Gastrointestinal Flashcards
1
Q
Causes of Hepatomegaly
A
3Cs
- Cirrhosis
- Carcinoma (metastases)
- Congestive cardiac failure
+ 3Is
- Infectious (viral hepatitis)
- auto-Immune (PBC, PSC, AIH)
- Infiltrative (Amyloidosis, Myeloproliferative disorders)
2
Q
Signs of liver decompensation
A
Signs of decompensated liver disease = JACE
- Jaundice
- Ascities
- Coagulopathy –> INR > 1.5
- Encephalopathy –> Asterixis
3
Q
Types and Causes of Ascites
A
Transudate (SAAG > 1.1)
- Liver
— Cirrhosis
—– Alcoholic liver disease
—– Viral hepatitis
— Budd Chirari syndrome
— Acute liver failure / decompensation
- Cardiac
— Congestive cardiac failure
Exudate (SAAG < 1.1)
- Infection
— Spontaneous bacterial peritonitis
- Inflammation
— Pancreatitis
- Malignancy
— Primary peritoneal cancer
— Metastases
4
Q
Ix to DDx causes of Ascites
A
Serum Ascitic Albumin Gradient (SAAG)
= (Serum Albumin) - (Ascitic Fluid Albumin)
High SAAG > 1.1 = Transdate
Low SAAG < 1.1 = Exudate
5
Q
Tx for Types of Ascites
A
Transudative Ascites
- Treat underlying cause
- Salt restriction
- Diuretics
- Paracentesis
+/- Liver transplant
Exudative Ascites
- Treat underlying cause
- Repeated paracentesis
6
Q
Causes of Palmar erythema
A
- Cirrhosis
- Hyperthyroidism
- Rheumatoid arthritis
- Pregnancy
- Polycythaemia
7
Q
Auto-antibodies in PBC, PSC and AIH
A
PBC: Anti-mitochondrial Ab
PSC: ANA, Anti-SMA (smooth muscle antibdoy), pANCA
AIH: Anti-SMA, Anti-LKM1, ANA
8
Q
Tx of GI perforation
A
Resuscitation with ABCDE approach
- IV Fluids
- Antibiotics (START EARLY)
—- Ceftriazone + Metronidazole
- Analgesia
- Anti-emetic
- NBM
- NG aspiration (NG tube)
- Catheter + Fluid monitoring
- Cross-match 6 units of Blood
- Correct any clotting abnormalities
- Stop drugs (NSAIDs, Aspirin, Warfarin, Heparin)
Emergency Surgery
- Exploratory laparotomy
—- Closure of perforation (hole sewn closed)
—- perforated peptic ulcer
–> repaired with omental patch +/- Bowel resection
—- If perforated divertuclae
–> Hartmann’s procedure
+/- Resection of malignancy
+/- Biopsy/Histology Peritoneal wash
+/- Drain abscess
9
Q
Insidious onset
Intermittent dysphagia
Regurgitation
Retrosternal chest pain
Heart burn
Sensation of lump in throat
Diagnosis? Ix?
A
Achalasia
Ix: OGD to exclude malignancy
Barium swallow (diagnostic) = bird’s beak
10
Q
Tx of Achalasia
A
Initial
- (1) CCBs
- (2) Nitrates
Long-term
- (1) Surgery
- Pneumatic dilatation (dilate LOS)
- Heller cardiomyotomy (incision of LOS muscles fibres)
- (2) CCBs + Nitrates
11
Q
Complications of Achalasia
A
Oesophageal cancer (100x)
GORD
Aspiration pneumonia
12
Q
Retrosternal burning discomfort / Heartburn
- Worsened by lying supine or large meals
- Relieved by Antacids
Acidic taste / Waterbrash (sour taste in mouth / mini-sick)
Nocturnal cough
+/- Dysphagia
+/- Odynophagia
Voice hoarseness
Wheeze
Diagnosis? Ix?
A
GORD
Ix: 8-week trial of PPI
Improvement in symptoms confirms diagnosis
If red flags –> OGD
13
Q
Tx of GORD
A
Conservative and Medical
- Weight loss, Smoking cessation, Reduce Alcohol
Medical
- Antacids
- (1) PPI
- (2) H2 receptor antagonists
If refractory -> Surgery
- Nissen fundoplication
14
Q
Complications of GORD
A
Barret’s oesophagus
Thus, require regular surveillance with endoscopy
15
Q
OGD shows :
salmon-coloured mucosa
Migration of Z line
Columnar epithelium
Dx? Tx:
A
Barrett’s oesophagus
Non-dysplastic
- (1) Endoscopic surveillance (every 2 years) + PPI
- (2) Anti-reflux surgery (Nissen fundoplication)
Dysplastic
- (1) Radiofrequency ablation
- +/- Endoscopic musocal resection (if nodular)
- (2) Oesophagectomy
16
Q
Scoring system for upper GI bleeds
A
Glasgow-Blatchford Bleeding Score
Stratifies upper GI bleeding into
high risk (urgent endoscopy)
or low risk (outpatient management)
17
Q
Tx of Upper GI bleed
A
If haemodynamically stable –> Conservative
If haemodynamically unstable
- (1) ABCDE
- IV Fluids +/- Blood transfusion +/- NG decompression
-
(1) OGD
- +/- Adrenaline +/- Thermocoagulation +/- Haemoclip
- (2) Laparoscopic surgery
- (3) Angiography (vasopressin injection)
- (4) Last line –> Sengstaken-Blakemore tube (compression)
18
Q
CXR signs of Boerhavve syndrome
A
Oesophageal perforation
–> Pneumomediastinum
19
Q
Plummer Vinson triad
A
Dysphagia
Iron deficiency anaemia
Oesophageal webs
20
Q
Ix and Tx for peptic ulcer disease
A
< 55 years old ==> H. pylori Urea breath test
> 55 years old or red flag symptoms ==> OGD + Biopsy
Treatment
- If H pylori +ve
-
Triple therapy = (2x ABx) + PPI
- Clarithromycin + Amoxicillin + Omeprazole
- Check for eradication @ 4 weeks (Urea breath test)
-
Triple therapy = (2x ABx) + PPI
- If H pylori -ve
- (1) PPI
- (2) H2 antagonist
21
Q
Peptic ulcer disease
Diarrhoea
Serum gastrin ↑
Diagnosis? Associations? Treatment?
A
Zollinger-Ellison syndrome
Gastrin-secreting neuro-endocrine pancreatic tumour
Associated with MEN1
Treatment = PPI + Surgical resection
22
Q
Consequences of Portal HTN
A
SAVE
- Splenomegaly
- ==> hypersplenism (↓Hb, ↓platelets and ↓WCC)
- Ascites
- Varices
- Oesophageal varices (90%)
- Caput medusa
- Haemorrhoids
- Encephalopathy
23
Q
↑↑AST:↑ALT >2
A
Alcohol liver disease
24
Q
Tx of Alcoholic hepatitis
A
Conservative
- Alcohol withdrawal programme
Medical
- Pabrinex
- +/- Corticosteroids (if severe)
- Manage complications
Surgical
- +/- Liver transplant
25
Auto-antibodies in autoimmune hepatitis
_Type 1_: Anti-smooth muscle antibody (**Anti-SMA**) and ANA
_Type 2_: Anti-Liver Kidney Microsome antibody (**Anti-LKM-1)**
26
**RUQ pain**
**Fever**
**Pruritis**
**Jaundice**
**Nausea & Vomiting**
Signs consistent with?
Acute hepatitis
27
Tx of autoimmune hepatitis
Medical
* **Immunosupression**
* Prednisolone
* Azathioprine or 6-MP (steroid-sparing)
Surgical
* **Liver transplant**
**Monitoring**
* Every year ==\> look for **Hepatocellular carcinoma**
* USS
* a-fetoprotein (AFP)
* Liver biopsy
*
28
Triad in Budd-Chiari syndrome
Ix for diagnosis
RAH
* **RUQ abdo pain**
* **Ascities**
* **Hepatomegaly** (tender)
_Ix:_ **USS Doppler for diagnosis**
29
Tx for Budd Chiari syndrome
Medical
* Onset \< 72 hours -\> **Thrombolysis**
* Onset \> 72 hours --\> **Anticoagulation** (LMWH + Warfarin)
* **Treat ascites** (Fluid and Na restriction, Diuretics, Paracentesis)
Afterwards --\> Surgical
* (2) **Angioplasty** (balloon dilatation + stent)
* (2) **TIPSS** (transjugular intrahepatic portosystemic shunt)
* If angio fails
* (3) **Surgical shunts**
* (4) **Liver transplant**
30
Compensated vs Decompensated Cirrhosis
**Compensated** = **Cirrhosis + no complication**
* i.e. Preservation of hepatic synthetic function
**Decompensated** = **Cirrhosis + Complications**
* e.g. ascites, jaundice, encephalopathy, varices, ↓ synthetic function
31
Causes of Cirrhosis
32
Signs of Chronic Liver Disease
Tip: ABCDE
* Asterixis
* Bruises
* Clubbing
* Dupuytren’s contracture
* Erythema (palmar)
* Fetor hepaticus
* Gynaecomastia
* Icterus (Jaundice)
* Jaundice
33
Scoring system for cirrhosis
Child's Pugh Score
Prognostic marker for severity of cirrhosis
Based on (**BRAIN)**
* **BR** (Bilirubin)
* **A**lbumin / **A**scites
* **I**NR
* e**N**cephalopathy
34
Caeruloplasmin and Urinary copper in Wilson's disease
Caeruloplasmin: ↓ in Wilson's disease
Urinary copper: ↑ in Wilson's disease
35
Tx for cirrhosis
Conservative
* Avoid alcohol
* Avoid hepatotoxic drugs (NSAIDs, Paracetamol)
* Diet & Exercise
* Vaccination (Hep A, Hep B)
Medical
* Treat underlying cause
* Treat complications
Surgical
* Liver transplant
Monitoring --\> Every 6 months
* AFP, USS, OGD
36
Tx of complications of cirrhosis
Varices --\> **Banding**
Pruritis --\> **Colestyramine**
Ascites
* **Fluid and Na restriction**
* **Diuretics**
* **Ascitic tap**
Coagulopathy
* **Vitamin K**
* **Platelets**
* **FFP**
Encephalopathy
* **Lactulose**
* **+ Phosphate enema**
37
**Diabetes mellitus**
**Bronze pigmentation**
**Slate-grey pigmentation**
**Hepatosplenomegaly**
**Cirrhosis**
**Hypogonadism**
**Dilated cardiomyopathy**
Diagnosis? Cause? Treatment?
**Haemochromatosis**
_Causes_
* Primary = autosomal recessive mutation in HFE gene
* Secondary = multiple blood transfusions
_Treatment_
* _If asymptomatic_ --\> Low iron diet
* _If symptomatic_
* **Venesection** (blood letting)
* **Desferrioxamine**
38
Scoring criteria for liver transplant
**King's College Criteria**
If paracetamol induced Acute Liver Failure
* **Acidosis** ( pH \< 7.30)
* **Hepatic encephalopathy** AND **coagulopathy** AND **AKI**
* **Hyperlactatemia**
* **Hyperphosphatemia**
If non-paracetamol induced Acute Liver Failure
* **PT\>100s**
* _or_ **3/5** of the following
* **Age \< 10** or **\> 40 years old**
* Caused by "**non-A, non-E viral hepatitis**" or drug-induced or indeterminable aetiology of ALF
* Interval from **onset of jaundice to encephalopathy \>7 days**
* **Bilirubin** \> 300 mM
* **PT**\>50s
39
**Fever, Malaise, Loss of appetite**
**Pyrexia of unknown origin**
**RUQ pain**
**Jaundice**
**Tender hepatomegaly**
**Hiccups**
**R sided pleural effusion**
Diagnosis? Types? Treatment
**Liver abscess**
Types
* **Pyogenic** (*E. coli*) - most common
* Biliary tract sepsis
* **Amoebic** (*Entamoeba histolytica*)
* "Anchovy sauce" fluid
* **Hydatid cyst** (*Echinococcus granulosis* / Tapeworm)
* _Sheep_-rearing communities
* Holds litres of fluid
* **Fungal**
* Immunocompromised
Treatment
* Surgical drainage or resection
* +/- Antibiotics +/- Anti-fungals +/- Anti-parasitics
40
Causes of acute liver failure
Common
* **Viral hepatitis**
* **Drugs** (Paracetamol, Anti-TB drugs)
Uncommon
* **Alcoholic liver disease** (decompensated)
* **Autoimmune hepatitis**
* **Budd-Chiari sndrome**
* Malignancy (**HCC**)
* **Haemochromatosis**
* **Wilson's disease**
41
Metabolic syndrome
Metabolic syndrome = Requires 3/5 (**DOHHH**)
* **D**iabetes mellitus / Insulin resistance
* **O**besity (central)
* **H**ypertension
* **H**ypertriglyceridaemia
* **H**yperlipidaemia
42
Hepatitis B serology
43
Treatment of NASH
Conservative
* **Diet and Exercise**
Medical
* **Orlistat**
* Manage Diabetes
* Manage Hyperlipidaemia
Surgical
* Liver transplant
* TIPSS
44
Ix for portal hypertension
_1st line investigation_
**USS** = dilated portal vein
_GOLD STANDARD_
Hepatic venous pressure gradient (**HVPG**) measurement
45
Tx for portal hypertension
Transjugular intrahepatic portosystemic shunt (**TIPSS**)
* Connects portal vein to hepatic vein
* Shunts portal blood into systemic venous drainage
* *_Complications_*: Hepatoencephalopathy
Oesophageal varices
* ABCDE + IV Fluids
* **Terlipressin**
* **Endoscopy + Band ligation** (1st line)
Ascites
* **Fluid and Na restriction**
* **Diruetics**
* **Paracentesis**
Hepatic encephalopathy
* **Lactulose and Phosphate enemas**
46
**Cirrhosis (**JACE**)**
**Portal hypertension (**SAVE**)**
**Parkinsonism**
**Dydsdiadochokinesia**
**Psychiatric symptoms**
**Kayser-Fleischer rings**
Diagnosis? Investigations? Treatment?
**_Wilson's disease_**
* **↑ 24hr urine copper**
* **↓ Ceruloplasmin**
Treatment
* Anti-copper therapy
* **Zinc** (life-long - reduces gut absorption)
* **Trientine** (copper chelator)
* *_or_* **Liver transplant**
47
**Hepatitis A**
Clinical features?
Investigations?
Treatment?
**Hepatitis A**
Faecal-Oral transmission
* **A**symptomatic
* **A**cute
* **A**ssociated with shellfish
Investigations ==\> **HAV IgM antibody, HAV IgG antibody**
Management ==\> **Supportive** (as self-limiting
48
Hepatitis E
Clinical features
Investigations
Management
Hepatitis E
Faecal-Oral transmission
* **E**nteric
* **E**pidermics (water)
* **E**xpectant mothers ==\> acute liver failure
Investigations ==\> HEV IgM antibody, HEV IgG antibody
Management ==\> Supportive (as self-limiting)
49
Hepatitis B serology
Interpretation
HbSAg: +ve if acute infection
HbSAb: +ve if vaccinated or cleared infection
HbcAb: encountered the real virus (IgM = acute, IgG = chronic)
EAg +ve: infectious
50
Tx for Hepatitis B
Acute Hepatitis B
* Supportive (90% will recover)
Chronic Hepatitis B
* **Peginterferon alpha 2a**
* Nuceloside analogue (**Entecavir**, Emtricitabine, Lamivudine)
* Nucleotide analogue (**Tenofovir**)
51
Ix for Hepatitis C
Treatment?
**PCR for HCV Viral RNA** (gold standard)
_Treatment_
* *_Acute_* --\> Supportive
* *_Chronic_* --\> **Directly acting anti-virals** (DAA)
* e.g. Sofosbuvir
* Specifc regimens based on genotype
* CURATIVE!
52
**Cholelithiasis**
**Cholecystitis**
**Choledocholithiasis**
**Cholangitis**
What is it?
Symptoms
Investigations
Tx
53
Types of Gallstones
Gallstones
* **Cholesterol** [80%]
* ∴ Majority are radiolucent
* **Bilirubin** (Pigmented = Black pigment stones) [10%]
* ∴ Radio-opaque (often precipitates as Calcium Bilirubinate)
* **Calcium**
* **Mixed** (Brown pigment stones) [10%]
54
Risk factors for gallstones
Tip: 4Fs
* **Fat** (Obesity)
* **Female** (↑oestrogen --\> ↑cholesterol content of bile)
* **Fertile** (Pregnancy)
* **Forty**
55
**Charcot’s triad**
**Reynaud's pentad**
What are they? What condition?
**Ascending cholangitis**
Charcot’s triad – RUQ pain, Jaundice, Fever
Reynaud's pentad – RUQ pain, Jaundice, Fever, Hypotension, Confusion
56
Treatment of gallstones
Asymptomatic gallstones
* (1) **Observation**
* (2) **prophylactic cholecystectomy**
* (3) **Ursodeoxycholic acid** (dissolve gallstones)
Symptomatic gallstones
* *_If in gallbladder_*
* *_Fit for surgery_* --\> **Cholecystectomy**
* *_Unfit for surgery_* --\> percutaneous cholecystectomy tube
* *_If in CBD_* --\> **ERCP** (*_or_* Cholecystectomy)
57
AXR shows **Porcelain gallbladder**
**(Calcification within the gallbladder)**
Diagnosis?
Chronic cholecystitis
58
**Pruritis**
**Steatorrhoea**
**Osteomalacia**
**Coagulopathy**
**Hepatomegaly (smooth, non-tender)**
**↑↑ ALP, ↑↑ BR**
Diagnosis? Ix for diagnosis? Tx?
**Primary biliary cholangitis**
**Anti-mitochondrial antibodies**
Affects **intra**hepatic bile ducts
Treatment
* Medical
* Symptomatic relief
* Pruritis --\> **Colestyramine**
* Osteopororis --\> **Bisphosphonates**
* Diarrhoea --\> **Codeine phosphate**
* Prevent complications
* **Vitamin supplementation (ADEK)**
* **Ursodeoxycholic acid**
* Surgical
* **Liver transplant**
59
**Male**
**Ulcerative colitis**
**Pruritis**
**RUQ abdo pain**
**Obstructive jaundice (pale stools, dark urine)**
**Hepatomegaly**
**Steatorrhoea**
Diagnosis? Investigation? Treatment?
**Primary sclerosing cholangitis**
PSC is associated with UC
Investigation
* **pANCA**
* **MRCP (diagnostic)**: "beaded" appearance
* **ERCP (diagnostic + therapeutic)**: "beaded" appearance
Treatment
* Medical
* Symptomatic relief (**colestyramine, codeine**)
* Prevent complications (**Vitamin ADEK, Bisphosphonates**)
* Ursodeoxycholic acid
* Surgical
* **Endoscopic stenting**
* **Liver transplant**
* Screening
* Cholangiocarcionoma --\> **Ca19-9**, USS
* Colorectal cancer --\> **Colonoscopy**
*
60
Causes of pancreatitis
* Idiopathic
* Gallstones [most common cause in Females]
* Ethanol [most common cause in Males]
* Trauma
* Steroids
* Mumps
* Autoimmune
* Scorpion stings
* H
* Hyperlipidaemia
* Hypercalcaemia
* Hyperparathyroidism
* ERCP
* Drugs (furosemide, thiazides, oestrogens, steroids, azathioprine, valproate)
61
**Epigastric pain (severe)**
**Radiating to back (or sides)**
**Relieved by sitting forward**
**Aggravated by movement (peritonitis)**
**Grey Turner's sign (flanks)**
**Cullen's sign (periumbilical)**
**Fox's (inguinal)**
**Chvostek's sign**
**Trousseau's sign**
Diagnosis? Treatment?
**Pancreatitis**
* Supportive
* IV Fluids
* Analgesia
* Anti-emetic
* Replace Ca2+ or K+
* +/- Insulin
* Nutritional support
* Treat Alcohol-induced (Pabrinex, Lorazepam)
* Treat Gallstones (cholecystectomy or ERCP)
62
Assess severity of Pancreatitis
modified Glasgow criteria
63
ERCP shows **"chain of lakes" appearance**
AXR shows: **pancreatitic calcification**
Diagnosis? Treatment?
Chronic pancreatitis
Conservative
* Alcohol abstinence
Medical
* Pancreatic enzyme replacement
* Manage diabetes
* +/- PPI
* +/- Octreotide
Surgical
* Treat complications
* Decompression (pseudocyst, biliary, pan duct)
* ESWL
* Pancreaticoduodenectomy
* Pancreatectomy
64
HLA and Coeliac disease
HLA-DQ2 and HLA-DQ8
- what 2 eat, what 2 ate (eight)
65
**Abdominal distention**
**Diarrhoea**
**Steatorrhoea**
**Weight loss**
**Faltering growth**
**Rash (knees, buttocks, trunk)**
Diagnosis? Ix? Tx?
**Coeliac disease**
**IgA anti-TTG Ab + Anti-EMA Ab + Total IgA levels**
* If TTG -ve and total IgA normal
* Unlikely Coeliac disease
* If TTG +ve BUT \< 10x ULN
* **Duodenal biopsy**
* If TTG +ve BUT \> 10x ULN
* **IgG EMA and HLA DQ2/DQ8 typing**
* If EMA +ve AND either DQ2/DQ8 +ve --\> no need for biopsy
* _or_ **Duodenal biopsy**
* **↑ intraepithelial lymphocytes (IELs)**
* **Villous atrophy**
* **Crypt hyperplasia**
_Treatment_ = Gluten free diet
+/- Supplementation (Iron, B12, Folate, Vit D and K, Ca)
66
**Umbilical pain / RIF pain**
**Loss of appetite**
**N&V**
**Rebound tenderness**
**Rovsing's sign =** pressure on L side causes pain in RIF
**Psoas sign** = R hip extension --\> RIF pain
**Obturator sign** = internal rot. of flexed R thigh --\> RIF pain
Diagnosis? Ix? Tx?
**Appenditicitis**
Ix: **Abdominal USS**
= aperistaltic, non-compressable appendix
Tx: **Appendectomy**
+ NBM, Analgesia, IV Fluids, IV ABx
67
_Define_
## Footnote
**Diverticulosis**
**Diverticular disease**
**Diverticulitis**
**Diverticulosis** = presence of diverticula
**Diverticular disease** = diverticulosis + complications
* Pain
* Inflammation
* Infection (± abscess, peritonitis)
* Fistulae
* Perforation
* Haemorrhage
* Strictures
**Diverticulitis** = inflammation/infection of colonic diverticula
68
Most common locations for diverticulae
Most common location for diverticulitis and diverticular bleeding
Diverticulae
* **Sigmoid and Descending colon**
* **Left sided** \> R
Diverticulitis
* **Left sided**
Diverticular bleeding
* **Right sided**
69
**_Intermittent_ LIF pain** (NOT constant)
**Change in bowel habit**
**Painless PR bleed**
**Bloating**
**(Pneumaturia, Faecaluria, Recurrent UTI)**
**No fever**
Diagnosis?
Divertular disease
70
**Constant LIF pain**
**Fever**
**Change in bowel habit**
**Mass in LIF**
Diagnosis?
Diverticulitis
71
Ix in diverticular disease or divertulitis
Ix in diverticulosis (no active complications)
Ix in diverticular disease or divertulitis
**CT scan**
Ix in diverticulosis (no active complications)
**Barium enema** (C/I in active disease)
**Colonoscopy** (C/I in active disease)
72
Hinchey classification of perforated divertulitis
73
Tx of diverticulosis
Tx of diverticular disease
Tx of acute diverticulitis
Tx of diverticulosis
* **High fibre diet**
* No follow-up required
Tx of diverticular disease
* **High fibre diet + Fibre supplementation**
* **Analgesia**
Tx of acute diverticulitis
* Simple
* **Oral/IV Antibiotics**
* **IV Fluids**
* **Analgesia**
* **Low residue diet** (clear liquids only) _or_ Bowel rest
* Complicated
* **IV Fluids**
* **IV Antibiotics**
* **Analgesia**
* **Low residue diet**
* If bleeding
* (1) **Colonoscopy + Haemostasis**
* (2) **Bowel resection**
* If perforation or abscess or fistaule or obstruction
* **Drainage of abscess**
* Surgery
* **Peritoneal lavage**
* **Hartmann's procedure**
74
Which organism causes dysentry and gastroenteritis
+ risk factors
75
Pathogens and Diarrhoea
76
Pathogens and Diarrhoea
77
Sx of Bowel obstruction
Sx of Bowel obstruction (Tip: AAAV)
* **Abdominal pain**
* **Abdominal distention**
* Tympanic abdomen (very distended)
* **Absolute constipation**
* **Vomiting**
* Occurs later as lower down in GI tract
78
Types of volvulus and X-ray signs
**Sigmoid volvulus** (most common)
* **"Coffee bean sign"**
* Emerges from LIF
* **Large bowel obstruction**
* Proximal bowel loops dilated
* Distal bowel loops collapsed
**Caecal volvulus**
* **"Fetal sign"**
* Emerges from RIF
* Small bowel now occupies RIF
* **Small bowel obstruction**
* Proximal bowel loops dilated
* Distal bowel loops collapsed
79
Tx for volvulus
ABCDE + IV Fluids + IV ABx + NBM + NG tube + Analgesia
Sigmoid volvulus
* (1) **Flexible sigmoidscopic decompression**
* **+ Rectal tube insertion**
* or (2) Percutaneous sigmoidostomy tube
Caecal volvulus
* **R hemicolectomy**
80
**Pain on defecation**
**Bright red PR bleeding**
Diagnosis? Most common location? Tx?
**Anal fissure**
Most common location = **posterior midline**
Management
* Conservative
* ****Treat constipation
* **High fibre diet**
* Increase fluid intake
* Laxatives
* Medical
* (1) **Rectal GTN ointment**
* (2) Topical CCB (Diltiazem)
* (3) Botox injection
* Surgical
* +/- Lateral sphincterotomy (cut sphincter)
* Complications: Incontinence
81
Goodsall's rule
**Goodsall's rule** for **Anal fistulae**
If external opening is ANTERIOR to anal canal
* Fistula tract runs radially and directly into the anal canal
* - i.e. simple direct route
If external opening is POSTERIOR to anal canal
* Fistula tract follows curved path, opening internally in posterior midline
* - i.e. longer curved route
82
Tx for anal fistaule
**Fibrin glue** (shut close)
**Fistulotomy** (cut and leave open)
**Seton technique** (suture)
83
Haemorrhoids
Most common locations
Grading
Ix for diagnosis
**3, 7 and 11 o'clock**
Grading
* Grade 1 - internal
* Grade 2 - external, spontaneously regresses
* Grade 3 - external, requires manual reduction
* Grade 4 - external, irreducible
Ix = **Proctoscope / Anoscope**
Tx:
* Conservative/Medical
* High fibre diet
* Laxatives (Lactulose)
* Surgical
* Rubber band ligation (most effective)
* Sclerotherapy
* Infrared photocoagulation
* Haemorrhoid arterial ligation
* Stapled haemorrhoidopexy
* Surgical haemorrhoidectomy (last rsort)
84
Triad of acute mesenteric ischaemia
Cause?
Characteristic AXR
**Acute onset, severe abdominal pain**
**Hypovolaemic shock**
**Normal abdominal examination**
Due to thrombus/embolus in SMA
AXR: **Gasless abdomen** (whited out)
85
Tx for acute mesenteric ischaemia
ABCDE + IV Fluids + Analgesia + NBM + NG tube
**Antibiotics**
Stable -\> **Thrombolysis** or **Thrombectomy**
Unstable -\> **Exploratory laparotomy + resect necrotic bowel**
86
**Post-prandial abdominal pain** ("gut claudication")
* Severe, Colicky, After meals
**Melaena**
**Diarrhoea**
**Malabsorption**
**Weight loss** (as eating less)
**PR bleed**
**Abdominal tenderness**
**Abdominal bruit**
Diagnosis? Ix? Tx?
Chronic mesenteric ischaemia
AXR: **Gasless abdomen** (whited out abdomen)
Mesenteric bypass
Mesenteric angioplasty + stent
87
**LLQ abdominal pain**
* Cramping
* Post-prandial ("Gut claudication")
**Bloody diarrhoea**
**Abdominal distension and tenderness**
Diagnosis? Ix? Tx?
**Ischaemic colitis**
**Low flow to IMA** (heart failure, blood loss, thromboembolic)
Barium enema: **Thumbprinting**
_Management_
* Treat underlying cause
* Antibiotics
* Angioplasty or Endovascular stent or Colonic resection
88
Most common causes
of small and large bowel obstruction
**Small bowel obstruction** (extramural) = AH
* **Adhesions**
* **Hernia**
**Large bowel obstruction** (intramural) = CSC
* **Colorectal cancer**
* **Strictures**
* Diverticular disease
* Crohn's disease
* **Caecal volvulus**
89
Small vs Large bowel obstruction
SBO
* Central abdo pain
* Late constipation
* Early vomiting
* Tinkling bowel sounds
* AXR
* **Central dilated bowel loops**
* **Valvulae conniventes** (entire width of bowel)
LBO
* Lower abdo pain
* Early constipation
* Late vomiting
* Normal bowel sounds
* AXR
* **Dilated bowel loops located periphery**
* Dilated \> 6cm diameter
* **Haustra** (do NOT cross entire bowel width)
90
Tx of SBO and LBO
SBO ==\> Conservative
* Drip and Suck (IV Fluids, NBM, NG tube)
* **Gastrograffin follow-up** (diagnostic + therapeutic)
* SBO is less likely to require surgery
LBO
* Surgery
* Hartmann's resection
* or Diverting loop colostomy
* If strictures --\> stent
* if sigmoid volvulus --\> Flatus tube
91
Closed vs Open loop obstruction
For large bowel obstruction
Closed loop obstruction
* If patent ileocaecal valve (i.e. closed/working)
* _AXR_: **dilated large bowel ONLY**
* --\> increase pressure at Caecum --\> perforation
Open loop obstruction
* If non-patent ileocaecal valve (open/not working)
* _AXR_: dilated large bowel and small open
* --\> less likely to perforate
92
Tx of paralytic ileus
First, exclude mechanical obstruction
(Gastrograffin contrast enema)
Then, give **Erythromycin**
93
AXR signs of GI perforation
Erect CXR signs of GI perforation
**Rigler's sign** = air on both sides of the bowel wall
**Pneumoperitoneum** = air under diaphragm
94
DDx indirect vs direct inguinal hernia
Through what?
Relation to inguinal ligament
Relation to pubic tubercle
Relation to inferior epigastric artery
How to DDx between them O/E
Which is more likely to strangulate
95
Which side is more common for inguinal hernias
Right sided inguinal hernia
are more common
96
**Mass in medial thigh**
**Below inguinal ligament**
**Neck of hernia inerior and lateral to pubic tubercle**
Diagnosis?
Femoral hernia
97
Which are more likely to strangulate
Inguinal or Femoral
Femoral hernia (most likely)
Indirect inguinal hernia
Direct inguinal hernia (least likely)
98
Risk factors for incisional hernia
* Pre-operative
* Age
* Obesity
* Malnutrition
* Comorbidities: DM, renal failure, malignancy
* Drugs: steroids, chemotherapy, radiotherapy
* Intra-operative
* Surgical technique/skill
* Inappropriate suture material
* Incision type
* Midline
* Placing drains through wounds
* Post-operative
* Increased intra-abdominal pressure (IAP) - cough, straining
* Infection
99
Tx for incisional hernia
Conservative --\> treat constipation and cough
If high risk of strangulation --\> Mesh repair
100
```
# Define terminology for hernias
Reducible
```
Incarcerated
Strangulated
Obstructed
Incarcerated = irreducible
Strangulated = vascular compromise
Obstructed = bowel obstruction
101
Location of the following hernias
Umbilical
Paraumbilical
Epigastric
Hiatus
Spigelian
Lumbar
**Umbilical** - umbilicus, through umbilical ring
**Paraumbilical** - just above or below the umbilicus, through linea alba
**Epigastric** - epigastric region, through linea alba (similar to paraumbilical)
**Hiatus** - internal, stomach/abdo contents, through oesophageal hiatus of diaphragm
**Spigelian** - lateral to umbilicus, through linea semilunaris
**Lumbar** - lumbar region, through superior lumbar triange (below 12th rib) or inferior lumbar triangle (below external oblique muscle)
102
**Bloody diarrhoea + mucus**
**Relapsing + remitting (well between attacks)**
**LLQ abdo pain**
**Tenesmus**
**Faecal urgency**
Diagnosis?
Ulcerative colitis
103
**Non-bloody diarrhoea**
**Abdominal mass**
**RLQ abdo pain**
**Steatorrhea**
**Aphthous ulcers**
**Glossitis**
**Bowel obstruction**
**Fistulae**
**Systemic symptoms - Fever | Malaise | Loss of appetite | Weight loss**
Diagnosis?
Crohn's disease
104
UC vs Crohn's disease
Location
Layers
Characteristics
Complications
105
Extra GI features in IBD
106
Barium enema findings in UC and CD
107
Ix for ? IBD
108
Surgical options for CD and UC
109
Classification for UC
**Truelove and Witt's severity index** for UC
110
Definition of toxic megacolon
Dilated bowel \> 6cm
111
Tx for UC and CD
Ulcerative colitis
* Acute flare
* (1) **IV Hydrocortisone**
* (2) **IV Ciclosporin or Infliximab**
* Induce remission
* (1) **5-ASA** (topical or oral)
* (2) **Prednisolone**
* Maintain remission
* (1) **5-ASA** (oral)
* (2) **Azathioprine** or **6-MP**
* +/- Surgery
**Crohn's disease**
* Induce remission --\> **Corticosteroids** (Budesonide, Prednisolone)
* Maintain remission --\> **Azathioprine or 6-MP**
* +/- Surgery
112
Abdo scars
113
Incisions through anterolateral abdo wall
What layers
Skin
Subcutaneous fatty layer
Membranous fascia
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum
114
