q
What is absorbed in the proximal small intestine and what is absorbed in the terminal ileum?
A
Proximal: iron, folate, calcium
Terminal: B12
8
Q
Most common causes of UGIB
Other causes
A
PUD
Oesophageal varices
Other causes: oesophagitis, gastritis, malignancy, M-W tear, vascular malformation…
9
Q
Risk factors for UGIB
A
Alcohol abuse Chronic renal failure NSAIDs Age Low socio-economic class
10
Q
Risk factors for re-bleeding following UGIB
A
Age over 60 Presence of shock on admission Coagulopathy Pulsatile haemorrhage Cardiovascular disease
11
Q
Examination of UGIB
A
Signs of shock and blood loss: obs, postural hypotension, pallor, urine output…
Elicit cause:
stigmata of liver disease
signs of tumour
s/c emphysema (oesophageal perf)
12
Q
Investigations for UGIB
A
FBC (serially every 4-6 hours) Cross-match (between 2-6 units) Coagulation profile LFTs U&Es Calcium (effect of blood transfusions) Gastrin (rare gastrinomas)
ENDOSCOPY
13
Q
Risk assessments in UGIB
A
Blatchford at first assessment
Rockall after endoscopy
14
Q
Medication to give for suspected variceal bleeding
A
Terlipressin
Prophylactic abx
15
Q
How to reconcile drug chart for bleeding patients
A
(Some hospitals say to give PPI for all UGIB, but better to wait til post-endoscopy)
Consider stopping all anticoag and antiplatelets during acute phase
Low-dose aspirin usually okay to continue later
Discuss with specialist risk/ benefits of clopi
SSRIs should be used with caution
CS will need careful concomitant PPI
16
Q
Ix for rectal bleeding
A
FBC
Consider: G&S Ferritin and iron studies Clotting studies LFTs Faecal calprotectin
17
Q
M-W vs Boerhaave
A
M-W: tear at gastro-oesophageal jct
Boerhaave: transmural oesophageal rupture
18
Q
Meds associated with GORD
A
NSAIDs
Doxycycline
Bisphosphonates
those affecting motility: TCAs, anticholinergics, nitrates, CCBs
19
Q
What is the normal oesophageal histology? What happens in Barrett’s?
A
from normal stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the stomach
20
Q
Mx reflux (if no alarm symptoms)
A
PPI for one-month
Next: H2-receptor antagonist
21
Q
Types of hiatus hernia (how common and definition)
A
Sliding (85-95%): gastro-esophageal jct slides up
Rolling (5-15%): jct remains in place but a part of stomach (or other organ) herniates up
22
Q
Presentation of hiatus hernias
A
Asymptomatic
Dyspepsia/ GORD
Para-oesophageal may also present with chest pain, epigastric pain, fullness, sx of obstruction
23
Q
Histological types of oesophageal cancer
A
SCC: alcohol + smoking,
AC: growing incidence - possibly more common in developed countries
24
Q
Barrett’s oesophagus is a precursor of which ca?
A
AC
SCC associated with chronic inflammation and stasis, eg achalasia
25
Why does oesophageal ca present late?
Need obstruction of ~75% for 'food sticking'
26
Difference between acute gastritis and acute erosive gastritis
Acute: almost always caused by drugs (aspirin) and alcohol - chemical exfoliation of surface epithelium
Acute erosive: partial loss of gastric mucosa - shock, severe burns, toxic substances
27
What is pernicious anaemia a risk factor for?
Carcinoma of stomach
28
What is reactive gastritis?
AKA reflux gastritis - duodenal contents into stomach
Caused by irritants: NSAIDs, alcohol, biliary reflux
or compromised motility
29
Causes of delayed gastric emptying.
Symptoms.
Mechanical: tumour, bezoar
Non-mechanical: gastroparesis
Asymptomatic or bloating, belching, N&V, weight loss...
30
Describe H.pylori
motile, Gram-negative spiral bacilli
31
PUD nearly always associated with
H.pylori
| NSAIDs
32
Relationship between H.pylori and:
Gastric ca
GORD
Increased risk of gastric AC
Associated with gastric MALT-lymphoma
Potential inverse relationship with GORD
33
Recommended first-line treatment of H.pylori
7 days BD: PPI, 1g amox, 400 mg metronidazole
If allergic: 500 mg clarithromycin
(If recently already had clarith, use alternative)
If had only dyspepsia, no need to re-test
If has PUD, re-test in 6-8 weeks
34
Uses for probiotics/ lactobacilli
Reduce activity of H.pylori
35
Causes PUD
```
H.pylori
NSAIDs
Steroids
Smoking
Alcohol
Stress
```
36
Which ulcer better after eating?
Food worse for gastric
| Better for duodenal
37
Investigations for dyspepsia
FBC
Testing for H.pylori
Endoscopy
38
Complications of PUD
Erosion > haematemesis/ melaena
Perforation > acute abdomen
Scarring > pyloric stenosis
39
Risk factors for gastric cancer
```
Age
Men
Low socio-economic class
H.pylori
Smoking
Poor fruit diet/ high salt + preserved
Familial
Pernicious anaemia
```
40
Poor signs associated with gastric carcinoma
```
Epigastric mass
Hepatomegaly
Jaundice
Ascites
Troisier's sign
Acanthosis nigricans
```
41
Definition of acute pancreatitis
Acute inflammation leading to release of exocrine enzymes/ autodigestion
42
Causes of acute pancreatitis
Gallstones (blocking bile duct)
Excess alcohol
```
Post-ERCP
Viral (Coxsackie, hep, mumps)
Metabolic (lots)
Ischaemia
Malignancy
IBD (maybe associated with mesalazine)
```
43
Symptoms and signs of acute pancreatitis
Sudden onset severe upper abdo pain with vomiting
(can radiate to back, can be peri-umbilical)
Pain tends to decrease over 72h
Looks unwell - possible jaundice
Hypoxaemia is characteristic
Tachycardia (dehydrated)
Mild pyrexia common (can be hypothermic)
44
Ix for acute pancreatitis
Serum lipase
FBC, U&Es, glucose, CRP, bone profile (hypocalcaemia), LFTs
AXR (eliminate other causes)
CXR (ARDs etc)
USS to visualise gallstones
45
Mx acute pancreatitis
```
MILD:
IV Fluids
NBM
Pethidine or buprenorphine + IV benzos
(morphine can cause spasticity of sphincer of Oddi)
(NG only for severe vomiting)
```
SEVERE:
ITU/ HDU
IV abx if evidence necrosis
46
Complications of acute pancreatitis
Necrosis (rising CRP, confirmed by dynamic CT)
Infection/ abscess (requires surgery)
Ascitic fluid collection
Pseudo-cyst: pancreatic juice in wall of fibrous or granulation tissue - requires surgery (can rupture/ haemorrhage) - occurs ~4 weeks after
47
Systemic complications of acute pancreatitis
```
Resp:
pulm oedema
pleural effusions
consolidation
ARDs
```
Cardiovascular:
hypovolaemia
DIC
Renal: dysfunction due to hypovolaemia/ intravascular coagulation
Metabolic
GI:
haemorrhage
ileus
48
Presentation of chronic pancreatitis
```
Abdo pain: typically epigastric, radiating to back
N&V
Decreased appetite
Steatorrhoea (exocrine dysfunction)
DM (endocrine dysfunction)
```
49
Why is chronic pancreatitis hard to diagnose?
Generalised symptoms
No dose-related link with alcohol
Amylase normal
Small-duct pancreatitis not easily seen on imaging
50
Tumour marker in pancreatic ca
CA19-9
51
Investigations for malabsorption
```
FBC
CRP
Vit B12/ folate
Ferritin
Clotting (for vit K)
Serum albumin/ LFTs
Calcium
Coeliac screen
Mg
```
Consider:
stool sample
hydrogen breath test (bacterial overgrowth)
52
Where is gluten found?
Wheat, rye and barley
53
Prevalence of coeliac
1% in UK
54
Skin problem with coeliac
Dermatitis herpetiformis
55
Classical histological finding in coeliac
Subtotal villous atrophy
56
Types of diarrhoea
Osmotic: reduced absorption of electrolytes
Secretory
Rapid transit (stasis can also cause diarrhoea by facilitating bacterial overgrowth)
57
Histology of C.difficile
Gram positive rod
58
Mx Cdiff
Fluids & electrolytes
Metronidazole or vancomycin
Avoid anti-diarrhoeals
NOTIFIABLE
59
Extra-intestinal manifestations of Crohn's
common
iritis, arthritis (sacroiliitis, ank spond) , erythema nodosum, pyoderma gangrenosum
clubbing
Similar UC
Basically steroids for everything
60
Common ages for Crohns
Young
And 50-70
Similar UC
61
When does Crohn's require urgent admission
```
Severe abdo pain
Severe diarrhoea (8+/day)
Bowel obstruction!
Systemically unwell
```
62
How to induce remission in Crohn's
If first presentation/ one per year: GC (eg pred)
If not tolerated: 5-aminosalicylate (5-ASA)
If more:
azathioprine add-on
or others
*anti-diarrhoeals contra-indicated during relapse
63
How many Crohn's require surgery?
50% within 10 years
64
Complications of Crohn's
Bowel: strictures, fistulae, perfs, increased risk carcinoma
Osteoporosis (esp if on steroids)
Deficiencies..
Gallstones (usually oxalate)
65
Serological markers to differentiate Crohn's and UC
p-ANCA UC
| ASCA Crohns
66
Mx of UC relapse
Mesalazine - first choice
CS (no role in maintenance)
67
Triad of IBS
6 months:
abdo pain
bloating
change in bowel habit
68
Ix IBS
```
FBC
CRP
Coeliac
CA 125
Faecal calprotectin
```
69
What is contained in an abdominal hernia?
Always contains portion of peritoneal sac - may contain viscera (usually small bowel)
70
Definition ileus
non-mechanical intestinal obstruction
71
Causes of small bowel obstruction
Adhesions, strangulated hernia, volvulus, malignancy (of caecum - small bowel malignancy rare)
72
Causes of large bowel obstruction
Malignancy
73
What does severe pain in bowel obstruction indicate
Ischaemia or perf
74
Why may a person with bowel obstruction be dehydrated?
Water unabsorbed in bowel
Reduced oral intake
vomiting
75
Ix bowel obstruction
Fluid chart
FBC, U&Es, G&S, cross-match, glucose
AXR
76
Diverticulosis
Diverticular disease
Diverticulitis
Got em
Cause symptoms
Evidence of inflammation (eg systemic sx)
77
Where does colorectal ca metastasise?
Liver
| Lungs, brain, bone
these are unusual in absence of liver mets
78
Which tumours require anterior resection?
Low sigmoid/ high rectum
79
Biochemical jaundice vs clinical jaundice
Bili 25 +
35+ to see (in sclera, good light!)
80
Signs of post-hepatic jaundice
Dark urine
Pale stools
Itching
Increased GGT and AP (damage to biliary tree)
81
Signs of pre-hepatic jaundice
```
Normal urine (unconjugated bili is insoluble)
Increased bili
```
82
Signs of hepatic jaundice
(mixed)
increased clotting (lack of bile > malabsorption of lipids/ vit K
Increased ALT and AST
83
Signs of liver disease
```
Spider naevi
Palmar erythema
Gynaecomastia
Testicular atrophy
Flapping tremor
Splenomegaly
Finger clubbing
Ascites
Peripheral oedema
```
84
False negatives for urinary bili
Rifampicin
| Old urine
85
Blood test for haemolysis
Lactate dehydrogenase is raised
86
Vitamin K affects which clotting blood
Prolonged prothrombin time
87
Signature serology for PBC
Antimitochondrial antibody
| about 35% have ANAs
88
Medication for pruritus
UDCA
| can be used as prophylaxis for gallstones, eg post-bariatric surgery
89
Why should HRT be avoided in PBC?
oestrogens promote cholestasis
90
Most common type of biliary stone
Cholesterol (80%)
91
Main difference between biliary colic and cholecystitis
inflammatory component: local peritonism, fever, raised WCC
92
Bedside test for cholecystitis
Murphy's sign
93
Ix gallbladder disease
FBC
LFTs
Uss
94
How does gallbladder empyema present?
Markedly toxic, markedly fever, leucocytosis
95
What is gallstone ileus?
Occlusion of intestinal lumen by stone
96
Pain relief for biliary colic/ cholescystitis
Morphine or pethidine parenterally
and/ or diclofenac suppository
Sometimes IV abx
97
Why are ppl with Crohn's predisposed to gallstones?
Malabsorption of bile salts from terminal ileum
98
Why do ppl with haemolytic anaemias get gallstones?
Increase in billi
99
Why may cholecystitis cause intercapsular pain?
T5-9 innervates gallbladder
| Shoulder pain: C3-5 if inflammation irritates diaphragm
100
What is Charcot's triad?
jaundice
fever (usually with rigors)
RUQ pain
ascending cholangitis
101
Levels of alcoholic liver disease
Equiv levels in non-alcoholic fatty liver disease
Hepatic steatosis
Alcoholic hepatitis
Alcoholic cirrhosis
NAFLD
NASH
Cirrhosis
102
Why does alcohol excess cause fatty liver?
Metabolism of EtOH prioritised over lipid metabolism and it builds up in hepatocytes
103
Risk factors for NAFLD
Obesity, DM, hyperlipidaemia
| + any hepatotoxin
104
How to diagnose NASH
Biopsy
| Or practically, based on EtOH intake
105
What is the most common cause of deranged LFTs in developed countries?
NAFLD
106
Blood tests suggestive of NAFLD
ALT mildly increased, relative to AST
Then reverses
(Up to 50% may have normal LFTs)
107
Imaging of NAFLD
USS: hyper-echogenic bright image
CT: may be helpful to monitor
MRI: fatty infiltration + other liver disease
108
Mx NAFLD
Weight loss, control of co-morbidities
| Vit E
109
Do ulcers require endoscopic follow-up?
Gastric: yes, at 8 weeks
Duodenal: only if symptoms recur (H.pylori breath test indicated)
110
Mx autoimmune hepatitis
Prednisolone and azathioprine indedinitely - remission in 90% cases
May need liver transplant
Can present as mild or acute liver failure
111
Presentation of acute Hep A
2-6 weeks incubation time
prodrome of mild-flu symptoms
can progress to icteric phase, with tender hepato-splemogegaly + lymphadenopathy
full recovery can take 6 months - complications v rare
112
Presentation of acute hep B
Incubation 60-90 days
subclinical or flu-like prodrome
acute infection may include jaundice or liver failure (including decompensated or fatal fulminant failure...)
113
How is chronic hep B divided?
Hep E antigen positive (higher rates of viral replication) or negative
114
Presentation of chronic hep B
Can be indolent
sometimes low-grade symptoms
higher chances HCC or cirrhosis - if significant fibrosis or other risk factors will be offered HCC screening
115
Presentation of hep C
acute: can present with jaundice
usually only presents in chronic state: at least 6 sub-types
usually non-specific symptoms
116
Which viral hepatitis unusual?
Hep D requires presence of HBV to replicate
117
How is Hep E transmitted?
Unlike others, the main resevoir is pigs/ contamination of water supplies
similar presentation as HAV
118
Earliest neurological sign in Wilson's
asymmetrical tremor
other neuro signs can be difficulty speaking, excess salivation, ataxia, personality changes
usually in 20s-30s
119
Diagnosing Wilson's
low caeroloplasmin + Kayser-Fleischer rings
can be treated! chelating agents and block Cu absorption
120
Presentation haemochromatosis
usually in 40s-60s
non-specific initially
diabetes, bronzing of skin, hepatomegaly, arthropathy, impotence/ hypogonadism, cardiac disease (arrhythmias, cardiomyopathy), neuro or psych disturbance
121
Causes of cirrhosis
```
EtOH
Hep B
Hep C
Wilson's
Haemachromatosis
Drugs
Autoimmune hepatitis
Congestive heart failure or TR
others
```
122
Classification of liver failure
Fulminant (within 8 weeks)
Late-onset (within 6 months)
Chronic (6 months+)
123
Causes portal HTN
Prehepatic: blockage of portal vein, eg portal vein thrombosis
Hepatic, eg cirrhosis
Posthepatic: blockage in venous sx after liver, eg Budd-Chiari, severe R HF
124
4 sites porto-systemic varices
Oesophageal
Rectal
Caput medusae
bare areas of GIT
125
Aetiology HCC
```
HBV or HCV
Alcoholism
haemachromotosis
metabolic sx
primary biliary cirrhosis
```
126
Name ca biliary treee
cholangiocarcinoma
127
Causes jaundice
Pre-hepatic: Gilbert's, haemolytic anaemias
Hepatic: viral hepatitis, alcoholic hepatitis, autoimmune hepatitis, drug-induced hep, decompensated cirrhosis
Post-hepatic: bile duct strictures, CBD stone, pancreatitis, tumours
128
Causes of abnormal plts number in gastro disease
Low: portal HTN, hypersplenism
High: chronic GI blood loss, inflammatory disease
129
How to read an AXR
```
Patient details/ indications
Date
Projection (usually AP)
Technical adequacy (hemidiaphragms to pubic symphysis)
Obvious abnormalities
```
BOWEL
Large from rectum (<6cm, except caecum), bowel wall thickness
Small (<3 cm), wall thickness
PRESENCE OF PNEUMOPERITONEUM (extra-luminal gas)
LIVER, GALLBLADDER, SPLEEN
URINARY TRACT
MAJOR VASCULATURE
SKELETON
IATROGENIC ABNORMALITIES (stents, clips etc.)
130
How to differentiate small and large bowel markings?
```
Haustra (partial) - large bowel
Valvulae conniventes (full width) - small bowel
```
131
Only indications for AXR
acute abdo ?obstruction
| acute exacerbation IBD ?megacolon
132
Causes of pneumoperitoneum
Perf
recent laparotomy
intra-abdo infection with gas-causing bugs
133
What is gallstone ileus?
Misnomer
| Mechanical obstruction: will see dilated loops of small bowel, pneumobilia and a calcific entity at ileo-caecal valve
134
Which organs does the MRCP look at?
Pancreas
Biliary tree
MRI scan
135
What does ERCP look at?
Bile duct and pancreatic duct
| good for gallstones and pancreatitis
136
What does faecal elastase look for?
Pancreatic insufficiency
>200 diagnostic
<100 negative
137
Which younger patients are eligible for bowel ca screening?
Familial adenomatous polyposis - other plyp diseases
Peutz-Jehgers
Strong family history
IBD affecting colon or rectum
acromegaly
people who have had bowel ca/ polyps in past
frequency depends on risk
138
E&D for endoscopy
nothing for 6 hours
139
E&D for sigmoidoscopy
fluids only 12h before procedure
140
how far does sigmoidoscope go?
| colonoscopy?
splenic flexure
usually no sedation needed
ileo-caecal valve
usually sedation
141
alternatives to colonoscopy you might consider for older person
CT colonography
| Ba swallow
142
Which GORD mx shouldn't be given with clopidogrel?
Omeprazole
| reduces efficacy - other PPIs ok
143
Which anti-emetics have prokinetic effects?
| Side-effects?
D2 receptor antagonists: metaclopramide, domperidone
| extra-pyramidal effects, esp children and YAs
144
Which anti-emetic to be avoided in hepatic encephalopathy?
Cyclizine (sedating effects)
| also avoid in BPH (anticholinergic effects)
145
Which anti-emetics best with chemo/ GA?
5-HT3 anatagonists: ondansetron
| not great with vertigo
146
When to avoid bulk-forming laxatives?
In ileus - causes obstruction
147
Indications for N-acetylcysteine
Paracetamol OD
prevent contrast nephropathy
mucolytic to decrease resp secretions
148
FISTULA
abnormal communication between 2 epithelial surfaces
149
SINUS
blind-ending track
150
ULCER
abnormal area of discontinuity in an epithelial surface
151
ABSCESS
cavity filled with pus
152
Post-op bleeding
primary
reactive
secondary
during procedure
within 24h
7-10 days after op
153
Abx prophylaxis for UGIB
co-amox (cipro if pen-allergic)
154
Who gets sucralfate?
1g qds following banding
155
Signs of acute flare IBD
```
6+ motions in 24hrs and at least 1 of:
fever above 37.5
tachycardia above 90
inflamm markers up (CRP above 45)
Hb below 100
Albumin below 30
```
156
Gastro causes of clubbing
IBD
Cirrhosis
Coeliac disease
157
What is sialodenosis
Parotid enlargement - might see in EtOH excess
158
What causes fetor hepaticus
hepatic failure - mercaptan accumulation
159
extra-intestinal manifestations of IBD
```
Clubbing
Eyes: episcleritis, conjunctivitis
Mouth: ulcers (esp Crohns)
Skin: EN, PG
Joints: seronegative spondyloarthropathy
PSC (esp Crohns)
```
160
When might you hear a bruit in the liver?
TIPSS
HCC
AV malformation
161
When might you have a pulsatile liver?
TR
162
McBurney's point
One-third between umbilicus and ASIS (appendicitis)
163
Obturator sign
Pain upon internnal rotation of leg: appendicitis and pelvic abscess
Bend leg at knee and rotate towards midline
164
Psoas sign
pain upon extending hip (straight leg pulled back)
appendicitis
psoas inflammation
165
Rovsings' sign
palpation of LLQ results in pain in RLQ
| appendicitis
166
What is dumping syndrome?
delivery of large amount hyperosmolar chyme into small bowel
following vagotomy and gastric drainage procedure
autonomic instability, abdo pain, diarrhoea
167
Fitz-Hugh-Curtis sx
Perihepatic gonorrhea sx
168
Plummer-Vinson sx
```
oesophageal web
iron-deficiency anaemia
dusphagia
spoon shaped nails
atrophic tongue/ oral mucosa
```
typically elderly women
10% will develop SCC
169
Short gut sx
<200 cm viable gut
170
Most common indication for surgery in Crohns
SBO
171
most common electrolyte deficiency causing ileus
hypokalaemia
172
most common cause of free peritoneal air
Perforated PUD
173
Primary
Secondary
Tertiary intention
Immediate closure in theatre
allowed to remain open and granulation tissue form (for dirty wounds)
delayed primary closure (with debridement)
174
Which parts of GI tract are retroperitoneal?
most of duodenum
ascending colon
descending colon
pancreas
175
Locations of:
foregut
midgut
hindgut
mouth to ampulla of vater
ampulla of vater to distal third of transverse colon
distal third transverse colon to anus
176
Normal diameter CBD
< 4 mm until age 40 - then add 1 mm per decade
if gallbladder been removed: 8-10 mm
177
Likely cause of high-output NG
In duodenum
