GASTROENTEROLOGY + GEN SURGERY Flashcards
(139 cards)
1
Q
What are some causes of dysphagia?
A
- Inflammatory = tonsilitis, pharyngitis, oesophagitis, oral candidiasis, aphthous ulcers
- Neuro/motility disorders = achalasia, diffuse oesophageal spasm, bulbar/pseudobulbar palsy, systemic sclerosis, MG
- Mechanical = foreign body, benign stricture, oesophageal web, malignant stricture, pharyngeal pouch, hiatus hernia (rolling), lung cancer
2
Q
What is the crucial investigation required in pts presenting with dysphagia?
A
ENDOSCOPY
3
Q
What are the ALARMS symptoms?
A
A - anaemia (IDA) L - loss of weight A - anorexia R - recent onset/progressive onset M - malaena/haematemesis S - swallowing problems
4
Q
What are the symptoms of oesophageal cancer?
A
- progressive dysphagia
- initially solids, progressing to liquids
- odynophagia
- retrosternal chest pain
- hoarseness
- occassional cough
WEIGHT LOSS
5
Q
How do you investigate someone with suspected oesophageal cancer?
A
- OGD with biopsy - mucosal lesion, adenocarcinoma/SCC
- Comprehensive metabolic profile
- Hypokalaemia
- Raised creatinine
- Raised serum urea/nitrogen - CT Thorax + abdomen for staging
6
Q
What are the clinical features of an oesophageal web?
A
- intermittent solid food dysphagia
- associated odynophagia
7
Q
How do you manage oesophageal webs?
A
Dilatation of the webs
8
Q
What is a benign oesophageal stricture? How does it present?
A
Occurs when stomach acid + other irritants damage lining of oesophagus over time. Leading to inflammation + scar tissue formation.
- progressive dysphagia to solids
- associated with chronic GORD
- may be hx of corrosive indigestion, radiation exposure or trauma
9
Q
What are the clinical features of pharyngeal pouch?
A
5x more common in men
- odynophagia
- regurgitation
- chronic cough
- aspiration
- neck swelling which gurgles on palpation
- halitosis
10
Q
What oesophageal disorder is commonly misdiagnosed as ACS?
A
OESOPHAGEAL SPASM
- as has spontaneous intermittent chest pain + dysphagia
11
Q
How is oesophageal spasm diagnosed + managed?
A
Barium swallow shows abnormal contractions e.g. corkscrew contractions
- managed with CCBs e.g. nifedipine
12
Q
What are the clinical features of achalasia?
A
- dysphagia to solids AND liquids from the start
- regurgitation
- gradual weight loss
- retrosternal pressure/pain
13
Q
How do you investigate suspected achalasia?
A
- Upper GI endoscopy
- Barium swallow
- loss of peristalsis + delayed oesophageal emptying
- beak-like gastro-oesophageal junction - Oesophageal manometry
- incomplete relaxation of LES + aperistalsis - CXR - fluid level in dilated oesophagus (absence of gastric gas bubble)
14
Q
How is achalasia managed?
A
- Endoscopic pneumatic dilatation or heller’s cardiomyotomy
- CCBs to manage symptoms while waiting for surgery
- Botulinum toxin can be injected if not suitable for surgery
15
Q
What are the typical clinical features of oesophageal candidiasis?
A
- dysphagia
- odynophagia
- hx of HIV or steroid inhaler use
16
Q
How do you manage oesophageal candidiasis?
A
- Fluconazole
2. Itraconazole
17
Q
What are some common differentials for pts presenting with dypepsia?
A
- functional dyspepsia
- h.pylori infection
- GORD + oesphagitis
- PUD
- Gastroparesis
- Gastritis + duodenitis
- UGI malignancy
18
Q
What are the 2ww rules for people with suspected UGI cancer?
A
Urgent upper GI endoscopy in those with - Dysphagia OR - Aged 55 or over with weight loss + any one of: > upper abdo pain > reflux > dyspepsia
19
Q
What are risk factors for developing peptic ulcer disease?
A
- h.pylori infection
- steroid use
- NSAIDs
- SSRIs
- Smoking
- Hx/FHx
20
Q
What investigations should be performed in suspected peptic ulcer disease?
A
- H.pylori urea breath test or stool antigen test (if under 55)
- Upper GI endoscopy - PPI must be stopped for 2 wks before
- CLO test (rapid urease test) - test for h.pylori via endoscopy
- FBC - indication as to presence of UGI bleed
- Fasting serum gastrin level - hypergastrinaemia in Zollinger-Ellison
21
Q
How do you manage PUD in patients with no red flag symptoms?
A
- Detect + treat H.pylori
- Advise to STOP smoking, NSAIDs, alcohol, drug abuse + aspirin
- Use PPI/H2 for 4-8wks, consider for longer until ulcer has resolved
22
Q
When is triple therapy for h/pylori eradication indicated? What is used?
A
Under 55y + tested +ve or over 55y with confirmed gastric ulcer
Use:
- clarithromycin
- amoxicillin (metronidazole if penicillin allergic)
- PPI
23
Q
What are some causes of upper GI bleed?
A
COMMON:
- oesophageal varices
- peptic ulcers
- Mallory-weiss tear
- Gastritis/erosions
- drugs
- cancer of stomach/duodenum
- oesophagitis
RARE:
- bleeding disorders, portal hypertensive gastropathy, Boerhaave syndrome, angiodysplasia, meckel’s diverticulum, peutz-jeghers syndrome
24
Q
What is the Glasgow Blatchford score? What is it used for?
A
Assess the likelihood that a person with UGI bleed will need medical intervention e.g. blood transfusion or endoscopic intervention
- score of more than 0 suggests need e.g. transfusion, endoscopy, biopsy etc
25
What is the management of an acute UGI bleed? (HINT: ABATED)
```
A - ABCDE + rhesus
B - Bloods
- FBC: IDA, platelets
- U+E: raised urea
- LFT: ?liver disease
- Clotting
- Crossmatch 2 units blood
A - Access with 2-large bore cannulae
T - Transfuse
E - Endoscopy - URGENT w/in 24h
D - Drugs: IV PPI, stop anticoagulants + NSAIDs
- In variceal bleeds also give terlipressin + prophylactic broad spectrum Abx
```
26
What is the definitive management/investigations for UGI bleed?
1. ENDOSCOPY
- within 4h for variceal haemorrhage
- within 24h for all others
- will help estimate risk of re-bleed + identify bleeding sites
2. Treatment options
- depends on cause
- sclerotherapy, variceal banding, argon plasma coagulation
27
What are some causes of oesophageal varices?
PRE-HEPATIC
- thrombosis (portal or splenic vein)
HEPATIC
- cirrhosis, schistosomiasis, sarcoid, myeloproliferative disease, congenital hepatic fibrosis
POST-HEPATIC
- Budd-Chiari syndrome, RHF, Constrictive pericarditis, veno-occlusive disease
28
When would you suspect varices as a cause of UGI bleed?
1. Alcohol abuse
2. Cirrhosis present
3. Signs of chronic liver disease
- encephalopathy, splenomegaly, ascites, hyponatraemia, coagulopathy, thrombocytopenia
29
What primary + secondary prophylactic management can be given for oesophageal varices?
PRIMARY (cirrhosis present)
- propranolol 40-80mg BD
- endoscopic band ligation
SECONDARY (after 1st bleed)
- propranolol 40-80mg BD
- endoscopic band ligation
- transjugular intrahepatic porto-systemic shunt (TIPS)
30
How do you manage bleeding peptic ulcers?
1. Control initially with adrenaline injection
2. Diathermy, laser coagulation or heat probe
3. Surgery in severe haemorrhage/re-bleeding
31
What are some conditions which can pre-dispose patients to Mallory-Weiss tear?
- alcoholism
- bulimia nervosa
- GORD
- hiatal hernia
32
How do you manage a Mallory-Weiss tear?
1. If bleeding stops spontaneously, conservative treatment sufficient
2. Control precipitating factors e.g. PPI in GORD
3. Treat haemodynamic instability if present
4. Surgical intervention if actively bleeding lesion
- adrenaline injection
- electrocoagulation
- endoscopic band ligation
33
What are the typical triad of features in Boerhaaves?
1. Vomiting/retching
2. Severe retrosternal pain - often radiates to back
3. Subcutaneous or mediastinal emphysema
34
How do you manage Boarhaaves?
1. Nil by mouth
2. Broad spectrum Abx
3. IV PPI
4. Surgical repair
35
What are the red flags for a change in bowel habit?
1. Aged over 60y
2. Unexplained anaemia
3. Weight loss
4. Rectal bleeding
36
What are the 2ww rules for suspected colorectal cancer?
1. Aged 40 or over with weight loss + abdo pain
2. Aged 50 or over with unexplained rectal bleeding
3. Aged 60 or over with IDA OR change in bowel habit
4. FOB
37
What are some causes of gastroenteritis? Who do each type tend to affect?
```
NOROVIRUS = most common in adults
ROTAVIRUS = most common in kids
E.COLI = travellers, watery stool
GIARDIASIS = prolonged non-bloody
CAMPYLOBACTER = bloody diarrhoea, flu-like prodrome, risks GBS
```
38
What investigations should be done in patients with gastroenteritis?
1. Clinical examination
2. U+E - raised Na + urea (dehydration)
3. Blood glucose - required before starting fluids
4. Stool MC+S if:
- recent travel abroad
- blood or mucus
- immunocompromised
- no improvement by day 7
- suspected septicaemia
5. Blood culture - if starting Abx
39
How do you manage gastroenteritis?
1. Attempt fluid challenge
2. ORS or IV fluids
3. Loperamide/Metoclopramide
4. Abx if bacterial
- campylobacter = erythromycin
- c.difficile = metronidazole + vancomycin
5. AVOID work/school for 48h after symptoms resolve
40
What patients should be tested for coeliacs disease even if they have no typical symptoms?
All newly diagnosed T1DM
41
What are the clinical features of ischaemic colitis?
- lower left sided abdominal pain
| - bloody diarrhoea
42
What investigations are performed in suspected ischaemic colitis?
1. CT
2. Colonoscopy with biopsy = GOLD STANDARD
3. Barium enema - thumbprinting of submucosal swelling
43
How do you manage ischaemic colitis?
1. Fluid replacement
2. Abx
- strictures are common!
44
What are the signs + symptoms of Crohns disease?
SYMPTOMS
- abdominal pain (diffuse or RUQ), non-bloody diarrhoea, nocturnal diarrhoea, perianal lesions
SIGNS:
- aphthous ulcers
- perianal abscess, fistula, skin tags
- anal stricture
- clubbing, arthritis, episcleritis/uveitis
- pyoderma gangrenosum, erythema nodosum
45
What investigations should you perform in suspected Crohn's disease?
1. FBC - anaemia
2. Faecal calprotectin
3. Iron studies
4. Serum B12
5. CRP/ESR
6. Stool testing - r/o c.diff
7. Abdo x-ray
8. CT abdomen
9. Colonoscopy (+biopsy) = definitive.
- skip lesions, cobblestoning, deep ulcers
10. OGD (affects whole GI tract)
46
How do you manage Crohns? (How to induce remission + maintain)
```
MUST STOP SMOKING!
INDUCING REMISSION:
1. Steroids (oral prednisolone, IV hydrocortisone)
2. Azathioprine
3. Methotrexate
```
MAINTENANCE:
1. Azathioprine
2. Methotrexate
47
Where does UC affect?
Always starts at rectum + never spreads beyond ileocaecal valve
- disease is also continuous
48
What are the symptoms + signs of Ulcerative Colitis?
SYMPTOMS:
- episodic/chronic diarrhoea (blood + mucus)
- crampy abdo pain (LLQ)
- Increased frequency + urgency of motions
- Blood in stool
- Tenesmus
SIGNS:
- clubbing
- arthritis/spondylitis
- erythema nodosum
- episcleritis/uveitis
- pyoderma gangrenosum
49
What investigations should be performed in suspected ulcerative colitis?
1. Bloods - FBC, U+E, LFT, ESR, CRP
- LFT should be done every 6-12 months to detect PSC
- U+E = hypokalaemic metabolic acidosis from diarrhoea
2. Faecal calprotectin
3. Stool MC+S - r/o c.diff
4. AXR - toxic megacolon if colon more than 6cm
5. Colonoscopy/Flexi sig - rectal involvement, continuous, loss of vascular markings
6. Biopsy - no inflammation beyond submucosa!, crypt abscesses, reduced goblet cells
7. Barium enema (only if mild UC) = drainpipe colon
50
What is used to determine severity of UC? Describe mild, moderate + severe,
Truelove + Witts Severity Assessment
(i) MILD = 4 or less motions/day
(ii) MODERATE = 4-6 motions/day
(iii) SEVERE = 6 or more motions/day + fever + blood + raised ESR + tachycardia + anaemia
51
How do you induce remission in UC?
MILD-MODERATE:
1. Aminosalicylate (topical mesalazine)
2. Topical steroid/oral mesalazine
3. Oral steroids or tacrolimus
SEVERE
1. IV hydrocortisone
2. IV ciclosporin
3. Colectomy
52
How do you maintain remission in UC?
1. Oral + topical mesalazine
2. Azathioprine
Surgery indicated in perforation, massive haemorrhage, toxic dilatation, failed medical therapy
- 1st = proctocolectomy + terminal ileostomy
- followed by colectomy + ileo-anal pouch (J pouch)
53
What are some causes of rectal bleeding?
1. Haemorrhoids - most common
2. Colorectal cancer - most serious
3. Anal fissure
4. Gastroenteritis
5. IBD
6. Diverticular disease
7. Angiodysplasia
8. UGI bleed
54
What are risk factors for developing anal fissures?
- constipation
- IBD
- STI: HIV, syphillis, herpes
55
How do you manage anal fissures? Both acute + chronic.
ACUTE (less than 6 wks)
1. High-fibre diet + fluid intake
2. Bulk forming laxative (methylcellulose), then lactulose
3. Lubricants
4. Topical anaesthesics
CHRONIC
1. Lactulose
2. Topical GTN or diltiazem
3. 2ndary care referral after 8 wks for IVA + botox
56
What is the most common type of colorectal cancer?
adenocarcinoma
57
What are the typical clinical features of colorectal carcinoma?
- change in bowels
- PR bleeding
- weight loss
- tenesmus
- IDA
- bowel obstruction
- abdominal mass
58
What tests should be done in suspected colorectal cancer?
1. FBC - microcytic anaemia
2. FOB - used for screening
3. Colonoscopy with biopsy = GOLD STANDARD
4. CT colonography - considered in pts not fit for scope
5. Staging CT TAP
6. CEA
59
What is Dukes classification for colorectal cancer?
A - confined to mucosa + part of muscle bowel wall
B - extending through muscle of bowel wall
C - lymph node involvement
D - metastatic disease
60
How is colorectal cancer managed?
MDT APPROACH - all varies depending on stage, general health + pts wishes etc.
1. Surgical resection
2. Chemotherapy
3. Radiotherapy
4. Palliation
61
What is a temporary loop ileostomy?
Temporary = ileostomy created to protect distal anastomosis
- 6-8 week period allows for healing of anastomosis, after this time it is reversed
Loop = both ends of section of small bowel brought to skin. The proximal, functioning end is turned inside-put to form a spout which protects surrounding skin
Usually found on lower right side of abdomen
62
What is the follow-up timelines for patients following curative colorectal cancer resections?
- CT TAP @ 1, 2 and 3 years
- Colonoscopy @ 1 and 5 years
- CEA 6-monthly for 3 years
63
What are the clinical features of diverticular disease?
- altered bowel habit
- blood mixed in stool
- abdominal pain (typically LLQ)
64
How is diverticular disease diagnosed?
1. Common incidental findings found on colonoscopy
2. Barium enema
3. CT abdomen is best for diverticulitis (enema or colonoscopy risk perforation in acute setting)
65
How is diverticular disease managed?
1. Advice re weight loss + high-fibre diet
| 2. Can use mebeverine for spasms
66
What are the clinical features of diverticulitis?
- LLQ pain + tenderness
- Fever
- Change in bowel habit
- Bleeding mixed in with stool
- N+V
67
What investigations should be performed in a pt presenting with suspected diverticulitis?
1. FBC - raised WCC
2. CRP raised
3. Erect CXR - r/o bowel perforation
4. CT with contrast
- use water soluble enema = gastrograffin
5. Colonoscopy - once stabilised
68
How do you manage diverticulitis?
MILD attacks = treat at home with bowel rest (fluids only) + Abx (co-amoxiclav) with follow-up after 48h
If unwell or complications e.g. rectal bleeding, then admission required.
1. NBM + IV fluids
2. IV Abx
3. Analgesia
4. Surgery determined by degree of infective complications
69
When do haemorrhoids become painful?
When they thrombose
- this happens when they protrude through the anal sphincter + venous return is blocked
- appear as purple, very tender, swollen lumps around anus
- PR exam impossible due to pain
70
What investigations should be performed in suspected haemorrhoids?
Like in all cases of rectal bleeding, do:
1. PR exam
2. Proctoscopy - to visualise internal haemorrhoids
3. Abdominal exam to r/o other DDx
4. Sigmoidoscopy - to visualise rectal pathology higher up
71
What are the types of anal prolapse? (HINT 1-4)
```
1 = no prolapse
2 = prolapse on straining, returns on relaxing
3 = prolapse when straining, has to be pushed back in
4 = prolapsed permanently
```
72
How do you manage haemorrhoids?
1st DEGREE:
- increase fluid + fibre
- topical analgesics
- stool softener
- topical steroid short-course
2nd + 3rd DEGREE or 1st IF ABOVE FAILS:
- rubber band ligation
- sclerosants
4th DEGREE:
- surgery = excisional haemorrhoidectomy
73
What investigations should be performed in suspected toxic megacolon?
1. FBC: raised WCC, reduced Hct
2. U+E: low K + Mg due to volume loss
3. CRP: raised
4. Serum albumin: low
5. Lactate: raised
6. Stool studies
7. CT abdo/pelvis
8. AXR: colonic dilatation over 6cm, absence of haustra
9. Erect CXR: ?perforation
10. Sigmoidoscopy
74
How should you manage toxic megacolon?
1. ABCDE + resus!
2. Broad spectrum Abx = metronidazole + ciprofloxacin
3. NG decompression
4. IV corticosteroid if IBD
5. Surgery - if no improvement after 72h of medical therapy
- abdominal colectomy with end ileostomy
75
What is the triad of symptoms in Budd-Chiari syndrome?
= Hepatic Vein Thrombosis
1. abdominal pain: sudden onset, severe
2. ascites → abdominal distension
3. tender hepatomegaly
76
What investigation is used to diagnose Budd-Chiari?
Ultrasound with doppler flow studies should be first investigation
77
What should you repeatedly monitor/assess for in pts with Acute Liver Failure?
- Hypoglycaemia
- Hyperkalaemia
- Renal failure
- Bacterial/fungal infection
- Cerebral oedema + raised ICP
- Metabolic acidosis
78
What are some causes of Acute Liver Failure?
1. DRUGS/TOXINS
- paracetamol OD
- anti-TB drugs
- halothane, ecstasy, carbon tetrachloride
2. INFECTION
- acute viral hepatitis, CMV, EBV
3. VASCULAR
- shock/ischaemic hepatitis, Budd-Chiari syndrome
4. OTHER
- Wilson's disease, autoimmune hepatitis
- Acute fatty liver, pregnancy
- extensive malignant infiltration
79
When should you suspect alcoholic hepatitis?
Pts who drink over 40units/week
OR
Develop withdrawal symptoms after 24-48h in hospital
80
What are the common features of acute liver failure?
- Jaundice
- Coagulopathy (INR over 1.5)
- Hepatic encephalopathy
81
What are the complications that can occur from acute liver failure?
1. Cerebral oedema
- mannitol + hyperventilate
2. Ascites
- fluid restrict, low-salt diet, diuretics
3. Bleeding - Vit K, platelets, FFP
82
What investigations do you perform in suspected cirrhosis?
1. LFTs
2. Albumin: low
3. U+E: hyponatraemia common
4. Clotting: PT prolonged, raised INR
5. FBC: low WCC in hypersplenism
6. FIBROSCAN CONFIRMS DIAGNOSIS
- tests to locate cause: iron studies, ANA, AMA, serum caeruloplasmin, alpha-1 antitrypsin
83
What treatment is given in SBP?
Cefotaxime
84
What investigation confirms hepatic steatosis?
USS
85
What are the clinical features of hereditary haemochromatosis?
1. early symptoms = fatigue, erectile dysfunction + arthralgia (often hands)
2. 'bronze' skin pigmentation
3. diabetes mellitus
4. LIVER: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
5. CARDIAC failure (2nd to dilated cardiomyopathy)
6. hypogonadism
7. arthritis (especially of the hands)
86
How do you investigate hereditary haemochromatosis?
1. LFTs deranged
2. Iron studies
- raised serum ferritin + transferrin saturation
- low TIBC
3. Genetic testing - CONFIRMS DIAGNOSIS (HFE mutation)
4. Imaging
- Xray = chondrocalcinosis
- MRI = deposits in liver
5. Liver biopsy = Perl's stain
6. ECG/Echo if dilated cardiomyopathy suspected
87
What are the triad of features in wilson's disease?
1. hepatic problems - 40%
- hepatitis + cirrhosis
2. CNS problems = 50%
- dysathria, dystonia, parkinsonism
3. Psychiatric problems - 10%
- depression, psychosis, dementia
88
What is used to treat Wilson's disease
1. Penicillamine
2. Zinc therapy
3. Trientine
89
How do you manage Hepatitis A?
1. Supportive - analgesia
- typical resolution in 1-3 months
2. AVOID alcohol
3. Interferon alpha if fulminant disease (RARE)
90
Who is at risk of Hepatitis B?
- IVDU + their partners
- Healthcare workers
- Haemophiliacs
- Dialysis pts
- Sexually promiscuous
- Babies from HBsAg +ve mothers
91
What does all of the following mean?
(i) HBsAg
(ii) Anti- HBs
(iii) Anti-HBc
(iv) HBeAg
(i) HBsAg = implies infectivity
- acute if less than 6 months
(ii) Anti- HBs = implies immunity
- resolved infection OR vaccination
(iii) Anti-HBc = past or current infection
- IgM remains for 4-6 months
- IgG = chronic infection
(iv) HBeAg = marker of infectivity
92
Can hep B be spread by breast feeding?
NO
93
What is the (i) screening + (ii) diagnostic test for Hepatitis C?
(i) hepatitis C antibody (anti-HCV) = screening
| (ii) HCV RNA (PCR) = diagnostic
94
What antibodies are associated with autoimmune hepatitis?
ANA
Anti-smooth muscle
LKM-1
95
How do you treat autoimmune hepatitis?
1. Steroids or azathiprine
| 2. Liver transplant
96
What condition is commonly associated with PBC?
Sjogrens syndrome (80%)
others = RA, systemic sclerosis, thyroid disease
97
What is the treatment for PBC?
1. Cholestyramine for pruritus
2. Fat-soluble vitamin supplementation
3. Ursodeoxycholic acid
4. Liver transplant
5. Steroids
98
What is the gold standard test to diagnose PSC?
MRCP
| - also ANCA+ve
99
How is PSC managed?
1. ERCP can dilate + stent any strictures
2. Ursodeoxycholic acid may protect against colorectal cancer
3. Cholestyramine for pruritus
4. Liver transplant if advanced disease
100
What are the USS findings in acute cholecystitis?
- thickened GB wall
- stones/sludge in Gb
- fluid around GB
- stones in duct
- duct dilatation (6mm plus 1mm for every decade over 60)
101
How do you distinguish between acute cholecystitis + ascending cholangitis?
Ascending cholangitis is RUQ pain, fever/raised WCC + jaundice
Acute cholecystitis there is no jaundice
102
How do you manage acute cholecystitis?
1. NBM
2. Fluids
3. Analgesia - diclofenac or morphine
4. Abx - cefuroxime IV
5. Laparoscopic cholecytectomy
103
What are the 2ww criteria for suspected pancreatic cancer?
1. Aged over 40 with jaundice
2. Consider if aged over 60 with weight loss + any of:
- diarrhoea
- constipation
- back pain
- abdominal pain
- new-onset DM
- nausea or vomiting
104
What investigations are performed in suspected pancreatic cancer?
1. Endoscopic USS with biopsy
2. CT TAP
3. CA19-9
105
What is the surgery used for pancreatic cancer?
only used in less than 20%
WHIPPLES RESECTION = pancreaticoduodenectomy
- removes head of pancreas, GB, duodenum + pylorus
106
How does hereditary spherocytosis present? How is it treated?
Jaundice, splenomegaly, gallstones + aplastic crisis in the presence of parovirus
- treated with folate supplementation + splenectomy. May also require cholecystectomy
107
How is G6PD inherited?
X-linked recessive
108
How does G6Pd deficiency present?
Jaundice (typically in neonatal period), gallstones, anaemia, splenomegaly
+ Heinz bodies on blood film
Diagnosed by doing G6PD enzyme assay
109
How is AIHA managed?
1. Blood transfusions
2. prednisolone
3. rituximab
4. Splenectomy
110
What is the diagnostic test for sickle cell anaemia?
Hb electrophoresis
111
What are general management you should advise pts of with sickle cell anaemia?
1. AVOID dehydration + other triggers of crisis
2. Ensure vaccines up to date
3. Abx prophylaxis = phenoxymethylpenicillin
4. Hydroxycarbamide = stimulates production of foetal Hb
5. Blood transfusion for severe anaemia
6. Bone marrow transplant can be curative
112
What are the 4 main types of sickle cell crises? Describe VERY briefly/
1. VASO-OCCLUSIVE CRISIS (painful crisis)
- block capillaries causing ischaemia
- can cause priapism in men
2. SPLENIC SEQUESTRIAN CRISIS
- RBCs blocking flow to spleen
- severe anaemia + shock
3. APLASTIC CRISIS
- caused by parovirus B19
- loss of creation of new cells (temporary)
4. ACUTE CHEST SYNDROME
- can be from infection (pneumonia/bronchiolitis) or non-infective (fat emboli)
113
What is the initial generic management of the acute abdomen?
1. ABCDE to prioritise resuscitation
2. NBM
3. IV access
4. IV Fluids
5. IV Abx if evidence of infection
6. Analgesia + anti-emetics
7. NG tube if vomiting/evidence of obstruction
8. Catheterise for fluid balance monitoring
9. Consent
10. Escalate care
114
What should a pt with AF + abdominal pain make you think of?
Mesenteric ischaemia
115
What are the clinical features of mesenteric ischaemia?
Acute severe abdominal pain
- central + constant, or around the RIF
Degree of illness out of proportion to clinical signs (no abdominal signs)
Rapid hypovolaemia + shock
116
What investigations should you perform in suspected mesenteric ischaemia?
1. FBC - raised Hb due to plasma loss, raised WCC
2. ABG - metabolic acidosis
3. Lactate raised
4. AXR - gasless abdomen
5. CT/MRI angiography
6. Laparotomy
117
How do you manage mesenteric ischaemia?
1. Fluid resuscitation
2. Thrombolysis with HEPARIN
3. Abx - gentamicin + metronidazole
4. Laparotomy to resect necrotic bowel
118
What are the causes of acute pancreatitis? (HINT: GET SMASHED)
```
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion venom
H - hyperlipidaemia/hypothermia/hypercalcaemia
E - ERCP
D - drugs
```
119
What is (i) Cullen's sign (ii) Grey-Turners sign?
(i) Cullens = periumbilical discolouration
| (ii) Grey-turners = Flank discolouration
120
What investigations should you perform in acute pancreatitis?
1. Amylase - 3x upper limit of normal
2. Lipase
3. ABG - raised lactate
4. LFT - raised AST
5. CRP raised
6. AXR
7. Erect CXR - r/o perforatoin
8. CT = gold standard
9. USS if gallstones + raised AST
10. ERCP - if LFTs worsen
121
How is pancreatitis managed? What scoring system is used to determine management?
Modified Glasgow Score
1. NBM - likely need NG tube to decrease pancreatic stimulation
2. IV fluids
3. Analgesia - pethidine, morphine
4. Hourly obs + bloods
5. May require Abx
6. Address cause
122
What is the main cause of chronic pancreatitis?
Alcohol
123
What are the clinical features of chronic pancreatitis?
- upper abdo pain worse 15-30 mins following meal
- steatorrhoea
- DM usually 20y after onset of symptoms
124
What test can be used to assess endocrine function of pancreas?
Faecal elastase
125
How do you manage chronic pancreatitis?
1. Pancreatic enzyme supplementation
2. Analgesia
3. Antioxidants
126
What is the gold standard test to diagnose appendicitis?
CT
127
What Abx can be given pre-op for appendicitis?
Cefuroxime + metronidazole
128
What are the 3 main causes of bowel obstruction?
1. Adhesions
2. Hernias
3. Malignancy
(also volvulus, ischaemia)
129
What is the initial management + tests for bowel obstruction?
DRIP + SUCK
- NBM, IV fluids, NG tube on free drainage
1. AXR
2. CT confirms diagnosis (use gastrograffin as contrast)
3. Bloods: Amylase, FBC, U+E, lactate
130
What is the most common type of volvulus?
Sigmoid volvulus (80%)
131
What is the classical sign of sigmoid volvulus on AXR?
Coffee bean sign
132
How do you manage sigmoid volvulus?
1. Right sigmoidoscopy + rectal tube insertion
| 2. Sigmoid colectomy sometimes required
133
What is paralytic ileus? When does it tend to occur?
Bowel goes to 'sleep' temporarily causing pseudo-obstruction
= very common post-abdominal surgery
- lasts 2-4 days
134
How should paralytic ileus be managed?
1. NBM + IV hydration
2. Reduce opioid analgesia + replace with non-opioid
3. NG decompression
4. Consider parenteral nutrition if more than 3 days without food
135
What is the best test to diagnose hiatus hernia?
Barium swallow
136
What are the 3 main causes of large bowel obstruction?
1. Adhesions
2. Hernias
3. Malignancy
137
What is paralytic ileus?
Adynamic bowel due to the absence of normal peristaltic contractions.
Contributing factors include = abdominal surgery, pancreatitis (or any localised peritonitis), spinal injury, hypokalaemia, hyponatraemia, uraemia, peritoneal sepsis & drugs (e.g. TCAs)
- common post surgery + lasts 2-4 days
138
What are the classic triad of features in chronic mesenteric ischaemia?
1. Colicky post-prandial abdominal pain
2. Weight loss (eating hurts)
3. Upper abdominal bruit and/or PR bleeding
139
How do you diagnose + manage chronic mesenteric ischaemia?
CT angiogram
| - percutaneous transluminal angioplasty + stent insertion
