Gastroenterology Flashcards

Question

Define appendicitis.

Answer 1

Inflammation of the appendix.

Answer 2

Periumbilical pain that moves to the right iliac fossa Anorexia is an important feature Vomiting (may occur after pain) Constipation Diarrhoea

Answer 3

o General Signs = tachycardia, fever, furred tongue, lying still, coughing hurts, foetor with/without flushing, shallow breaths o RIF Signs = Guarding, Rebound and percussion tenderness, PR pain on the right side (sign of low-lying pelvic appendix) o Special Signs - Rovsing's Sign - palpation of the left iliac fossa causes more pain in the right iliac fossa than the left - Psoas Sign - pain on extending the hip (caused by retrocaecal appendix) - Cope Sign - pain on flexion and internal rotation of the hip (occurs if the appendix is in close proximity to the obturator internus)

Answer 4

- Bloods = High WCC (mainly neutrophils) and High CRP - Ultrasound may help - CT - high diagnostic accuracy

Answer 5

- Prompt appendicectomy - Antibiotics = broad-spectrum -\> cefuroxime, metronidazole - Laparoscopy - diagnostic and therapeutic advantages

Answer 6

- Perforation - Appendix mass = occurs when the inflamed appendix becomes covered with omentum - Appendix abscess = may occur if appendix mass fails to resolve -\> treatment involves drainage and antibiotics

Answer 7

Chronic hepatitis of unknown aetiology, characterised by autoimmune features, hyperglobulinaemia and the presence of circulating autoantibodies.

Answer 8

May be asymptomatic and discovered incidentally through abnormal LFT Insidiously present with: Malaise Fatigue Anorexia Weight loss Nausea Jaundice Amenorrhoea Epistaxis - 25% with acute hepatits = fever, anorexia, juandice, nausea, vomiting, diarrhoea, RUQ pain, serum sickness

Answer 9

- Stigmata of chronic liver disease - spider naevi etc - Ascites, oedema and hepatic encephalopathy are late features - Cushingoid features

Answer 10

o Bloods - LFTs = High: AST, ALT, GGT, ALP and bilirubin with Low: albumin - Clotting = High PT (in severe disease) - FBC = Low Hb, platelets and WCC (if hypersplenism from portal hypertension) - Hypergammaglobulinaemia = presence of ANA, ASMA and Anti-LKM antibodies o Liver Biopsy = check whether hepatitis or cirrhosis o US, CT or MRI of liver and abdomen o ERCP - rule out primary sclerosing cholangitis

Answer 11

Prolonged exposure of the normal squamous epithelium to refluxate of GORD leads to mucosal inflammation and erosion, leading to replacement of the mucosa with metaplastic columnar epithelium.

Answer 12

Patients are likely to experience symptoms of GORD = Heartburn, Nausea, Water-brash (sour taste in the mouth), Bloating, Belching, Burning pain when swallowing

Answer 13

OGD and biopsy

Answer 14

Oesophageal adenocarcinoma = 5-10% over 10-20 years

Answer 15

Inflammation of the gallbladder.

Answer 16

o Causes = Stones o Riks factors = age, female, obese, DM, drugs (OCP, octreotide), family history, Caucasian, haemolytic disorder (or other irsk factor for pigment stone)

Answer 17

o Systemically unwell o Fever o Prolonged abdominal pain o Pain referred to the right shoulder

Answer 18

o Tachycardia o Pyrexia o RUQ/epigastrium pain/tenderness o Guarding or rebound tenderness o Positive Murphys sign = when hands place under costal margin and patient inspires they will stop and wince

Answer 19

o Bloods = FBC (high WBCC), LFT (high ALP and GGT in ascending cholangitis), blood cultures, amylase (exclude pancreatitis o Imaging = USS, AXR

Answer 20

o Conservative (only mild biliary colic) = follow a low-fat diet o Medical = NBM, IV fluids, Analgesia, Anti-emetics, Antibiotics (if infection is present) - If there is an obstruction, urgent biliary drainage by ERCP or via a percutaneous route is necessary o Surgical = Laparoscopic Cholecystectomy

Answer 21

o Stones within the gallbladder = Biliary colic, Cholecystitis, Gallbladder empyema, Gallbladder cancer (RARE) o Stones outside the gallbladder = Obstructive jaundice, Pancreatitis, Ascending cholangitis, Cholecystoduodenal fistula, Gallstone ileus, Bouveret syndrome (gallstones cause gastric outlet obstruction), Mirizzi syndrome o Complications of cholecystectomy = Bleeding, Infection, Bile leak, Post-cholecystectomy syndrome, Port-site hernia

Answer 22

End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes. o Cirrhosis is considered DECOMPENSATED if it becomes complicated by any of: - Ascites - Jaundice - Encephalopathy - GI bleed

Answer 23

o Chronic alcohol misuse (most common in the UK) o Chronic viral hepatitis (hep B/C - most common worldwide) o Autoimmune hepatitis o Drugs (e.g. methotrexate, hepatotoxic drugs) o Inherited = Alpha₁-antitrypsin deficiency, Haemochromatosis, Wilson's disease, Galactosaemia, Cystic Fibrosis o Vascular = Budd-Chiari Syndrome, Hepatic Venous Congestion Chronic Biliary Diseases o Non-Alcoholic Steatohepatitis (NASH) o Associated with obesity, diabetes, total parenteral nutrition, short bowel syndromes, hyperlipidaemia and drugs (e.g. amiodarone, tamoxifen)

Answer 24

o Non-specific early symptoms = Anorexia, Nausea, Fatigue, Weakness, Weight loss o Decreased liver function = Bruising, Abnormal swelling, Ankle oedema o Reduced detoxicification function = Jaundice, Personality change, Altered sleep, Amenorrhoea, Galactorrhoea o Portal Hypertension = Abdominal swelling/Ascites, Haematemesis, PR bleeding/malaena

Answer 25

Asterixis Bruises Clubbing Dupuytren's contracture Palmar erythema Jaundice Gynaecomastia Leukonychia Parotid enlargement Spider naevi Scratch mark (from cholestatic pruritis) Ascites Enlarged liver (may be shrunken in the later stages) Testicular atrophy Caput medusae Splenomegaly

Answer 26

Bloods = FBC (low platelets + Hb - due to hypersplenism because of portal hypertension), LFTs (normal sometimes but often = High AST, ALT, ALP, GGT and bilirubin and Low albumin), Clotting ( prolonged PT) Serum alpha-fetoprotein (Tumour marker for liver cancer and Raised in chronic liver disease) o Investigations to determine CAUSE = Viral serology, alpha₁-antitrypsin, Caeruloplasmin (copper-carrying complex that is LOW in Wilson's disease), Iron studies, Anti-mitochondrial antibody, ANA, ASMA (autoimmune hepatitis) o Ascitic Tap = MC&S (ascitic tap with neutrophils \> 250/mm3 = spontaneous bacterial peritonitis (SBP)), Biochemistry, Cytology o Liver Biopsy = Grading (Child-Pugh) and Staging o Imaging = USS, CT or MRI - to detect complications such as: acites, HCC, hepatic or portal vein thrombosis, exclude biliary obstruction, MRCP o Endoscopy = examine varices

Answer 27

o Treat the CAUSE if possible o Avoid alcohol, sedatives, opiates, NSAIDs and drugs that affect the liver o Nutrition is important - enteral supplements should be given -\> NG feeding may be indicated o Treating Complications - Encephalopathy = Treat infections, Exclude GI bleed, Use lactulose and phosphate enemas, Avoid sedation - Ascites = Diuretics (spironolactone with/without furosemide), Sodium restriction, Therapeutic paracentesis, Monitor weight, Fluid restrict if plasma sodium \< 120 mmol/L, Avoid alcohol and NSAIDs o Spontaneous Bacterial Peritonitis = Antibiotics, Prophylaxis against recurrent SBP with ciprofloxacin

Answer 28

Portal hypertension with ascites Hepatic encephalopathy Variceal haemorrhage SBP HCC Renal failure (hepatorenal syndrome) Pulmonary hypertension (hepatopulmonary syndrome)

Answer 29

o Appendicitis

Answer 30

Bleeding Wound infection Infection and redness and swelling (inflammation) of the belly that can occur if the appendix bursts during surgery (peritonitis) Blocked bowels Injury to nearby organs

Answer 31

o Acute cholecystitis O gallstone complications - pancreatitis, jaundice o Gallbladder trauma

Answer 32

Bile leak Bleeding Infection Injury to nearby structures, such as the bile duct, liver and small intestine Risks of general anesthesia

Answer 33

An inflammatory disease caused by intolerance to gluten, causing chronic intestinal malabsorption.

Answer 34

o Sensitivity to gliadin (compenent of gluten) o Genetics = HLA-B8, HLA-DR3 and HLA-DQW2 haplotypes

Answer 35

May be asymptomatic Abdominal discomfort, pain and distention Steatorrhoea Diarrhoea Tiredness, malaise, weight loss (despite normal diet) Failure to 'thrive' in children Amenorrhoea in young adults

Answer 36

o Signs of anaemia = pallor o Signs of malnutrition = Short stature, Abdominal distension, Wasted buttocks in children (Triceps skinfold thickness gives indication of fat stores) o Signs of vitamin/mineral deficiencies = Osteomalacia, Easy bruising o Dermatitis herpetiformis = Intense, Itchy blisters on elbows, Knees or Buttocks

Answer 37

o Blood = FBC (low Hb, iron and folate), U&E, Albumin, Calcium, Phosphate o Serology = IgG anti-gliadin antibodies, IgA and IgG anti-endomysial tranglutaminase antibodies can be diagnostic o Stool = Culture to exclude infection, Faecal fat tests for steatorrhoea o D-xylose test = Reduced urinary excretion after oral xylose indicates small bowel malabsorption o Endoscopy = Allows direct visualisation of villous atrophy in the small intestine (mucosa appears flat and smooth) o Biopsy will show villous atrophy and crypt hyperplasia in the duodenum

Answer 38

o Advice = Avoid gluten (wheat, rye and barley products) o Medical = Vitamin and mineral supplements, Oral corticosteroids if disease does not subside with avoidance of gluten

Answer 39

Iron, folate and B12 deficiency Osteomalacia Ulcerative jejunoileitis GI lymphoma (particularly T cell) Bacterial overgrowth Cerebellar ataxia (rarely)

Answer 40

o Lower GI bleeding o Suspicion of cancer History of colonic polyps o Suspicion of inflammation - IBD (Crohn,s UC), diverticulitis o Therapeutic indications

Answer 41

o PR bleeding o Infection o Bloating, nausea, pain and cramping o Anaesthetic risks

Answer 42

Chronic granulomatous inflammatory disease that can affect any part of the gastrointestinal tract.

Answer 43

Crampy abdominal pain (due to inflammation, fibrosis or bowel obstruction) Diarrhoea (may be bloody or steatorrhoea) Fever, malaise, weight loss Symptoms of complications Sometimes right iliac fossa pain due to inflammation of terminal ileum

Answer 44

Weight loss Clubbing Signs of anaemia Aphthous ulcers in mouth Perianal skin tags, fistulae and abscesses Uveitis, erythema nodosum, pyoderma gangrenosum

Answer 45

o Blood = FBC (low Hb, high platelets, high WCC), U&Es, LFTs (low albumin) High ESR, Normal or raised CRP o Stool microscopy and culture = Exclude infective colitis o AXR = Could show evidence of toxic megacolon o Erect CXR = If there is a risk of perforation o Small bowel barium follow-through could show = Fibrosis/strictures, Deep ulceration (rose thorn ulcers), Cobblestone mucosa o Endoscopy (OGD, colonoscopy) and Biopsy = Differentiate UC and CD, Useful for monitoring malignancy and disease progression, Can show mucosal oedema and ulceration with 'rose thorn fissures', Fistulae and abscesses, Transmural chronic inflammation with infiltration of macrophages, lymphocytes and plasma cells, Granulomas with epithelioid giant cells may be seen in blood vessels and lymphatics o Radionucide-labelled neutrophil scan = Localise the inflammation

Answer 46

o Acute Exacerbation = Fluid resuscitation, IV/oral corticosteroids, 5-ASA analogues, Analgesia, Parenteral nutrition if necessary, Monitor markers of disease activity e.g. fluid balance, ESR, CRP, platelets, Hb o Long-Term = 5-ASA analogues (more commonly used in UC), Immunosuppression (using steroid-sparing agents), Anti-TNF agents o General Advice = Stop smoking, Dietician referral (low fibre diet necessary if there are stricture present) o Surgery indicated if = Medical treatment fails, Failure to thrive in children in the presence of complications - Involves resection of affected bowel and stoma formation

Answer 47

o GI = Haemorrhage, Strictures, Perforation, Fistulae, Perianal fistulae and Abscesses, GI cancer, Malabsorption o Extraintestinal Features = Uveitis, Episcleritis, Gallstones, Kidney stones, Arthropathy, Sacroiliitis, Ankylosing spondylitis, Erythema nodosum, Pyoderma gangrenosum, Amyloidosis

Answer 48

The presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel.

Answer 49

Diverticulosis associated with complications. - e.g. haemorrhage, infection, fistulae

Answer 50

Acute inflammation and infection of colonic diverticulae.

Answer 51

o low-fibre diet -\> loss of stool bulk -\> high colonic intrluminal pressure in order to propel stool out -\> herniation of the mucosa and submucosa through muscularis

Answer 52

o Often ASYMPTOMATIC (80-90%) o Complications can lead to symptoms such as: - PR bleeding - Diverticulitis (causing LIF and lower abdominal pain and fever) - Diverticular fistulation (causing pneumaturia, faecaluria and recurrent UTI)

Answer 53

o Diverticulitis - tender abdomen and signs of local or generalised peritonitis if a diverticulum has perforated

Answer 54

o Bloods = FBC (increased WCC, increased CRP), Clotting and cross-match if bleeding o Barium Enema (with or without air contrast) = Saw-tooth appearance of lumen o Flexible Sigmoidoscopy and Colonoscopy = Diverticulae can be visualised and other pathology (e.g. polyps and tumours) can be excluded - Barium enema and colonoscopy shouldn't be performed in the acute setting because there is a high risk of perforation -\> in acute setting = CT scan

Answer 55

o Asymptomatic = soluble high-fibre diet (20-30 g/day) o GI Bleed = IV rehydration, antibiotics and blood transfusion if necessary, angiography and embolisation or surgery if severe o Diverticulitis = IV antibiotics, IV fluid rehydration, Bowel rest, Abscesses may be drained by radiologically sited drains o Surgery = Patients with recurrent attacks or complications (e.g. perforation and peritonitis), Open surgery (Hartmann's procedure (proctosigmoidectomy leaving a stoma), One-stage resection and anastomosis (with or without defunctioning stoma)), Laparoscopic drainage, peritoneal lavage and drain placement can be effective

Answer 56

Diverticulitis Pericolic abscess Perforation Faecal peritonitis Colonic obstruction Fistula formation (bladder, small intestine, vagina) Haemorrhage

Answer 57

Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdominal discomfort.

Answer 58

o Viral = Rotavirus, Adenovirus, Astrovirus, Calcivirus, Norwalk virus, Small round structures viruses o Bacterial = Campylobacter jejuni, , E coli (particularly O157), Salmonella, Shigella, Vibrio cholerae, Listeria, Yersinia enterocolitica o Protozoal = Entamoeba histolytica, Cryptosporidium parvum, Giardia lamblia o Toxins (from) = Staphylococcus aureus, Clostridium botulinum, Clostridium perfringens, Bacillus cereus, Mushrooms, Heavy metals, Seafood o Commonly contaminated foods = Improperly cooked meat, Old rice, Eggs and poultry, Milk and cheeses, Canned food

Answer 59

o Sudden onset nausea, vomiting, anorexia, diarrhoea (bloody or watery) o Abdominal pain or discomfort o Fever and malaise o Recent travel, antibiotic use and recent food intake, anyone else is ill? o Time of Onset: Toxins = early (1-24 hours), Bacterial/viral/protozoal = 12+ hours - Botulinum causes paralysis and Mushrooms can cause fits, renal or liver failure

Answer 60

o Diffuse abdominal tenderness o Abdominal distension o Bowel sounds are often INCREASED o In SEVERE gastroenteritis = pyrexia, dehydration (due to diarrhoea), hypotension and peripheral shutdown

Answer 61

o Bloods = FBC, blood culture (identify bacteraemia), U&Es (dehydration) o Stool = Faecal microscopy and analysis for toxins (particularly for the toxin causing pseudomembranous colitis (C. difficile toxin) o AXR or ultrasound = exclude other causes of abdominal pain (e.g. bowel perforation) *- Sigmoidoscopy: usually unnecessary unless inflammatory bowel disease needs to be excluded*

Answer 62

o Bed rest o Fluid and electrolyte replacement with oral rehydration solution o IV rehydration may be necessary in those with severe vomiting o Antibiotic treatment is only used if severe or if infective agent has been identified - If botulism is present treat with botulinum antitoxin (IM) and manage in ITU (often a notifiable disease and is an important public health issue)

Answer 63

Suspected: o Obstructive jaundice o Pancreatitis o Cholangitis o Recurrent biliary colic o Post-liver injury bile lead o Post-laproscopic cholecystectomy with bile leak

Answer 64

o Prancreatitis o Vein irritation leading to a tender lump for a couple of days o Cholangitis o Infection o Perforation o Sedation risks o Pneumonia is very frail patients

Answer 65

o Dyspepsia/indigestion o Haematemesis/malaena o Vomiting o Anaemia o History of peptic ulcers o Dysphagia o Epigastric mass o Weight loss

Answer 66

o Infection o Perforation o Sedation risks

Answer 67

Very severe, RUQ pain resulting from obstruction of the gallbladder or common bile duct, usually by a stone - can be poorly localised due to its visceral nature.

Answer 68

o Caucasian o Fat o Fertile o Forty o Female

Answer 69

o Severe, crampy RUQ pain - can also be poorly localised due to its visceral nature -\> doesn't fluctuate and has a tendency to persist - Pain may radiate to the right scapula o Nausea and vomiting o Individuals may present with pain following ingestion of a fatty meal

Answer 70

o RUQ/epigastric pain/tenderness o Jaundice

Answer 71

o Urinalysis, CXR and ECG to exclude other causes (e.g. basal pneumonia, inferior MI) o Ultrasound - dilatation of the CBD, gallbladder wall may be thickened o LFT o ERCP - useful diagnostically and therapeutically o CT - may be useful if other forms of imaging have been insufficient

Answer 72

o Complications of surgery - Injury to the bile duct - Fat intolerance - due to inability to secrete a large amount of bile into the intestine because the patient no longer has a gallbladder - Post-cholecystectomy syndrome - presence of abdominal symptoms (e.g. dyspepsia, nausea/vomiting, RUQ pain) after the removal of the gallbladder

Answer 73

o Analgesia o IV fluids o NBM o Laparoscopic cholecystectomy - ERCP can also be used to help remove stones or stent a blocked bile duct

Answer 74

A functional bowel disorder defined as recurrent episodes of abdominal pain/discomfort (in the absence of detectable organic pathology) for \> 6 months of the previous year, associated with two of the following: o Altered stool passage o Abdominal bloating o Symptoms made worse by eating o Passage of mucous

Answer 75

o Visceral sensory abnormalities o Gut motility abnormalities o Psychosocial factors (e.g. stress) o Food intolerance (e.g. lactose) o Many more.....

Answer 76

o 6+ months history of abdominal pain - pain is often colicky, in the lower abdomen o Pain relieved by defecation or passing of flatus o Altered bowel frequency (\> 3 motions per day or \< 3 motions per week) o Abdominal bloating o Change in stool consistency o Passage with urgency or straining o Tenesmus

Answer 77

o Normal - May show a slightly distended abdomen which is mildly tender on palpation of the iliac fossae

Answer 78

o Diagnosis is mainly from the history but organic pathology must be excluded - Blood = FBC (anaemia), LFT, ESR, CRP, TFT, anti-endomysial/anti-tranglutaminase antibodies (coeliac disease) - Stool examination = microscopy and culture for infective cause - Ultrasound = exclude gallstone disease - Urease breath test = exclude dyspepsia due to Helicobacter pylori - Endoscopy = if other pathologies suspected

Answer 79

o Advice = Dietary modification o Medical = Depends on the main symptoms affecting the patient - Antispasmodics (e.g. buscopan) - Prokinetic agents (e.g. domperidone, metaclopramide) - Anti-diarrhoeals (e.g. loperamide) - Laxatives (e.g. senna, movicol, lactulose) - Low-dose tricyclic antidepressants (may reduce visceral awareness) - Psychological therapy (CBT, relaxation and psychotherapy)

Answer 80

Physical and psychological morbidity Increased incidence of colonic diverticulosis

Answer 81

Perforation of the wall of the GI tract with spillage of bowel contents.

Answer 82

o Large Bowel = Diverticulitis, Colorectal cancer, Appendicitis, Volvulus, UC (toxic megacolon) o Gastroduodenal = Perforated duodenal or gastric ulcer, Gastric cancer o Small Bowel (RARE) = Trauma, Infection (e.g. TB), Crohn's disease o Oesophagus = Boerhaave's perforation - rupture of the oesophagus following forceful vomiting o Risk factors of cause (e.g. gastroduodenal - NSAIDs, steroids, bisphosphonates)

Answer 83

o Peritonitic abdominal pain - Make sure you rule out ruptured AAA

Answer 84

o Sudden onset sever epigastric pain - worse on movement -\> pain then become generalised o Gastric cancer red flags as clue for cause - weight loss, vomiting/nausea

Answer 85

Severe pain following an episode of violent vomiting Neck/chest pain and dysphagia develop soon afterwards

Answer 86

o Very UNWELL o Signs of shock o Pyrexia o Pallor o Dehydration o Signs of peritonitis (guarding, rigidity, rebound tenderness, absent bowel sounds) o Loss of liver dullness (due to overlying gas)

Answer 87

o Bloods = FBC, U&E, LFTs, Amylase (slightly aised with perforation) o Erect CXR = Air under the diaphragm o AXR = Abnormal gas shadowing o Gastrograffin Swallow = For suspected oesophageal perforations

Answer 88

o Resuscitation = Correct fluid and electrolytes, IV antibiotics o Large Bowel = Peritoneal lavage, Resection of perforated section (usually as part of a Hartmann's procedure) o Gastroduodenal = Laparotomy, Peritoneal lavage, Perforation is closed with an omental patch, Gastric ulcers are biopsied for H. pylori o Oesophageal = Pleural lavage, Repair of ruptured oesophagus

Answer 89

o Large and Small Bowel = Peritonitis -\> sepsis and multiorgan failure o Oesophagus =Mediastinitis, Shock, Sepsis, Death

Answer 90

Inflammation of the oesophagus caused by reflux of gastric acid and/or bile.

Answer 91

o Disruption of mechanisms that prevent reflux - Mechanisms that prevent reflux: - Lower oesophageal sphincter - Acute angle of junction - Mucosal rosette - Intra-abdominal portion of oesophagus (diaphragm acts as a sphincter) * o Prolonged oesophageal acid clearance contributes to 50% of cases*

Answer 92

o Epigastric/substernal burning discomfort or 'heartburn' - aggravated by Lying supine, Bending, Large meals, Drinking alcohol and relieved by Antacids o Waterbrash (regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus often with some acid material from the stomach) o Aspiration - may result in hoarseness, laryngitis, nocturnal cough and wheeze o Dysphagia - caused by formation of peptic stricture after long-standing reflux

Answer 93

o Usually NORMAL o Occasionally - epigastric tenderness, wheeze on chest auscultation, dysphonia

Answer 94

o Often a CLINICAL diagnosis o Upper GI endoscopy, biopsy and cytological brushings - Confirms presence of oesophagitis and can exclude malignancy o Barium Swallow can detect = Hiatus hernia, Peptic stricture, Extrinsic compression of the oesophagus o CXR = CXR can lead to the incidental finding of a hiatus hernia o 24 hr oesophageal pH monitoring

Answer 95

o Advice = Weight loss, Elevating head of bed, Avoid provoking factors, Stop smoking, Lower fat meals, Avoid large meals late in the evening o Medical = Antacids, Alginates, H2 antagonists (ranitidine) Proton pump inhibitors (lansoprazole, omeprazole) o Endoscopy =Annual endoscopic surveillance - looking for Barrett's Oesophagus o Surgery = Antireflux surgery - Nissen Fundoplication (fundus of the stomach is wrapped around the lower oesophagus - helps reduce the risk of hiatus hernia and reduce reflux)

Answer 96

o Oesophageal ulceration o Peptic stricture o Anaemia o Barrett's oesophagus o Oesophageal adenocarcinoma o Associated with asthma and chronic laryngitis

Answer 97

Anal vascular cushions become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal.

Answer 98

Constipation Prolonged straining Derangement of the internal anal sphincter Pregnancy Portal hypertension

Answer 99

o Usually asymptomatic o Bleeding - bright red blood that is on the toilet paper and drips into the pan after passage of stool o Absence of red flag symptoms (weight loss, anaemia, change in bowel habit, passage of clotted or dark blood, mucus mixed with the stool) o Itching o Anal lumps o Prolapsing tissue

Answer 100

1st or 2nd degree haemorrhoids are NOT usually visible on external inspection Internal haemorrhoids are NOT normally palpable on DRE unless they are thrombosed Haemorrhoids are usually visible on proctoscopy

Answer 101

o DRE o Proctoscopy o Rigid or flexible sigmoidoscopy - exclude a rectal or sigmoid source of bleeding - *Haemorrhoids are common so the presence of haemorrhoids doesn't mean that you shouldn’t consider any other source of bleeding*

Answer 102

o Conservative = High-fibre diet, Increase fluid intake, Bulk laxatives, Topical creams (e.g. local anaesthetics) o Injection Sclerotherapy to induce fibrosis of the dilated veins o Banding = Barron's bands are applied proximal to the haemorrhoids o Surgery (reserved for symptomatic 3rd and 4th degree haemorrhoids) = Milligan-Morgan haemorrhoidectomy, Stapled haemorrhoidectomy

Answer 103

o Bleeding o Prolapse o Thrombosis o Gangrene o Injection Sclerotherapy = Prostatitis, Perineal sepsis, Impotence, Retroperitoneal sepsis, Hepatic abscess o Haemorrhoidectomy = Pain, Bleeding, Incontinence, Anal stricture

Answer 104

The abnormal protrusion of a peritoneal sac through a weakness of the abdominal wall in the inguinal region. - Direct = Protrusion of the hernial sac directly through a weakness in the transversalis fascia and posterior wall of the inguinal canal - Indirect = Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal

Answer 105

o Male o Prematurity o Age o Obesity o Raised intra-abdominal pressure (e.g. chronic cough) o Constipation o Bladder outflow obstruction o Intraperitoneal fluid (e.g. ascites)

Answer 106

o Asymptomatic o Patient notices a 'lump in the groin' o May cause discomfort and pain o May be irreducible o May present because it has increased in size o May present because of complications (e.g. bowel obstruction)

Answer 107

o Groin lump that extends to the scrotum (males) or labia (women) o Distinguishing inguinal and femoral hernias - Inguinal = superior and medial to the pubic tubercle - Femoral = inferior and lateral to the pubic tubercle o Check for cough impulse o Indirect hernias can be reduced and controlled by applying pressure over the deep inguinal ring o Auscultation - there may be bowel sounds over the hernia o Tenderness if strangulated o Check for signs of complications -\> e.g. Bowel obstruction and systemic upset (pyrexia, tachycardia etc.)

Answer 108

o Bloods = FBC, U&Es, CRP, Clotting, Group and save (if operation is likely), ABGs (may show lactic acidosis from bowel ischaemia) o Imaging = Erect CXR (check for perforation), USS (exclude other causes of groin lump), AXR (check for obstruction)

Answer 109

o Surgical - usually elective repair of uncomplicated hernias - Mesh Repair = hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia -\> can be done laparoscopically o Emergency (obstructed or strangulated) = laparotomy with bowel resection may be indicated if the bowel is gangrenous

Answer 110

o Incarceration o Strangulation o Bowel obstruction o Maydl's hernia (strangulated W-shaped loop of small bowel) o Richter's hernia (strangulation of only part of the bowel circumference) o Surgery Complications = Pain, Wound infection, Haematoma, Penile/scrotal oedema, Mesh infection, Testicular ischaemia

Answer 111

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus.

Answer 112

o Obesity o Low-fibre diet o Chronic oesophagitis o Ascites o Pregnancy

Answer 113

o Most are asymptomatic - Sliding hernias are more likely to cause symptoms o Patients may present with symptoms of GORD o Heartburn o Waterbrash *- No correlation between the size of the hernia and severity of the symptoms*

Answer 114

o Bloods = FBC (check for iron deficiency anaemia) o Radiology = CXR (gastric air bubble may be seen above the diaphragm), Barium swallow o Endoscopy

Answer 115

o Medical = Modify lifestyle factors (e.g. lose weight), Inhibit acid production (e.g. PPIs), Enhance upper GI motility o Surgical - unnecessary in a MAJORITY of patients -\> usually performed in patients with complications of reflux disease despite aggressive medical treatment or pulmonary complications (e.g. aspiration pneumonia) - Nissen Fundoplication = stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter - Belsey Mark IV Fundoplication = 270 degree wrap - Hill Repair = gastric cardia is anchored to the posterior abdominal wall

Answer 116

o Oesophageal - Intermittent bleeding - Oesophagitis - Erosions - Barrett's oesophagus - Oesophageal strictures o Non-Oesophageal - Incarceration of hiatus hernia -\> can lead to strangulation and perforation

Answer 117

Inflammation of the colon due to bacteria, parasites or viruses.

Answer 118

o Lack of sanitation o Drinking contaminated water o Antibiotic use

Answer 119

o Diarrhoea o Blood and mucus in the stools o Lower abdominal pain o Malaise o Low-grade fever

Answer 120

o Diagnosis is largely clinical o Stool culture may be used to identify the causative organism

Answer 121

Obstruction of a mesenteric vessel leading to bowel ischaemia and necrosis. - 'Watershed zone' (area between the supply of the superior and inferior mesenteric arteries - near the splenic flexure) is most vulnerable to intestinal ischaemia

Answer 122

o Embolus (60%) and Thrombosis (40%) - Can be a consequence of: Volvulus, Intussusception, Bowel strangulation, Failed surgical resection

Answer 123

o AF o Endocarditis (can throw emboli) o Arterial Thrombosis: hypercholesterolaemia, hypertension, diabetes mellitus, smoking o Venous Thrombosis: portal hypertension, splenectomy, septic thrombophlebitis, OCP, thrombophilia

Answer 124

o Severe acute colicky abdominal pain o Vomiting o Rectal bleeding o History of chronic mesenteric artery insufficiency = Gross weight loss, Post-prandial abdominal pain o History of heart or liver disease

Answer 125

o Diffuse abdominal tenderness o Abdominal distension o Tender palpable mass (ischaemic bowel) o Bowel sounds may be absent o Disproportionate degree of cardiovascular collapse

Answer 126

o Diagnosis based on clinical suspicion or after laparotomy o Imaging = AXR (thickening of small bowel folds and signs of obstruction), Mesenteric Angiography o Bloods = ABG (lactic acidosis), FBC, U&Es, LFTs, Clotting, Cross-match

Answer 127

Obstruction of the normal movement of bowel contents. o Classifications: - Small or Large bowel - Partial or Complete obstruction - Simple or Strangulated

Answer 128

o Extramural = Hernia, Adhesions, Bands, Volvulus o Intramural = Tumours, Inflammatory strictures (e.g. Crohn's strictures, diverticulitis) o Intraluminal = Pedunculated tumours, Foreign body

Answer 129

o Severe gripping colicky pain with periods of ease o Abdominal distension o Frequent vomiting (it may be bile-stained or faeculent) o Absolute constipation

Answer 130

o Abdominal distension with generalised tenderness o May see visible peristalsis o Tinkling bowel sounds o Peritonitis - absent bowel sounds, guarding and rebound tenderness o Look for abdominal scars - previous abdominal surgery increases the risk of adhesions o Inspect for abdominal mass (e.g. hernias, intussusception, carcinoma)

Answer 131

o AXR = check for valvulae conniventes (small bowel) or haustra (large bowel) o Water-Soluble Contrast Enema o Barium follow through

Answer 132

o Medical = Drip and Suck - Gastric aspiration via NG tube if the patient is vomiting - IV fluids - Electrolyte replacement - Monitor vital signs, fluid balance and urine output o Surgical = Emergency laparotomy in acute obstruction

Answer 133

o Dehydration o Bowel perforation o Peritonitis o Sepsis/Toxaemia o Gangrene of ischaemic bowel wall

Answer 134

Liver infection resulting in a walled off collection of pus.

Answer 135

Liver infection resulting in a walled off collection of cyst fluid.

Answer 136

o Pyogenic (producing pus) = E coli, Klebsiella, Enterococcus, Bacteriodes, Streptococci, Staphylococci, 60% are caused by biliary tract disease (e.g. gallstones, strictures, congenital cysts) o Amoebic abscess = Entamoeba histolytica o Hydatid cyst = Tapeworm - Echinococcus granulosis o Other causes = TB

Answer 137

o Fever o Malaise o Nausea o Anorexia o Night sweats o Weight loss o RUQ/epigastric pain that may be referred to the shoulder o Jaundice o Diarrhoea o Pyrexia of unknown origin o Recent foreign travel

Answer 138

o Fever - continuous or spiking o Jaundice o Tender hepatomegaly (right lobe affected more than left) o Right lung base = Dullness to percussion and reduced breath sounds - Due to reactive pleural effusion

Answer 139

o Bloods = FBC (mild anaemia, leukocytosis, high eosinophils (if hydatid disease)), LFTs (high ALP, high bilirubin), ESR and CRP o Blood cultures = Amoebic and hydatid serology o Stool MC&S = E. histolytica o Liver US or CT/MRI - localises structure of mass o CXR - check for right pleural effusion or atelectasis, raised hemidiaphragm

Answer 140

Severe liver dysfunction leading to jaundice, encephalopthy and coagulopathy. - Can be hyperacute, acute or chronic - Acute-on-Chronic Liver Failure = acute deterioration (decompensation) in patients with chronic liver disease

Answer 141

o Viral = Hepatitis A, B, C, D and E o Drugs = Paracetamol overdose, Idiosyncratic drug reactions *- Less common causes = Autoimmune hepatitis, Budd-Chiari syndrome, Pregnancy-related, Malignancy (e.g. lymphoma), Haemochromatosis, Mushroom poisoning (Amanita phalloides), Wilson's disease*

Answer 142

o Many are asymptomatic o Fever o Nausea o Jaundice o Symptoms of the cause

Answer 143

o Jaundice o Encephalopathy o Asterixis o Fetor hepaticus (bad breath due to thiols shunting into the lung because of portal hypertension) o Ascites and splenomegaly (less common if acute or hyperacute) o Bruising or bleeding o Signs of secondary causes (e.g. bronze skin colour, Kayser-Fleisher rings) o Pyrexia - may indicate infection or liver necrosis

Answer 144

o Identify the cause = Viral serology, Paracetamol levels/tox-screen, Autoantibodies (e.g. ASM, Anti-LKM), Ferritin (haemochromatosis), Caeruloplasmin and urinary copper (Wilson's disease) o Bloods = FBC (low Hb (if GI bleed), high WCC (if infection)), U&Es (may show renal failure (hepatorenal syndrome)), Glucose, LFTs (high bilirubin, high AST, ALT, ALP, GGT, low albumin), ESR/CRP, Coagulation screen, ABG, Group and save o Liver USS/CT o Ascitic Tap - send for MC&S -\> if neutrophils \> 250/mm3 = spontaneous bacterial peritonitis o Doppler scan of hepatic or portal veins = check for Budd-Chiari syndrome o EEG - monitor encephalopathy

Answer 145

o Resuscitation - ABC o Treat the cause if possible o Treatment/prevention of complications - invasive ventilation and cardiovascular support is often required - Manage encephalopathy = lactulose and phosphate enemas - Antibiotic and antifungal prophylaxis - Hypoglycaemia treatment - Coagulopathy treatment = IV vitamin K, FFP, platelet infusions - Gastric mucosa protection = PPIs or sucralfate - Avoid drugs metabolised by the liver - Cerebral oedema = decrease ICP with mannitol - Renal Failure = haemodialysis and nutritional support o Surgical = Liver transplant

Answer 146

o Infection o Coagulopathy o Hypoglycaemia o Disturbance of electrolyte balance and acid-base balance o Disturbance of cardiovascular system o Hepatorenal syndrome o Cerebral oedema (causing raised ICP) o Respiratory failure

Answer 147

Tearing of the lining of the oesophagus around the junction with the stomach as a result of violent vomiting or straining to vomit.

Answer 148

o Chronic alcohol abuse o Bulimia o Other causes: trauma, intense coughing, gastritis

Answer 149

o Most cases do not cause any symptoms o Abdominal pain o Severe vomiting o Haematemesis o Involuntary retching o Malaena o Symptoms of hypovolaemia if SEVERE blood loss (e.g. light-headedness)

Answer 150

o Bloods = FBC (anaemia) o OGD

Answer 151

o 80-90% of the time, the bleeding from a Mallory-Weiss tear will stop on its own - surgery may be necessary if the bleeding doesn't stop - Injection sclerotherapy - Coagulation therapy - Arteriography o Transfusions may be required if blood loss has been severe o Anti-reflux medications may also be prescribed

Answer 152

o Boerhaave's perforation

Answer 153

o Stomach decompressions o Reduce incidence and risk of vomiting o Monitor/evaluate GI bleeding o Prolonged ileus o Administration of medications or oral contrast in a patient who is unable to swallow o Detection of transdiaphragmatic stomach herniation

Answer 154

o Bleeding o IC placement o Pulmonary placement o Pneumothorax o Vomiting/retching o Perforation o Sinusitis o Aspiration

Answer 155

A term used to describe a range of conditions caused by the build-up of fat in the liver due to causes other than excessive alcohol use. ## Footnote *- Increases the risk of DM, MI, stroke*

Answer 156

o Usually no symptoms in the early stages - usually found as an incidental finding o Dull or aching RUQ pain o Fatigue o Unexplained weight loss o Weakness o Symptoms of cirrhosis will be experienced in the most advanced stages of NASH

Answer 157

o Obesity o Type 2 diabetes mellitus o Hypertension o Hypercholesterolaemia o Age \> 50 yrs o Smoking

Answer 158

o RUQ pain/tenderness o Signs of cirrhosis (e.g. jaundice, ascites, pruritus - in advanced stages of NASH)

Answer 159

o Bloods = LFTs (elevated AST and ALT) o Liver Ultrasound = may show steatosis o Liver Biopsy

Answer 160

o Conservative - controlling risk factors: - Blood pressure - Diabetes - Cholesterol - Lose weight - Stop smoking - Exercise regularly - Reduce alcohol consumption - although it is not caused by excessive alcohol, drinking can make it worse

Answer 161

o Cirrhosis - Ascites - Oesophageal varices - Hepatic encephalopathy - Hepatocellular carcinoma - End-stage liver failure

Answer 162

An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.

Answer 163

o GET SMASHED - Gallstones - Ethanol - Trauma - Steroids - Mumps/HIV/Coxsackie - Autoimmune - Scorpion Venom - Hypercalcaemia/hypercalcaemia/hypothermia - ERCP - Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)

Answer 164

o Severe epigastric pain o Radiating to the back o Aggravated by movement but relieved by sitting forward o Associated with anorexia, nausea and vomiting o Check whether the patient has a history of high alcohol intake or gallstones

Answer 165

o Epigastric tenderness o Fever o Shock o Decreased bowel sounds (due to ileus) o In severe pancreatitis = Cullen's sign (periumbilical bruising), Grey-Turner sign (flank bruising)

Answer 166

o Bloods = Very high serum amylase (doesn't correlate with severity), High WCC, U&Es (to check for dehydration), High glucose, High CRP, Low Calcium (saponification - calcium binds to digested lipids from the pancreas to form soap), LFTs (may be deranged if gallstone pancreatitis or alcohol), ABG o Imaging - USS = check for evidence of gallstones in biliary tree - Erect CXR = check for pleural effusion or bowel perforation - AXR = exclude other causes - CT Scan = if diagnosis is uncertain or if persisting organ failure

Answer 167

o Assessment of severity has TWO main scales = Modified Glasgow Score (combined with CRP (\> 210 mg/L) and APACHE-II Score o Medical Management: - Fluid and electrolyte resuscitation - Urinary catheter and NG tube if vomiting - Analgesia - Blood sugar control - HDU and ITU care - Prophylactic antibiotics may be useful in reducing mortality o ERCP and Sphincterotomy = used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct o Surgical (necrotising pancreatitis should be managed by specialists) = Necresectomy (drainage and debridement of necrotic tissue) may be necessary

Answer 168

o Local = Pancreatic necrosis, Pseudocyst, Abscess, Ascites, Pseudoaneurysm, Venous thrombosis o Systemic = Multiorgan dysfunction, Sepsis, Renal failure, ARDS, DIC, Hypocalcaemia, Diabetes o Long-Term = Chronic pancreatitis

Answer 169

Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.

Answer 170

o Alcohol - 70% o Idiopathic - 20% o Rare = recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism

Answer 171

o Recurrent severe epigastric pain o Pain radiates to the back o Pain relieved by sitting forward o Pain can be aggravated by eating or drinking alcohol o Over many years -\> weight loss, bloating and steatorrhoea

Answer 172

o Epigastric tenderness o Signs of complications e.g. weight loss, malnutrition

Answer 173

o Bloods = High glucose (endocrine dysfunction), Amylase and lipase usually normal, High Ig (especially IgG4 in autoimmune pancreatitis) o Ultrasound o ERCP or MRCP = early changes that can be seen include main duct dilatation and stumping of branches with late manifestations including duct strictures with alternating dilatation o Abdominal X-Ray = pancreatic calcification o CT Scan = pancreatic calcification and pancreatic cysts Tests of pancreatic exocrine function: o Faecal elastase (reflects pancreatic exocrine function)

Answer 174

o General = symptomatic and supportive (e.g. dietary advice, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia) o Endoscopy Therapy = Sphincterotomy, Stone extraction, Dilatation and stenting of strictures, Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal o Surgical: - Lateral pancreaticojejunal drainage (modified Puestow procedure) - Pancreatic resection (pancreaticoduodenectomy or Whipple's procedure) - Limited resection of pancreatic head (Beger procedure) - Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)

Answer 175

o Local = Pseudocysts, Biliary duct stricture, Duodenal obstruction, Pancreatic ascites, Pancreatic carcinoma o Systemic = Diabetes, Steatorrhoea, Chronic pain syndromes, Dependence on strong analgesics

Answer 176

Ulceration of areas of the GI tract caused by exposure to gastric acid and pepsin. ## Footnote *- Peptic ulcers are most commonly gastric and duodenal (but they can also occur in the oesophagus and Meckel's diverticulum).*

Answer 177

o Helicobacter pylori o NSAIDs o RARE = Zollinger-Ellison syndrome - condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas cause overproduction of gastric acid, resulting in recurrent peptic ulcers

Answer 178

o Epigastric pain o Relieved by antacids o Symptoms have a variable relationship to food intake: - Gastric = pain is worse soon after eating (50 year olds) - Duodenal = pain is worse several hours after eating (30 year olds) o Patients may present with complications e.g. haematemesis, melaena

Answer 179

o Commonly there are no physical findings o Epigastric tenderness o Signs of complications e.g. anaemia

Answer 180

o Bloods = FBC (for anaemia), Serum amylase (to exclude pancreatitis), U&Es, Clotting screen, LFT, Cross-match if active bleeding, Secretin test (if Zollinger-Ellison syndrome suspected (tumour causes too much gastric acid production)) - IV secretin causes a rise in serum gastrin in ZE patients but not in normal patients) o Endoscopy = Visualization and biopsies of gastric ulcers can be taken to rule out malignancy o Rockall Scoring = Scores the severity after a GI bleed (\< 3 carries good prognosis but \> 8 carries high risk of mortality) o Testing for H. pylori - C13-urea breath test = radio-labelled urea is given by mouth -\> C13 is detected in the expelled air - Serology = IgG antibody against H. pylori confirms exposure to H. pylori but NOT eradication - Campylobacter-like organism (CLO) test = gastric biopsy is placed with a substrate of urea and a pH indicator -\> if H. pylori is present, ammonia is produced from the urea and there is a colour change from yellow to red

Answer 181

o Acute - Fluid resuscitation needed if the ulcer is perforated or bleeding, Close monitoring of vital signs - Endoscopy -\> injection sclerotherapy, laser coagulation, electrocoagulation - Surgical treatment o Surgery = Indicated if ulcer has perforated or if the bleeding ulcer can't be controlled o Helicobacter pylori eradication = Triple therapy for 1-2 weeks o I fpeptic ulcer isn't H. pylori based = Treat with PPIs or H2 antagonists, Stop NSAID use or use misoprostol if NSAID use is necessary

Answer 182

o Rate of major complication = 1 % per year o Major complications = haemorrhage (haematemesis, melaena, iron-deficiency anaemia), perforation, obstruction/pyloric stenosis (due to scarring, penetration, pancreatitis)

Answer 183

A pus collection in the perineal region.

Answer 184

An abnormal chronically infected tract communicating between the perineal skin and either the anal canal or the rectum.

Answer 185

o IBD o Diabetes mellitus o Malignancy

Answer 186

o Constant throbbing pain in the perineum o Intermittent discharge (mucus or faecal staining) near the anal region o Personal or family history of IBD

Answer 187

o Localised tender perineal mass (may be fluctuant) o Small skin lesion near the anus (opening of the fistula) o DRE = thickened area over the abscess/fistula may be felt but DREs are not always possible due to pain and anal sphincter spasm o Goodsall's Law = a rule that allows you to correlate the location of the internal fistula opening based on the location of the external fistula opening - if the external fistula opening is anterior to the anal canal, the fistula runs radially and directly into the anal canal - a fistula that is 3 cm away and any fistula that has an external fistula opening lying posterior to the transverse anal line will follow a curved path and open internally in the posterior midline

Answer 188

o Bloods = FBC, CRP, ESR, Blood culture o Imaging = MRI, Endoanal Ultrasound (less useful than MRI)

Answer 189

o Requires Surgical treatment - Open Drainage of Abscess - Laying Open of Fistula o Antibiotics

Answer 190

o Recurrence o Damage to internal anal sphincter o Incontinence o Persisting pain

Answer 191

Inflammation of the peritoneal lining of the abdominal cavity. It can be localised to one part of the peritoneum or generalised.

Answer 192

o Localised Peritonitis = Appendicitis, Cholecystitis, Diverticulitis, Salpingitis o Primary Generalised Peritonitis (bacterial infection) = Ascites, Nephrotic syndrome o Secondary Generalised Peritonitis (bacterial translocation or spillage of bowel contents = Peptic ulcers, recent surgery

Answer 193

o Inflammation of the parietal peritoneum is usually continuous, sharp, localised, exacerbated by movement and coughing o Symptoms may be vague in those with liver disease and ascites (due to confusion caused by encephalopathy)

Answer 194

o Check vital signs and look for signs of dehydration or compromised perfusion o Localised Peritonitis = Tenderness on examination, Guarding, Rebound tenderness o Generalised Peritonitis = Very unwell, Systemic signs of toxaemia or sepsis, Patient will lie still, Shallow breathing, Rigid abdomen, Generalised abdominal tenderness, Reduced bowel sounds, DRE may show anterior tenderness (suggests pelvic peritonitis)

Answer 195

o Bloods = FBC, U&Es, LFTs, Amylase, CRP, Clotting, Group & Save, Blood cultures, Pregnancy test, ABG o Imaging = Erect CXR (check for air under the diaphragm), AXR (check for bowel obstruction), USS or CT abdomen, Laparoscopy o If Ascites = Tap and cell count, SBP = \> 250 neutrophils/mm³, Gram stain and culture

Answer 196

o Localised Peritonitis = depends on cause -\> some require surgery (e.g. appendicitis) but some can be treated with antibiotics (e.g. salpingitis) o Generalised Peritonitis = Patient may be at risk of DEATH from sepsis or shock - IV fluids, IV antibiotics, Urinary catheter, NG tube, Central venous line, Laparotomy, Antibiotics

Answer 197

o Early = Septic shock, Respiratory failure, Multiorgan failure, Paralytic ileus, Wound infection, Abscesses o Late = Incisional hernia, Adhesions

Answer 198

An abnormal epithelium-lined tract filled with hair that opens onto the skin surface, most commonly in the natal cleft.

Answer 199

o Hirsutism o Spending a long time sitting down o Occupational (e.g. hairdressers may develop interdigital pilonidal sinus)

Answer 200

o Painful natal cleft o Discharging swelling o Often recurrent

Answer 201

o Midline openings or pits between the buttocks o Hairs may protrude from the swelling o If infection or abscess, the swelling will become tender o It may be fluctuant and discharge pus or blood-stained fluid on compression

Answer 202

o None needed o Bloods = WCC (check for infection) and fasting glucose (diabetics are at risk)

Answer 203

o Acute Pilonidal Abscess = Incision and drainage o Chronic Pilonidal Sinus = Excision under general anaesthesia with exploration o Prevention = Good hygiene, Shaving

Answer 204

o Pain o Infection o Abscess o Recurrence

Answer 205

Abnormally high pressure within the hepatic portal vein. -clinically significant portal hypertension is defined as a hepatic venous pressure gradient \> 10 mm Hg

Answer 206

o Pre-Hepatic = Congenital stenosis, Portal vein thrombosis, Splenic vein thrombosis, Extrinsic compression o Hepatic = CIRRHOSIS, Chronic hepatitis, Schistosomiasis, Myeloproliferative disease o Post-Hepatic = Budd-Chiari syndrome (hepatic vein obstruction), Constrictive pericarditis, Right heart failure

Answer 207

o Features of Liver Disease = Jaundice, History of alcohol abuse, Risk factors for viral hepatitis, Family history (e.g. haemochromatosis) o Complications of Portal Hypertension = Haematemesis or melaena, Lethargy, irritability, changes in sleep (hepatic encephalopathy), Ascites, Abdominal pain and fever (spontaneous bacterial peritonitis), Pulmonary involvement

Answer 208

o Signs of Portal Hypertension = Caput medusae, Splenomegaly, Ascites o Signs of Liver Failure = Jaundice, Spider naevi, Palmar erythema, Confusion, Asterixis, Fetor hepaticus, Enlarged or small liver, Gynaecomastia, Testicular atrophy

Answer 209

o Bloods = LFTs, U&Es, Blood glucose, FBC, Clotting screen (prolongation of PT is one of the earliest signs of liver failure), Ferritin (haemochromatosis), 1-antitrypsin levels, Caeruloplasmin (Wilson's disease) o Hepatitis serology o Autoantibodies (e.g. anti-smooth muscle antibodies in autoimmune hepatitis) o Imaging = Abdominal USS, Doppler USS, CT/MRI, Endoscopy (check for oesophageal varices) o Measure hepatic venous pressure gradient (HVPG) o Liver Biopsy - if indicated

Answer 210

o Treatment is mainly focused on treating the underlying cause where possible o Conservative = Salt restriction, Diuretics o Liver transplant

Answer 211

o Bleeding from oesophageal varices o Ascites o Pulmonary complications o Liver failure o Hepatic encephalopathy o Cirrhotic cardiomyopathy

Answer 212

A chronic inflammatory liver disease involving progressive destruction of intrahepatic bile ducts, leading to cholestasis, and, ultimately, cirrhosis.

Answer 213

o Asymptomatic with incidental finding on blood tests o Insidious onset with vague symptoms such as = Fatigue, Weight loss, Pruritis o Discomfort in the RUQ (rare) o Complication of liver decompensation = e.g. jaundice, ascites, variceal haemorrhage o Symptoms of associated conditions = e.g. Sjogren's syndrome, arthritis, Raynaud's phenomenon

Answer 214

o Early = No signs o Late = Jaundice, Skin pigmentation, Scratch marks, Xanthomas (secondary to hypercholesterolaemia), Hepatomegaly, Ascites, Signs of chronic liver disease

Answer 215

o Bloods = LFTs (High ALP + GGT, bilirubin may be high or normal, ALT and AST are normal initially but will increase as the disease progresses and cirrhosis develops), Clotting (prolongation of PT), High Cholesterol, TFTs (associated with thyroid disease) o Antibodies = Antimitochondrial antibodies (typical feature of PBC), High IgM o Ultrasound = exclude extrahepatic biliary obstruction (e.g. gallstones) o Liver Biopsy = chronic inflammatory cells and granulomas around the intrahepatic bile ducts, destruction of bile ducts, fibrosis and regenerating nodules of hepatocytes

Answer 216

A chronic cholestatic liver disease characterised by progressive inflammatory fibrosis and obliteration of intrahepatic and extrahepatic bile ducts.

Answer 217

o May be asymptomatic and diagnosed after persistently raised ALP o May present with: - Intermittent jaundice with pruritis - RUQ pain - Weight loss - Fatigue - Episodes of fever and rigors caused by acute cholangitis - Must check for a history of ulcerative colitis

Answer 218

o May have no signs o Jaundice o Hepatosplenomegaly o Spider naevi o Palmar erythema o Ascites

Answer 219

o Bloods = LFTs (high ALP + GGT, mildly elevated ALT + AST, low albumin with high bilirubin in later stages) o Serology = IgG high in children, IgM high in adults, ASMA and ANA present in 30%, perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) present in 70% o ERCP = stricturing and interspersed dilation of intrahepatic and extraheptic bile ducts, small diverticuli on the common bile duct may be seen o MRCP = enables non-invasive imaging of the biliary tree o Liver Biopsy = Confirm diagnosis and allows staging

Answer 220

The abnormal protrusion of the full thickness (or only the mucosal layer) of rectum through the anus.

Answer 221

o Constipation o Causes of increased straining o Cystic fibrosis (in children) o Previous trauma to the anus/perineum o Neurological conditions (e.g. cauda equina syndrome, MS)

Answer 222

o Protruding anal mass o Initially associated with defecation o May require digital replacement o Constipation o Faecal incontinence o PR mucus or bleeding *- May be an emergency if irreducible or strangulated prolapse*

Answer 223

o Prolapse may be seen on straining o May be ulcerated or necrotic if the vascular supply is compromised o Reduced anal sphincter tone

Answer 224

o Imaging = Proctosigmoidoscopy, Defecating proctogram or barium enema o Anal sphincter manometry o Pudendal nerve studies o Sweat Chloride Test = Performed in children to test for cystic fibrosis

Answer 225

Chronic relapsing and remitting inflammatory disease affecting the large bowel.

Answer 226

o Ashkenazi jews and Caucasians o Peak onset = 20-40 yrs

Answer 227

o Bloody or mucous diarrhoea (stool frequency depends on severity of disease) - \< 4 = mild, 4-6 = moderate, 6+ = severe o Tenesmus and urgency o Crampy abdominal pain before passing stool o Weight loss o Fever o Extra-GI manifestations = e.g. uveitis, scleritis, erythema nodosum, pyoderma gangrenosum

Answer 228

o Signs of iron deficiency anaemia o Dehydration o Clubbing o Abdominal tenderness o Tachycardia o Blood, mucus and tenderness on PR examination o Extra-GI manifestations = e.g. uveitis, scleritis, erythema nodosum, pyoderma gangrenosum

Answer 229

o Bloods = FBC (low Hb, high WCC, high ESR or CRP, low albumin) o Stool = Faecal calprotectin allows differentiation of IBS from IBD -\> it is raised in inflammatory processes (i.e. IBD) o AXR = Rule out toxic megacolon o Flexible Sigmoidoscopy or Colonoscopy (and biopsy) = Determines severity, Histological confirmation, Detection of dysplasia o Barium Enema = Show mucosal ulceration with granular appearance and filling defects (due to pseudopolyps), Narrowed colon, Loss of haustral pattern/ leadpipe appearance *- Colonoscopy and barium enema may be dangerous during an acute exacerbation -\> risk of perforation*

Answer 230

o Mild Disease = Oral or rectal 5-ASA derivatices (e.g. mesalazine, olsalazine, sulphasalazine) and/or rectal steroids o Moderate to Severe Disease = Oral steroids, Oral 5-ASA, Immunosuppression (with azathioprine, cyclosporine, 6-mercaptopurine or infliximab o Advice = Patient education and support o Regular colonoscopic surveillance o Surgical = If medical treatment fails, presence of complications or to prevent colonic carcinoma = Proctocolectomy with ileostomy or Ileo-anal pouch formation

Answer 231

o IV rehydration o IV corticosteroids o Antibiotics o Bowel rest o Parenteral feeding may be necessary o DVT prophylaxis o If toxic megacolon = patient is likely to need a proctocolectomy because toxic megacolon has a high mortality

Answer 232

o GI = Haemorrhage, Toxic megacolon, Perforation, Colonic carcinoma, Gallstones, Primary sclerosing cholangitis o Extra-gastrointestinal = Uveitis, Renal calculi, Arthropathy, Sacroiliitis, Ankylosing spondylitis, Erythema nodosum, Pyoderma gangrenosum, Osteoporosis (from chronic steroid use), Amyloidosis

Answer 233

Hepatitis caused by infection with the RNA viruses, hepatitis A or hepatitis E virus, that follow an acute course without progression to chronic carriage.

Answer 234

o Incubation period of HAV and HEV: 3-6 weeks o Prodromal period symptoms = Malaise, Anorexia, Fever, Heachache, Nausea and vomiting o Hepatitis symptoms = Dark urine, Pale stools, Jaundice lasting around 3 weeks, Itching and Jaundice may last several weeks in HAV infection o Asymptomatic in 90% of HCV

Answer 235

o Pyrexia o Jaundice o Tender hepatomegaly o Spleen may be palpable o Absence of stigmata of chronic liver disease - some spider naevi may appear transiently o Often No signs with HCV

Answer 236

Hepatitis caused by infection with hepatitis B virus (HBV), which may follow an acute or chronic course.

Answer 237

o Faecal-Oral

Answer 238

o Sexual contact o Blood o Vertical tranmission - mother to baby

Answer 239

o There is no specific management other than bed rest and symptomatic treatment (e.g. antipyretics, antiemetics or cholestyramine (for severe pruritus)) o Prevention and Control = Public Health -\> safe water, sanitation and food hygiene o Immunisation is available for HAV *- Is a notifiable diseases*

Answer 240

o Fulminant hepatic failure (more common with HBV) - has 80% mortality o Chronic infection o Cirrhosis o Cholestatic hepatitis with prolonged jaundice and pruritus can develop after HAV infection o Extra-hepatic immune complex disorders (e.g. glomerulonephritis, polyarteritis nodosa) o Post-hepatitis syndrome = continued malaise for weeks to months

Answer 241

o IV drug use o Unscreened blood and blood products o Infants of HBeAg-positive mothers o Sexual contact with HBV carriers o Younger individuals (particularly babies) are more likely to become chronic carriers o Genetic factors are associated with varying rates of viral clearance o Tattooing

Answer 242

Hepatitis D virus is a defective virus, that may only co-infect with HBV or superinfect people who are already carriers of HBV.

Answer 243

Hepatitis caused by infection with hepatitis C virus (HCV), often following a chronic course (in 80% of cases).

Answer 244

o Prevention = blood screening, safe sex, instrument sterilisation o Passive immunisation o Active immunisation o Acute HBV Hepatitis = Symptomatic treatment (antipyretics, antiemetics and cholestyramine) and bed rest o Chronic HBV = Nucleoside/nucleotide analogues (adefovir, entecavir, telbivudine, tenofovir) and Interferon alpha -\> SE = flu-like symptoms such as fever, chills, myalgia, headaches, bone marrow suppression and depression *- Notifiable disease*

Answer 245

o Prevention = screen blood, blood products and organ donors o NO VACCINE AVAILABLE o Medical - Acute = Supportive (antipyretics, antiemetics, cholestyramine) - Chronic = Pegylated interferon, Ribavirin (guanosine nucleotide analogue) o Regular USS of the liver may be needed if the patient has cirrhosis

Answer 246

Rotation of a loop of small bowel around the axis of its mesentery that results in bowel obstruction and potential ischaemia. o The areas usually affected = Sigmoid colon (65%), Caecum (30%) *- Volvulus Neonatorum - occurs in neonates and typically affects the midgut*

Answer 247

o Adults = Long sigmoid colon, Long mesentery, Mobile caecum, Chronic constipation, Adhesions, Chagas disease, Parasitic infections o Neonatal = Malrotation

Answer 248

o Severe colicky abdominal pain and swelling o Absolute constipation o Vomiting o History of transient attacks in which spontaneous reduction of the volvulus has occurred o Neonatal volvulus presents around 3 months

Answer 249

o Signs of bowel obstruction with abdominal distension and tenderness o Absent or tinkling bowel sounds o Fever o Tachycardia o Signs of dehydration

Answer 250

o AXR o Erect CXR = if perforation is suspected o Water-soluble contrast enema = Shows site of obstruction o CT Scan

Answer 251

An autosomal recessive disorder characterised by reduced biliary excretion of copper and accumulation of copper in the liver and brain, especially in the basal ganglia.

Answer 252

o Liver = May present with hepatitis, liver failure, cirrhosis - Jaundice, Easy bruising, Variceal bleeding, Encephalopathy o Neurological = Dyskinesia, Rigidity, Tremor, Dystonia, Dysarthria, Dysphagia, Drooling, Dementia, Ataxia o Psychiatric = Conduct disorder, Personality change, Psychosis

Answer 253

o Liver = Hepatosplenomegaly, Jaundice, Ascites/oedema, Gynaecomastia o Eyes = Kayser-Fleischer Rings, Sunflower cataract (copper accumulation in the lens, seen with a slit lamp)

Answer 254

o Bloods = LFTs (high AST, ALT, ALP), Low serum caeruloplasmin (caeruloplasmin is an acute phase protein so may give false-negatives if there is an underlying infectious/inflammatory process), Raised serum copper o 24 hour urinary copper levels = increased in Wilson's disease o Liver biopsy = increased copper content o Genetic analysis - Wilson's is caused by a wide variety of gene mutations so there isn't a simple genetic test that can be done

Answer 255

An autosomal recessive disease in which increased intestinal absorption of iron causes accumulation of iron in tissues, which may lead to organ damage.

Answer 256

o Often asymptomatic until the late stages of the disease - symptoms usually start between 40-60 yrs o Early symptoms are vague = Fatigue, Weakness, Arthropathy, Erectile dysfunction, Heart problems o Late symptoms = Diabetes mellitus, Bronzed skin, Hepatomegaly, Impotence, Amenorrhoea, Hypogonadism, Cirrhosis, Cardiac, Neurological and Psychiatric problems

Answer 257

o Bloods = Serum ferritin (high), Transferrin (low), Transferrin saturation (high), TIBC (low), LFT o Tests to exclude other causes of high ferritin = CRP (inflammation), Chronic alcohol consumption, ALT (liver necrosis) o LFTs o Other investigations for abnormal liver function (e.g. hepatitis serology) o Genetic testing o Liver biopsy (rarely required)

Answer 258

o Bloods = LFTs (high AST, ALT, ALP and bilirubin), High ESR, Low albumin, FBC (high platelets (if severe)), Clotting (prolonged PT (severe)) o Vital Serology - HAV = Anti-HAV IgM (during acute illness, disappears after 3-5 months) then Anti- HAV IgG (recovery phase and lifelong persistence) - HBV = HBsAg positive, IgM anti-HBcAg (acute phase) then HBsAg positive, IgG anti-HBcAg, HBeAg positive or negative (chronic) - Anti-HBsAg antibody positive or IgG anti-HBcAg shows a cleared HBV or vaccinated - HCV = Anti-HCV antibodies -\> IgM (acute) or IgG (chronic) - HDV = IgM or IgG against HDV or PCR - HEV = Anti-HEV IgM (raised 1-4 weeks after onset) then Anti-HEV IgG o Urinalysis = Positive for bilirubin and Raised urobilinogen o Liver biopsy