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Gastrointestinal Flashcards

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1
Q

What is achalasia and what causes it?

A

An oesophageal motility disorder, characterised by loss of peristalsis and failure of relaxation of the lower oesophageal sphincter due to degeneration of the ganglion cells in the myenteric plexus

Unknown cause

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2
Q

When does achalasia usually present?

A

25-60yo

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3
Q

How does achalasia present?

A 
Insidious onset and gradual progression
Dysphagia - fluids and solids
Difficulty burping
Regurgitation - esp night
Substernal cramps - atypical chest pain
Heartburn
WL
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4
Q

How is achalasia investigated?

A

CXR:
Fluid level in dilated oesophagus
No gastric air bubble
Double R heart border - dilated oesophagus

Barium swallow:
Tapering dilated oesophagus - beak-shaped

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5
Q

What is alcoholic hepatitis?

A

Inflammatory liver injury caused by chronic heavy intake of alcohol

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6
Q

What causes alcoholic hepatitis?

A

Heavy alcohol intake for 15-20 years

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7
Q

What percentage of heavy drinkers develop alcoholic hepatitis?

A

10-35%

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8
Q

How does alcoholic hepatitis present?

A 
Many asymptomatic and undetected
Malaise
D+V
Low appetite
Epigastric to R hypochondria pain
Low grade fever

If severe: jaundice, abdo swelling, swollen ankles, GI bleed

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9
Q

How is alcoholic hepatitis investigated?

A
  1. BLOODS:
    High - WCC, bilirubin, AlkPh, AST/ALT, GGT
    Low - platelets, MCV, Hb, albumin
    Prolonged PT
  2. Percutaneous or transjugular biopsy
    - Centrilobular ballooning
    - Giant mitochondria
    - Degeneration and necrosis of hepatocytes
    - Steatosis
  3. US
  4. Upper GI endoscopy - ?varices
  5. EEG - slow-wave activity for encephalopathy
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10
Q

How is alcoholic hepatitis managed acutely?

A
  1. Thiamine, vit C, multivitamins
  2. Monitor and corect K, Mg, glucose
  3. Ensure adequate UO
  4. Treat encephalopathy - oral lactulose + phosphate enemas
  5. Treat ascites - diuretics (spiro + furosemide)
  6. Treat HRS - glypressin + N-acetylcysteine
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11
Q

How is malnutrition in alcoholic hepatitis managed?

A

Nutrition support - oral or NG
Increase calorie intake
Folic acid, B group, thiamine - start parentally, then orally
If severe: steroids short-term

Long-term - sort out alcohol dependence

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12
Q

What are the complications of alcoholic hepatitis?

A
  • Acute liver decompensation
  • Hepatorenal syndrome (renal failure secondary to advanced liver disease
  • Cirrhosis
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13
Q

What is the prognosis for alcoholic hepatitis?

A

Mortality
1st month - 10%
First year - 40%
If alcohol use continues, most –> cirrhosis in 1-3 years

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14
Q

What is an anal fissure?

A

Tear in the mucosa of the anal canal, just inside the anal margin

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15
Q

How are anal fissures classified?

A

Acute: present <6w
Chronic: present for >6w

Or primary + secondary

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16
Q

What can cause secondary anal fissures?

A

Constipation –> hard stool
IBD –> ulceration w inflammatory process
STD
Rectal malignancy

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17
Q

What causes primary anal fissures?

A

Unclear

Increased anal tone and ischaemia hindering healing process

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18
Q

Who are anal fissures most common in?

A

Below 40

350x more likely in women

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19
Q

How do anal fissures present?

A

Pain on defecation - like passing shards of glass
Pain may persist for several hours after
Bright fresh blood on passing stools

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20
Q

What are the signs of anal fissure O/E?

A

Hard abdo - faecal loading
Linear split of mucosa
Most are posterior to midline
DO NOT ATTEMPT DRE
Acute: clear edges, linear
Chronic: deeper, external skin tag at distal end
Secondary: more likely to be multiple, lateral, irregular demarcation

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21
Q

How are anal fissures managed?

A
  1. Keep stools regular and soft - adequate fluid intake, laxatives, 18-30g fibre/day
  2. Pain relief - analgesia prn, warm baths, GTN ointment (relax SM and decrease anal tone), topical anaesthetic if severe
  3. Topical diltiazem (CCB) –> vasodilation and SM relaxation
  4. Botox
  5. Internal sphincterectomy
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22
Q

What is a side-effect of GTN?

A

Headache

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23
Q

What is a side-effect of botox or surgery for anal fissures?

A

Temporary incontinence/flatus/faeces

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24
Q

What are the complications of anal fissures?

A
  • Tear fails to heal –> chronic, extensive scarring
  • Anal fistula
  • Anal stenosis - scar tissue
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25
What is the prognosis for anal fissures?
Most heal in 2w with conservative management Recurrence is common, 50% of those who use GTN For secondary, depends on pathology
26
What is appendicitis?
Sudden inflammation of the appendix usually initiated by obstruction of the lumen
27
What causes appendicitis?
Gut organisms invade wall after luminal obstruction by lymphoid hyperplasia, faecolith or filarial worms Leads to oedema, ischaemic necrosis, perforation
28
What is the most common cause of acute abdomen in the UK?
Appendicitis
29
When is appendicitis most common?
10-20yo
30
What are the symptoms of appendicitis?
Pain - early periumbilical pain --> RIF as peritoneum becomes involved, worse on moving, breathing, coughing N+V + low appetite - usually constipated, low fever
31
What are the signs of appendicitis O/E?
Localised tenderness, guarding and rebound tenderness in RIF Rovsing's sign -> +ve if pain in RIF is greater than LIF when LIF pressed Psoas sign -> pain on extending hip of retrocaecal appendix Cope sign -> pain on flexion and internal rotation of right hip -> if appendix in close relation to obturator internus
32
What are the complications of appendicitis?
Rupture > faecal matter into peritoneal cavity > peritonitis Appendix mass may form > surrounded by omentum > adheres
33
How is appendicitis managed?
Appendectomy
34
What is an appendectomy?
Surgical removal of the vermiform appendix
35
What are the indications for an appendectomy?
Acute appendicitis
36
What are the possible complications of an appendectomy?
Uncommon ``` Ileus Haemorrhage Wound infection Local abscess Pelvic abscess ```
37
What is autoimmune hepatitis?
An inflammatory liver disease of unknown cause characterised by suppressor T-cell defects with autoantibodies directed against hepatocyte surface antigens
38
How is autoimmune hepatitis classified?
Based on different autoantibodies Type 1 (classic) - ANA, ASMA, AAA (anti-actin), ASLA (anti-soluble liver antigen) Type 2 - ALKM-1 (liver/kidney microsomes), ALC-1
39
What causes autoimmune hepatitis?
Genetically predisposed Environmental agent - virus or drugs Leads to hepatocyte expression of HLA antigens T-cell mediated AI attack of these hepatocytes Chronic inflammatory changes Lymphoid infiltration of portal tracts Hepatocyte necrosis > fibrosis > cirrhosis
40
What are the risk factors for autoimmune hepatitis?
Personal Hx of Ai disesae | FHx
41
Who is autoimmune hepatitis most common in?
WOMEN Bimodal: 10-30 and >40 yo Mostly young or middle aged women
42
How does autoimmune hepatitis present?
Insidious onset 40% present with acute hepatitis + signs of AI disease: Fever, malaise, low appetite, jaundice, n+v, RUQ pain, urticaria, pleurisy, pulmonary infiltration, glomerulonephritis +- serum sickness - polyarthritis, arthralgia, maculopapular rash +- keratoconjunctivitis sicca - dry eye syndrome Everyone else - gradual jaundice or asymptomatic Amenorrhoea common
43
What are the signs of autoimmune hepatitis O/E?
Stigmata of CLD Spider naevi Later - oedema, ascites, encephalopathy Cushingoid features
44
What is Barrett's oesophagus?
A change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia (columnar)
45
What causes Barrett's oesophagus?
Prolonged exposure or normal distal oesophageal squamous epithelium to GORD reflux (stomach acid) Causes mucosal inflammation and erosion Leads to replacement of mucosa with metaplastic columnar epithelium
46
What are the complications of Barrett's oesophagus?
Oesophageal adenocarcinoma Oesophageal stricture QOL deficit
47
What are the risk factors for Barrett's oesophagus?
3-5% of GORD sufferers get it | Increased risk if had it for longer/more frequent symptoms
48
Who usually gets Barrett's oesophagus?
White men | Increasing age
49
How is Barrett's oesophagus diagnosed?
Biopsy of endoscopically visible columnisation | Allows histological corroboration using Prague criteria
50
What are the symptoms of Barrett's oesophagus?
Regurgitation | Heartburn
51
How is Barrett's oesophagus managed?
1. PPI + surveillance 2. Anti-reflux surgery If dysplastic: 3. Radiofrequency ablation +- mucosal resection 4. Oesophagectomy
52
What is cirrhosis?
End-stage of chronic liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
53
What happens when cirrhosis decompensates?
``` Complications Ascites Jaundice Encephalopathy GI bleeding ```
54
What does cirrhosis look like histologically?
Loss of normal hepatic architecture Bridging fibrosis Nodular regeneration
55
What are the most common causes of cirrhosis?
UK: alcohol abuse WW: HBV, HCV
56
What genetic diseases can cause cirrhosis?
Haemochromatosis Alpha-1 antitrypsin deficiency Wilson's disease CF
57
What are the causes of cirrhosis?
Alcohol abuse HBV, HCV Genetic: haemochromatosis, a1-AT def, Wilson's CF NASH Chronic biliary disease - PBC, PSC AI hepatitis Hepatic vein events - Budd-Chiari, congestion Drugs - methotrexate, amiodarone, methyldopa
58
What drugs can cause cirrhosis?
Methotrexate Amiodarone Methyldopa
59
What can trigger cirrhosis decompensation?
``` Infection GI bleeding Constipation High protein meal Electrolyte imbalances Alcohol/drugs Tumour development Portal vein thrombosis ```
60
How does cirrhosis present?
Early - non-specific - low appetite, weakness, WL, fatigue, n Decreased liver synthetic function - easy bruising, abdo swelling, ankle oedema Decreased detox function - jaundice, personality change, altered sleep, amenorrhoea Portal HTN - abdo swelling, haematemesis, PR bleeding, melaena May be asymp besides raised LFTs
61
What are the signs of CLD O/E?
``` Nail clubbing Palmar erythema Spider nevi (angiomata) Gynaecomastia Feminising hair distribution Testicular atrophy Small irregular shrunken liver Anaemia Caput medusae ```
62
What are the signs of liver decompensation O/E?
Encephalopathy: Drowsiness Hyperventilation Asterixis Jaundice (excretory dysfunction) Ascites (portal hypertension and hypoalbuminemia) Leukonychia (hypoalbuminaemia) Peripheral oedema (hypoalbuminaemia) Bruising (coagulopathy) Acid-base imbalance, most commonly respiratory alkalosis
63
How is cirrhosis investigated?
1. BLOODS: FBC (low Hb, platelets due to hypersplenism) LFTs may be normal Raised transaminases/GGT/bili + low albumin ``` 2. CLOTTING Prolonged PT (due to reduced synthesis of clotting factors) ``` 3. IMAGING US/CT/MRI to detect complications
64
How is cirrhosis managed?
Treat cause Avoid alcohol, sedatives, NSAIDs, drugs that affect liver Monitor nutrition, if dietary intake is poor, give enterally
65
What is Coeliac disease?
Inflammatory disease caused by intolerance to gluten, causing chronic intestinal malabsorption
66
What causes Coeliac disease?
HLA-DQ2/8 T-cell mediated Prolamin (alcohol-soluble proteins in wheat, barley, rye, oats) intolerance causes villous atrophy and malasborption
67
What conditions is Coeliac disease associated with?
``` AI disease Dermatitis herpetiformis (chronic watery, itchy blisters on extensor surfaces) ```
68
Who is Coeliac disease most common in?
Irish | Children + 50-60yos
69
What are the symptoms of Coeliac disease?
1/3 asymptomatic - Steatorrhoea - Diarrhoea - Abdo pain, bloating - N+v, WL, fatigue, malaise - Failure to thrive in kids - Amenorrhoea
70
What are the signs of Coeliac disease O/E?
- Aphthous ulcers, angular stomatitis - Dermatitis herpetiformis - Anaemia: pallor, weakness - Malnutrition: short, abdo distension, wasted buttock, decreased triceps skinfold thickness - Vit/min deficiencies: osteomalacia, easy bruising
71
How is Coeliac disease investigated?
1. BLOODS - IDA (low Hb + MCV)/ macrocytic anaemia (if folate/B12 deficiency) 2. IgA-tTg test/endomysial antibody (if Iga-tTg not available) 3. Small bowel histology - presence of intra-epithelial lymphocytes, villous atrophy, and crypt hyperplasia
72
How is Coeliac disease managed?
Avoid gluten | Vitamin and mineral supplements
73
What are the complications of Coeliac disease?
Iron, folate, B12 deficiency Osteomalacia Ulcerative jujunoileitis GI lymphoma
74
What is colonoscopy?
Endoscopic examination of large bowel and distal small bowel, using a fibre optic camera, passed on a flexible tube through the anus
75
What are the indications for colonoscopy?
- GI haemorrhage - Unexplained changes in bowel habits/suspected malignancy - Diagnose CRC and IBD - Older patients: drop in hct (IDA) - Positive FOB
76
What are the possible complications of colonoscopy?
GI perforation 1:2000 Bleeding 2.6:1000 Death 3:100,000
77
What is Crohn's disease?
Chronic granulomatous inflammatory disease that can affect any part of the GI tract
78
What are the characteristic features of Crohn's disease?
Skip lesions | Transmural inflammation
79
What are the risk factors for Crohn's disease?
Mutation of NOD2/CARD15 gene Smoking x4 NSAIDs may exacerbate
80
When does Crohn's disease incidence peak?
10-30y
81
Who usually gets Crohn's disease?
10-30yo women | Lower prevalence in Asian
82
What are the signs of Crohn's disease?
WL Clubbing Signs of anaemia - pallor, weakness Abdo tenderness/masses Aphthous ulcers in mouth Perianal skin tags, fistulae, abscesses, anal strictures Signs of complications - eye/joint/skin disease
83
What are the symptoms of Crohn's disease?
Crampy abdo pain Diarrhoea w urgency +- blood/steatorrhoea Fever, malaise, Wl, low appetite
84
How is Crohn's disease investigated?
1. FBC - anaemia, leukocytosis/thrombocytosis, high ESR/CRP (inflammation), U+E, LFTs (low Alb) 2. Iron studies - ?GI bleeding/malabsorption 3. Low B12/folate 4. Stool culture: exclude infectious colitis 5. AXR: look for complications of toxic megacolon 6. Erect CXR: if perforation risk 7. Small bowel barium follow-through: fibrosis/strictures/deep ulceration 8. Colonoscopy + biopsy: differentiate between CD and UC, monitor progression, malignancy
85
What is seen on colonoscopy of CD?
Mucosal oedema and ulceration - rose thorn fissures, cobblestone mucosa Fistulae Abscesses Transmural chronic inflammation + infiltration of macrophages, lymphocytes, plasma cells
86
What are the complications of CD?
GI: SBO, toxic dilatation, haemorrhage, bowel stricture, perforation, fistulae, perianal fistulae and abscess, GI carcinoma, malabsorption
87
What are the extra-intestinal features of IBD?
Eyes: uveitis, episcleritis Gallstones, kidney stones Joints: arthropathy, sacroilitis, ankylosing spondylitis Skin: erythema nodosum, pyoderma gangronosum Amyloidosis
88
What is the prognosis for CD?
Chronic relapsing condition | 2/3 need surgery eventually
89
How is CD managed?
1. Steroids for acute exacerbations - IV hydrocortisone 2. 5-ASA analogues (sulfasalazine, mesalazine) to induce remission 3. Immunosuppression - azathioprine, methotrexate, 6-mercatopurine 4. Anti-TNF agents - infliximab, adalimumab Advice: stop smoking, dietician referral Surgery if medical Tx doesn't work
90
What is diverticular disease?
Diverticulae are present and symptomatic (associated with complications, eg haemorrhage, fistulae, infection)
91
What is a diverticulum?
Outpouching of colonic mucosa and submucosa through the muscular wall of the large bowel, usually at sites on entry of perforating arteries
92
What is diverticulosis?
Presence of asymptomatic diverticulae
93
What is diverticulitis?
Acute inflammation and infection of the diverticulae
94
What are the risk factors for diverticular disease?
Low fibre - loss of stool bulk > increased intraluminal pressures required to propel stool > mucosa must herniate through muscle layers Over 50 years Obesity ``` Little exercise Red meat Alcohol Caffeine Steroids NSAIDs ```
95
Where are most diverticulae present?
Sigmoid colon
96
Who usually gets diverticular disease?
30% of Westerners have diverticulosis by age 60 | Rare under 40
97
What is a symptom of diverticulosis?
Altered bowel habit
98
What are the signs of diverticulitis?
Localised tenderness Palpable mass (sometimes) Local/generalised peritonitis if perforation has occurred +- reduced BS (may be increased w obstruction)
99
What are the symptoms of diverticular disease?
Bloating Constipation Mild LLQ pain
100
How does diverticulitis present?
``` LLQ pain Fever Tachycardia Localised/generalised peritonism High WCC, CRP, ESR Reduced BS ```
101
What are the complications of diverticulitis?
1. Perforation > peritonitis 2. Abscess - tender mass, persistent fever 3. Fistulae - colovesicula (pneumaturia, faecaluria)/colovaginal (stool through vagina, freq vaginal infections, discharge) 4. Stricture/obstruction - progressive fibrosis from recurrent episodes
102
How is diverticular disease investigated?
1. BLOODS - FBC (high WCC, CRP in diverticulitis) Check clotting and XM if bleeding 2. Barium enema +- air contrast - shows presence of diverticulae w saw-tooth appearance of lumen 3. Flexi-sigmoidoscopy
103
How is diverticular disease managed?
Diverticulosis - high fibre diet, probiotics, anti-inflammatories (mesalazine) GI bleeding - manage conservatively with IV rehydration, ABx and transfusions Complications - surgery - resection + stoma
104
What is ERCP?
Technique that combines the use of endoscopy and fluoroscopy to diagnose and treat problems of the biliary/pancreatic ductal systems. Can inject a contrast medium into the biliary ducts and pancreas so they can be seen on radiographs
105
What are the indications for ERCP?
``` Obstructive jaundice Gallstones w dilated bile ducts on USS Biliary strictures/suspected bile duct tumours Suspected injury to bile ducts Sphincter of Oddi dysfunction Chronic pancreatitis Suspected pancreatic tumour Endoscopic sphincterotomy Removal of stones Insertion of bile duct stents Dilation of strictures in PSC or anastomostic strictures on liver transplant ```
106
What are the possible complications of ERCP?
Pancreatitis Intestinal perforation Allergy to contrast dye (iodine) Oversedation - low BP, resp depression, n+v
107
What is endoscopy - OGD?
Oesophagogastroduodenoscopy Telescopic examination of the inside of the oesophagus, stomach and duodenum Biopsies can also be taken
108
What are the indications for OGD?
``` PUD diagnosis Haematemesis Melaena Dyspepsia Dysphagia Coeliac disease - biopsy Confirming suspected malignancy ```
109
What are the possible complications of OGD?
Minor - bleeding, infection | Major - perforation
110
What are gallstones
Stone formation in the gallbladder
111
What does bile contain?
Cholesterol Phospholipids Bile pigments - broken down Hb
112
What are the risk factors for gallstones?
5 Fs | Fair, fat, female, fertile, forty
113
Who usually gets gallstones?
Women 3x more in younger population | M=F after 65y
114
What are the signs of gallstones?
90% asymp | RF for being symptomatic - smoking, obesity
115
How are gallstones investigated?
USS - Acoustic shadow within gallbladder - Increased diameter of GB wall - Dilatation of biliary tree
116
What are the different types of gallstones?
PIGMENT STONES - 10& Small, friable, irregular, radiolucent Associated w haemolytic disorders - SCD, thalassaemia, spherocytosis BLACK/BROWN CALCIUM BILIRUBINATE STONES Increased bili due to haemolysis/cirrhosis Or brown due to stasis and infection (bile duct infestation) MIXED STONES Ca, salts, pigments, cholesterol Associated w increased age, F, obese, TPN, OCP, octreotide, FH, ethnicity, CD, ileal resection
117
What causes biliary colic?
Symptomatic gallstones with cystic duct obstruction or if passed into CBD
118
How does biliary colic present?
``` Sudden onset, severe RUQ/epigastric pain, radiating to back Constant Worse after fatty meal Associated n+v May last several hours Subsides spontaneously/with analgesia +- jaundice ```
119
What causes cholangitis?
Gallstone obstructs CBD Leads to bile duct infection, biliary obstruction Also caused by strictures, stenosis, parasites, tumours
120
What is cholangitis?
Infection of the biliary tree | Most commonly caused by obstruction
121
What is Charcot's triad of cholangitis?
RUQ pain + jaundice + rigors
122
How does cholangitis present?
``` Fever RUQ pain Jaundice Mental status change Tachycardia Hypotension ```
123
How can you differentiate between biliary colic, acute cholecystitis and cholangitis?
Biliary colic: RUQ pain Acute cholecystitis: RUQ pain + fever/high WCC Cholangitis: RUQ pain + fever/high WCC + jaundice
124
How is cholangitis investigated?
1. BLOODS High WCC/Ur/Cr/bili/transaminases/AlkPh/CRP Low platelets/K/Mg Culture: Gram -ve usually (sepsis) 2. IMAGING ERCP/abdominal USS - dilated bile duct
125
How is cholangitis managed?
1. IV ABx - piperacillin/tazobactam 2. Non-operative biliary decompression - ERCP +- sphincterotomy and placement of drainage stent 3. Opioid analgesics 4. Lithotripsy if stones hard to remove
126
How are gallstones treated?
Cholecystectomy ERCP with biliary sphincterotomy and stone extraction Lithotripsy
127
What are the complications of gallstones in the GB and cystic duct?
Biliary colic Acute/chronic cholecystitis Mucococele: obstructed GB fills with mucus Empyema: obstructed GB fills with pus Carcinoma Mirizzi's syndrome: stone in GB presses on bile duct causing jaundice
128
What are the complications of gallstones in the bile ducts?
Obstructive jaundice Cholangitis Pancreatitis
129
What are the complications of gallstones in gut?
Gallstone ileus | Gallstone erodes through GB not duodenum, obstruction of terminal ileum
130
What is cholecystitis?
Acute inflammation of the gallbladder | Major complication of gallstones in cystic duct
131
What causes cholecystitis?
Complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall
132
What are the risk factors for cholecystitis?
``` Gallstones Female Increasing age Obesity Rapid WL Pregnancy CD High lipids ```
133
What are the symptoms of cholecystitis?
Continuous epigastric/RUQ pain May refer to R shoulder due to diaphragmatic irritation Vomiting Fever
134
What are the signs of cholecystitis?
``` Tachycardia Pyrexia RUQ/epigastric tenderness Local peritonism +- GB mass Positive Murphy's sign - 2 fingers over RUQ, ask pt to breathe in deeply, +ve if this causes pain and arrest of inspiration as inflamed GB hits fingers (must not cause same pain in LUQ) ```
135
How is cholecystitis investigated?
1. BLOODS FBC (high WCC) High CRP LFTs - high bilirubin, AlkPh, GGT (cholestatic picture) 2. RUQ USS - thick-walled, shrunken GB, pericholecystic fluid, stones, CBD dilatation
136
How is cholecystitis managed?
Mild-moderate: NPO, IV fluids, ABx (cefuroxime), analgesia, close monitoring of blood pressure, pulse, and urinary output Severe: urgent cholecystectomy + ITU
137
What are the complications of cholecystitis?
Perforation Gangrenous cholecystitis Gallstone ileus
138
What is cholecystectomy?
Surgical removal of the gallbladder
139
What are the indications for cholecystectomy?
1. Symptomatic cholelithiasis | 2. Cholecystitis
140
What are the possible complications of cholecystectomy?
Early - infection, haemorrhage, bile leak, injury to CBD/other bile ducts Late - postcholecystectomy syndrome (persistent dyspeptic symptoms), port-site hernias
141
What is GORD?
Inflammation of the oesophagus caused by reflux of gastric acid and/or bile
142
What causes GORD?
Lower oesophageal sphincter hypotension due to: - Abdominal obesity / overeating - Gastric acid hypersecretion - Hiatus hernia - Slow gastric emptying - Smoking, alcohol, pregnancy - Surgery for achalasia - Drugs - tricyclics, anticholinergics, nitrates - Systemic sclerosis
143
What are the RFs for GORD?
- Abdominal obesity - Gastric acid hypersecretion - Hiatus hernia - Slow gastric emptying (fatty meal) - Overeating - Smoking, alcohol, pregnancy - Surgery for achalasia - Drugs - tricyclics, anticholinergics, nitrates - Systemic sclerosis - Anything causing increased intra-abdominal pressure or inadequate cardiac sphincter
144
What are the symptoms of GORD?
``` Heartburn - worse after meals, lying, alcohol, bending over Burping Acid brash: acid/bile regurg Water brash: increased salivation Painful swallowing ``` Nocturnal asthma Chronic cough Laryngitis - hoarseness Sinusitis
145
What are the signs of GORD O/E?
Sometimes epigastric tenderness Wheeze Dysphonia
146
How is GORD investigated?
1. Upper GI endoscopy, biopsy and cytological brushings - confirm oesophagitis, exclude malignancy (all patients over 45) 2. Barium swallow - detect hiatus hernia, peptic stricture, extrinsic compression of oesophagus 3. CXR - hiatus hernia - gastric bubble behind cardiac shadow 4. 24h oesophageal pH monitoring
147
How is GORD managed?
1. Lifestyle advice - WL, elevate head of bed, stop smoking, lower fat meals 2. Medical - antacids + alginates/H2 antagonists - ranitidine/PPI - lansoprazole 3. Endoscopy - annual for Barrett's oesophagus 4. Surgery - anti-reflux surgery 5. Nissen fundoplication - fundus of stomach wrapped around lower oesophagus and help with seromuscular sutures, helps reduce hiatus hernias and reflux
148
What are the complications of GORD?
``` Oesophageal ulceration Peptic strictures Anaemia Barrett's oesophagus Oesophageal adenocarcinoma Asthma Chronic laryngitis ```
149
What is gastroenteritis?
Acute inflammation of the lining of the GI tract, manifested by nausea, vomiting, diarrhoea and abdo discomfort
150
What causes gastroenteritis?
Viruses, bacteria, protozoa or toxins in contaminated food or water ``` Improperly cooked meat: S. aureus, C. perfringens Old rice: B. cereus, S. aureus Eggs/poultry: Salmonella Milk/cheese: Listeria, Campylobacter Canned food: Botulism ``` Inflammatory mechs: cytokine release > epithelial invasion > damage and bacteraemia (Shigella, Enteroinvasive E. Coli, Salmonella) Non-inflamm mechs: production of enterotoxins, causing enterocytes to secrete water and electrolytes (V. Cholera, eneterotoxigenic E. coli)
151
What are the risk factors for gastroenteritis?
``` Recent travel Poor personal hygiene Undercooked food Swimming in contaminated water Exposure to others with GE Compromised immune system - AIDS Achlorhydria - absence of HCl in gastric secretions ```
152
How does gastroenteritis present?
``` Sudden onset n+v Diarrhoea (bloody or watery) Abdo pain Fever Malaise ```
153
How does time on onset of gastroenteritis change depending on causative organism?
Toxins - early, 1-24h Bacterial/viral/protozoal - 12h later Parasites - days
154
What are the signs of gastroenteritis O/E?
Diffuse abdo tenderness Abdo distension Increased BS Severe: fever, dehydration, hypotension, peripheral shutdown
155
How is gastroenteritis investigated?
1. BLOODS - FBC/culture/UE 2. Stool MCS 3. AXR/US to exclude other causes
156
How is gastroenteritis managed?
Bed rest Fluid and electrolyte replacement IV rehydration with severe vomiting Most self-limiting
157
What are the complications of gastroenteritis?
``` Dehydration Electrolyte imbalance Prerenal failure Secondary lactose intolerance, esp in kids Sepsis, shock HUS (E. Coli 0157) GBS (Campylobacter) Botulism (resp muscle weakness or paralysis) ```
158
What is GI perforation?
Perforation of the wall of the GIT with spillage of bowel contents Medical emergency, life-threatening
159
What can cause perforation?
``` Appendicitis Cancer IBD Diverticulitis GB disease Peptic ulcer Trauma - blunt or sharp ```
160
How does perforation present?
Severe abdo pain, worse on palpation and mvmt Chills and fever NV Bowel - pain at site then spreads across abdo Gastric - burning epigastric pain, flatulence and dyspepsia Duodenal - sudden epigastric pain, R of midline
161
What are the signs of perforation O/E?
Rigid, silent, distended abdomen w tenderness and rebound tenderness No flatus/motion Distended abdomen
162
How is perforation investigated?
Erect CXR - gas under diaphragm (70% perforated peptic ulcer) AXR - abnormal gas shadows in tissues/Rigler's sign (gas on either side of bowel wall)
163
What is peritonitis?
Inflammation of the peritoneum | Perforation of the intestine causes the contents to leak into abdo cavity
164
How does peritonitis present?
``` Fatigue Oliguria SOB Tachycardia Dizziness ```
165
What are the signs of peritonitis O/E?
Positive cough test - coughing causes pain in abdo Tenderness +- rebound pain Board like abdo rigidity Absent BS
166
What are haemorrhoids?
Disrupted and dilated anal cushions
167
What causes haemorrhoids?
Gravity + increased anal tone + straining
168
What are the risk factors for haemorrhoids?
``` Constipation Prolonged straining Derangement of internal anal sphincter Pregnancy Portal HTN ```
169
How do haemorrhoids present?
Bright red rectal bleeding +- mucous, pruritis ani +- anaemia No WL, tenesmus, change in bowel habits
170
How are haemorrhoids investigated?
Protoscopy or sigmoidoscopy to view internal haemorrhoids
171
How are haemorrhoids managed?
1. Dietary and lifestyle modification - 25-30g fibre/day 2. Rectal hydrocortisone 3. Rubber band ligation/sclerotherapy/IR photocoagulation/ligation/haemorrhoidopexy 4. Surgical haemorrhoidectomy
172
What are the complications of haemorrhoids?
``` Anaemia Thrombosis Incarceration Faecal incontinence Pelvic sepsis Anal stenosis ```
173
What are the indications for haemorrhoidectomy?
- Thrombosed external haemorrhoids which are diagnosed <72h | - Internal haemorrhoids - failed medical management
174
What are the complications of haemorrhoidectomy?
- Anal fistula/fissure - Continued constipation - PR bleeding - Excessive fluid discharge from rectum - Pyrexia - Unable to urinate or defecate
175
What is a hernia?
A protrusion of a viscus through an abdominal opening
176
What is a femoral hernia?
Bowel enters femoral canal, appears below and lateral to the pubic tubercle, medial to femoral pulse
177
What causes femoral hernias?
Increased intraabdominal pressure with pressure on the weakened area (enlarged prostate, pregnancy, frequent cough, chronic constipation, intense workouts)
178
Who are femoral hernias most common in?
Women 4x
179
Where is the neck of a femoral hernia?
Inferior and lateral to pubic tubercle
180
Where is an indirect inguinal hernia?
Passes through internal inguinal ring and out through external Runs lateral to inferior epigastric vessels
181
Where is a direct inguinal hernia?
Emerges through Hesselbach's triangle Pushes directly forward through posterior wall of inguinal canal, into a defect in abdominal wall Runs medial to inferior epigastric vessels
182
Who are indirect and direct inguinal hernias more common in?
Indirect - children due to failure of closure of inguinal canal during development Direct - elderly
183
What are the risk factors for inguinal hernias?
``` Increased intra-abdo pressure: Chronic cough Constipation Urinary obstruction Heavy lifting Ascites Abdo surgery Infants: prematurity, male ```
184
How can hernias be investigated?
Ultrasound
185
How are inguinal hernias managed?
Asymp: watchful waiting | Incarcerated/strangulated: urgent surgical repair + prophylactic ABx (cefazolin)
186
How can you differentiate between femoral and inguinal hernias on examination?
Ask patient to cough Femoral: inferior and lateral to pubic tubercle Inguinal: superior and medial
187
How can you differentiate between a direct and an indirect inguinal hernia on examination?
Reduce hernia Occlude deep inguinal ring with 2 fingers Ask pt to cough If hernia is restrained --> indirect
188
What is a hiatus hernia?
Herniation of part of the gastric cardia through the oesophageal aperture of the diaphragm
189
What causes hiatus hernias?
1. Widening of diaphragmatic hiatus 2. Pulling up of stomach due to oesophageal shortening 3. Pushing up of stomach due to increased intra-abdominal pressures
190
What are the risk factors for hiatus hernias?
``` Increasing age Obesity Pregnancy Ascites Genetic predisposition Shortening of oesophagus, e.g. chronic oesophagitis ```
191
Who are hiatus hernias most common in?
Obese women | People with Barrett's oesophagus
192
What do hiatus hernias increase your risk of?
6x oesophageal adenocarcinoma
193
How do hiatus hernias present?
``` Many asymptomatic Heartburn Flatulence GORD Dysphagia (rarely) ```
194
In what type of hiatus hernias is acid reflux more common?
Sliding (gastro-oesophageal junction slides up into chest) - LOS is less competent
195
How are hiatus hernias managed?
PPIs for symptomatic GORD | Surgical repair + Nissen's fundoplication
196
How are hiatus hernias investigated?
CXR - retrocardiac air bubble/normal | Upper GI series - stomach is partially/completely intrathoracic
197
What is intestinal ischaemia?
A group of disorders that cause decreased blood flow to the GI tract
198
What are the 3 main types of intestinal ischaemia?
Acute mesenteric Chronic mesenteric Chronic colonic
199
What causes acute intestinal ischaemia?
ARTERIAL: thrombotic - atherosclerosis, embolic - MI, AF, endocarditis NON-OCCLUSIVE: low-flow state, e.g. decreased CO VENOUS: embolus, thrombosis - hypercoag disorders, tumours, infection OTHER: trauma, vasculitis, radiotherapy, strangulation (volvulus, hernia)
200
What causes chronic intestinal ischaemia?
Low-flow state + atheroma
201
How does acute intestinal ischaemia present?
Moderate-severe colicky/constant poorly localised pain (RIF) + no abdo signs + shock Physical findings out of proportion with degree of pain Later stages - peritonism +- mass
202
What is chronic mesenteric ischaemia?
AKA intestinal angina Chronic atherosclerotic disease of vessels supplying intestine Usually all 3 major mesenteric arteries involved
203
Who usually gets the 3 different types of intestinal ischaemia?
Acute mesenteric - over 50s + young w RFs Chronic mesenteric - over 60s Chronic colonic - over 60s + young w non-CV causes (OCP+cocaine)
204
What causes chronic mesenteric ischaemia?
Atherosclerotic causes
205
How does chronic mesenteric ischaemia present?
``` Postprandial severe, colicky pain Weight loss (eating hurts) Upper abdo bruit +- PR bleed, NV, malabsorption Usually Hx of CV disease ```
206
What is chronic colonic ischaemia also known as?
Ischaemic colitis
207
What is chronic colonic ischaemia?
Compromise of blood flow to colon Transverse and descending segments at risk due to supply from marginal branches and arterial/lymphatic watershed near splenic flexure
208
What causes chronic colonic ischaemia?
``` Thrombosis Emboli Decreased CO Arrhythmias Shock Trauma Strangulated hernia/volvulus Surgery Vasculitis - SLE Coag disorders ```
209
What are the signs of chronic colonic ischaemia?
Acute onset abdo pain (LIF) NV Loose motion w dark blood
210
What causes small bowel obstruction?
Hernias | Adhesions
211
What causes large bowel obstruction?
Colon cancer Constipation Diverticular stricture Volvulus
212
What are the rare causes of intestinal obstruction?
``` Crohn's stricture Gallstone ileus Intussusception TB Foreign body ```
213
What are the symptoms and signs of intestinal obstruction?
``` N+V Low appetite Faeculent vomiting Colic Constipation Abdo distension Tinkling bowel sounds ```
214
How do the symptoms of small and large bowel obstruction differ?
Small: vomiting occurs earlier, less distension, more pain Large: more constant, more distension
215
How is intestinal obstruction investigated?
AXR Small bowel: central gas shadows with valvulae conniventes (completely cross lumen) + no gas in large bowel Large bowel: peripheral gas shadows proximal to blockage but not in rectum + haustra do not cross lumen's width
216
What is ileus?
Functional obstruction from reduced peristalsis and bowel motility - no pain and absent bowel sounds
217
What are the complications of intestinal obstruction?
Perforation Sepsis Death
218
What is irritable bowel syndrome?
``` A functional bowel disorder defined as recurrent episodes (in the absence of detectable organic pathology) of abdo pain/discomfort for more than 6 months of the previous year, associated with 2 of the following: Altered stool passage Abdo bloating Symptoms worse on eating Passage of mucous ```
219
What are the risk factors for IBS?
Visceral sensory abnormalities Gut motility problems Stress Food intolerance
220
Who is IBS most common in?
Women 2x | Under 40
221
What are the symptoms of IBS?
>6m hx of abdo pain relieved by defecation/associated w altered stool form/bowel frequency >3 daily/<3/weekly AND more than 2 of: urgency, incomplete evacuation, abdo bloating, mucous PR< tenesmus, worsening of symptoms after food Also: nausea, bladder symptoms, backache
222
How is IBS investigated?
1. FBC: NORMAL (if anaemia, or anything raised --> not IBS) 2. STOOL SAMPLE: normal (if not --> GE) 3. Anti-tTG/anti-EMA: normal (raised in Coeliac) 4. AXR: normal (no obstruction) 5. Flexisig/colonoscopy: normal mucosa (not IBD)
223
How is IBS managed?
1. Lifestyle modification - less caffeine/lactose, more fibre 2. Anti-diarrhoeals - loperamide 3. Laxatives - ispaghula/lactulose 4. Anti-spasmodics - dicycloverine/peppermint oil
224
What are the complications of laparoscopic abdominal surgery?
Immediate - extraperitoneal insufflation, injury to viscera/vessels Early - shoulder tip pain, wound infection, peritonitis, bile duct injury Late - incisional hernia
225
What is a liver abscess?
Purulent collections in the liver parenchyma that result from bacterial, fungal, or parasitic infection
226
What causes liver abscesses?
Pyogenic liver abscess: often polymicrobial E. Coli Klebsiella Streptococcus constellatus/anginosus/intermedius Enterococcus Anaerobes: Bacteroides fragilis, Fusobacterium necrophorum 60% by biliary tract disease - gallstones, strictures, cysts: Amoebic: Entamoeba histolytica Hyadatid: tapeworm Echinoccous granulosis TB
227
Where are pyogenic, amoebic and hyadatid liver abscesses most common?
Pyogenic - industralised world Amoebic - Central and South America, Africa, Asia Hyadatid - sheep-raring countries
228
How do liver abscesses present?
``` Fever, malaise, nausea, low appetite, night sweats, WL Jaundice Diarrhoea PUO RUQ/epigastric pain --> shoulder Tender hepatomegaly R pleural effusion - dull + reduced BS ```
229
How are liver abscesses investigated?
1. BLOODS FBC: leukocytosis, elevated neutrophil count, anaemia LFTs: high alk phos, mildly high aminotransferases and bilirubin, hypoalbuminaemia Culture PT/APTT: normal (check before doing aspiration) 2. Liver US 3. Contrast abdo CT: hypodense liver lesions 4. Gram stain and culture of aspirated fluid
230
What is a liver cyst?
A closed sac containing air, fluid or semi-solid material (not pus --> abscess) Cells making shell of sac are abnormal
231
What causes liver failure?
Infection: viral hepatitis (B,C,CMV) / yellow fever Drugs: paracetamol OD, halthane, isoniazid Toxins: Amanita phalloides mushroom, carbon tetrachloride Vascular: Budd-Chiari syndrome, veno-occlusive disease Others: alcohol, PBC, haemochromatosis, AI hep, a1AT deficiency, Wilson's, fatty liver of pregnancy, malignancy
232
What percentage of acute liver failure is due to paracetamol OD in the UK?
50%
233
What are the symptoms of liver failure?
May be asymptomatic Fever Nausea +- Jaundice
234
What are the signs of liver failure?
``` Jaundice Hepatic encephalopathy Fetor hepaticus (pear drops) Asterixis Constructional apraxia +- Ascites or splenomegaly Bruising or bleeding for puncture sites of GIT ```
235
What is a mallory-weiss tear?
Lacerations in region of gastro-oesophageal junction, often caused by retching
236
How is acute liver failure investigated?
1. LFTS - high bilirubin, high liver enzymes 2. INR - high 3. Urea and creatinine - high 4. FBC - leukocytosis, anaemia, thrombocytopenia 5. Hepatitis markers
237
What are the risk factors for NASH?
``` Alcohol Obesity DM Hyperlipidaemia Drugs - amiodarone, tamoxifen Total parenteral nutrition ```
238
How does NASH present?
Asymptomatic +- Hepatomegaly Splenomegaly + ascites --> cirrhosis not NASH
239
How is NASH investigated?
LFTs - AST/ALT ratio < 1 (>2 --> alcohol use) | Liver biopsy - fatty liver
240
How is NASH managed?
``` Address cause Weight reduction Diabetic control Alcohol abstinence Drug cessation ```
241
What is acute pancreatitis?
Acute inflammatory process of the pancreas
242
What causes acute pancreatitis?
Insult results in activation of pancreatic proenzymes within duct/acini resulting in tissue damage and inflammation Most common causes: alcohol (80%), gallstones Drugs: steroids, azathioprine, thiazides, valproate, furosemide Trauma, infection, abdo surgery, high lipids, hyperPT, anatomical, idiopathic
243
How does acute pancreatitis present?
Gradual or sudden severe epigastric pain, radiates to back, relieved sitting forward, worse on movement N+V Decreased appetite Hypovolaemia - low BP, sweating, tachycardia, dry mucous membranes, tachypnoea Rigid abdomen Cullen's + Grey-Turner's - haemorrhagic
244
What are the risk factors for acute pancreatitis?
``` Men 40-55 - alcohol Women 50-70 - gallstones Alcohol High lipids Drugs: steroids, azathioprine, thiazides, valproate, furosemide ERCP Trauma SLE Sjogren's ```
245
How is acute pancreatitis investigated?
``` BLOODS - Serum lipase/amylase - 3x normal AST/ALT - 3x normal - gallstone disease FBC - leukocytosis + high hct (dehydration)/low hct (haemorrhage) ABG - hypoxaemia ``` IMAGING- AXR - isolated dilatation of a segment of gut adjacent to pancreas + cut-off sign CXR - atelectasis + pleural effusion
246
What is chronic pancreatitis?
Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain
247
What are the causes of chronic pancreatitis?
Alcohol 70% Idiopathic 20% Rarely: familial, CF, haemochromatosis, pancreatic duct obstruction, hyperPTH congenital (pancreatic divisum), AI pancreatitis
248
What are the symptoms of chronic pancreatitis?
``` Recurrent severe epigastric pain radiating to back, better on sitting forward or heat, worse on eating/alcohol Bloating Steatorrhoea WL N+V ```
249
What are the signs of chronic pancreatitis?
Epigastric tenderness | Signs of WL, malnutrition, DM
250
How is chronic pancreatitis investigated?
1. Blood glucose - raised 2. CT - pancreatic calcifications, enlargement, ductal dilation, vascular complications 3. Abdo US - structural changes 4. Abdo XR - pancreatic calcifications
251
How is chronic pancreatitis managed?
1. Analgesia 2. Lifestyle and dietary modifications - cut down alcohol, smoking 3. Pancreatin (enzymes) + omeprazole 4. Octreotide 5. Antioxidants
252
What are the complications of chronic pancreatitis?
``` Pancreatic exocrine insufficiency DM Pancreatic calcifications Pancreatic duct obstruction Low-trauma fracture ```
253
What causes PUD and gastritis?
Imbalance between damaging action of acid and pepsin and mucosal protective mechanisms
254
What are the risk factors for PUD and gastritis?
H. pylori Drugs - NSAIDs, steroids, SSRI Reflux of duodenal contents into stomach Stress
255
What kind of PUD is more common?
Duodenal x4
256
Who are duodenal and gastric ulcers more common in?
Duodenal: 30yos Gastric: 50+
257
What are the symptoms of PUD and gastritis?
``` Epigastric pain relieved by antacids Bloating Fullness after meals Heartburn WL Worse soon after eating - gastric Worse hours later - duodenal ```
258
How are PUD and gastritis investigated?
``` Bloods: FBC - anaemia Amylase - normal U+Es Clotting screen - if GI bleeding LFTs Cross-match if actively bleeding ``` Endoscopy + brushings Rockall scoring: assess severity after GI bleed H. pylori testing: C-urea breath test, IgG against pylori, stool antigen test
259
How are PUD and gastritis managed?
1. Fluid resus 2. IV omeprazole for UGI bleed 3. Endoscopy - haemostasis by injection, sclerotherapy or electrocoagulation 4. Surgery 5. H.pylori eradication - triple therapy - PPI + clarithromycin + amoxicillin 6. OR if not H. pylori - omeprazole/ranitidine (H2 ant), stop NSAID use 7. Lifestyle - prevent stress, avoid trigger foods
260
What are the complications of PUD and gastritis?
``` Haemorrhage Perforation Obstruction Pyloric stenosis due to scarring Malignancy ```
261
What is a perianal fistula?
An abnormal chronically infected tract communicating between the perineal skin and either the anal canal or the rectum
262
What causes perianal fistulae?
Bacteria tracking from anal glands, causing infection and then development of a fistula as a complication of an abscess Or complication of cirrhosis
263
What are the risk factors for perianal abscesses and fistulae?
IBD DM Malignancy Cirrhosis
264
What are the symptoms of perianal abscesses and fistulae?
``` Constant throbbing pain in perineum Intermittent discharge - mucous/faecal Localised tender perineal mass/small skin lesion Pain, swelling, redness Fevers, general weakness ```
265
How are perianal abscesses and fistulae managed?
Seton + antibiotics | Surgery - fistulotomy
266
What is a pilonidal sinus?
An abnormal epithelium-lined tract filled with hair that opens to the skin surface, most commonly in the natal cleft
267
What caused pilonidal sinuses?
Shed/sheared hairs penetrating skin Causes inflammatory reaction and sinus development Intermittent negative pressure draws in more hair Perpetuates cycle
268
What are the risk factors for pilonidal sinuses?
Hirsutism + long time sitting | Hairdressers - interdigital sinuses
269
How do pilonidal sinuses present?
Painful natal cleft Discharge Swelling
270
How are pilonidal sinuses managed?
Surgical: Incision + drainage Packed w iodine-soaked dressings Prevention: Hygiene + hair removal
271
What are the complications of pilonidal sinuses?
Pain Infection Abscess Recurrence
272
What is portal hypertension?
Abnormally high pressure in portal vein
273
What causes portal hypertension?
Prehepatic: portal/splenic vein thrombosis Hepatic: cirrhosis, schistosomiasis, sarcoid, myeloproliferative disease, congenital hepatic fibrosis Post-hepatic: Budd-Chiari (hepatic vein thrombosis), congestive HF, constrictive pericarditis, veno-occlusive disease
274
How does portal hypertension present?
``` Signs of CLD Haematemesis PR bleeding/melaena Oesophageal varices - upper GI bleed Encephalopathy Splenomegaly Ascites/oedema Caput medusa ```
275
How is portal HTN investigated?
US - dilated portal vein | Hepatic venous pressure gradient = 5mmHg or more
276
How is portal HTN managed?
1. Portosystemic shunt 2. TIPS 3. Bleeding prevention - non-specific β-blockers, nitrate isosorbide mononitrate, terlipressin 4. Ascites - salt restriction, spiro, paracentesis 5. Encephalopathy - phosphate enemas, lactulose
277
What is primary biliary cholangitis?
Chronic disease of the small intra-hepatic bile ducts Intra-lobular bile ducts are damaged by chronic autoimmune granulomatous inflammation causing cholestasis which may lead to fibrosis, cirrhosis and portal HTN
278
What causes PBC?
Unknown environmental triggers + genetic predisposition leading to loss of immune tolerance to self-mitochondrial proteins Anti-mitochondrial antibodies
279
What are the risk factors for PBC?
``` Female x10 45-60yo FHx Many UTIs Smoking Other AI disease ```
280
How does PBC present?
``` Pruritis Fatigue + daytime sleepiness Dry eyes + mouth (associated Sjogren's) Postural dizziness/blackouts Hepatomegaly ```
281
How is PBC investigated?
1. BLOODS High AlkPh + GGT - cholestasis High bilirubin + low albumin - impaired liver synthetic function High ALT 2. Abdo US - excludes obstructive lesion within visible bile ducts 3. Antimitochondrial antibody/ANA immunofluorescence
282
What is primary sclerosing cholangitis?
Chronic progressive cholestatic liver disease, characterised by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts, resulting in diffuse, multi-focal stricture formation
283
Who does PSC commonly affect?
Young and middle-aged men with underlying IBD (mostly UC)
284
How does PSC present?
``` RUQ/epigastric pain WL Intermittent jaundice Pruritis Fatigue Or asymptomatic ```
285
How is PSC investigated?
1. BLOODS: high AlkPh + GGT, slightly high transaminases, later on low Alb + high bili 2. Serology: high IgG kids, IgM adults, ASM, ANA, pANCA 3. ERCP: stricturing and dilation of intrahepatic bile ducts 4. MRCP 5. Liver biopsy: confirms Dx and allows staging
286
What is rectal prolapse?
The mucosa (partial/type 1) or all layers (complete/type 2) protrude through the anus
287
What causes rectal prolapse?
Lax sphincter or prolonged straining
288
What are the risk factors for rectal prolapse?
``` Increased intra-abdo pressures Previous surgery Pelvic floor dysfunction Parasitic infections - schistosomiasis Neuro disease Psychiatric disease ```
289
How does rectal prolapse present?
``` Incontinence Mass protruding through anus Pain Constipation Mucus or rectal bleeding ```
290
What is Wilson's disease?
Inherited disorder of biliary copper excretion with too much copper in the liver and CNS
291
What causes Wilson's disease?
Genetic, autosomal recessive disorder of gene n Chr13 that codes for ATP7B (copper transporting ATPase) Copper absorption and transport to liver is fine but incorporation into caeruloplasmin in hepatocytes and excretion into bile is impaired Copper accumulates in liver - damages hepatocyte mitochondria - cell death - release of free copper into plasma - deposited in other tissues
292
How does Wilson's disease present?
``` Hx of hepatitis Tremor Dysarthria: slurred Dystonia in arms Incoordination Sloppy/small handwriting Dysdiadochokinesis Abnormal eye movements Normal sensation, muscular strength and reflexes Kayser-Fleischer rings Hepatosplenomegaly, jaundice, ascites, gynaecomastia ```
293
How is Wilson's disease investigated?
LFTS: abnormal - raised aminotransferases + raised bilirubin (jaundice)/low bilirubin (liver failure)
294
What is volvulus?
Rotation of a loop of bowel around the axis of its mesentery that results in bowel obstruction and potential ischaemia
295
What causes volvulus?
Anatomical factors - long mesentery, adhesions, tumours
296
What are the risk factors for volvulus?
``` Long sigmoid colon and mesentery Mobile caecum Chronic constipation Very high residue diet Tumour Adhesions Chaga's disease of colon Parasitic infections ```
297
How does volvulus present?
``` Severe colicky abdo pain and swelling Absolute constipation Later, vomiting Distension Absent/tinkling bowel sounds Fever, tachycardia, dehydration ```
298
How is volvulus investigated?
AXR - coffee bean sign Erect CXR - air under diaphragm if perforated Water-soluble contrast enema - shows site of obstruction CT scan
299
What is ulcerative colitis?
Relapsing and remitting inflammatory disorder of the colonic mucosa
300
What causes UC?
Unknown but theory: autoimmune disease initiated by an inflammatory response to colonic bacteria
301
Who usually presents with UC?
20-40 + 60 yos peak Men more than women Scandinavia + Northern Europe
302
What are the risk factors for UC?
FHx of IBD | HLA-B27
303
How does UC present?
``` Rectal bleeding + mucous Bloody diarrhoea Abdo pain Malnutrition Urgency + tenesmus (rectal UC) ``` Extra-intestinal signs: clubbing, aphthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, iritis, arthritis, sacroilitis, ankylosing spondylitis, amyloidosis
304
How is UC investigated?
1. BLOODS: Low Hb/albumin High WCC/ESR/CRP LFTs, cultures, U+Es 2. STOOL - exclude infectious colitis 3. Faecal calprotectin - marks disease severity 4. AXR: mucosal thickening, colonic dilatation 5. Erect CXR: perforation 6. Barium enema: lead-pipe pattern (no haustra) 7. Colonoscopy/flexisig: inflammatory infiltrate, goblet cell depletion, glandular distortion, ulcers, crypt cell abscesses
305
How is UC managed?
Mild - 5-ASA (sulfasalazine) + steroids (prednisolone) Moderate - prednisolone + steroid enemas + sulfasalazine + immunosuppresion (azathioprine, cyclosporin, 6-mercatopurine, infliximab) Sever - NBM + IV fluids + IV/PR hydrocortisone + blood transfusion + colectomy + parental nutrition
306
What are the complications of UC?
``` Perforation Bleeding Toxic dilatation of colon Venous thrombosis Colonic cancer ```
307
What is hepatitis A?
RNA virus Spread - faeco-oral/shellfish Problem for travellers - endemic in Africa and S America RFs - poor sanitation, unsafe water/food Prodromal period: fever, malaise, no appetite, nausea, arthralgia, vomiting Later: jaundice, adenopathy, dark urine, pale stool
308
How is hepatitis A investigated?
Very high AST High ALT 2-40 days post-exposure High anti-HAV IgM from day 25 Anti-HAV IgG for life Urine: high urobilinogen, bilirubin
309
How is hepatitis A treated?
Supportive treatment | Immunisation
310
What is the prognosis of hepatitis A?
Self-limiting Recovery in 36 weeks Chronicity doesn't occur
311
What is hepatitis E?
RNA virus Similar to HAV Older men, commoner than HAV in UK
312
When does hepatitis E have a high mortality?
Pregnancy
313
How is hepatitis E investigated?
Anti-HEV IgM and IgG
314
What is hepatitis C?
ssRNA flavivirus spread via parental route: unscreened blood transfusion, IVDU, sexual, acupuncture tattoo, haemodilaysis, health workers
315
What are the risk factors for progression of HCV?
``` Male Older Increased viral load Alcohol HIV HBV ```
316
How does HCV present?
Mostly silent chronic infection | Sometimes jaundice + mild flu-like illness
317
How is HCV investigated?
AST:ALT<1:1 until cirrhosis Anti-HCV IgM and IgG HCV-PCR - HCV RNA present Liver biopsy
318
How is HCV treated?
Stop alcohol Supportive treatment Protease inhibitors - boceprevir PEG IFN-a and ribavirin
319
What are the complications of HCV?
Fulminant liver failure | HCC
320
What is hepatitis B?
dsDNA virus spread via blood products, IVDU, sexual, direct contact
321
Where is HBV endemic?
Far East Africa Mediterranean
322
How does HBV present?
Prodrome: malaise, headache, loss of appetite, N+V, diarrhoea, RUQ pain +- Serum-sickness type illness: fever, arthralgia, polyarthritis, urticaria Later jaundice w pale stool, dark urine
323
How is HBV investigated?
Anti-HCV IgM (acute) and IgG (chronic) HBsAg (surface antigen) 1-6 months after exposure Liver biopsy PCR LFTs: high AST/ALT, bili, AlkPh
324
How is HBV treated?
Stop alcohol Immunise sexual contacts Acute: symptomatic antiemetics, antipyretics, cholestyramine Chronic: PEG IFNa-2a and lamivudine
325
What are the side-effects of IFNa
``` Flu-like chills Myalgia Headache BM suppression Depression ```
326
What are the complications of HBV?
Leads to cirrhosis | Higher risk of HCC
327
What is hepatitis D?
Incomplete RNA virus (needs HBV to assemble) | ssRNA virus coated with HBsAg
328
How can HDV be prevented?
HBV vaccination
329
How is HDV treated?
IFN-a - limited success | May need transplant

Y3 (20 decks)

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