Gastrointestinal Flashcards

Question

What are the newer therapies being used in constipation management

Answer 1

Typically offered in ongoing contipation despite use of two conventional laxatives from two different classes for at least 6 months Prokinetics (e.g. Prucalopride): -Prucalopride is commonly used that works as a selective serotonin 5-HT4 receptor agonist. -It simulates mass colonic movement and has an action on other areas of the gastrointestinal tract. -It is contraindicated in colonic obstruction and should be used with caution in patients with ischaemic heart disease. Secretagogues (e.g. Linaclotide, Lubiprostone): -work by increasing intestinal chloride secretion that is associated with increased water secretion into the bowel lumen. -Linaclotide activates the secretion of chloride through guanylcyclase C which activates CFTR chloride channels. -Lubiprostone is derived from prostaglandin E1 and directly activates chloride channels and CFTR. -Lubiprostone has been withdrawn in the UK market. Opioid-antagonists (e.g. Naloxegol): -Naloxegol is a peripherally acting opioid receptor antagonist. -It decreases the constipating effects of opioids without altering their central analgesic effects.

Answer 2

Typical regimen of high-dose macrogol which is an osmotic laxative If there has been an inadequate response then macrogol can be combined with suppositories or enemas After a few days of an osmotic laxative, or if stools are soft, a stimulant laxative can be used (avoid if stools are hard)

Answer 3

A treatment for patients with constipation related to disordered defecation or those with faecal incontinence. It involves providing the patient with coaching and visual cues to help assist them with isolating and coordinating the pelvic floor muscles during defecation. Anorectal biofeedback is run by experienced bowel nurse specialists and can be completed with or without the use of anorectal physiology. It essentially helps patients to strengthen or relax the pelvic floor muscles during defecation.

Answer 4

Rarely needed In severe cases, surgical intervention may be offered (eg. subtotal colectomy, segmental colectomy, STARR procedure) Mechanism behind contipation is important to determine to decide appropriate surgical intervention Need to exclude gastrointestinal dysmotility that responds poorly to surgery.

Answer 5

The passage of loose/ watery stool at least 3 times per 24hrs

Answer 6

Classification based on duration: -Acute: <2 weeks -Sub-acute: 2-4 weeks -Chronic: >4 weeks Classification based on etiology: mainly for acute -Community acquired -Hospital-acquired

Answer 7

GI: -Infection -- gastroenteritis -- tropical infections -Inflammation -- IBD -- diverticulitis -Coeliac disease -Lactose intolerance -Colorectal carcinoma -IBS -Overflow Endocrine: -Thyroxicosis -Addison's Drugs: -Antibiotics -PPIs -Metformin -Laxatives -Digoxin -Propanolol -Alcohol

Answer 8

Extent of investigations depends on symptoms severity, chronicity, and red flags Bloods: -FBC -U and Es -LFTs -TFTs -Calcium -Inflammatory markers -Coeliac serology -Faecal calprotectin Stool: -MC+S -C.diff toxin -Ova and parasites -Faecal elastase (chronic pancreatitis) -Gut hormones (gastronome, VIPoma) Breath: -13C breath test (H.pylori) -Hydrogen breath test (lactose intolerance) Endoscopy

Answer 9

Usually spontaneously resolves Manage underlying causes Oral rehydration solution or IV fluids if severe dehydration Consider loperamide

Answer 10

u-opioid receptor agonist in the myenteric plexus, reducing smooth muscle tone Doesn't cross blood brain barrier so no CNS effects Indications: -Watery diarrhoea that interferes with daily function -IBS -Traveller's diarrhoea

Answer 11

A sudden or chronic decrease in the intake of sufficient nutrition to support the body's requirements for growth, healing and maintenance of life Estimated that over 30% of patients admitted to hospital will experience a form of malnutrition

Answer 12

A brief period of inadequate nutrition that is most commonly in relation to an acute illness with a high inflammatory state and results in muscle wasting and rapid weight loss

Answer 13

Inadequate nutrition that lasts longer than 3 months Often secodnary to social, behavioural and economic factors in addition to illness related causes

Answer 14

Malnutrition Univeral Screening Tool (MUST) Malnutrition Screening Tool (MST) Mini-nutrtion Assessment (MNA)

Answer 15

As metabolic demand increase due to illness, injury or stressors such as exercise, people adapt their nutritional intake to meet the body's requirements. In settings of chronic disease and certain drugs, this normal course of adaptation because difficult and can lead to acute or chronic malnutrition Three main reasons people may become malnourished: -Inadequate amounts of nutrients (e.g. poor variety in diet) -Difficulty absorbing nutrients (e.g. gastrointestinal dysfunction such as coeliac disease) -Increased nutritional demands (e.g. post-surgery for healing)

Answer 16

Highest risk: -those with chronic illnesses -the elderly -those living in supported accommodation -patients drinking excessive amounts of alcohol over a prolonged period. Other risk factors for malnutrition include: -Being hospitalised for extended periods of time -Problems with dentition, taste or smell -Polypharmacy -Social isolation and loneliness -Mental health issues including grief, anxiety and depression -Cognitive issues including confusion

Answer 17

-High susceptibility or long durations of infections -Slow or poor wound healing -Altered vital signs including bradycardia, hypotension, and hypothermia -Depleted subcutaneous fat stores -Low skeletal muscle mass In children, other indicators are: -Wasting: low weight for height -Stunting: low height for age -Underweight: low weight for age

Answer 18

Hypoalbuminaemia occurs in conditions where there is an excessive amount of protein being lost or where the production of albumin is impaired Can also occur in the context of inflammatory states such as infections Serum albumin should not be relied on in isolation to assess a patient's nutritional state as there are a wide variety of factors which influence levels

Answer 19

Weight history: -current weight -recent changes to weight -changes to fit of clothes Meal history: -regularity of meals including skipping meals Protein intake: -intake of high-quality protein Hydration: -intake of fluids

Answer 20

Weight: -unexpected weight loss from someone’s normal weight is indicative of a period of malnutrition. -This includes people who are clinically overweight and obese. Body mass index (BMI): -a patient’s BMI indicates whether they might be malnourished. -It is not however as accurate as history and clinical examination, and should never be used in isolation. Review of muscle mass stores Review of subcutaneous fat stores Consideration could also be given to measuring: -a patient’s grip strength -triceps skin fold thickness -mid-arm muscle circumference

Answer 21

Consideration of patients goals of care, prognosis and social factors Dietician involvement Treat reversible causes (eg infection or inflammatory state) Oral nutrition used as long as possible with use of oralnutritional support such as high-energy-high-protein supplements and fortified food products Minor changes to diet can have significant positive impact on patient's nutritional status If unable to safely swallow or unable to take sufficient calories orally, NG feeding should be considered. For long term feeding, a gastrostomy (PEG or RIG) or jejunostomy should be considered Parenteral nutrtion should be reserved for patients with intestinal failure or inaccessible givestive tracts

Answer 22

A condition caused by rapid re-introduction of normal nutrition in patients who are chronically malnourished In chronic malnutrition, a patient's intracellular stores of key electrolytes become depleted. If a patient then is suddenly provided with normal levels of nutrition, there is a sudden shift of these electrolytes from the extracellular to the intracellular compartment driven by a large insulin response and other factors. Can ultimately lead to a sudden drop in extracellular levels of key electrolytes resulting in hypokalaemia and hypophosphataemia This can subsequently lead to cardiac complications (eg arrhythmias)and seizures

Answer 23

Nutrition is re-introduced more gradually under the guidance of a dietician and the patients electrolytes are monitored closely, allowing deficiencies to be identified early and replaced appropriately

Answer 24

Impaired immunity (increased risk of infections) Poor wound healing Growth restriction in children Unintentional weight loss, specifically the loss of muscle mass Multi-organ failure Death

Answer 25

Gastro-oesophageal reflux disease Where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus The oesophagis has a squamous epithelial lining making it more sensitive to the effects of stomach acid compared to the stomach which has columnar epithelial lining, which is more protected against stomach acid

Answer 26

Dyspepsia Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice

Answer 27

Dysphagia (difficulty swallowing) at any age gets a two week wait referral Aged over 55 (this is generally the cut off for urgent versus routine referrals) Weight loss Upper abdominal pain / reflux Treatment resistant dyspepsia Nausea and vomiting Low haemoglobin Raised platelet count

Answer 28

Lifestyle advice -Reduce tea, coffee and alcohol -Weight loss -Avoid smoking -Smaller, lighter meals -Avoid heavy meals before bed time -Stay upright after meals rather than lying flat Acid neutralising medication when required: -Gaviscon -Rennie Proton pump inhibitors (reduce acid secretion in the stomach) -Omeprazole -Lansoprazole Ranitidine -This is an alternative to PPIs -H2 receptor antagonist (antihistamine) -Reduces stomach acid Surgery -laparoscopic fundoplication. -involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Answer 29

H. pylori is a gram negative aerobic bacteria. It lives in the stomach. It causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer. It avoids the acidic environment by forcing its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid. It also produces ammonia to neutralise the stomach acid. The ammonia directly damages the epithelial cells. Other chemicals produced by the bacteria also damage the epithelial lining.

Answer 30

Offer a test for H. pylori to anyone with dyspepsia. They need 2 weeks without using a PPI before testing for H. pylori for an accurate result. Tests -Urea breath test using radiolabelled carbon 13 -Stool antigen test -Rapid urease test can be performed during endoscopy. -- A rapid urease test is also known as a CLO test (Campylobacter-like organism test). -- It is performed during endoscopy and involves taking a small biopsy of the stomach mucosa. -- Urea is added to this sample. -- If H. pylori are present, they produce urease enzymes that converts the urea to ammonia. -- The ammonia makes the solution more alkali giving a positive result on when the pH is tested.

Answer 31

The eradication regime involves triple therapy with a proton pump inhibitor (e.g. omeprazole) plus 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days. The urea breath test can be used as a test of eradication after treatment. This is not routinely necessary.

Answer 32

Constant reflux of acid results in the lower oesophageal epithelium changing in a process known as metaplasia from a squamous to a columnar epithelium. This change to columnar epithelium is called Barretts oesophagus. When this change happens patients typically get an improvement in reflux symptoms. Barretts oesophagus is considered a “premalignant” condition and is a risk factor for the development of adenocarcinoma of the oesophagus (3-5% lifetime risk with Barretts). Patients identified as having Barretts oesophagus are monitored for adenocarcinoma by regular endoscopy. In some patients there is a progression from Barretts oesophagus (columnar epithelium) with no dysplasia to low grade dysplasia to high grade dysplasia and then to adenocarcinoma. Treatment of Barretts oesophagus is with proton pump inhibitors (e.g. omeprazole) Ablation treatment during endoscopy using photodynamic therapy, laser therapy or cryotherapy is used to destroy the epithelium so that it is replaced with normal cells. This is not recommended in patients with no dysplasia but has a role in low and high grade dysplasia in preventing progression to cancer.

Answer 33

Squamous cell carcinoma (SCC): usually located in the upper or middle oesophagus. Accounts for >90% of cases worldwide. Adenocarcinoma (AC): usually located in the lower oesophagus. Due to chronic reflux and development of a columnar metaplasia, which is a precursor lesion known as Barrett’s oesophagus. Rarer forms of oesophageal cancers include small cell carcinoma, sarcoma, lymphoma, melanoma and choriocarcinoma.

Answer 34

Two major risk factors: -smoking -alcohol Oesophageal neoplasia develops due to sequential mutations that occur in the oesophageal epithelium, which allows cells to proliferate uncontrollably. Several risk factors for both SCC and AC increase the likelihood of developing these mutations.

Answer 35

Smoking Alcohol consumption Foods containing N-nitroso compounds Chewing of areca nuts Previous partial gastrectomy Atrophic gastritis Human papillomavirus (HPV): mainly genotypes 16 and 18 Tylosis: rare condition leading to hyperkeratosis of hands and feet

Answer 36

Chronic reflux Barrett’s oesophagus: 30-fold increase risk of AC Smoking Obesity Zollinger-Ellison syndrome: gastrin-secreting tumour leading to excess hydrochloric acid.

Answer 37

Squamous cell carcinoma -Due to chronic alcohol consumption and smoking, which damage cellular DNA. -Leads to development of genetic mutations that promote abnormal cell growth. -Overtime, the cells proliferate uncontrollably leading to invasive cancer. -SCC may be seen as an infiltrating and ulcerated mass in the middle oesophagus, especially if advanced. -There is early invasion into surrounding lymph nodes and the tumour may metastasize to liver, bone and lung. Adenocarcinoma -Typically, chronic reflux leads to inflammation and damage of the lower oesophageal mucosa. -This results in columnar metaplasia, which refers to the transformation of the mature squamous cell type to columnar cell type. -This metaplastic epithelium may become dysplastic, which refers to cells with abnormal growth and development. -The dysplastic epithelium acquires further genetic mutation that promotes development of invasive carcinoma. -Most commonly located near the gastro-oesophageal junction and there is usually early lymph node involvement.

Answer 38

The hallmark feature of oesophageal cancer is dysphagia, which refers to difficulty swallowing. Symptoms -Constitutional symptoms: fevers, anorexia, lethargy, weight loss -Dysphagia: difficulty swallowing -Weight loss: due to tumour-related anorexia and poor nutrition from swallowing difficulties -Bleeding: haematemesis and melaena -Pain: typically retrosternal pain -Aspiration: cough, shortness of breath, fever -Hoarseness: if there is extension to involve the recurrent laryngeal nerve Signs -Lymphadenopathy: if local tumour spread -Cachexia -Pallor: due to anaemia -Hepatomegaly: if metastatic spread

Answer 39

Urgent (two week wait) referral -This means referring a patient for appropriate investigations (e.g. gastroscopy) for suspected oesophageal cancer within two weeks. -It is usually combined with a clinic appointment and CT imaging. -Dysphagia, OR -> 55 years with weight loss and one of the following: -- Upper abdominal pain -- Reflux -- Dyspepsia Non-urgent referral -This means referral for a non-urgent gastroscopy to assess for oesophageal pathology. -Usually performed within 6 weeks. -Haematemesis, OR -> 55 years with treatment resistant dyspepsia, OR -> 55 years with upper abdominal pain and anaemia, OR -Thrombocytosis with one of the following: -- Nausea/vomiting -- Weight loss -- Reflux -- Dyspepsia --Upper abdominal pain -Nausea/vomiting with one of the following: -- Weight loss -- Reflux -- Dyspepsia -- Upper abdominal pain

Answer 40

Using upper GI endoscopy and biopsy of suspected lesions Gastroscopy: -camera test that allows direct visualisation of the upper GI tract -biopsies taken at the time and are sent for histological analysis for signs of malignancy

Answer 41

Gastroscopy and biopsy Further investigations for assessment of distant spread anf key-organ function to help guide management: -Bloods: -- Full blood count -- Serum iron, transferrin saturation, total iron binding capacity (TIBC) -- Urea & electrolytes -- Liver function tests -- Bone profile -- Clotting screen -- Renal function -Imaging: -- CT CAP (for staging) -- Abdominal ultrasound (liver mets) -- PET-CT (for potential surgical candidates to assess distant disease not detected by convential CT) Diagnostic laparoscopy (may be used to more accurately stage if it will alter management) Endoscopic ultrasound (staging if will change management)

Answer 42

Cancer stage is based on tumour size, presence of lymph node involvement and distant spread. We call these three factors ‘TNM’ (tumour, nodes, metastasis). Tumour TX: Primary tumour cannot be assessed T0: No evidence of primary tumour Tis: Carcinoma in situ/high-grade dysplasia T1: Tumour invades lamina propria or submucosa T1a: Tumour invades mucosa or lamina propria or muscularis mucosae T1b: Tumour invades submucosa T2: Tumour invades muscularis propria T3: Tumour invades adventitia T4: Tumour invades adjacent structures T4a: Tumour invades pleura, pericardium, diaphragm or adjacent peritoneum T4b: Tumour invades other adjacent structures such as aorta, vertebral body or trachea Node NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in 1–2 regional lymph nodes N2: Metastasis in 3–6 regional lymph nodes N3: Metastasis in 7 or more regional lymph nodes Metastasis MX: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis NOTE: Non-regional lymph node spread is considered M1a disease.

Answer 43

Depends on extent of cancer and pts fitness Surgery: (treatment of choice where possible) resection of oesophageal or gastro-oesophageal tumours (e.g. oesophagectomy). Endoscopic techniques: mucosal resection or submucosal dissection. Radiotherapy: use of high energy rays to destroy cancer cells. Chemotherapy: use of anti-cancer medications to destroy cancer cells. Targeted cancer drugs: monoclonal antibodies against certain receptors (e.g. HER2). Palliative care: use of chemotherapy/radiotherapy or stenting to control disease and/or symptoms without aiming to cure. Best supportive care: focus primarily on symptoms and quality of life without systemic treatments. The choice of treatment depends on whether the cancer is limited, locally advanced or advanced/metastatic. -Limited: (Staging: T1-2, N0, M0) refers to small tumours without lymph node involvement or distant spread -Locally advanced: (Staging: T3-4 or N1-2, M0) refers to larger tumours with/without lymph node involvement but without distant spread -Advanced/metastatic: refers to metastatic disease with spread to distant sites

Answer 44

Palliative treatment should be considered in patients with locally advanced disease who are not operative candidates or not fit enough to undergo radical treatment (e.g. poor performance status, extensive co-morbidities). Options include: -Radiotherapy: if tumour lies within a radiotherapy field that allows high-doses to be applied. -Chemotherapy: regimens depend on fitness of the patient. -Local tumour treatment: endoscopic stenting, palliative radiotherapy. -Best supportive care: focusing on symptom control only.

Answer 45

Involves endoscopically placing a stent within the oesophagus to keep the lumen open and prevent dysphagia.

Answer 46

This describes a patients' level of functioning in terms of their ability to care for themselves, what they can do as part of their daily activities and their physical ability. Performance status can be measures using the World Health Organisation (WHO) / Eastern Cooperative Oncology Group (ECOG) scale. Grade 0: Fully active, able to carry out all normal activities. Grade 1: Restricted physical activity but ambulatory and able to carry out light sedentary work (e.g. office work). Grade 2: Ambulatory and capable of all self care but unable to carry out any work activities. Out of bed >50% of day. Grade 3: Capable of only limited self-care, confined to bed or chair > 50% of waking hours. Grade 4: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair. Grade 5: Death.

Answer 47

The five year survival of oesophageal cancer is poor at ~16% Early diagnosis and treatment is potentially curative, especially if the disease is resectable. However, oesophagectomy is a major operation with significant morbidity and mortality.

Answer 48

Hernias occur when there is a weak point in a cavity wall, usually affecting the muscle or fascia This weakness allows a body organ that would normally be contained within that cavity to pass through the cavity wall

Answer 49

There are many types of hernias that present differently depending on where they are and what organs are involved. The typical features of an abdominal wall hernia are: -A soft lump protruding from the abdominal wall -The lump may be reducible (it can be pushed back into the normal place) -The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity) -Aching, pulling or dragging sensation

Answer 50

There are three key complications of hernias: -Incarceration -Obstruction -Strangulation Incarceration: -The hernia cannot be reduced back into the proper position (it is irreducible). -The bowel is trapped in the herniated position. -Incarceration can lead to obstruction and strangulation of the hernia. Obstruction: -The hernia causes a blockage in the passage of faeces through the bowel. -Presents with vomiting, generalised abdominal pain and absolute constipation (not passing faeces or flatus). Strangulation -The hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia. -Presents with significant pain and tenderness at the hernia site. -A surgical emergency. -The bowel will die quickly (within hours) if not corrected with surgery. -There will also be a mechanical obstruction when this occurs.

Answer 51

A very specific situation that can occur in any abdominal hernia. Where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. Can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

Answer 52

A specific situation where two different loops of bowel are contained within the hernia.

Answer 53

Conservative management: -Leave the hernia alone. -Most appropriate when the hernia has a wide neck (low risk of complications) and in patients that are not good candidates for surgery due to co-morbidities. Tension-free repair: -Placing a mesh over the defect in the abdominal wall. -The mesh is sutured to the muscles and tissues on either side of the defect, covering it and preventing herniation of the cavity contents. -Over time, tissues grow into the mesh and provide extra support. -This has a lower recurrence rate compared with tension repair, but there may be complications associated with the mesh (e.g., chronic pain). Tension repair: -A surgical operation to suture the muscles and tissue on either side of the defect back together. -Rarely performed and have been largely replaced by tension-free repairs. -The hernia is held closed (to heal there) by sutures applying tension. -This can cause pain and there is a relatively high recurrence rate of the hernia.

Answer 54

Inguinal hernias present with a soft lump in the inguinal region (in the groin). There are two types: Indirect inguinal hernia Direct inguinal hernia

Answer 55

Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended / ectopic testes Kidney transplant

Answer 56

Where the bowel herniates through the inguinal canal. (The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).) In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum. In females, the round ligament is attaches to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora. During fetal development, the processus vaginalis is a pouch of peritoneum that extends from the abdominal cavity through the inguinal canal. This allows the testes to descend from the abdominal cavity, through the inguinal canal and into the scrotum. Normally, after the testes descend through the inguinal canal, the deep inguinal ring closes and the processus vaginalis is obliterated. However, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia. There is a specific finding of indirect inguinal hernias that help you differentiate them from a direct inguinal hernias. When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

Answer 57

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. The hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle (not along a canal or tract like an indirect inguinal hernia). Pressure over the deep inguinal ring will not stop the herniation. Hesselbach’s triangle boundaries (RIP mnemonic): R – Rectus abdominis muscle – medial border I – Inferior epigastric vessels – superior / lateral border P – Poupart’s ligament (inguinal ligament) – inferior border

Answer 58

Involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh. The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of: -Incarceration -Obstruction -Strangulation Boundaries of the femoral canal (FLIP mnemonic): F – Femoral vein laterally L – Lacunar ligament medially I – Inguinal ligament anteriorly P – Pectineal ligament posteriorly Don’t get the femoral canal confused with the femoral triangle. The femoral triangle is a larger area at the top of the thigh that contains the femoral canal. You can remember the boundaries with the SAIL mnemonic: S – Sartorius – lateral border A – Adductor longus – medial border IL – Inguinal Ligament – superior border Use the NAVY-C mnemonic to remember the contents of the femoral triangle from lateral to medial across the top of the thigh: N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes)

Answer 59

Occur at the site of an incision from previous surgery. They are due to weakness where the muscles and tissues were closed after a surgical incision. The bigger the incision, the higher the risk of a hernia forming. Medical co-morbidities put patients at higher risk due to poor healing. Incisional hernias can be difficult to repair, with a high rate of recurrence. They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

Answer 60

Occur around the umbilicus due to a defect in the muscle around the umbilicus. Umbilical hernias are common in neonates and can resolve spontaneously. They can also occur in older adults.

Answer 61

Simply a hernia in the epigastric region (upper abdo)

Answer 62

Occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain. There may not be a noticeable lump. An ultrasound scan can help establish the diagnosis. Spigelian hernias generally have a narrower base, increasing the risk of incarceration, obstruction and strangulation.

Answer 63

May also be called rectus diastasis and recti divarication. It refers to a widening of the linea alba, the connective tissue that separates the rectus abdominis muscle, forming a larger gap between the rectus muscles. It is not technically a hernia. This gap becomes most prominent when the patient lies on their back and lifts their head. There is a protruding bulge along the middle of the abdomen. The linea alba is the aponeurosis of the two sides of the rectus abdominis muscle. The gap is created because the linea alba is stretched and broad. This can be congenital (in newborns) or due to weakness in the connective tissue, for example following pregnancy or in obese patients. No treatment is required in most cases, but surgical repair is possible.

Answer 64

Where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis. They occur due to a defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries. They are often asymptomatic but may present with irritation to the obturator nerve, causing pain in the groin or medial thigh. Howship–Romberg sign refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve. It can also present with complications of: -Incarceration -Obstruction -Strangulation CT or MRI of the pelvis can establish the diagnosis. It may be found incidentally during pelvic surgery.

Answer 65

Refers to the herniation of the stomach up through the diaphragm. The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place. A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.

Answer 66

Type 1: Sliding - the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax. Type 2: Rolling - a separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus Type 3: Combination of sliding and rolling Type 4: Large opening with additional abdominal organs entering the thorax

Answer 67

Increasing age Obesity Pregnancy

Answer 68

Dyspepsia (indigestion), with symptoms of: -Heartburn -Acid reflux -Reflux of food -Burping -Bloating -Halitosis (bad breath)

Answer 69

Can be intermittent, meaning they may not be seen on investigations. May be seen on: -Chest x-rays -CT scans -Endoscopy -Barium swallow testing

Answer 70

Conservative (with medical treatment of gastro-oesophageal reflux) Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment. Involves laparoscopic fundoplication. Involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Answer 71

Ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer)

Answer 72

Stomach mucosa is prone to ulceration from: -Breakdown of the protective layer of the stomach and duodenum -Increase in stomach acid The protective layer in the stomach is comprised of mucus and bicarbonate secreted by the stomach mucosa The protective layer can be broken down by: -Medications (eg steroids or NSAIDs) -H. pylori Increased acid can result from: -stress -alcohol -caffeine -smoking -spicy foods

Answer 73

Epigastric discomfort or pain Nausea and vomiting Dyspepsia Bleeding causing haemateemsis, coffee ground vomit and melaena Iron deficiency anaemia (due to constant bleeding Eating typically worsens the pain of gastric ulcers and improve the pain of duodenal ulcers

Answer 74

Diagnosed by endoscopy During endoscopy a rapid ureas test (CLO test) can be performed to check for h. pylori Biopsy should be considered during endoscopy to exclude malignancy as cancers can look similar to ulcers during the procedure Medical treatment is the same as with GORD with high dose PPI Endoscopy can be used to monitor the ulcer to ensure it heals and to assess for further ulcers

Answer 75

Bleeding fromt the ulcer is a common and potentially life threatening complication Perforation resulting in an acute abdomen and peritonitis which requires urgent surgical repair (usually laparoscopic) Scarring and strictures of the muscle and mucosa which can lead to narrowing of the pyloris causing difficulty emptying stomach contents. This is Pyloric stenosis.

Answer 76

Exit of the stomach

Answer 77

Upper abdominal pain Distension Nausea and vomiting, particularly after eating

Answer 78

An autoimmune condition where the exposure to gluten causes an autoimmune reaction that causes inflammation in the small bowel

Answer 79

Auto-antibodies are created in response to exposure to gluten These auto-antibodies target the epithelial cells of the intestine and lead to inflammation The key auto-antibodies involved are: -anti-tissue transglutaminase (anti-TTG) -anti-endomysial (anti-EMA) -deaminated gliadin peptides antibodies (anti-DGPs) These antibodies relate to disease activity and will rise with more active disease and may disappear with effective treatment Inflammation affects the small bowel, particularly the jejunum. It causes atrophy of the intestinal villi The intestinal cells have villi on them that help with absorbing nutrients from food passing through the intestine Inflammation causes malabsorption of nutrients and symptoms of the disease

Answer 80

Often asymptomatic Failure to thrive in young children Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia secondary to iron, B12 or folate deficiency Dermatitis herpetiformis (an itchy blistering skin rash typically on the abdomen) Rarely coeliac disease can present with neurological symptoms: -peripheral neuropathy -cerebral ataxia -epilepsy

Answer 81

HLA-DQ2 gene (90%) HLA-DQ8 gene

Answer 82

Investigations must be carried out whilst the patient remains on a diet containing gluten otherwise it may not be possible to detect antibodies or inflammation in the bowel Check total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies (which are IgA and if totally deficient then may give a false coeliac result): -Raised anti-TTG antibodies -Raised anti-endomysial antibodies Endoscopy and intestinal biopsy show: -crypt hypertrophy -villious atrophy

Answer 83

Other autoimmune conditions: -Type 1 diabetes -Thyroid disease -Autoimmune hepatitis -Primary biliary cirrhosis -Primary sclerosing cholangitis

Answer 84

Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis Enteropathy associated T cell lymphoma (EATL) of the intestine Non-hodgkin lymphoma Small bowel adenocarcinoma (rare)

Answer 85

Lifelong gluten free diet is essentially curative Relapse will occur on consuming gluten again Checking coeliac antibodies can be helpful in monitoring the disease

Answer 86

Small stones that form within the gallbladder They form from concentrated bile in the bile duct and most of them are made of cholesterol They may be asymptomatic or can cause pain and lead to complications such as acute cholecystitis, acute cholangitis and pancreatitis (when gallstones block the drainage of the pancreas)

Answer 87

Blockage to the flow of bile

Answer 88

Gallstones are present

Answer 89

Gallstones in the bile duct

Answer 90

Intermittent right upper quadrant pain caused by gallstones irritating bile ducts by temporarily obstracting drainage of the gallbladder They may get lodged at the neck of the gallbladder or in the cystic duct, then when they fall back into the gallbladder the symptoms resolve Symptoms are: -severe, colicky epigastric or RUQ pain -Often triggered by meals (particularly high fat) -Last between 30 mins to 8 hrs -May be associated with nausea and vomiting

Answer 91

Inflammation of the gallbladder

Answer 92

Inflammation of the bile ducts

Answer 93

Infected tissue and pus collecting in the gallbladder Management involves IV antibiotics and one of two main options: -cholecystectomy (to remove the gallbladder) -cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

Answer 94

Surgical removal of the gallbladder Indicated in symptomatic patients or in those where gallstones are leading to complications Stones in the bile ducts can be removed before by ERCP or during surgery Laparoscopic is preferred to open (right subcostal Kocher incision) as it as fewer complications and a faster recover

Answer 95

Insertion a drain into the gallbladder

Answer 96

Fat, Fair, Female, Forty

Answer 97

May be asymptomatic Typical symptoms of biliary colic Alternatively may present with complication of gallstones: -acute cholecystitis -acute cholangitis -obstructive jaundice (if the stone blocks the ducts) -pancreatitis

Answer 98

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder which leads to biliary colic. Therefore, those with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction

Answer 99

Bilirubin normally drains from the liver, through the bile ducts and into the intestines Raised bilirubin, jaundice with pale stools and dark urine represents an obstruction to flow within the biliary system Obstruction may be caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (eg cholangiocarcinoma or tumour of the head of the pancreas

Answer 100

Aka ALP or Alk Phos A non-specific marker It is an enzyme originating in the liver, bilary system and bone. Abnormal results can indicate liver or bone problems It is often raised in pregnancy due to production by the placenta A raised ALP is consistent with biliary obstruction in the presence of right upper quadrant pain and/or jaundice Can also be raised by: -liver or bone malignancy -primary biliary cirrhosis -Paget's disease of the bone -etc

Answer 101

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are enzymes produced in the liver A helpful marker of hepatocellular injury (damage to liver cells) In patients with cholestasis (eg due to gallstones), ALT and AST can increase slightly with a higher rise in ALP (an obstructive picture) IF ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (a hepatitic picture)

Answer 102

First line investigation for symptoms of gallstone disease Most sensitive imagine for gallstones Limited by the patient's weight, gaseous bowel obstructing the view and discomfort from the probe Findings: -Gallstones in the gallbladder -Gallstones in the ducts -Bile duct dilatation (normally less than 6mm diameter) -Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder) -The pancrease and pancreatic duct

Answer 103

An MRI scan with a specific protocol that produces a detailed image of the biliary system It is very sensitive and specific for biliary tree disease such as tones in the bile duct and malignancy MRCP is used in many pictures eg identifying biliary strictures or congenital abnormalities Used for further investigation in gallbladder disease if the ultrasound scan does not show stones in the duct but there is bile duct dilatation or raised bilirubin, suggestive of obstruction

Answer 104

Involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the spincter of Oddi), giving access to the biliary system Main indication for ERCP is to clear stones in the bile ducts ERCP allows the operator to: -Inject contrast and take x rays to visualise the biliary system and diagnose pathology (eg stones or strictures) -Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) -Clear stones from the ducts -Insert stents to improve bile duct drainage (eg with strictures or tumours) -Take bipsies of tumours

Answer 105

Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

Answer 106

Asymptomativ patients treated conservatively with no required intervention Symptomatic patients or those with complications are treated with cholecystectomy, which is surgical removal of the gallbladder (dependent on fitness for surgery)

Answer 107

A group of non-specific symptoms that can occur after cholecystectomy May be due to changes in the bile flow after removal of gallbladder Will improve with time Symptoms: -Diarrhoea -Indigestion -Epigastric or RUQ pain or discomfort -Nausea -Intolerance of fatty foods -Flatulence

Answer 108

Bleeding Infection Pain Scars Damage to bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks VTE Post-cholecystectomy syndrome

Answer 109

Infammation of the gallbladder caused by a blockage of the cystic duct preventing the gallbladder from draining Key complication of gallstones (95% of cases caused by gallstones) Gallstones may be trapped in the neck of the gallbladder or in the cystic duct Can be caused by other things (rare) eg patients on TPN or long periods of fasting where gallbladder is not being stimulated by food to regularly empty leading to build up of pressure

Answer 110

RUQ pain Radiation to right shoulder Fever Nausea and vomiting Tachycardia Tachypnoea RUQ tenderness Murphy's sign positive Raised inflammatory markers and white blood cells

Answer 111

Place a hand in RUQ and apply pressure Ask patient to take a deep breath in The gallbladder will move downwards during inspiration and come in contact with your hand Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Answer 112

First line: -Abdominal ultrasound showing: -- Thickened gallbladder wall -- Stones or sludge in gallbladder -- Fluid around the gallbladder MRCP: -May be used to visualise the biliary tree in more detial if a common bile duct stone is suspected but not seen on ultrasound scan (eg bile duct dilatation or raised bilirubin)

Answer 113

Emergency admission for investigations and management Conservative: -Nil by mouth -IV fluids -Antibiotics (as per local guidelines) -NG tube if required for vomiting ERCP can be used to remove stones trapped in common bile duct Cholecystectomy (removal of gallbladder) is usually performed during acute admission (within 72 hours of symptoms). In some cases it may be delayed 6-8 weeks after the acute episode to allow the inflammation to settle

Answer 114

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Gastrointestinal Flashcards

(139 cards)