Gastrointestinal (3) Flashcards

Question

What is the prognosis of hernias?

Answer 1

Prognosis is excellent after surgical repair. The incidence of recurrent hernia with mesh repair is reported to be less than 2%. Moderate to severe chronic groin pain is reported to occur in 10% to 12% of patients after inguinal hernia repair. Groin pain higher incidence after open repair compared to laparoscopic repair.

Answer 2

The protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm. It most commonly contains a variable portion of the stomach but can contain transverse colon, omentum, small bowel, or spleen.

Answer 3

Congenital Traumatic Non-traumatic Sliding (90-95%) - the hernia moves in and out of the chest. Usually protrusion of gastro-oesophageal junction followed by body of stomach above diaphragm which causes a decreased LOS pressure. Paraoesophageal (rolling) (5-10%) - the hernia goes through a whole in the diaphragm next to the oesophagus. The fundus or body of stomach usually herniate and the gastro-oesophageal junction remains below the diaphragm. This can produce rotation and twisting of the stomach, leading to intermittent strangulation with obstruction and ischaemia.

Answer 4

Aetiology is unknown however can be congenital, traumatic and non-traumatic (sliding or para-oesophageal) ``` Risk factors: Obesity Previous gastro-oesophageal procedure Elevated intra-abdominal pressure: Chronic cough, Ascites, Multiparity, pregnancy Low-fibre diet Male Advanced age Structural abnormality of oesophageal hiatus Chronic oesophagitis ```

Answer 5

Estimates of the prevalence of hiatus hernia in western populations range up to 50%. The prevalence may be lower in eastern populations. The incidence of symptomatic cases of hiatus hernia is closely related to the diagnosis of GORD Sliding hernias are the most common. 70% of patients are over 70 years old.

Answer 6

Mostly asymptomatic Sliding hernias most likely to cause symptoms. Present with symptoms of GORD: Heartburn Regurgitation Waterbrash Chest pain (oesophageal spasm) Dysphagia/odynophagia (oesophagitis) Haematemesis Cough/wheeze (aspiration)

Answer 7

CXR - gastric air bubble may be seen above the diaphragm Upper gastrointestinal series (X ray of upper GI tract) - shows intrathoracic stomach OGD - inflammation of oesophagus and proximal migration of gastro-oesophageal junction CT or MRI Oesophageal manometry or pH monitoring - double hump configuration Bloods FBC - check for iron deficiency anaemia

Answer 8

Medical: Modify lifestyle factors (e.g. lose weight) Inhibit acid production (e.g. PPIs) Enhance upper GI motility Surgical with or without anti-reflux procedure: Necessary in a MINORITY of patients - those with complications of reflux disease despite medical treatment or pulmonary complications (e.g. aspiration pneumonia) Nissen Fundoplication: The stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter and reduce the likelihood of herniation

Answer 9

``` Oesophageal: Intermittent bleeding Oesophagitis Erosions Barrett's oesophagus Oesophageal strictures ``` Non-Oesophageal: Incarceration of para-oesophageal hiatus hernia - strangulation and perforation Gastric volvulus Obstruction ``` Surgical complications: Dysphagia Haemorrhage Fundal necrosis Diarrhoea ```

Answer 10

Generally GOOD | Sliding hernias have a better prognosis than rolling hernias

Answer 11

Obstruction of a mesenteric vessel causing reduced blood flow to the GI tract leading to bowel inflammation, odeoma, ulceration, ISCHEMIA AND NECROSIS. Most commonly affects the splenic flexure (the watershed between the SMA and IMA).

Answer 12

Embolus (60%) Thrombosis (40%) ``` Can be a consequence of: Volvulus Intussusception Bowel strangulation Failed surgical resection ``` ``` Arterial inflow obstruction: Atheroma Thrombosis Embolism (cardiac arrhythmia) Vasculitis ``` Venous outflow obstruction Reduced perfusion - Hypotension, Shock

Answer 13

``` AF Endocarditis (can throw emboli) ``` Arterial Thrombosis: hypercholesterolaemia, hypertension, diabetes mellitus, smoking Venous Thrombosis: portal hypertension, splenectomy, septic thrombophlebitis, OCP, thrombophilia Old age Hypercoagulable states Myocardial infarction History of vasculitis

Answer 14

Uncommon More common in elderly (60-80 years) More common in those with co-morbidities (AF, MI, atherosclerosis)

Answer 15

``` Severe acute colicky abdominal pain Vomiting/nausea Rectal bleeding History of chronic mesenteric artery insufficiency Gross weight loss Post-prandial abdominal pain History of heart or liver disease Melaena Diarrhoea ```

Answer 16

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

Answer 17

Diagnosis based on clinical suspicion or after laparotomy AXR - thickening of small bowel folds and signs of obstruction, bowel dilation and thickening of walls ``` Bloods: ABG - lactic acidosis FBC - leukocytosis, anaemia U&Es LFTs Clotting - underlying prothrombotic condition Lactate - elevated Cross-match ``` Mesenteric Angiography if stable ECG - may show arrhythmia Erect CXR - check for perforation Contrast CT/CT angiogram Sigmoidoscopy/colonoscopy

Answer 18

A mechanical disruption in the patency of the GI tract, resulting in a combination of vomiting, absolute constipation, and abdominal pain.

Answer 19

``` Small bowel: Previous surgery (adhesions) – 80% Hernia Crohn’s disease Malignancy Appendicitis Volvulus Intussusception (children) Ileus ``` Large bowel: Malignancy (90%) Volvulus (5%) Benign stricture (3%)

Answer 20

COMMON More common in the ELDERLY due to increasing incidence of adhesions, hernias and malignancy Lifetime incidence between 0.1% and 5% in patients who have not undergone previous surgery Rises to over 60% in patients who have undergone previous surgery

Answer 21

``` Severe gripping colicky pain with periods of ease Abdominal distension Frequent vomiting (it may be bile-stained or faeculent) Absolute constipation Obstipation (failure to pass stool or flatus) Nausea Fever ```

Answer 22

``` Abdominal distension Abdominal tenderness Peritonitis - absent bowel sounds, guarding, rebound tenderness Palpable abdominal mass Palpable rectal mass Tachycardia Hypotension Tinkling bowel sounds or no bowel sounds if advanced Visible peristalsis Abdominal scars from previous surgeries ``` DRE - hard faeces or empty rectum Signs of malignancy - Weight loss, Rectal bleeding

Answer 23

Abdo X-Ray: Dilated intestinal loops, valvulae conniventes (small bowel - diameter more than 3cm) or haustra (large bowel - diameter more than 6cm) Partial SBO: gas throughout the abdomen and into the rectum Complete SBO: no distal gas, and staggered air-fluid levels Complicated SBO: free air under the diaphragm suggestive of perforation; thumb-printing of the bowel suggestive of ischaemia Bloods: FBC - high WCC Urea - increased if dehydrated Electrolyes - low K+, Na+ Abdo CT Water soluble contrast enema Barium follow through

Answer 24

IV fluid resuscitation and nasogastric decompression Electrolyte replacement Monitor vital signs, urine output, fluid balance Correction of underlying cause Analgesia and anti-emetic Pre-operative prophylactic antibiotic and surgery (emergency laparotomy)

Answer 25

``` Dehydration Bowel perforation Peritonitis Toxaemia Gangrene of ischaemic bowel wall Sepsis Multi-organ failure Intra-abdominal abscess Short bowel syndrome ```

Answer 26

Medical emergency. Patients treated in a timely manner have a very good prognosis. In untreated patients, obstruction progresses to intestinal necrosis, perforation, sepsis, and multi-organ failure.

Answer 27

``` Purulent collections in the liver parenchyma that result from bacterial, fungal, or parasitic infection of the liver which has spread from: Biliary tree Portal vein (from appendicitis) Hepatic vein Bacteraemia Trauma ```

Answer 28

``` Pyogenic (producing pus): E.coli Klebsiella sp. Streptococcus milleri Enterococcus Bacteroides Staphylococci ``` Amoebic: Entamoeba histolytica

Answer 29

``` Biliary tract abnormalities Age >50 years Malignancy Diabetes mellitus Interventional biliary or hepatic procedures Travel in endemic areas Underlying malignancy ```

Answer 30

``` Uncommon Higher incidence in Asia Slightly more common in men Incidence increases with age Pyogenic most common in industrial world Amoebic most common worldwide Fungal infections can occur in immunocompromised ```

Answer 31

``` Abdominal pain - RUQ/epigastric may be referred to shoulder Nausea and vomiting Cough, SOB, chest pain Weight loss Fatigue Fevers and chills Anorexia Night sweats Jaundice Diarrhoea History of foreign travel ```

Answer 32

``` RUQ tenderness Hepatomegaly Ascites Signs of pleural effusion in right lower zone - dullness to percussion, reduced breath sounds Signs of shock Jaundice ```

Answer 33

Bloods: FBC - Mild anaemia, Leukocytosis, elevted neutrophil LFTs - High ALP, mildly high bilirubin and AST and ALT, low albumin High ESR and CRP PT to see if aspiration can occur Liver USS - guide aspiration of abscess Contrast enhanced CT abdo Blood cultures: Amoebic and hydatid serology Stool MC&S - for E. histolytica Culture of aspirated fluid and gram stain CXR - check for right pleural effusion or atelectasis, raised hemidiaphragm Aspiration and culture of the abscess material

Answer 34

Severe liver dysfunction leading to jaundice, encephalopathy and coagulopathy.

Answer 35

Liver failure is classified based on the time interval between the onset of jaundice and the development of encephalopathy. ``` Hyper-acute = <7 days Acute = 1-4 weeks Sub-acute = 4-12 weeks ```

Answer 36

Viral: Hepatitis A, B, C, D and E Drugs: Paracetamol overdose, idiosyncratic drug reactions, long-term alcohol use ``` Autoimmune hepatitis Budd-Chiari syndrome Pregnancy-related Malignancy (e.g. lymphoma) Haemochromatosis Mushroom poisoning (Amanita phalloides) Wilson's disease ```

Answer 37

Alcohol abuse Poor nutritional status (depletion of glutathione stores) Pregnancy (hepatitis E) Chronic hepatitis B

Answer 38

Jaundice: decreased secretion of conjugated bilirubin Encephalopathy: Nitrogenous products (e.g. ammonia) is absorbed in the gut and goes via the portal circulation to the liver. If the liver is failing, these toxic products can go through the liver and reach the brain and exert its effects Coagulopathy: Reduced synthesis of clotting factors and reduced platelets. Platelet functional abnormalities associated with jaundice or renal failure

Answer 39

Paracetamol overdose accounts for over 50% of acute liver failure in the UK Rare

Answer 40

``` May be asymptomatic Fever Nausea and vomiting Abdominal pain Jaundice Malaise ```

Answer 41

Sleep reversal -> Lethargy -> Somnolence -> Stupor Reduced awareness and attention span -> Poor memory and confusion

Answer 42

``` Jaundice Asterixis Bruising or bleeding Encephalopathy Fetor hepaticus Hepatomegaly ``` Abdo or RUQ tenderness Ascites and splenomegaly (less common if acute or hyper-acute) Signs of secondary causes (e.g. bronze skin colour, Kayser-Fleisher rings in Wilson’s) Pyrexia: may indicate infection or liver necrosis ``` Signs of hepatic encephalopathy • Asterixis • Hyperreflexia • Nystagmus • Clonus • Rigidity ``` Signs of cerebral oedema • Hypertonia • Decerbrate posturing • Loss of pupillary reflexes

Answer 43

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

Answer 44

Resuscitation - ABC Treat the cause: N-acetylcysteine for paracetamol overdose Treatment/prevention of complications: Monitor - vital signs, PT, pH, creatinine, urine output, encephalopathy Manage encephalopathy: lactulose and phosphate enemas Antibiotic and antifungal prophylaxis Hypoglycaemia treatment Coagulopathy treatment - IV vitamin K, FFP, platelet infusions Gastric mucosa protection - PPIs or sucralfate AVOID sedatives or drugs metabolised by the liver Cerebral oedema - decrease ICP with mannitol Renal Failure: Haemodialysis Nutritional support Surgical - liver transplant

Answer 45

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

Answer 46

Depends on severity and aetiology

Answer 47

A tear or laceration of the lining of the oesophagus along the right border of or near the gastro-oesophageal junction which causes upper GI bleeding as a result of recent violent vomiting or straining to vomit.

Answer 48

``` Coughing Retching Vomiting Straining Hiccups Closed-chest pressure or cardiopulmonary resuscitation Acute abdominal blunt trauma Alcohol Medications (aspirin or NSAIDs). ``` Most common causes: chronic alcohol abuse, bulimia, trauma, intense coughing and gastritis. Hiatal hernia is considered a precipitating factor, causing an oesophageal tear to occur. Conditions that may induce vomiting: GI disease: food poisoning, infectious gastroenteritis, peptic ulcer disease, malrotation, intussusception, volvulus, gastric outlet obstruction, and gastroparesis Hepatobiliary disease: hepatitis, gallstones, and cholecystitis Renal disease: nephrolithiasis, renal failure, and ureteropelvic obstruction Neurological disease: tumours, hydrocephalus, congenital disease, trauma, meningitis, pseudotumour cerebri, migraine headaches, and seizures Psychiatric disease: anorexia nervosa, bulimia, and cyclic vomiting syndrome.

Answer 49

Common - 50-150 per 100,000 people per year Mortality between 8-14% Mallory-Weiss tear responsible for 3-15% of upper GI bleeds More common in men In women of childbearing age, most common cause is hyperemesis gravidarum Most common between 30-50 years

Answer 50

Small and self-limiting haematemesis - flecks or streaks of blood mixed with gastric contents and/or mucus, coffee ground vomit, bright-red bloody emesis Light headedness/dizziness (symptoms of hypovolaemia) Dysphagia Odynophagia Meleana Abdominal pain Involuntary retching

Answer 51

Postural hypotension | Signs of anaemia - tachycardia, pallor, fatigue

Answer 52

``` Bloods: FBC - may show anaemia Urea - high if ongoing bleeding LFTs - normal, rule out underlying liver-disease PT - normal ``` CXR - usually normal, used to check for oesophageal perforation OGD - DIAGNOSTIC OF MWT. Tear or laceration shows as red longitudinal defect

Answer 53

80-90% of the time, the bleeding from a Mallory-Weiss tear will stop on its own Urgent evaluation and monitoring Endoscopy with or without intervention If bleeding does not stop - Surgery Injection sclerotherapy Coagulation therapy Arteriography If severe blood loss - transfusions Anti-reflux medications may also be prescribed

Answer 54

Boerhaave's Perforation - spontaneous perforation of oesophagus resulting from a sudden increase in intraoesophageal pressure combined with negative intrathoracic pressure Re-bleeding Hypovolaemic shock Hypokalaemia due to vomiting

Answer 55

For most patients, bleeding is self-limited, and will have stopped by the time of endoscopy. Prognosis is excellent in patients without associated disease or complications. A routine second endoscopic evaluation is not recommended unless the patient remains symptomatic after initial treatment. Re-bleeding occurs in 8-15% of patients, usually within 24 hours.

Answer 56

A sudden inflammation of the pancreas due to autodigestion by its own enzymes with variable involvement of other regional tissues or remote organ systems. Mild: minimal organ dysfunction and uneventful recovery Severe: organ failure and/or local complications i.e. necrosis, abscesses and pseudocyst

Answer 57

``` Most common causes are gallstones and ethanol I - diopathic - 10-20% G - allstones E - thanol T - rauma S - teroids M - umps A - utoimmune S - scorpion sting H - yperlipidaemia/hypercalcaemia E - RCP D - rugs (diuretics, valproic acid, azathioprine) ```

Answer 58

In the UK - 50% of cases are caused by gallstones, 25% by alcohol, and 25% by other factors. Gallstone pancreatitis is more common in white women >60 years of age Alcoholic pancreatitis is seen more frequently in men Peak age = 60 years old

Answer 59

``` Severe sudden onset epigastric pain which radiates to the back and is better on bending over/leaning forwards Pain made worse by movement Nausea Vomiting Anorexia ```

Answer 60

Cullen sign - bruising around umbilicus Grey-Turner's sign - bruising across flanks Epigastric tenderness without guarding or rebound Decreased bowel sounds if severe Fever Shock - tachypnoea, tachycardia, hypotension Signs of hypocalcaemia - Chocstek's sign (Facial muscle spasm when facial nerve is tapped), Trousseau's sign (Carpopedal spasm when pressure cuff is applied). Signs of cause: Hepatomegaly - alcohol Xantholasma - hyperlipidaemia Parotid grand swelling - mumps

Answer 61

Bloods: FBC - leukocytosis, increased haematocrit Amylase and lipase - more than 3 times upper limit of normal CRP/ESR - raised U&Es (to check for dehydration) Serum calcium - LOW - saponification: calcium binds to digested lipids from pancreas to form soap LFTs - may be deranged if gallstone pancreatitis or alcohol ABG - hypoxia or metabolic acidosis USS: check for evidence of gallstones in biliary tree Erect CXR: may be pleural effusion. Rule out perforation AXR: exclude other causes of acute abdomen CT Scan: if diagnosis is uncertain or if persisting organ failure - show inflammation, necrosis, pseudocysts

Answer 62

``` Fluid resuscitation Analgesia Bowel rest if necessary Cessation of alcohol ERCP and elective cholecystectomy post-pancreatitis if gallstones are cause ```

Answer 63

``` Local: Pancreatic necrosis Liquefactive haemorrhagic necrosis Pancreatic pseudocyst Pancreatic abscess ``` ``` Systemic: DIC ARDS Pleural effusion Sepsis Multiorgan dysfunction Renal failure Hypocalceamia ``` Long term: CHRONIC PANCREATITIS

Answer 64

Following a bout of acute pancreatitis: Abdominal pain Anorexia/loss of appetite Palpable mass in abdomen Pancreatic abscess presents the same but with fever and high WCC

Answer 65

80% of patients with acute pancreatitis have mild disease and will improve within 3 to 7 days of conservative management. Overall mortality rate is low (approximately 5%) Mortality rate rises to 25% to 30% in severe acute pancreatitis

Answer 66

Persistent inflammation of the pancreas causing progressive injury to the pancreas and surrounding structures, resulting in irreversible scarring, calcification and parenchymal atrophy leading to loss of endocrine and exocrine function.

Answer 67

``` Main causes are alcohol (70%) and idiopathic (20%) Repeated bouts of acute pancreatitis Gallstones Tumour causing duct obstruction Trauma Cystic fibrosis Hyperlipidaemia Hypercalcaemia ```

Answer 68

Most common cause in children = cystic fibrosis Prevalence 0.04-5% Alcoholic chronic pancreatitis presentation 36-44y/o

Answer 69

Repeated bouts of epigastric pain which radiates to the back Pain relieved by sitting forward Pain can be aggravated by eating or drinking alcohol Weight loss Steatorrhoea - greasy, smelly stools Bloating

Answer 70

Weight loss Jaundice - if caused by pancreatic tumour causing obstruction of CBD Epigastric tenderness

Answer 71

Bloods: Serum amylase/lipase - may be normal due to pancreatic insufficiency Bilirubin and ALP - may be elevated if due to tumour compressing CBD Glucose - high due to Diabetes mellitus following loss of endocrine function Ig4 high if autoimmune Ultrasound - may show gallstones ERCP or MRCP: may show stenosis and dilatation of ducts - chains of lakes pattern AXR: pancreatic calcification CT Scan: May show pancreatic calcification and pancreatic cysts Tests of pancreatic exocrine function: Faecal elastase (pancreatic exocrine function) - LOW 72hr stool collection - high fat due to fat malabsorption

Answer 72

``` Adequate fluid intake Alcohol cessation Low fat meals Reduce meat intake Glycaemic control Oral pancreatic enzyme replacement Nutritional supplements ```

Answer 73

``` Local: Pseudocysts Biliary duct stricture Duodenal obstruction Pancreatic ascites Pancreatic carcinoma ``` ``` Systemic: Diabetes mellitus Vitamin A, D, E, K (fat soluble vitamins) deficiency Steatorrhoea Chronic pain syndromes Dependence on strong analgesics ```

Answer 74

Ten-year survival after diagnosis is 20% to 30% lower than the general population Chronic pain usually decreases Depends on aetiology Leading cause of death in alcoholic pancreatitis is CVS disease

Gastrointestinal (3) Flashcards

(99 cards)