Gastroenterology_Medicine & Surgery Flashcards
1
Q
Causes of hepatic decompensation in CLD? Key features of decompensation?
Dx & Mx of decompensated chronic liver disease?
A
Cause of hepatic decompensation in CLD:
- Hypokalaemia
- Constipation (given lactulose in hospital)
- Alcohol
- GI bleed (lots of protein (Hb) enters the bowel –>liver can’t cope)
- HCC
Decompensated CLD –> Ascites, jaundice & encephalopathy
- Severely scarred liver (cirrhosis) in CLD –> back pressure on portal vein –> PORTAL HTN = splenomegaly, ascites, varices - caput medusae, oesophageal & rectal
Ix:
-
Serum Ascites Albumin Gradient (SAAG) - serum albumin conc vs ascites conc - 11.1g/L
- <11.1g/L = exudative cause - peritonitis (infection), peritoneal malignancy OR n_ephrotic syndrome_ (pee out albumin so low serum albumin)
- Otherwise = transudative cause - cirrhosis, renal failure, HF
- >250 neutrophils = spontaneous bacterial peritonitis (SBP) –> Tazocin/3rd gen cephalosporin
- If protein conc <15g/L give prophylactic oral ciprofloxacin
Mx:
- Paracentesis (ascitic drain) –> post-paracentesis circulatory dysfunction (drops BP) SO if >5L drained give human albumin solution (HAS) 8g/L drained
- Spironolactone (2nd line - Furosemide) - to prevent fluid accumulation
- (Salt restrict)
- Hepatic encephalopathy (liver not dealing with toxins) - give Lactulose + Rifaximin to prevent
- Coagulopathy - OGD (check for varices) + vit K (needed for clotting)
2
Q
Chronic liver disease
- Functions of liver? Outcome of failure?
- Causes? Presentation? Ix?
- Important complication?
- Scoring?
A
Functions of the liver –> failure:
- Albumin (plasma oncotic pressure) –> oedema
- Bilirubin metabolism –> jaundice
- Clotting factors –> coagulopathy
- Detoxification –> encephalopathy
Causes:
- Common - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis)
- Less common - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson’s disease
Presentation:
- Spider naevi (≥5, SVC distribution, flush inside to out), palmar erythema, gynecomastia, Dupuytren’s contracture (alcoholic liver disease), clubbing
- Specific signs:
- Needle marks/tattoos - hep C
- Parotid swelling - alcohol-related liver disease
- Bronzed complexion/insulin injection signs - haemochromatosis
- Obesity/DM - non-alcoholic fatty liver disease
- Xanthelasma - cholestatic disorder
Ix:
- Alcohol history
- Hep B/C serology
- Ferritin, transferrin, A1AT, ceruloplasmin (Wilson’s)
- Ig, auto-abs (ANA in AI hep, AMA in PBC)
Important complication = VARICES
- Normal venous return: GI tract –hepatic portal vein –> liver –> hepatic vein –> systemic circulation
- Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum
- MEMORY AID: BUTT, GUT, CAPUT
- Pathological process:
- In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein –> reducing blood flow to the systemic circulation
- Backflow of blood to the hepatic portal vein = increased –> backflow to hepatosystemic anastomoses:
- Oesophagus –> Oesophageal varices
- Spleen –> Splenomegaly
- Umbilicus –> Caput Medusae
- Only from portal HTN if running from below umbilicus up
- Rectum –> Rectal varices
Score for prognosis & need for liver transplant = Child-pugh score (A = 5-6; B = 7-9; C = 10-15 –> C is most severe)
3
Q
Jaundice breakdown & causes by type & Ix to differentiate
A
Pre-hepatic - unconjugated bilirubin comes from breakdown of RBCs
- Haemolysis related-causes (excess prod) - AIHA, SCD, G6PD def, malaria
- Ix:
- Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it)
- Urine: normal (unconjugated bilirubin is insoluble)
- Stool: normal as liver functioning normally
Hepatic - bilirubin absorbed into liver –> conjugated –> excreted via biliary tract into duodenum
- Liver disease related-causes - cirrhosis, hepatitis, Gilbert’s syndrome, drugs
- Ix:
- Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation)
- Urine: dark (leaked conjugated bilirubin is soluble)
- Stool: slightly pale (reduced conjugated bilirubin to GI tract)
Post-hepatic - conjugated bilirubin –> soluble urobilingogen (yellow): 1) Absorbed into circulation –> excreted via kidneys 2) Remaining –oxidised–> stercobilin (brown)
- Biliary disease related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC
- Ix:
- Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can’t reach duodenum and instead leaks into blood)
- Urine: dark (leaked conjugated bilirubin is soluble)
- Stool: very pale (no conjugated bilirubin reaches GI tract –> no stercobilin generated)
4
Q
Chronic diarrhoea - ddx? Sx? Distribution? Histology? Ix? Mx?
A
IBD
-
Crohn’s disease
- Sx: RIF pain (terminal ileum), failure to thrive (incl. between attacks)
- Distribution: mouth to anus (esp. terminal ileum), skip lesions
- Histology: transmural, non-caseating granuloma (also in sarcoidosis)
-
Ix:
- OGD/colonoscopy/capsule endoscopy
- Gastografin follow-through
-
Mx:
- Induction:
- Steroids (induce remission)
- 5-ASA (mesalazine)
- Maintenance:
- Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine)
- Biologics e.g. Anti-TNF (infliximab)
- Induction:
- Complications: strictures, obstruction, fistulae
-
Ulcerative colitis
- Sx: gen. abdo pain, PR blood & mucus
- Distribution: ONLY rectum & colon, continuous
- Histology: mucosa & submucosa, mucosal ulcers, crypt abscesses
-
Ix:
- Flexible sigmoidoscopy/colonoscopy
-
Mx:
- Induction:
- 5-ASA
- Steroids
- Maintenance:
- 5-ASA (mesalazine)
- Steroid-sparing agents (azathioprine)
- Biologics (infliximab)
- Surgery (proctocolectomy, IJ pouch)
- Induction:
- Complications: toxic megacolon, colonic carcinoma, PSC
- Extra-intestinal signs of IBD - A PIE SAC
- Aphthous ulcers (crohn’s)
- Pyoderma gangrenosum
- Iritis, uveitis, episcleritis (Crohn’s)
- Erythema nodosum
- Sclerosing cholangitis (PSC in UC)
- Arthritis
- Clubbing fingers (CD > UC)
- Truelove & Witts’ severity index = severity criteria for IBD
Coeliac disease
-
Def: inflammatory response to gluten (immune reaction to gliadin)
- DQ2/8 (on HLA typing)
-
Sx: abdo Sx (steatorrhoea, diarrhoea, bloating), failure to thrive
- Exam: blistering rash on both knees. aphthous mouth ulcers
- Assoc: T1DM
- Distribution: duodenum
- Histology: subtotal villous atrophy with crypt hyperplasia
-
Ix: (maintain normal diet - eat gluten for 6wks before testing)
- Haematinics - macrocytic anaemia, low Fe, B12/folate
- Serological testing:
- Screening: Anti-TTG & total IgA (check for selective IgA def in case this caused false ‘-ve’ anti-tTg abs)
- If weakly +ve –> anti-endomysial abs (more sensitive & specific)
- OGD & duodenal biopsy
- Histology: sub-total villous atrophy with crypt hyperplasia
- Mx: gluten avoidance
Irritable bowel syndrome - Dx of exclusion
-
Sx: bloating, related to stress, diarrhoea/constipation, relieved by defecation
- “Pellet-like stools”
- Ix: faecal calprotectin (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD)
- Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants
5
Q
Mesenteric ischemia:
- What is the blood supply to the GI tract?
- What area of GI tract is vulnerable to ischaemia?
- Breakdown of mesenteric ischemia? Sx? Ix? Mx?
What is the difference between Mesenteric ischemia & ischemic colitis? Sx? Ix?
A
Blood supply
- Coeliac axis - oesophagus, stomach, start of small intestine
- Superior mesenteric artery (SMA) - most of the small intestines up to 2/3 transverse colon
- Inferior mesenteric artery (IMA) - from 2/3 along transverse colon down to rectym
- NOTE: area 2/3 along transverse colon @splenic flexure = WATERSHED ZONE (limited supply from superior & inferior mesenteric arteries) –> vulnerable to ischaemia!!
__Mesenteric ischemia
-
Acute - occlusion of SMA by thrombus/embolus
- Sx: severe abdo pain, normal abdo exam, shock
-
Ix:
- AXR (gasless abdo)
- VBG (lactic acidosis)
-
CT abdo with contrast (if suspect mesenteric ischaemia)/CT angiogram (if LA)
- If not primary surgery –> followed by mesenteric angiography (Dx non-occlusive mesenteric ischaemia)
- Mx: resus + CCOT + NBM
- Empirical abx
- Bypass ± bowel resection
- Heparin post-op
-
Chronic - narrowing of SMA by atherosclerosis (stable angina of bowel)
- Sx: colicky post-prandial abdo pain (more work for bowel to do –> pain, just like in stable angina & exercise)
- Ix: as above
- Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery)
Ischemic colitis
- Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus
- Sx: abdo pain, PR bleeding
- Ix: sigmoidoscopy/colonoscopy
- Mx: seek GI & surgical input (can develop chr ulcerating IC)
- Mild - conservative (IV abx, fluids, bowel rest, DM control)
- Prophylactic LMWH
- Segmental resection + stoma
- Mild - conservative (IV abx, fluids, bowel rest, DM control)
6
Q
Most common reason to do AXR? Most common causes of this reason by type?
AXR interpretation?
Key volvulus signs on AXR?
A
Reason to do AXR: worried about bowel obstruction (small/large bowel)
Small bowel obstruction on AXR:
- valvulae conniventes (from one wall to other)
- Central to image
- >3cm distension
- Causes: adhesions (surgery, sepsis), hernia, neoplasm, volvulus, IBD
Large bowel obstruction on AXR:
- Haustra (Not full width of bowel)
- Outsides of image
- >6cm distension
- Causes: neoplasm, diverticular disease, volvulus, faecal impaction
NOTE: 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm)
Volvulus signs (twisting of loop of bowel on mesentery –> balloon animal):
- Coffee bean sign - sigmoid volvulus (large bowel just before rectum)
- Embryo sign - caecal volvulus (large bowel just after small bowel)
7
Q
At the end of abdo exam what do you offer to do? Exposure in abdo exam?
A
GOR(D)
- external Genitalia
- hernial Orificies
- digital Rectal
Ideally nipples to knees but in this case, I will do nipples to the groin due to possible patient discomfort
8
Q
Erythema nodosum is associated with which conditions?
A
IBD (also pyoderma gangrenosum),
Sarcoidosis
TB
Meds (OCP, sulphonamides, aspirin/NSAIDs)
9
Q
Primary Sclerosis Cholangitis (PSC) vs Primary Biliary Cholangitis (PBC)
- Associations? Ix? Tx?
A
-
PSC - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice)
- Associations: UC (10% but 80% PSC have UC), Cholangiocarcinoma
-
Ix: MRCP, pANCA
- ‘Beads on string’ on ERCP
- Tx: supportive, liver transplant
-
PBC - intrahepatic only (benign condition - middle-aged female, intractable itching)
-
Associations: AI diseases (RA, Sjogren’s, hypothyroidism)
- Sicca syndrome (70%) - dry eyes & mouth (like Sjogren’s syndrome)
- Fat malabsorption w/ steatorrhoea (incl vitamins ADEK):
- Low vit D can cause osteomalacia & proximal myopathy e.g. difficulty climbing stairs & pain in lower back
- Low vit K can cause coagulopathy
- Ix: anti-mitochondrial Ab (AMA), high cholesterol
- Tx: ursodeoxycholic acid (prognostic benefit)
-
Associations: AI diseases (RA, Sjogren’s, hypothyroidism)
10
Q
AI hepatitis - RFs? Ix? Mx? Complications?
A
RFs:
- Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA)
- Genetic predisposition:
- For T1 AIH - HLA-DR3/4
- For T2 AIH - HLA-DQB1/DRB1
Ix:
- Anti-smooth muscle Ab (SMA), ANA
- T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA
- T2: anti-LKM1
Mx: high-dose prednisolone + long-term azathioprine
Complications:
- Cirrhosis in 40%, relapse high if stop IS
11
Q
How do you tell between spleen & kidney on examination?
A
Spleen (vs kidney):
- Moves down with inspiration
- You can’t get above it
- Has a notch
- Dull to percussion & not ballotable
12
Q
Causes of hepatomegaly, splenomegaly & enlarged kidney(s)?
A
Hepatomegaly causes:
- Hepatitis (infective and non-infective)
- Hepatocellular carcinoma/hepatic mets
- Wilson’s disease, Haemochromatosis
- Primary biliary cirrhosis
- Leukaemia, Myeloma, haemolytic anaemia
- Glandular fever
- Tricuspid regurgitation
Splenomegaly causes:
- Portal HTN secondary to liver cirrhosis
- Splenic mets
- Haemolytic anaemia, Congestive HF, Glandular fever
Large kidney causes:
- Bilaterally enlarged: polycystic kidney disease, amyloidosis
- Unilaterally enlarged: renal tumour
13
Q
Alcoholic liver disease - presentation? Bloods? Decompensated Mx?
A
Presentation: peripheral neuropathy, cerebellar, Wernicke’s, gout, parotitis, Dupuytren’s contracture
Bloods: AST > ALT (2:1)
Decompensated Mx:
-
Discrimination function calculated (PT/INR + bilirubin):
- <32/Inf/upper GI bleed –> no steroids
- Otherwise –> steroids
14
Q
Upper GI bleed - scoring for need for intervention? Mx?
A
Blatchford score
Variceal bleed
- Massive haemorrhage –> balloon tamponade
- A-E assessment –> IV fluids, blood transfusion
- F1 Essentials:
- 2x large bore cannula
- VBG
- G&S/X-match
- Bleep the bleed reg
- F1 Essentials:
- Drugs with prognostic benefit:
- IV Terlipressin (ADH analogue –> vasoconstriction)/Somatostatin (used for same reason)
- Prophylactic abx - Ceftriaxone/Norfloxacin (abx)
- Intervention (discuss with on-call bleed registrar) –> endoscopic band ligation
15
Q
Peptic ulcer disease - RFs? Types? What artery is most likely to bleed in duodenal ulcer?
Presentation? Ix? Mx? Scoring to evaluate risk of re-bleed/death?
A
RFs:
- H. pylori exposure
- Aspirin/NSAID use
Types:
- Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ NSAIDs
- Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ H. pylori, worse by stress/at night –> radiates to back, put weight on, malaena
- Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum –> likely cause of bleeding in PUD
Presentation:
- Chr/recurrent upper abdo pain - related to eating & nocturnal
- Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas
- Pointing sign on exam - show where pain is with 1-finger
- NOTE: ‘Coffee grounds’ vomiting = upper GI bleed (mostly due to PUD > gastric erosions)
Ix:
-
OGD endoscopy = gold-standard
- Immediately if dyspepsia + upper GI bleed
- Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain –> exclude malignancy
- Repeat within 6-8wks to ensure ulcer healing/rule out malignancy
- H. pylori stool antigen/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx)
- Bloods - FBC
Mx: consider STOPPING NSAIDs
- Active bleed:
- Urgent evaluation (A-E + Blatchford score) + blood transfusion
- OGD endoscopy (Dx & Tx) –> high-dose IV PPI afterwards (continue oral PPI for 6wks)
- Rockall score (for risk of rebleed/death) –> if re-bleed –> repeat endoscopy & Tx endoscopically/emergency surgery
- If H. pylori +ve:
-
H. pylori eradication - triple therapy for 7 days (PPI + 2 abx = Amox + clari/metro) –> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx)
- If pen allergic –> PPI + Clari + Metro
- If long-term NSAID/aspirin use:
- Consider stopping NSAIDs/aspirin
- Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks –> H. pylori eradication afterwards
-
H. pylori eradication - triple therapy for 7 days (PPI + 2 abx = Amox + clari/metro) –> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx)
- If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist)
- If recurrent/refractory ulcers –> long-term PPI/H2 antagonist
16
Q
- Joint pain in both knees, XR shows chondrocalcinosis
- Wakes at night frequently to urinate, PMHx T2DM, low albumen on blood
Dx? Classification? Presentation? Ix? Mx?
A
Dx: haemochromatosis
- Risk of HCC (hepatocellular carcinoma)
Classification:
- Hereditary - AR, gene on chr6 (carried by 1:10 Europeans)
- Secondary e.g. from frequent blood transfusions (SCD)
Presentation - from Fe-deposition in various tissues:
- Arthritis (esp hands), bronze DM (tan), cirrhosis
- Hypogonadism (accumulates in testis)
- Dilated cardiomyopathy (accumulates in heart)
- XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis
Ix:
- Blood iron profile:
- TF saturation high (>55% men, >50% women)
- Ferritin normal/slightly high (>500)
- Low TIBC (as all transferrin saturated)
Mx:
- Venesection (until transferrin saturation normal)
- Desferrioxamine (iron chelator to prevent recurring)
- Monitoring ; TF saturation <50% & serum ferritin <50ug/l
23
Q
Dysphagia DDx? Ix?
A
Dysphagia - difficulty swallowing
- vs Odynophagia - painful swallowing
- vs Globus sensation - lump in throat, no pain
Oropharyngeal - difficulty initiating swallowing (± cough, choking, aspirating, regurgitation) - pressure in throat
- Oral:
- mastication (CN 5,7,11) e.g. CVA
- Low saliva e.g. Sjogren’s syndrome
- Pharyngeal:
- Neuromuscular - CVA, Myasthenia Gravis, Parkinson’s
- Upper oesophageal sphincter - decreased relaxation
Oesophageal - difficulty after swallowing - pressure in chest
- Solids & liquids - motor
- Intermittent: oesophageal dysmotility
- Progressive (solids –> both): achalasia (“birds beak”), systemic sclerosis
- Solids only - obstructive
- Non-progressive: lower oesophageal rings/webs, oesophagitis
- Progressive: stricture, cancer
Ix:
- Barium swallow - if a possible proximal oesophageal lesion
- Upper endoscopy ± biopsy
- If affects solids & liquids –> manometry
26
Q
Hernia (surgery) - def? types? Mx?
A
Def: protrusion of a viscus through its wall
Types:
- Incisional hernia - iatrogenic following surgery
- Groin hernia - ASIS & pubic tubercle palpated:
- Femoral (W>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation
-
Inguinal - above & medial to the pubic tubercle
- Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring
- Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring
- Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear
- Other groin lumps:
- Lymphadenopathy - along inguinal ligament
- Vascular - pulsatile varicose veins below inguinal ligament
Mx: surgical (mesh)
NOTE: hernias are safer the larger the defect as less likely to strangulate
27
Q
What are the borders of Hesselbach’s triangle?
A
28
Q
Abdominal scars
A
- Midline sternotomy - AAA, laparotomy
- Rooftop scar - liver transplant, Whipple’s procedure, gastric surgery, oesophagectomy
- Kocher – open gallbladder surgery
- Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick)
- Lanz/McBurney’s = Appendicectomy
- Pfannenstiel = C-section/prostatectomy/cystectomy
29
Q
Colorectal cancer - Presentation? Ix? Mx? Screen?
A
Presentation:
- Bowel habit change
- Palpable mass
- IDA, PR bleed (clots, fresh)
- Acute (obstruction, perforation)
Ix: colonoscopy
Mx: based on TNM staging post-CT
- Colon cancer
- T4 (local advancement) –> neoadjuvant Tx
- Otherwise –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
- Rectal cancer
- T3-4 –> neoadjuvant Tx –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
- T1-2NOMO –> transanal excision
Screen: 60-74yrs FIT testing (or FOB)
32
Q
Abdo pain ddx?
A
Upper:
- RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis
- Epigastric pain: PUD, GORD, pancreatitis
Middle:
- Flank pain: pyelonephritis (loin to groin pain)
- Umbilical pain - AAA (consider if >65yrs, HTN)
Lower:
- RIF pain: appendicitis, ureteric colic, hernia, testicular torsion
- Suprapubic pain: UTI
- LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion
- In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID
- Ask about _P_ain, _P_regnancy, _P_V bleeding, _P_V discharge
NOTE: also consider psych cause of generalised abdo pain (esp in kids)
34
Q
Biliary anatomy?
A
- Right and left hepatic ducts merge to form the common hepatic duct
- Gallbladder - stores & concentrates bile and releases it to emulsify fats
- Cystic duct connects gallbladder to the biliary tree
- Cystic duct and common hepatic duct come together to form the common bile duct
- Pancreatic duct feeds into the common bile duct - where it secretes exocrine hormones
- All of the above feed through the Ampulla of Vater into the duodenum –> allowing secretion of bile into the intestines
35
Q
RFs? Types of stone? RUQ pain Ix?
Biliary colic - Def? Presentation?
Cholecystitis - Def? Presentation? Ix?
Ascending cholangitis - Def? Presentation? Acute Mx?
A
RFs (5Fs): Fat, Female, Fertile, Forty, Fair
Types of gallstone: mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous)
RUQ Pain Ix:
- Abdo USS
- Stone in CBD (common bile duct) –> ERCP
- Deranged LFTs/dilated ducts –> MRCP
- None of above –> cholecystectomy
Biliary colic:
- Def: pain due to blockage of bile flow due to a gallstone
- Presentation: RUQ pain, worse after fatty meals (stimulates gallbladder contraction –> bile release for fat emulsification)
Cholecystitis:
- Def: inflammation of the gallbladder (typically in context of gallstones)
-
Presentation: RUQ pain (+ tenderness - Murphy’s sign), FEVER
- Murphy’s only +ve if not present on the left as well
- Ix:
- Urine dip – infection, bHCG
- Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen
- Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum)
Ascending cholangitis:
- Def: inf ascending the biliary tree, usually in the context of gallstone
-
Presentation (due to obstruction of Common Bile Duct - bile stagnates and becomes infected):
- Charcot’s triad - RUQ pain, fever, JAUNDICE
- Reynold’s pentad (severe) - above + shock + confusion
-
Surgical EMERGENCY - Mx via sepsis 6 protocol (abx = Tazocin) + drain obstruction:
-
Endoscopic retrograde cholangiopancreatography (ERCP) - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system
- Complications: pancreatitis, bleeding (from dilation of AoV), perforation
- Percutaneous transhepatic cholangiogram (PTC) - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree –> dislodge stone/alternative route for bile to flow - leave in cholecystostomy
- Cholecystostomy - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy
- Patients will likely require a later cholecystectomy (after dealing with the acute infection)
-
Endoscopic retrograde cholangiopancreatography (ERCP) - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system
36
Q
Appendicitis - presentation? DDx? Scoring? Mx?
A
Presentation:
- Acute umbilical to RIF pain (McBurney’s point)
- Tenderness + guarding (if rigid abdo - perforated apendix)
- N&V –> anorexia (not wanting to eat anything from nausea), change in bowel habit
- Rovsig’s sign - pain in RIF on LIF palpation
- Psoas sign & Obturator sign
DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction
Ix:
- Urinalysis, bloods - FBC, U&E, CRP
- USS abdo/pelvis –> consider contrast-enhanced CT-AP
Alvarado score - >4 = likely appendicitis
Mx:
- A-E (incl. fluids)
- Sepsis bundle - abx when Dx confirmed
- Laparoscopic appendicectomy
- Conservative only if uncomplicated appendicitis
38
Q
Bowel obstruction - immediate Mx, small vs large bowel obstruction - causes, features, Mx?
A
Immediate Mx:
- NBM, Ryles tube (aspirate stomach contents)
- IV fluids
- AXR -> CT (identify transition point of obstruction)
Small bowel obstruction:
- Causes: Adhesions (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian)
- Features: central dilated loops of bowel, >3cm, valvulae coniventes
- Mx: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative)
Large bowel obstruction:
- Causes: tumour, volvulus
- Features: peripheral dilated loops of bowel, >6cm, haustra
- Mx: surgery, flatus tube (in sigmoid volvulus)
NOTE: 3/6/9 rule
39
Q
Right & left hemicolectomy - indications, process & what are you left with?
Panproctocolectomy - indications, process & what are you left with?
Total vs subtotal colectomy - process & what are you left with?
Hartmann procedure - indications, process & what are you left with?
Anterior vs AP resection - indications, process & what are you left with?
Urostomy (ileal conduit) - indications & process?
A
Right hemicolectomy - right colon
- Indication: problems affecting the right side of the colon e.g. malignancy
- Process: removing from ileocaecal valve to 1/3 the way along the transverse colon
- What are you left with:
- Primary anastomoses (ileum attached to the remaining colon)
- Sometimes left with a stoma
Left hemicolectomy - left colon
- Indication: problems affecting the descending colon e.g. tumour
- Process: removing from 2/3 the way along the transverse colon to the sigmoid area
- What are you left with: primary anastomoses from the transverse colon to the sigmoid colon
Panproctocolectomy - total colon & rectum e.g. UC
- Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC
- Process: remove full colon & rectum (from ileocaecal valve to the anus)
- What are you left with: end ileostomy (loose end of ileum brought to the skin)
Total colectomy vs subtotal colectomy
- Total colectomy:
- Process: remove full colon but not the rectum
- What are you left with: ileal-pouch anal anastomosis (loose end of ileum used to reform a rectum, don’t need a stoma)
- Subtotal colectomy:
- Process: remove colon except for the rectum and part of the sigmoid colon
- What are you left with: end-ileostomy & rectal/sigmoid stump
Hartmann procedure - emergency sigmoid colon
- Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don’t want to create anastomoses as unlikely to succeed)
- Process: sigmoidectomy
- What are you left with: end-colostomy and rectal stump –> at a future date can be reversed but many just stay with end-colostomy
Anterior vs AP resection - for rectal tumours (A higher; P lower)
- Anterior:
- Indication: higher rectal tumours
- Process: removing sigmoid colon + top part of the rectum
- What are you left with: end-colostomy/primary anastomoses ± defunctioning loop ileostomy
- DLI - loop of ileum brought to surface, split so 2 lumens on surface –> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing
- NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains)
- AP (abdominoperineal):
- Indication: low-lying rectal tumours
- What are you left with: end-colostomy
- Process: remove everything up to the top of the sigmoid colon
Colostomy (ileal conduit)
- Indications:
- Bladder cancer (had cystectomy)
- Neurogenic bladder
Radiation injury to the bladder - Chronic pelvic pain
- Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch
