Gastroenterology Flashcards
Define Achalasia.
Condition in which normal muscular activity of the oesophagus is disturbed (absent or un-cordinated) due to failure or incomplete relaxation of the lower oesophageal sphincter.
What are the presenting symptoms of achalasia?
o Insidious onset with gradual progression of:
- intermittent dysphagia
- difficulty breathing
- regurgitation and heartburn - particularly at night
- chest pain
- weight loss - due to eating less
What are the signs of achalasia on examination?
Signs are signs of complications
- Aspiration pneumonia
- Malnutrition
- Weight loss
What are the appropriate investigations for achalasia?
o CXR may show widened mediastinum, double right heart border (dilated oesophagus), air-fluid level in the upper chest, absence of the normal gastric air bubble
o Barium swallow may show dilated oesophagus which smoothly tapers down to the sphincter (beak-shaped)
o Endoscopy to exclude malignancy (which could mimic achalasia)
o Manometry (used to assess pressure at the LOS)
Define Acute Cholangitis.
Infection of the bile duct.
What are the causes of acute cholangitis?
Obstruction of the gallbladder or bile duct due to stones
ERCP
Tumours (e.g. pancreatic, cholangiocarcinoma)
Bile duct stricture or stenosis
Parasitic infection (e.g. ascariasis)
What are the presenting symptoms of acute cholangitis?
- Charcot’s Triad = RUQ pain, jaundice and fever with rigors
- Extended with 2 more symptoms to create Reynolds’ Pentad = mental confusion and septic shock
- pruritus
What are the signs of acute cholangitis on examination?
Fever
RUQ tenderness
Mild hepatomegaly
Jaundice
Mental status changes
Sepsis
Hypotension
Tachycardia
Peritonitis (uncommon - check for alternative diagnosis)
What are the appropriate investigations for acute cholangitis?
o Bloods = high WCC, possibly raised CRP/ESR, raised ALP + GGT, U&Es may show signs of renal dysfunction, check for sepsis, raised amylase if the lower part of the common bile duct is involved
o Imaging
- X-ray KUB: look for stones
- Abdominal ultrasound: look for stones and dilation of the common bile duct
- Contrast-enhanced CT/MRI: good for diagnosing cholangitis
- MRCP: may be necessary to detect non-calcified stones
What is the management of acute cholangitis?
- Broad-spectrum antibiotics once cultures have been taken
- Endoscopic biliary drainage is usually required to clear the underlying blockage
- Resuscitation?Ventilation if the patient becomes septic
What are the possible complications of acute cholangitis?
Liver abscesses
Liver failure
Bacteraemia
Gram-negative sepsis
Septic shock
AKI
Organ dysfunction
Percutaneous or endoscopic drainage can cause - intra-abdominal bleeding, sepsis, fistulae, bile leakage
Mortality = 17-40%
Define Alcoholic Hepatitis.
Inflammatory liver injury caused by chronic heavy intake of alcohol.
What are the presenting symptoms of alcoholic hepatitis?
May remain asymptomatic and undetected
May be mild illness with symptoms = nausea, malaise, epigastric pain, right hypochondrial pain, low-grade fever
More severe presenting symptoms = jaundice, abdominal discomfort or swelling, swollen ankles, GI bleeding
There may be events that trigger the disease (e.g. aspiration pneumonia, injury)
What are the signs of alcohol excess on examination?
Malnourished
Palmar erythema
Dupuytren’s contracture
Facial telangiectasia
Parotid enlargement
Spider naevi
Gynaecomastia
Testicular atrophy
Hepatomegaly
Easy bruising
What are the signs of severe alcoholic hepatitis on examination?
Febrile
Tachycardia
Jaundice
Bruising
Encephalopathy (e.g. liver flap, drowsiness, disorientation)
Ascites
Hepatomegaly
Splenomegaly
What are the appropriate investigations for alcoholic hepatitis?
o Bloods
- FBC = Low Hb, High MCV, High WCC, Low platelets
- LFTs = High AST + ALT, High bilirubin, High ALP + GGT, Low albumin
- U&Es = Urea and K+ tend to be low
- Clotting = prolonged PT is a sensitive marker for significant liver damage
o Ultrasound - check for other causes of liver impairment (e.g. malignancy)
o Upper GI Endoscopy - investigate varices
o Liver Biopsy - can help distinguish from other causes of hepatitis
o EEG - slow-wave activity indicates encephalopathy
What is the management of acute alcoholic hepatitis?
Thiamine, Vitamin C and other multivitamins (Pabrinex)
Monitor and correct K+, Mg2+ and glucose
Ensure adequate urine output
Treat encephalopathy with oral lactulose or phosphate enemas
Ascites - manage with diuretics (spironolactone with/without furosemide)
Therapeutic paracentesis
Glypressin and N-acetylcysteine for hepatorenal syndrome
What are the possible complication of alcoholic hepatitis?
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
- 40% 1-year mortality and 10% 1-month mortality
Define Anal Fissure.
A painful tear in the squamous lining of the lower anal canal.

What are the causes of anal fissures?
- Most are caused by hard faeces
- Anal sphincter spasm can constrict the inferior rectal artery, causing ischaemia and impairing the healing process
- Rare causes = syphilis, herpes, trauma, Crohn’s, anal cancer, psoriasis
What are the presenting symptoms of anal fissures?
Tearing pain when passing stools
There may be a little bit of blood in the faeces or on the paper
Anal itching (pruritus ani)
What are the signs of anal fissures on examination?
Tears in the squamous lining of the anus on examination.
What is the management of anal fissures?
o Conservative - high-fibre diet, softening the stools (laxatives), good hydration
o Medical - lidocaine ointment (LA), GTN ointment (relaxes the anal sphincter and promoted healing), diltiazem (relaxes the anal sphincter and promotes healing), botulinum toxin injection
o Surgical - lateral sphincterotomy
What are the possible complication of anal fissures?
Chronic anal fissures