Gastrointestinal 💩 Flashcards

Question

What are the signs of PUD?

Answer 1

- Epigastric tenderness to palpation - Signs of hypovolaemia

Answer 2

(worse eating = gastric; relieved eating = duodenal)

Answer 3

OGD- used for definitive diagnosis 2 week wait referral if age>55 with weight loss and any dyspepsia, reflux, or upper abdominal pain.

Answer 4

H. Pylori positive AND NSAID use: * Stop NSAID * PPI x 2 months, then triple h. pylori therapy after PPI completion H. Pylori positive and no NSAID use: * H. pylori eradication therapy H. Pylori negative: * PPI 4-8 weeks Repeat OGD to confirm healing 6-8 weeks after starting therapy. If Haemorrhaging * Medical emergency * Endoscopic clipping * IV PPI * Discontinue NSAIDs LAPAROTOMY DEFINITIVE TX

Answer 5

Inflammation of the oesophagus.

Answer 6

* eating right before bed * excessive caffeine, alcohol, chocolate. * greasy/ spicey food * smoking * obesity * hiatus hernia * certain medications

Answer 7

- Epigastric/ chest pain (burning) - Acidic/ sour taste - Dysphagia - Odynophagia - Hoarseness - Persistent cough

Answer 8

* epigastric tenderness

Answer 9

Age >+55 with weight loss and any of the following: * Upper abdominal pain * Reflux * Dyspepsia Dysphagia Loss of appetite

Answer 10

* Barret’s oseophagus * Oesophageal cancer * Strictures

Answer 11

OGD with oesophageal biopsies: - Reveals inflamed oesophageal tissue and mucosal erosions. Biopsies to check for increased eosinophils and cellular changes.

Answer 12

* Avoid greasy, spicey, citrus, chocolate, peppermint, caffeine, alcohol, smoking. * Weight loss * PPI

Answer 13

* Refer to allergist, avoid food allergies. * Daily PPI * Topical steroids: fluticasone MDI without spacer (spray into mouth then swallow)

Answer 14

* Stop offending medication and offer alternative. * Remain upright 30 mins after consuming. * Liquid version

Answer 15

Tear/ laceration near gastro-oesophageal junction.

Answer 16

-Excessive alcohol -Vomiting (gastroenteritis, hyperemesis gravidarum, bulimia, migraine) -Coughing -Blunt abdominal trauma -Iatrogenic (NG tube placement, OGD)

Answer 17

- History of predisposing condition (vomiting) - Haematemesis - Epigastric/ back pain - Light headedness - Odynophagia - Dysphagia - Melaena

Answer 18

- No specific findings - Signs of hypovolaemia (tachycardia, hypotension)

Answer 19

* OGD * CXR (pneumomediastinum) * FBC- to assess for significant loss of blood. * LFTs, PT/INR, PTT to assess for bleeding risk

Answer 20

Control bleeding * Endoscopy with haem clip placement/ band ligation and / or epinephrine injection. IV access * Fluid replacement, blood transfusion if necessary IV PPI bolus, then oral x 4-8 weeks Antiemetic: * Metoclopramide * Prochlorperazine

Answer 21

Oesophageal narrowing secondary to oesophageal wall injury and scarring.

Answer 22

* Oesophagitis * exposure to external beam radiation * post-endoscopic therapy * Oesophageal malignancy * Infections (HIV, CMV, HSV, Candida)

Answer 23

* Progressive dysphagia (if rapid, more likely malignant cause) * Odynophagia * Regurgitation * Heartburn * Chest pain * Weight loss * epigastric tenderness

Answer 24

Urgent 2 week wait OGD (dysphagia always requires urgent referral) this is to rule out cancer. Barium swallow (oesophagogram

Answer 25

* endoscopic dilation * acid suppression via PPI

Answer 26

Dilated oesophageal veins secondary to portal hypertension.

Answer 27

-previous variceal bleed -ongoing alcohol use -severe liver cirrhosis or liver failure

Answer 28

* Haematemesis * Melaena * Light headedness * Iron deficiency anaemia * Sx of liver cirrhosis such as., malasie, fatigue, weight loss, enlarged/ swollen abdomen, nose bleeds, blleding from lower limbs, jaundice, itch, hand tremors

Answer 29

* Signs of Liver Cirrhosis: jaundice, hepatosplenomegaly, palmar erythema, clubbing, ascites, gynecomastia, caput medusae etc. * Chronic portal/ splenic vein thrombosis: pancytopenia, ascites.

Answer 30

* OGD * FBC, PT/INR, LFT, U&Es (isolated elevated blood urea nitrogen (BUN) is a sign of acute UGI bleeding) * HBV/HCV serology * Liver USS

Answer 31

Cirrhosis and no varices: * 7% risk developing varices anually * Surveillance endoscopy q 2-3 years, or yearly if hepatic decompensation Varices without bleeding * Non-cardio selective beta blockers (e.g. propranolol, carvedilol) * Endoscopic variceal ligation Actively bleeding varices * Medical emergency * Control bleeding: Endoscopic variceal band ligation or vasoconstrictor pharmacotherapy (terlipressin, somatostatin) * IV volume resuscitation and blood transfusion

Answer 32

Stomach cancer that begins in the tissues lining the stomach.

Answer 33

Adenocarcinoma which originates from glandular cells of the stomach mucosal layer.

Answer 34

- Pernicious anaemia - H pylori - N-nitroso compounds (cured meats) - Diet low in fruits, vegetables - High-salt diet - smoking - Family history - Male - Blood Group A - Polyps

Answer 35

* Upper abdominal pain * Weight loss * Loss of appetite * Dysphagia * Nausea, vomiting * Melaena * Lymphadenopathy

Answer 36

* Epigastric tenderness to palpation * Lymphadenopathy (Virchow’s node, Irish node, St Mary joseph’s nodule)

Answer 37

* Surgery if localised spread * Radiation therapy after surgical resection * Chemotherapy if more advanced.

Answer 38

SCC Adenocarcinoma

Answer 39

Carcinogenic effects of alcohol and tobacco.

Answer 40

Long term GORD leading to Barret's Oesophagus

Answer 41

- Barret’s oesophagus - long-term GORD - Excessive alcohol - Smoking - male - FHx of oesophageal, gastric, oral, pharyngeal cancer - diet low in fresh fruit & veg.

Answer 42

- Dysphagia - Odynophagia - Weight loss - Appetite loss - Haematemesis - Nausea and vomiting - Dyspepsia - Hoarseness - Hiccups - Postprandial cough - Reflux - Upper abdominal pain

Answer 43

Inflammation of the peritoneum.

Answer 44

* bacterial * appendicitis * ruptured peptic ulcer * chemical irritation * spontaneous bacterial peritonitis

Answer 45

Symptoms: * Severe pain * Pain on coughing and sneezing Signs: * Patient lying very still * Guarding * Rebound tenderness. * Percussion tenderness * Low BP * tachycardic

Answer 46

* SEPSIS 6 * Labs: WCC, VBG, CRP, renal profile, LFT * Imaging: Abdo XR, USS, CT (looking for free gas - pneumoperitoneum, rigler’s sign and football sign). * Peritoneal fluid analysis: peritoneal fluid obtained by paracentesis help identify the causative organism and guide treatment.

Answer 47

- Surgical intervention: For conditions such as a perforated viscus, appendicitis, or diverticulitis, surgical intervention is often required to control the source of infection or inflammation. - Antibiotics: Empirical antibiotic - Supportive care: Fluid resuscitation, pain management, and monitoring of vital signs are crucial in the management of peritonitis.

Answer 48

Small bowel obstruction (SBO) is a mechanical disruption in the small bowel, leading to significant clinical symptoms such as bilious or feculent vomiting, abdominal pain and distension, and complete constipation.

Answer 49

Large bowel obstruction refers to a medical emergency where the intestines' normal passage of food, fluids, and gas is impeded, requiring immediate medical intervention.

Answer 50

- Adhesions - Intra-abdo hernia - Crohns - Malignancy - Foreign body - Kids: intussusception, volvulus, atresia - Appendicitis - Gallstone ilius

Answer 51

* secondary to malignancy or diverticulitis * Elderly * Colonic Tumours * Diverticular disease * Strictures * Volvulus * Hernias * Adhesions

Answer 52

* Intermittent, colicky abdominal pain. * Early onset vomiting, followed by constipation. * No passage of flatus. * Dehydration, hypovolaemia. * Abdominal distension, there may be visible peristalsis. * May not be tender on examination- tenderness occurs when blood supply compromised. * Bowel sounds may be increased - tinkling- or silent

Answer 53

* Earlier onset constipation, later onset vomiting. * Feculent vomiting due to reverse peristalsis. * Colicky abdominal pain. * Abdominal tenderness and distension. * Abdominal mass due to tumor. * Hepatomegaly- secondary to metastases. * Dehydration

Answer 54

* Abdominal XR= distended bowel loops, erect film may show air-fluid level. * Blood tests: FBC, electrolyte imbalances and suggest fluid shifts, raised lactate on VBG can suggest ischaemia. * CEA may be done later on when suspecting colorectal cancer. Abdominal X-ray: A primary tool for DIAGNOSING large bowel obstruction CT Abdomen: Essential in identifying the cause (e.g. malignancy), as well as providing more details such as the transition point and distinguishing between caecal and sigmoid volvulus. A CT abdomen is usually the best way to investigate bowel obstruction and will reveal distended bowel loops Coffee-bean-shaped mass is the result of a sigmoid volvulus, which is a twist of the bowel on its mesenteric base. The majority of patients are treated conservatively, with insertion of a flatus tube following decompression with a sigmoidoscope. Caecal volvulus is a cause of large bowel obstruction. The abdominal x-ray shows the 'embryo sign' - a large, dilated loop of colon, arising from the right lower quadrant

Answer 55

* nil by mouth * NG tube * analgesia * Abx prophylaxis * surgery if needed Metoclopramide is contraindicated in bowel obstruction as its prokinetic nature can worsen the symptoms of bowel obstruction.

Answer 56

Results from injury to the bowel wall resulting in exposure of peritoneal cavity to bowel contents.

Answer 57

- Secondary to infection - Obstruction - Trauma - Invasive procedure

Answer 58

* Clinical features of the underlying cause of the perforation. * Generalised abdominal pain- sudden or progressively worsening. * Abdominal distension. * Tenderness on examination with signs of peritonitis. * Early in presentation observations may be normal but will deteriorate and become septic.

Answer 59

* Point of Care USS- look for pneumoperitoneum; use in A & E. * Erect abdominal XR- free air under the diaphragm suggests perforation. * CT scan for diagnosing free air but also site of perforation.

Answer 60

Bowel infarction, commonly is the occlusion of the Superior Mesenteric a.

Answer 61

Arterial embolism * (due to AF, endocarditis for example) or thrombus (atherosclerosis, aortic aneurysm or dissection, reduced cardiac output, dehydration). Mesenteric venous thrombus * (hypercoagulability disorders, tumour causing venous compression, intra- abdominal infection, portal hypertension). Non-occlusive mesenteric ischaemia * hypotension, vasopressive drugs, cocaine, digitalis). Secondary to intestinal obstruction

Answer 62

* Sudden onset, moderate to severe colicky or constant generalised abdominal pain. * Pain can be vague and insidious. * Vomiting and diarrhoea (may be bloody). * Classical presentation- pain out of proportion to exam findings. * In the early stage there is minimal or no tenderness or signs of peritonitis. * Later stages- peritonism, distension, absent bowel sounds. * shock

Answer 63

* CT angiogram- GOLD standard. * US or MRI. * ECG- to confirm AF or MI. * ECHO- for cause of embolism or valvular pathology * Metabolic acidosis ABG

Answer 64

* Resuscitation- IV fluids and oxygen. * NG tube. * IV broad spectrum antibiotics. * IV unfractionated heparin if no contraindication. * Surgical management if peritonitis.

Answer 65

Chronic atherosclerotic disease of the mesenteric arteries.

Answer 66

- smoking - HTN - Hyperlipidaemia - Diabetes mellitus - Females - 50-70 age

Answer 67

* History of weight loss, postprandial pain (30-60 minutes after eating) and a fear of eating, weight. * Pain is colicky and generalised. * Examination is non-specific- some tenderness, poorly localised. There may be an abdominal bruit or signs of cardiovascular disease.

Answer 68

* Arteriography- GOLD standard. * Mesenteric duplex ultrasonography (may be affected by obesity and respiration). * VBG- raised lactate

Answer 69

* Smoking cessation * Antiplatlet therapy In symptomatic patients: * Open or endovascular revascularisation * Parenteral nutrition may be necessary Risk factor modification: * Smoking cessation, control of diabetes and hypercholesterolemia Symptom relief: * Medications like vasodilators may be used to increase blood flow to the intestines. Revascularization: Percutaneous transluminal angioplasty (PTA) with or without stenting or surgical revascularization procedures are typically used for patients with severe symptoms or when conservative management fails.

Answer 70

Is a chronic condition caused by transient bowel ischaemia.

Answer 71

Causes: (same as acute mesenteric ischaemia) Arterial embolism * (due to AF, endocarditis for example) or thrombus (atherosclerosis, aortic aneurysm or dissection, reduced cardiac output, dehydration). Mesenteric venous thrombus * (hypercoagulability disorders, tumour causing venous compression, intra- abdominal infection, portal hypertension). Non-occlusive mesenteric ischaemia * (hypotension, vasopressive drugs, cocaine, digitalis). Secondary to intestinal obstruction Usually, segmental meaning that it affects splenic flexure or rectosigmoid area.

Answer 72

* Crampy left sided abdominal pain lasting for a few hours. * Followed by rectal bleeding- dark red blood often without stool.

Answer 73

* Thumbprinting on AXR is a sign of large bowel wall thickening, usually due to oedema

Answer 74

Inflammation of the Appendix.

Answer 75

Delay in diagnosis results in abscess formation, perforation, peritonitis, and sepsis.

Answer 76

* Periumbilical or epigastric pain that localises to the right iliac fossa within 24-48 hours * Pain worse on movement * Nausea and vomiting, loss of appetite * Constipation or diarrhoea * Fever * Right lower quadrant tenderness * Peritonism- guarding, rebound tenderness, percussion tenderness. * A palpable mass

Answer 77

* Rosving’s sign - palpation of the left lower quadrant causes tenderness in the right lower quadrant. * Psoas sign - with the patient lying on their left side, passive extension of the right thigh exacerbates the pain (retrocaecal appendicitis) * Obturator sign- passive internal rotation of the flexed right thigh exacerbates the pain * pregnancy test * urinanalysis * FBC/ CRP

Answer 78

* Emergency admission under the surgical team * Imaging may include USS, abdominal CT and MRI. * Non-operative management may include IV fluids and antibiotics. * But appendectomy is the GOLD- standard treatment for uncomplicated appendicitis * Laparoscopic appendectomy is significant; advantages including reduced post-operative pain, reduced wound infection rates, reduced length of hospital admission, earlier return to work.

Answer 79

Inflammation of mucous membranes of the GI tract.

Answer 80

* Viral and self-limiting * Admit if systematically unwell and signs suggestive of dehydration or shock, intractable vomiting, or high output diarrhoea, suspected serious complication, suspected or confirmed STEC infection. * Reassure * Encourage fluids * Regular diet * Hand hygiene

Answer 81

- Assess for signs of dehydration or shock. - Abdominal assessment - Stool culture NOT RECCOMENDED

Answer 82

* Rotovirus * Norovirus

Answer 83

* Campylobacter jejuni and campylobacter coli (most common). * Escherichia coli (common in age >5)

Answer 84

- May present with just vomiting. - Diarrhoea is profuse and watery. - Colicky abdominal pain

Answer 85

- Bloody diarrhoea - Abdominal pain and tenderness - Nausea and vomiting - Fever - Altered bowel habit which can persist for many months afterwards

Answer 86

Diverticula are mucosal protrusions, creating a blind pouch through the muscular bowel wall

Answer 87

The presence of diverticula where there are no symptoms associated with it, usually undiagnosed.

Answer 88

Diverticula become inflamed and infected.

Answer 89

- Family hx - Age over 50 - Smoking - Low fibre diet - Obesity - Drugs- NSAIDS and opiates

Answer 90

* No inflammation and infection * Intermittent abdominal pain and tenderness in the left lower quadrant. * Pain may be triggered by eating and relieved by passage of flatus or opening bowels. * Constipation, diarrhoea, mucus in stool, occasional large rectal bleeding

Answer 91

* Abdominal imaging (CT scan or ultrasound) * Blood tests demonstrating inflammation (leukocytosis) * Colonoscopy/endoscopy CT ABDO AND PELVIS DIAGNOSTIC

Answer 92

If suspected diagnosis but not confirmed, routine referral into colorectal surgeons. Dietary advice as per diverticulosis. If persistent symptoms despite these changes bulk-forming laxative could be given. Paracetamol PRN. Symptomatic: * increase dietary fibre intake and hydration. If there is evidence of diverticulitis (leukocytosis, fever), patients are initially managed with oral antibiotics (e.g. 7 days co-amoxiclav). * Analgesia may also be required, prescribed in a step-wise fashion, starting with oral paracetamol. * A low residue diet is advised.

Answer 93

Asymptomatic

Answer 94

Incidental finding and no further Ix needed.

Answer 95

* Recommend a healthy diet containing wholegrains, fruits and veg * Gradually increase fibre in diet (to reduce flatulence) 30g fibre each day. * Adequate fluid intake

Answer 96

* Fever * Change in bowel habit * Significant rectal bleeding * Nausea, vomiting, dysuria, urinary frequency * Constant severe LLQ pain

Answer 97

In primary care: * If mild, uncomplicated diverticulitis- 5/7 co-amoxiclav or combination cafalexin/metronidazole, or trimethoprim/metronidazole if penicillin allergy. * Analgesia- paracetamol * Clear fluids only- introducing food again after 2-3 days if symptoms improving * Bloods including inflammatory markers * Review after 48 hours and admit if persistent or deteriorating symptoms Urgent admission: * If suspected complication * Severe abdominal pain that cannot be managed in primary care * Dehydration * Unable to tolerate oral antibiotics * Frailty, significant co- morbidities, immunocompromise Management of diverticulitis: Patients unresponsive to antibiotics, or presenting with an abscess, perforation, stricture, or obstruction may require surgical intervention. * A localised abscess may be drained under CT/ultrasound guidance, with surgery considered if this fails. * Recurrent severe episodes of diverticulitis may necessitate consideration for elective colectomy. * For acute rectal bleeding: Haemodynamic stabilisation of the patient should be followed by endoscopic haemostasis. Surgery is an option if bleeding continues despite endoscopy.

Answer 98

Chronic, relapsing, non-infectious inflammatory conditions; Characterised by the inappropriate activation of the bowel mucosal immune system in response to normal bowel bacterial flora

Answer 99

Characterised by full-thickness intestinal wall inflammation of distinct sections of the GI tract anywhere from mouth to anus.

Answer 100

- Family hx - Smoking - Infectious gastroenteritis - Appendicectomy - drugs

Answer 101

Symptoms: - Extraintestinal manifestations involving joints, eyes, liver, and skin. - Unexplained persistent diarrhoea for 4-6 weeks - Blood/ mucus in the stools - Nocturnal diarrhoea - Faecal urgency - Tenesmus - Abdo pain - Fatigue, malaise, anorexia, fever

Answer 102

Signs: * Clubbing, pallor, mouth ulcers * Abdo tender/ mass * Perianal abnormality or tender * Weight * Arthritis, erythema nodosum, eye pathology * PR exam to check for perianal skin tags, fistulae, or perianal abscess * Erythema nodosum (painful erythematous nodules/plaques on the shins) * Pyoderma gangrenosum (a well-defined ulcer with a purple overhanging edge) * Anterior uveitis (painful red eye with blurred vision and photophobia) * Episcleritis (painless red eye). * Enteropathic arthropathy (symmetrical, non-deforming) * Axial spondyloarthropathy (sacro-iliitis), * Gallstones (these are more common in Crohn's disease than in ulcerative colitis) - reduced bile acid reabsorption and increased calcium loss predisposes to gallstones * AA amyloidosis (secondary to chronic inflammation) and renal stones (more common in Crohn's disease than in ulcerative colitis)

Answer 103

Induce Remission: * Monotherapy with glucocorticoids (oral prednisolone, or IV hydrocortisone if severe flare needing admission). * Biologics for acute management of severe flares Maintaining Remission: * Azathioprine or mercaptopurine may be added on to induce remission if there are 2 or more exacerbations in a 12-month period or the glucocorticoid cannot be tapered (assess TPMT activity before offering- underactivity increases risk of bone marrow suppression) * Methotrexate - intolerant/have a contraindication to azathioprine or mercaptopurine. * Biological agents (such as infliximab or adalimumab) in severe Crohn's disease who fail to respond to the above. (CXR before tx initiation due to risk of re-activation of latent TB). Surgical management: * Rarely curative in Crohn's disease (unlike in UC) because disease can occur anywhere along the GI tract. * Surgical options will depend on the part of the GI tract that is affected, and is indicated in those who have failed medical therapy or in those with severe stricturing or fistulating disease:

Answer 104

Bedside: * Stool culture- exclude infection * Faecal calprotectin - raised (helps distinguish IBD and IBS). Blood tests: * Raised white cell count * Raised ESR/CRP * Thrombocytosis * Anaemia (secondary to chronic inflammation) * Low albumin (secondary to malabsorption) * Haematinics and iron studies including (B12, folate) Imaging: * MRI - suspected small bowel disease. * Upper GI series may show the 'string sign of Kantour'. * Colonoscopy with biopsy will reveal: - Intermittent inflammation ('skip lesions') - Cobblestone mucosa (due to ulceration and mural oedema) - Rose-thorn ulcers (due to transmural inflammation), ± fistulae or abscesses. - Non-caseating granulomas

Answer 105

Fistulas Strictures Abscesses Malabsorption Perforation Nutritional Deficiencies Increased Risk of Colon Cancer Osteoporosis Intestinal Obstruction Toxic Megacolon

Answer 106

Ulcerative colitis (UC) is a chronic relapsing-remitting inflammatory disease that primarily affects the large bowel. It usually affects the rectum first, then can extend to the part of the colon (left-hand-side colitis) or the entire colon (pancolitis). It does not spread beyond the ileocaecal valve or to the small bowel, except where backwash ileitis can occur.

Answer 107

Non-smoke/ ex-smoker No appendectomy Drugs (NSAIDs) 20-40 years

Answer 108

GI symptoms: * Diarrhoea often containing blood and/or mucus * Tenesmus or urgency * Generalised crampy abdominal pain in the left iliac fossa Systemic symptoms: * Weight loss * Fever * Malaise * Anorexia

Answer 109

General signs: * pallor due to anaemia and clubbing * Abdominal exam - distension or tenderness * PR exam- tenderness, and blood/mucus. Extra-intestinal signs: * Dermatological manifestations: erythema nodosum, pyoderma gangrenosum * Ocular manifestations: anterior uveitis, episcleritis, conjunctivitis * MSK manifestations: clubbing, non-deforming asymmetrical arthritis, sacroiliitis * Hepatobiliary manifestations: jaundice due to PSC (80% of those with PSC have ulcerative colitis). * Other features include AA amyloidosis

Answer 110

Bedside: * Stool microscopy * Faecal calprotectin Bloods: * FBC (anaemia and a raised WCC), ESR/CRP raised, LFTs - low albumin Imaging/Invasive: * Abdo X-ray and erect CXR in acute settings to exclude toxic megacolon and perforation. * Long-standing UC will show 'lead-pipe' colon on AXR * Colonoscopy, barium enema, and biopsy are used to CONFIRM the diagnosis- shows continuous inflammation starting at the rectum that does not go beyond the submucosa with an erythematous mucosa, loss of haustral markings, and pseudopolyps. Biopsy: loss of goblet cells, crypt abscess, and inflammatory cells (predominantly lymphocytes) Barium enema will reveal lead-piping inflammation (secondary to loss of haustral markings), thumb-printing (a marker of bowel wall inflammation), and pseudopolyps (due to areas of ulcerating mucosa adjacent to areas of regenerating mucosa).

Answer 111

Mild-moderate disease: * 1st line-Topical aminosalicylate. * If remission is not achieved in 4 weeks, consider adding an oral aminosalicylate. * Then a trial of Etrasimod (also known as Velsipity). Proctitis and proctosigmoiditis: * Step 1: Topical ASA or oral ASA. * Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus. Left sided or extensive disease * Step 1: High dose oral ASA. * Step 2: Consider adding oral prednisolone. If this does not help after 2-4 weeks or symptoms worsen, consider adding oral tacrolimus. Acute severe disease * Step 1: IV corticosteroids (contraindicated/ not tolerated= IV ciclosporin). * Step 2: If no improvement in 72 hours or worsening symptoms, add IV ciclosporin or consider surgery (if IV ciclosporin contraindicated/ not tolerated= infliximab). * Step 3: A trial of Etrasimod (also known as Velsipity). Indications for emergency surgery: * Acute fulminant ulcerative colitis * Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids * Symptoms worsening despite IV steroids Note that an alternative is to initiate rescue therapy (with ciclosporin or infliximab) if the patient has a sub-optimal response to intravenous steroids but is stable enough to delay surgery. Surgery should be considered if patients fail to respond to rescue therapy within 3 days. - If systemically unwell, A&E - If systemically well then refer to gastroenterology. - Specialist: Drug treatments to prevent relapse: amino salicylates, corticosteroids, calcineurin inhibitors, immunosuppressive drugs, biologic therapy.

Answer 112

* Toxic megacolon * Massive lower GI haemorrhage * Colorectal cancer: There is a higher risk with disease duration, severity and extent of colitis, and concomitant PSC. NICE guidance suggests offering colonoscopy surveillance to high risk patients. * Cholangiocarcinoma * Colonic strictures: cause large bowel obstruction. * Primary Sclerosing Cholangitis * Inflammatory pseudopolyps * Increased risk of VTE

Answer 113

The progressive non-obstructive dilation of the colon which can be segmental or total leading to systemic toxicity

Answer 114

- C. difficile colitis can lead to toxic megacolon

Answer 115

Critically ill Severe abdominal pain Distension Diarrhoea Vomiting Abdo tenderness Reduced bowel sounds

Answer 116

Radiographical evidence of colon distension (>6cm) * AND 3 of: fever, tachycardia, >120 bpm HR, neutrophilia >10500, anaemia * AND 1 of: dehydration, mental status changes, electrolyte abnormalities, hypotension.

Answer 117

- Medical management and supportive care- ICU, IV fluids, abx - Surgical management may be needed and includes subtotal colectomy with ileostomy

Answer 118

Dilated haemorrhoidal veins located within submucosal layer of lower rectum.

Answer 119

* External- distal to the dentate line * Internal- proximal to dentate line

Answer 120

Increased intra-abdominal pressure: -constipation -heavy lifting -Abdominal exercises -pregnancy, childbirth - ascites -pelvic mass -chronic cough Aging Low fibre-diet Congenital weakness of venous walls

Answer 121

- Rectal bleeding - Perianal pruritus - Sensation of fullness in perianal area - Significant acute perianal pain - painless

Answer 122

* Characteristic haemorrhoid on PR exam * Bleeding * Firm, painful, inflamed perianal mass if thrombosed.

Answer 123

Clinical exam - Inspecting anal verge and perianal area - Digital rectal exam Anoscope when external exam is normal. Colonoscopy when physical exam and anoscope findings negative.

Answer 124

A & E admission * If severe pain, acutely thrombosed external haemorrhoids presenting within 72 hours Ensure soft stools * Treat constipation * Encourage fluid intake * Increase fibre intke Topical treatments * Ointment if external, suppository if internal * Differ in medication combination (corticosteroid, astringent, emollient, local anaesthetic). Refer if no improvement with conservative care: * Banding * Sclerotherapy * Photocoagulation * Haemorrhoidectomy

Answer 125

Tear or ulcer in the lining of the anal canal. Acute <6/54 Chronic >6/52

Answer 126

Primary anal fissures: -trauma to secondary or loose stools Secondary anal fissures: -IBD -STIs -colorectal cancer -psoriasis -bacterial/ fungal/ viral skin infections -anal trauma -pregnancy/ childbirth Age 15-40

Answer 127

- Anorectal fistula - Infection/ abscess - Faecal impaction

Answer 128

Symptoms: - Anal pain on defecation (severe, sharp followed by deep burning pain lasting several hours) - Tearing sensation when passing stools - Bright red blood on stool or toilet paper

Answer 129

Signs: - Fissure visible on PR exam - Sentinel pile (skin tags associated with fissure)

Answer 130

Clinical diagnosis via physical exam * Acute anal fissures - Superficial with well-demarcated edges * Chronic anal fissures - Wider and deeper with muscle fibres visible in the base - Edges often swollen. - skin tag * Primary anal fissures Singular - Posterior midline of anus * Secondary anal fissures - Multiple - Irregular outline - Location may be lateral. Avoid DRE – refer if diagnosis uncertain.

Answer 131

Ensure soft stools: - Treat constipation - Adequate fluid intake, increase dietary fibre. Keep anal area dry and clean. Manage pain: - Paracetamol or ibuprofen - Sit in shallow, warm bath several times daily. - Topical anaesthetic (lidocaine 5%) for extreme pain applied before pooing. If primary fissure and symptoms persist> 1 week with conservative treatment - Rectal glyceryl trinitrate (GTN) 0.4% ointment x 6-8 weeks If unhealed after 6-8 week, refer to colorectal surgery.

Answer 132

Infection of soft tissues around the anus (perianal) or rectum (perirectal).

Answer 133

-immunodeficiency -diabetes -receptive anal intercourse - Crohn’s disease

Answer 134

Symptoms: - Perianal pain - Perianal swelling, erythema - Discharge - Rectal bleeding - Fever - Malaise

Answer 135

Signs - Fever - Tachycardia - Perianal tenderness - Perianal/ rectal induration - Perianal erythema - Perianal warmth - Perianal swelling - Perianal fluctuance - Purulent discharge

Answer 136

* Clinical diagnoses- PR exam * Ultrasound, MRI * Culture and sensitivity of discharge (if recurrent of high risk e.g., immunodeficiency)

Answer 137

Prompt drainage of abscess: - Sepsis if untreated - Perianal- outpatient incision& drainage - Perirectal- surgical drainage Sitz baths following drainage. Broad-spectrum abx in high-risk patients (DM, immunocompromised, elderly, significant associated cellulitis). Treatment failure- possible unrecognised anal fistula.

Answer 138

Is abnormal connection between rectum and clear skin near anus.

Answer 139

* Usually caused by anorectal abscess.

Answer 140

- Perianal tenderness - Perianal swelling erythema - Purulent discharge - Fistula opening - Induration of fistula tract

Answer 141

Symptoms: - Perianal pain - Perianal irritation/ pruritus - Purulent discharge - Rectal bleeding - Perianal swelling/ redness - Bowel incontinence

Answer 142

- Clinical diagnosis - Imaging studies if diagnosis uncertain: fistulogram CT or MRI in complex or recurrent fistulas - Fistulogram- x-ray using radio-opaque material injected onto potential fistula.

Answer 143

Treated via surgery- fistulotomy

Answer 144

Acquired disease where hair follicles become inverted into the skin, creating a chronic cyst and sinus tract.

Answer 145

Asymptomatic presentation: - One or more non-tender lumps in natal cleft - Emergent hair Symptoms: - Acute abscess (painful, lump in natal cleft, purulent discharge, erythema, fever) Discharging sinus: chronic pain, chronic discharge/ bleeding and recurrent abscess formation.

Answer 146

clinical diagnosis

Answer 147

Asymptomatic: - Local hygiene with regular baths/ showers Symptomatic: - Acute abscess (same-day I & D) and abx if there is associated cellulitis. Discharging sinus requires surgical correction.

Answer 148

Projections arising from colonic mucosal surface.

Answer 149

- Adenomatous polyps

Answer 150

Familial adenomatous polyposis (FAP) syndrome: - Autosomal dominant - Can have 100s-1000s polyps. * Almost 100% risk for colorectal cancer by 40 ages.

Answer 151

- Usually, asymptomatic - Rectal bleeding - Mucus discharge - Tenesmus - Change in bowel habits

Answer 152

- Colonoscopy - Colonoscopy with biopsy (when concern for colorectal cancer).

Answer 153

Adenomatous polyps: - Removed endoscopically. - Surveillance for cancer Hyperplastic/ metaplastic polyps: - Benign so no action required.

Answer 154

Coeliac disease is a T cell-mediated autoimmune disorder affecting the small intestine. The condition arises due to the production of an auto-antibody against gluten.

Answer 155

- Reduced quality of life - Depression, anxiety - Faltered growth, delayed puberty - Nutritional deficiencies - Hyposplenism, asplenism - Increased risk of non-Hodgkin lymphoma, small bowel adenocarcinoma, pancreatic cancer.

Answer 156

female Infancy or between the ages of 50-60 Irish descent Fhx HLA-DQ2 allele Autoimmune diseases- type 1 diabetes mellitus.

Answer 157

* Abdominal pain *Distension * Nausea and vomiting * Diarrhoea * Steatorrhoea (severe disease) * Fatigue * Weight loss/ failure to thrive in children (severe disease) * Rash

Answer 158

* Abdomen tender * Abdominal distension * Dermatitis herpetiform * Pallor (secondary to anaemia) * Short stature & wasted buttocks (secondary to malnutrition) * Signs of vitamin deficiency due to malabsorption (e.g., bruising secondary to vitamin K deficiency) * Dermatological manifestations: dermatitis herpetiformis (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk).

Answer 159

Bedside: * Stool culture - infectious causes. * Faecal calprotectin - IBD is a differential. Bloods: * FBC, U&E, bone profile, LFT, Iron, B12, Folate levels * First line serological tests such as anti-TTG IgA antibody and IgA level, followed by anti-TTG IgG, anti-endomyseal antibody, (anti-gliadin is not recommended by NICE.) Imaging/Invasive: * OGD and biopsy = GOLD standard; sub-total villous atrophy, crypt hyperplasia, and intra-epithelial lymphocytes. The patient needs to have been eating gluten for 6 weeks prior to the investigation. Howell-Jolly bodies (Hyposplenism). On a blood smear stained with standard H&E, DNA stains purple (basophilic) and protein stains pink (eosinophilic). NICE guidelines dictate that coeliac disease should be tested for in those with a new diagnosis of autoimmune thyroid disease or type 1 diabetes.

Answer 160

* Lifelong commitment to a gluten-free diet. Patient education about food items containing gluten is crucial. (gluten include bread, pasta, pastries and most beers). * dietician referral * Regular monitoring to screen for potential complications. * Dermatitis herpetiformis is managed with dapsone Assess need for DEXA scan: for assessing complications Annual Bloods Vaccines * Influenza, meningococcal, pneumococcal

Answer 161

Colorectal cancer is a type of malignancy that starts in the colon or rectum. It is a result of uncontrolled cell growth in the lining of the colon or rectum. It may start as benign polyps, which can over time progress to cancerous tumours if not removed.

Answer 162

Strong risk factors * Increasing age * Hereditary syndromes * Familial adenomatous polyposis * Hereditary nonpolyposis colorectal cancer (Lynch Syndrome) * Juvenile polyposis * Peutz-Jeghers syndrome * Increased alcohol intake * Smoking tobacco * Processed meat * Obesity * Previous exposure to radiation * IBD * HPV-16 Weak risk factors * Lack of dietary fibre * Limited physical activity * Asbestos exposure * Red meat (non-processed)

Answer 163

* Rectal bleeding * Unexplained weight loss * Change in bowel habit * Abdominal pain: Persistent abdominal discomfort or pain may be present. * Iron-deficiency anaemia * Bowel obstruction: advanced tumours can obstruct the bowel, resulting in abdominal pain, nausea and vomiting. * fever * mass * palpable lymph node

Answer 164

Adenocarcinoma

Answer 165

Urgent two-week referral if: * Positive faecal occult blood test * Age ≥40 with unexplained weight loss and abdominal pain * Age ≥50 with unexplained rectal bleeding * Age ≥60 with: - Iron-deficiency anaemia or - Change in bowel habit. * Anyone with abdominal or rectal mass. * if age <50 with rectal bleeding and any of the following: - Abdominal pain - Change in bowel habit. - Weight loss - Iron-deficiency anaemia

Answer 166

Faecal immunochemical test (FIT) - Abdominal mass - Change in bowel habit - Iron-deficiency anaemia - Age ≥40 with unexplained weight loss and abdominal pain - Age <50 with rectal bleeding and either abdominal pain or weight loss - Age ≥50 with rectal bleeding, abdominal pain or weight loss - Age ≥60 with any anaemia

Answer 167

If FIT test positive refers under 2 week-wait rule If FIT test negative and strong clinical concern of cancer due to ongoing unexplained symptoms refer to colorectal specialist

Answer 168

NHS Bowel Cancer Screening Programme Screening via FIT test * Colonoscopy offered if FIT test abnormal Screening every 2 years to those age 60-74 * Expanding to age 50-74 over the next 4 years (2021-25) Family history * Begin screening age 50 if family history in 1st-degree relative

Answer 169

* FBC (anaemia), iron studies, and carcinoembryonic antigen (CEA) * GOLD standard - colonoscopy * CT chest, abdomen and pelvis- staging * In rectal disease, a pelvic MRI or endorectal ultrasound are preferred over CT scan, as are better for identifying locally invasive disease.

Answer 170

Protrusion of abdominal contents through weaknesses in the abdominal wall.

Answer 171

* Obesity * Prior hiatal surgery * Increased intra-abdominal pressure, such as from chronic cough, multiparity, or ascites * heavy lifting * abdominal exercises * abdominal weight gain * pregnancy * abdominal surgery

Answer 172

* Sliding hiatal hernia (80%): the gastro-oesophageal junction slides up into the chest. Results in acid reflux. Treatment similar GORD. * Rolling hiatal hernia (20%): the gastro-oesophageal junction stays in the abdomen, but part of the stomach protrudes into the chest alongside the oesophagus. More urgent treatment since volvulus can lead to ischemia and necrosis.

Answer 173

Heartburn Dysphagia Regurgitation Odynophagia Shortness of breath Chronic cough Chest pain

Answer 174

Barium swallows- most sensitive to diagnose Endoscopy Oesophageal manometry

Answer 175

Conservative management * Weight loss * Elevating the head of the bed * Avoidance of large meals and eating 3-4 hours before bedtime * Avoidance of alcohol and acidic foods * Smoking cessation Medical management * PPI for 4-8 weeks Surgical management * Nissen's fundoplication. * Urgent surgery is required in the presence of haemorrhage, volvulus, ischaemia, necrosis or obstruction.

Answer 176

The bowel can be reduced back into the abdominal cavity. These are painless and often asymptomatic.

Answer 177

An acute condition where a hernia compromises the blood supply to the intestines or abdominal tissues. This process leads to ischaemia and subsequent necrosis of the affected bowel tissue if left untreated, posing a risk of sepsis and bowel perforation. This constitutes a surgical emergency.

Answer 178

An incarcerated hernia also presents with abdominal pain and an irreducible mass, but unlike a strangulated hernia, the blood supply is not necessarily compromised.

Answer 179

Uncomplicated hernias appear as a lump or swelling which can be reducible. If reducible, the hernia is often painless.

Answer 180

* Severe abdominal pain * Vomiting * A history of intermittent pain, particularly when the hernias are still reducible * Signs of bowel obstruction may also be present such as abdominal distension, inability to pass gas or stool, and constipation.

Answer 181

Irritable Bowel Syndrome is a common, chronic GI disorder characterised by abdominal pain or discomfort associated with altered bowel habits, without any identifiable structural or biochemical abnormalities.

Answer 182

- Women - 20-30 age - Genetic - Lifestyle and diet - psychosocial

Answer 183

* Abdominal discomfort/ pain relieved by defecation OR associated with altered bowel habits * At least two of the following: - Altered stool passage - Abdominal bloating - Symptoms worsened by eating - Passage of mucus - Lethargy - Nausea - Backache - Bladder issues Sx must persist for >6 months

Answer 184

Rule out other organic diseases: * Faecal calprotectin (raised in IBD, not IBS) * FBC, ESR/CRP (also raised in IBD, not IBS) * Coeliac serology As per NICE guidelines, abdominal ultrasound, sigmoidoscopy/colonoscopy, Thyroid Function Tests (TFTs), Faecal Occult Blood Test (FOBT), faecal ova and parasite test, and hydrogen breath test are not required for diagnosis.

Answer 185

Dietary and lifestyle modifications: * Including regular exercise, stress management, and dietary changes (such as low-FODMAP diet). Pharmacotherapy: * Antispasmodics such as mebeverine, laxatives, or anti-diarrhoeal agents depending on predominant sx. * 2nd-line low-dose tricyclic antidepressants Refractory IBS - symptoms not improving for 12 months: * psychotherapy: cognitive-behavioral therapy, hypnotherapy, and mindfulness-based therapy

Answer 186

I GET SMASHED Idiopathic Gallstones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren's syndrome) Scorpion stings Hypercalcaemia, hypertriglyceridemia, hypothermia ERCP Drugs (e.g. thiazides, azathioprine, sulphonamides)

Answer 187

FATSHEEP Furosemide Aziathropine/ asparginase Thiazides/ tetracyclines Statins/ sodium valproate/ sulfonamides Hydrochlorothiazine Estrogens Ethanol Protease inhibitor & NRTIs (HIV tx)

Answer 188

MILD acute pancreatitis: absence of organ failure & local/ systemic complications SEVERE acute pancreatitis: transient organ failure AND OR local/ systemic complications without organ failure for >48hrs.

Answer 189

* stabbing epigastric pain radiating to back/ RLQ/ RUQ * pain relieved sitting forward/ foetal position. * n+v

Answer 190

fever hypovolaemia (tachycardia, dry mucous membrane) Grey turner's sign Cullens sign Distended stomach

Answer 191

* FBC, U&E, LFT - raised WBC= necrotising pancreatitis - raised LFT= Gallstone pancreatitis - raised amylase x3 = pancreatitis - lipase (sensitive and specific) * USS abdo= gallstones * MRCP = obstruction * ERCP * CT GOLD = complications * general obs- febrile/ shock

Answer 192

* Peripancreatic Fluid Collection- cause infection, abcess * Pseudocyst- rupture/ infection * Pancreatic Abcess * Haemorrhage * ARDS * Hypovolaemia * DM * Fistulae * Pancreatic Necrosis

Answer 193

Severity of pancreatitis is stratified using the Glasgow Score - each scores 1 point and a score of 3 or more = severe pancreatitis: PaO2 < 8kPa Age > 55 years Neutrophils > 15 Calcium < 2 Renal i.e. Urea > 16 Enzymes i.e. LDH > 600 or AST > 200 Albumin < 32 Sugar i.e. Glucose > 10 This should be calculated on admission and at 48 hours.

Answer 194

* A-E resus * IV fluids- crystalloid * analgesia- opiates * anti-emetic * catheterisation * IV abx- necrotising pancreatitis * Calcium if low * Insulin if needed * CBG monitor * drainage of pancreatic collections * Surgery for complications * Lap Chole for gallstone pancreatitis * CIWA, vitamins- etoh pancreatitis

Answer 195

Characterised by persistent inflammation and fibrosis of both the exocrine and endocrine components of the pancreas.

Answer 196

* chronic alcohol use * hyperparathyroidism * obstruction - cancer * genetics- cystic fibrosis * idiopathic

Answer 197

* epigastric pain worse after food, better leaning forward * Bloating * weight loss * exocrine dysfunction (malabsorption/ steatorrhoea) * diabetes * signs of chronic liver disease

Answer 198

* Blood glucose * Faecal elastase low * Amylase and lipase NOT raised * Abdo XR * CT * USS

Answer 199

* pseudocyst * Pancreatic cancer * DM * malabsorption/ steatorrhoea

Answer 200

* Reduce/ stop etoh * Diet * Analgesia * Insulin * Pancreatic enzyme replacement therapy (creon) * Coeliac plexus block * Pancreatectomy

Answer 201

Refers to the irreversible scaring of the liver with the loss of normal hepatic architecture.

Answer 202

Most common: * Hep B and C * etoh * NAFLD Autoimmune: * Autoimmune hepatitis * Primary biliary cirrhosis * Primary sclerosis cholangitis * Sarcoid Genetic: * Haemochromatosis * Wilson's disease * Alpha-1-antitrypsin deficiency Drugs: * Methotrexate * Amiodarone * Isoniazid Others: * Budd-Chiari Syndrome * Heart failure * Tertiary syphilis

Answer 203

Compensated Cirrhosis: * Fatigue and anergia * Anorexia and cachexia * Nausea or abdominal pain * Spider naevi * Gynaecomastia * Finger clubbing * Leuconychia * Dupuytren's contracture * Caput medusae * Splenomegaly Decompensated Cirrhosis- In addition to the symptoms of compensated cirrhosis: * Ascites and oedema * Jaundice * Pruritus * Palmar erythema * Gynaecomastia and testicular atrophy * Easy bruising * Encephalopathy/confusion * Liver 'flap'

Answer 204

* liver failure * ascites * SPB * renal failure * hepatocellular carcinoma * esophageal varices

Answer 205

Initial: * LFT, FBC, U&E, INR * Specific tests to determine cause - hepatitis serology - CMV - Iron studies - alpha-1 anti-trypsin - ceruloplasmin level - auto-antibodies Imaging and Invasive: * peritoneal tap for MC&S (ascites) * Doppler USS (Budd chiari syndrome) * Transient elastography= fibroscan * Retest 2 yearly * Liver Biopsy= confirm Child-pugh score MELD score

Answer 206

To measure the severity of Liver Cirrhosis * Bilirubin * Albumin * PT * Encephalopathy * Ascites The scores are added and the degree of cirrhosis is classified as Child-Pugh A (<7 points), B (7-9 points) or C (>9 points). LEARN THE VALUES

Answer 207

The Model for End-Stage Liver Disease (MELD) score evaluates the severity of liver disease based on bilirubin, creatinine, and INR levels. Higher scores indicate a greater risk of mortality within a three-month period. MELD scores are used to prioritise patients for liver transplantation. In liver cirrhosis, MELD scores ≥15 typically indicate significant disease severity, with increased mortality rates and the need for liver transplantation consideration.

Answer 208

Conservative: * Good nutrition and no alcohol * Avoiding NSAIDs, sedatives, and opiates * 6 month USS & serum α-fetoprotein tests for hepatocellular carcinoma detection. * Upper GI endoscopy surveillance for oesophageal varices. Medical: * Cholestyramine for pruritus * Managing ascites with fluid restriction, low-salt diet, pharmacological management with spironolactone; furosemide, therapeutic paracentesis, and albumin infusions in severe cases * Reducing recurrent episodes of encephalopathy through prophylactic lactulose and rifaximin * Using prophylactic antibiotics in patients at high-risk of spontaneous bacterial peritonitis Surgical: * Liver transplantation is the only definitive management for liver cirrhosis.

Answer 209

If Paracetamol-Induced: * Arterial pH <7.3 24 hours after OR * PT > 100s AND - creatinine >300 - grade III/ IV encephalopathy Non paracetamol Liver failure: * PT >100s OR 3 or more of the following: - Drug-indcued - <10 yrs age/ >40 yrs age - 1 week from 1st jaundice to encephalopathy - PT >50s - Bilirubin >/=300

Answer 210

Liver failure refers to the loss of liver function and the development of complications including coagulopathy, jaundice or encephalopathy. It can occur acutely if onset of symptoms in less than 26 weeks with a previously healthy liver and subdivided into hyperacute (< 7 days), acute (8-21 days), or subacute (4-26 weeks) liver failure. Chronic liver failure occurs on a background of liver cirrhosis.

Answer 211

* Viral Hepatitis: Hepatitis A, B, and E infections * Drug-Induced: paracetamol (acetaminophen), halothane, isoniazid, and certain abx * Toxic Exposures: Amanita phalloides mushrooms or industrial chemicals like carbon tetrachloride. * Vascular Disorders: Budd-Chiari syndrome

Answer 212

* Alcohol misuse * Chronic Viral Hep B/C * NAFLD * Autoimmune liver disease (PBC, PSC) * genetics

Answer 213

* Jaundice * abnormal bleeding * hepatic-encephalopathy ACUTE: * RUQ pain * N+V * malaise * sweet/ musty breath * abnormal blood clotting * low glucose * high lactate * acidosis * impaired renal function * hyperammonaemia * cerebral oedema=> Raised ICP

Answer 214

* Grade 1 Altered mood and behaviour, disturbance of sleep pattern, dyspraxia * Grade 2 Drowsiness, confusion, slurring of speech, personality change * Grade 3 Incoherency, restlessness, asterixis * Grade 4 Coma

Answer 215

* FBC, LFT, U&E * INR * Ix the causes: - paracetamol level - infections: hep, CMV - iron studies - alpha-1 anti-trypsin deficiency - ceruloplasmin level (wilson's) - Auto-antibodies * Ascites= peritoneal tap mc & s * Abdo USS * OGD- varices * Doppler US (budd chiari)

Answer 216

* RESUS * IV NAC * A-E

Answer 217

* vit K IV * fresh frozen plasma if bleeding

Answer 218

IV piperacillin-tazobactim

Answer 219

* lactulose * rifaximin (2nd line abx) * IV mannitol to reduce cerebral oedema

Answer 220

* terlipressin if rapid progression * midodrine if slow progression

Answer 221

* Acute overdose - excessive paracetamol taken in less than 1 hour, usually in the context of self-harm * Staggered overdose - excessive paracetamol ingested over longer than 1 hour, usually in the context of self harm * Therapeutic excess - excessive paracetamol taken with the intent to treat pain or fever and without self-harm intent, ingested at a dose greater than 75mg/kg/24 hours.

Answer 222

* asymptomatic * n+v * loin/abdo pain * haematuria/ proteinuria * coma

Answer 223

Blood tests for paracetamol levels should be taken at least 4 hours after ingestion, as this is when plasma paracetamol concentration peaks so an earlier blood test may underestimate levels Other important blood tests include: * FBC * U & E * Clotting Screen * LFT * VBG-metabolic acidosis * Blood glucose * Salicylate levels (to look for a mixed overdose with aspirin)

Answer 224

PLEASE REFER TO NOTES

Answer 225

Grade I- mild ascites (detected via USS) Grade II- moderate (mederate symetrical distension) Grade III- large (marked distension)

Answer 226

* abdo distension * abdo discomfort * dyspnoea * reduced mobility * anorexia/ early satiety * tense abdomen * shifting dullness * stigmata of underlying cause

Answer 227

* Ascitic tap under USS to avoid perforation * SAAG * bloods- underlying causes * imaging- CT abdo/ CXR-HF

Answer 228

Serum Ascites Albumin gradient * albumin conc minus ascites albumin * High SAAG > 1.1g/L (cirrhosis/ HF/ Budd chiari/ constrictive pericarditis/ hepatic failure. * Low SAAG < 1.1g/L (cancer/ Tb/ Peritonitis/ infections/ pancreatitis/ hypoalbuminaemia (nephrotic)

Answer 229

* High SAAG = reduce salt and reduce fluid * 1st spironolactone +/- furosemide * Large ascites: - paracentesis with HAS (human albumin solution) * SBP - tx IV piperaciliin - 1st prophylaxis = ciprofloxacin * TIPS= rescue and recruit

Answer 230

6-12 hrs after last drink: * insomnia, tremor, anxiety, agitation, n+v, sweating, palpitations 12-24hrs after last drink: * hallucinations 72 hrs after last drink: delirium tremens * delusion * confusion * seizures * tachy * HTN * hyperthermia

Answer 231

* AUDIT, SADQ * bloods * neuroimaging if seizures/ confusion * CIWA

Answer 232

Supportive: * IV fluids * glucose * electrolytes * Pabrinex * nutritional supplements Chlordiazepoxide IV Lorazepam = seizures Pabrinex (prophylaxis as wernicke's encephalopathy) ORAL LORAZEPAM 1ST LINE = delirium tremens

Gastrointestinal 💩 Flashcards

(261 cards)