Flashcards in Gastrointestinal Deck (445)
What is achalasia?
An oesophageal motility disorder, characterised by loss of peristalsis and failure of relaxation of the lower oesophageal sphincter (LOS)
What is the aetiology of achalasia?
- Degeneration of ganglion cells of the meyenteric plexus in the oesophagus due to an unknown cause.
- Oesophageal infection with Trypanosoma cruzi seen in Central and South America producers a similar disorder- Chaga's disease
What is the epidemiology of achalasia?
Usual presentation age: 25-60 years
What are the presenting symptoms of achalasia?
Insidious onset and gradual progression of
- Intermittent dysphagia involving solids and liquids
- Difficulty belching
- Regurgitation (particularly at night)
- Chest pain (atypical/cramping, retrosternal)
- Weight loss
What are the signs of achalasia on examination?
May reveal signs of complications
What are the investigations of achalasia?
- CXR: may show widened mediastinum and double right border (dilated oesophagus), an air-fluid level in upper chest and absence of the normal gastric air bubble
- Barium swallow: Dilated oesophagus which smoothly tapers down to the sphincter (beak-shaped)
- Endoscopy: To exclude malignancy which can mimic achalasia
- Manometry: Elevated resting LOS pressure (over 45mmHg), Incomplete LOS relaxation, Absence of peristalsis in the distal (smooth muscle portion) of the oesophagus
What is acute cholangitis?
- Infection of the biliary tree, most commonly caused by obstruction.
- In its less severe form, there is biliary obstruction with inflammation and bacterial seeding and growth int he biliary tree
What is the aetiology of acute cholangitis?
- Most common aetiology is cholelithiasis leading to choledocholithiasis and biliary obstruction.
- Iatrogenic biliary tract injury, most commonly caused via surgical injury cholecystectomy, can lead to benign strictures, which in turn can lead to obstructions
- Acute prancreatitis
- Malignant strictures
What is the epidemiology of acute cholangitis?
- Relatively uncommon
- Male to female ratio is equal
- Median age of presentation is 50-60
What are the presenting symptoms of acute cholangitis?
- Right upper quadrant pain
- Right upper quadrant tenderness
What are the signs of acute cholangitis on examination?
- Alcoholic stools
- Mental status changes
What are the investigations for acute cholangitis?
- FBC: Raised WBC, decreases platelets
- Serum urea: Raised in severe cases
- Serum creatinine: Raised in severe cases
- ABG: Metabolic acidosis
- LFT: Hyperbilinuraemia
- CRP: Raised
- Serum K & Mg: May be decreased
- Blood cultures: Bacteria usually gram negative, but gram positive bacteria and anaerobes are also implicated in cholangitis
How is acute cholangitis managed?
- IV antibiotics (Piperacillin/Tazobactam
- Biliary decompression
- Opioid analgesics
What are the possible complications of acute cholangitis?
- Acute prancreatitis
- Inadequate biliary drainage following performance of endoscopy, radiology or surgery
- Hepatic abscess
What is the prognosis of acute cholangitis?
- If adequate biliary drainage is quickly obtained, most patients experience rapid clinical improvement
- Outcome worse for patient's with underlying medical conditions
What is alcoholic hepatitis?
Inflammatory liver injury caused by chronic heavy intake of alcohol
What is the aetiology alcoholic hepatitis?
One of the three forms of liver disease caused by excessive intake of alcohol, a spectrum that ranges from alcoholic fatty liver (steatisus) to alcoholic hepatitis and chronic cirrhosis
- In alcoholic hepatitis, the liver histopathology shows centrilobar ballooning degeneration and necrosis of hepatocytes, steatosis, neutrophilic inflammation, cholestasis, Mallory hyaline inclusions and giant mitochondria
What is the epidemiology of alcoholic hepatitis?
10-35% of heavy drinkers develop this form of liver disease
What are the presenting symptoms of alcoholic liver disease?
- May remain asymptomatic and undetected unless they present for other reasons
- Mild illness with nausea, malaise, epigastric or right hypochondrial pain
- Low grade fever
What are the signs of acute hepatitis on examination?
- Signs of alcohol excess: Malnourishes, palmar erythema, Dupuytren's contracture, facial telangiectasia, parotid enlargement, spider naevi, gynaecomastia, testicular atrophy, hepatomegaly, easy bruising
- Signs of severe alcoholic hepatitis: Febrile (50% pts), tachycardia, jaundice, bruising, encephalopathy, ascites, hepatomegaly, splenomegaly
What are the investigations for alcoholic hepatitis?
- Blood: Decreased Hb, Increased MCV, Increased WCC, Decreased platelets. U&E: Urea and K low unless significant renal impairment. Clotting: Prolonged PT sensitive marker of sig. liver damage
- Ultrasound: For other causes of liver impairment (e.g. malignancies
- Upper GI endoscopy: Investigate for varices
- Liver biopsy: Percutaneous or transjugular may be helpful to distinguish from other causes of hepatitis
- Electroencephalogram: For slow wave activity indicative of encephalopathy
How is alcoholic hepatitis managed?
- Acute: Thiamine, Vitamin C and other multivitamins. Monitor and correct K, MG and glucose abnormalities. Ensure adequate glucose output. Treat encephalopathy with oral lactose and phosphate enemas. Ascites manages by diuretics
- Nutrition: Oral and or nasogastric feeding important with increased caloric intake. Protein restricted to be avoided unless patient is encephalopathic. Nutritional supplementation and vitamins started parenterally and continues orally after
- Steroid therapy
What are the possible complications of alcoholic hepatitis?
- Acute liver decompensation
- Hepatorenal syndrome (renal failure secondary to advanced liver disease
What is the prognosis of alcoholic hepatitis?
Morality in first months is 10%; 40% in first year
- If alcoholic intake continues, most progress to cirrhosis within 1-3 years
- Maddrey's discriminant function. If less than 32, indicates more than 50% 30-day mortality
- Glasgow alcoholic score
What is an anal fissure?
Split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding
What is the aetiology of anal fissures?
- Passage of hard stool bolus may precipitate an anal fissure
- Fissure may begin during episode of loose stool, or often occurs spontaneously with no obvious precipitating factor
- Opiate analgesia is associated with constipation and a subsequence increased incidence of anal fissure
- Hard stool tears the anal skin at pectin (at dentate line)
- Pregnancy is risk factor
What is the epidemiology of anal fissures?
- Equally common in men and women
- Often affects young adults ages 15-40, but may be seen in older adults
- May be seen in younger adults due to poor toileting
What are the presenting symptoms of anal fissures?
- Pain on defecation
- Tearing sensation on passing stool
- Fresh blood on stool or on paper
- Anal spasm
What are the signs of anal fissures on examination?
- Sentinel pile
- Fissure visible on retraction of buttock