GASTROINTESTINAL

Question 1

GI bleed discharge score

safely from the ED

Answer 1

Glasgow Blatchford

Gi Bleed

Question 2

Pancreatitis cause and markers

Answer 2

GET SMASHED
Gall Stone, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpian Sting, ERCP, Drugs

• Amylase + lipase

Question 3

Variceal bleeds treatment

Answer 3

Terlopressin and Broad Spec Abx

Question 4

Vomiting Blood Causes

Answer 4

Mallory Weis Tear
Duodenal Ulcer/ Peptic
Eroded ulcer
Epistaxsis swallowed
Varices

Question 5

**Upper GI bleeding

Oesophageal

• oesophagitis
• cancer
• mallory weiss tear
• varices

Gastric

• gastric cancer
• dielafoy lesion
• diffuse erosion gastritis
• gastric ulcer

Answer 5

Oesophageal
Oesophagitis= small volume, usually hx of GORD
Cancer = Small volume, associated dysphagia, weightloss, recurrent
Mallory Weis tear = brisk moderate volume bright red blood following repeated vomiting. Malaena rare. Ceases spontaneously.
Varices = Large vol freshblood haemodynamically unstable

Gastric
Gastric cancer = frank hameatemesis or altered blood mixed with vomit. Erosion of major vessel = big bleed
Dieulafoy lesion = No prodromal features prior. Arteriovenous malformaiton produces considerable haemorrhage.
Diffuse erosive = Haemetemesis and epigastric discomfort. usually underlying cause e.g recent NSAID usage. Large volume haemorrhage may occur with haemodynamic comproise
Gastric ulcer: small low volume bleeds more common = fe deficient anaemia.

Question 6

**Constipation
Cause

CF

IVX

drugs:

Answer 6

Cause: Bowel obstruction, paralytic ileus, ano-rectal stricture/fissure/prolapose, poor diet, medicaitons, hypothyroid, neuromuscular

CF: abdo pain, hair irregular stool, distension, tinkling bowel/asbent, pr bleeding

IVX: over 40 + recent change in bowel habit, PR, FBC, U+E, ca
sigmoidoscipy

Drugs:
Bulk forming: fybogel 
Stool softener
Stimulant laxative: co-danthramer or senna X in bowel obstruction 
Osmotic laxative: movicol- lactulose

Question 7

** Diarrhoea

cause

syx

ivx
management
- drug Tx

Answer 7

Cause: gastroenteritis, drugs, colorectal cancer, uc/crohns, coeliac, c.diff

RF: food poisioining, travel, recent abx use

Syx: stomach cramps, V+N, anorexia, anaemia, fresh Pr bleed mucus

IvX: bloods, U+E, ESR, coeliac serology, sigmoidoscpy, stool sample, colonoscopy

Management: treat cause
ORAL rehydration
codiene phosphate or LOPERAMIDE

refer urgent if over 40+ 6 week change in bowel habit

Question 8

Malnutrition

Answer 8

• Nutritional deficiency state of protein, energy or micronutrients causing measurable harm to body composition, function or clinical outcome
• PEM = protein-energy malnutrition

o Kwashiorkor = fair to normal energy but inadequate protein
- Oedema and hepatomegaly
o Marasmus = inadequate energy and protein= Ass with severe wasting

Question 9

Oesophagitis and reflux / GORD

Cause
RF

CF:
IVX:

TX drugs:

Answer 9

Cause: defective sphincter, hiatus heria, increased intra abdominao pressure, h.pylori.

RF: smoking, obesity, pregnancy

CF: heartburn, retrosternal discomfort, acid brash,

IVX: FBC to exclude anaemia
Upper GI endoscopy of symtoms >4 weeks +55 yrs
Oesophageal PH monitoring

Management: lifestyle, avoid fatty spicy food and alcohol

TX: Antacids
Alginates = gaviscon
PPI lansoprazole
Ranitidine = h2 receptor agonist

Refer if > cancer eg weight loss, dysphagia

Question 10

Oesophageal carcinoma

Most common?

CF:
IVX:

Management

Answer 10

SCC most common then adeno

RF: diet, alcohol, smokingm barrets

CF: dysphagia, vomiting, anorxia, dyspepsia

IVX: Bloods, endoscopy urget, CXR

MAnagement: abx prophylaxis and chemo/ surgery

Question 11

Hiatus hernia

Sliding
Para-oesopheal

CF:

Management:

Answer 11

• Herniation of a part of abdominal viscera through the oesophageal aperture of the diaphragm
- Sliding (stomach moves up into oesophagus through current hole) and Para-oesophageal (out side)

RF: obesity, pregnancy, ascites

CF: Many are asymptomatic, Heart burn esp on bending or lying, GOR, Diff in swallowing

Management: Rx not needed if aymptomatic except for para-oesophageal hernias = fundoplication
PPI higher dose long term

Question 12

Peptic ulcer

IVX:

Management:

Answer 12

• Gastric and duodenal ulcers

Gastric = worsened by eating
Duodenal = relieved by eating 

Cause: H.pylori, smoking, Nsaids

IVX: Upper GI endoscopy, stop PPI 2 weeks before
FE def anemia
Test for H pylori- carbon 13 urea breath test

Management: stop smoking, Triple therapy for 4 weeks
PPI + Amoxicilin + Clarithromycin / metronidazole

Question 13

Gastric Carcinoma

cF:
which node associated?

ivx:

Management:

Answer 13

• Poor prognosis and non specific presentation
Cause: often adenocarcinoma at gastro-oesophageal junction

RF: pernicious anaemia, H.pylori, smoking

CF: dyspepsia, vomiting, decrease weight, epigastric mass, virchows node

IVX: refer- urgent 2 week wait if chronic gi bleeding/ progressive dyspepsia
FBC +LFTs + rapid access flexible endoscopy

Management: nutritional support, total/subtotal gastrectomy
Palliative chemo, corticosteroids, stenting to relieve dysphagia
Prevention: high intake fruit and veg and weight loss

Question 14

Carcinoma of pancreas

95% are?

CF:

IVX:

Answer 14

Late presentation, early mets and poor survival rates
95% adenocarcinomas

RF: smoking, alcohol, chronic pancreatitis

CF: tumours of head pancreas can cause painless obstructive jaundice, anaemia, weight loss, acute pancreatitis, splenomegaly, diabetes

IVX: bloods, CA-19, amylase, hyperglycamiea,
USS of live and pancreas
abdo CT

Management: radical surgery- and chemo, palliation
mean survivial 6 months

Question 15

Coealic disease

which HLA?

CF:

IVX:

Answer 15

HLA-DQ2 (90%) or HLA-DQ8 (its bad 2. 8 gluten)
Gluten - gliadin

CF: steatorrhoea, diarrhoea, abdo pain, bloating, N+V, angular stomatitis, fatigue, weakness, Fe def anaemia, weight loss, FTT, buttock wasting

IVX: ILA and HLA DQ2 testing
–> Ensure that the person has eaten gluten-containing foods in 1+ meal a day, for 6 weeks, before testing
Check serum i(Ig)A tTGA and total IgA first-line.
Endoscopy

Management: Life long gluten free diet.

Question 16

Acute pancreatitis

Key clinical features?
which sign?

IVX

Management
pain relief?

Answer 16

Biggest cause = Gallstones and Alcohol
GETSMASHED
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, scorpian bite, hyperlipdeamia, ERCP, drugs.

CF: sudden epigrastric pain RADIATES TO BACK, vomiting, grey turner sign

IVX: Serum amylase- raised
Serum lipase = RAISED

Management: NBM, FLUIDS analgesia = pethidine

Question 17

Peritonitis

Answer 17

• Inflammation in the peritoneum itself
• SBP = spontaneous bacterial peritonitis = occurs in pts with ascites secondary to chronic liver disease

CF: fever, pain anywhere in abdo, guarding, rigidity and lie with knees flexed

IVX: Fbc raised Acc, blood cultures, culture peritoneal fluid, urinalysis and XR

Management: Iv fluids, systemtic abx and surgery to treat cause

Question 18

Inguinal hernia

Answer 18

• Protrusion of abdo contents through the fascia in the abdo wall, through the internal inguinal ring

RF: infants- male, obesity, constipation

CF: swelling in groin, indirect- pain in scrotum, soft and reducible

IVX: US and reduce heria and occlude deep ring

In children repair asap, adults can be left/ reduced using mesh

INDIRECT – thro’ internal inguinal ring, passes along inguinal cancal thro abdo wall – LAT to inf Epigastric vessels
DIRECT – hernia thro’ post wall inguinal canal. More common elderly. MEDIAL to inf Epigastric vessels

Question 19

Femoral hernia

Answer 19

• Protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal position

RF: mainly females

CF: lump in groin, swells during coughing. pain if incarcerated

IVX: USS,CT, MRI

Management: high risk strangulation–> elective repairment

Question 20

Incisional hernia

Answer 20

•Failure of wound to heal

CF: Bulge or protrusion at or near area of surgical incision

Management: Bulge or protrusion at or near area of surgical incision

Question 21

Umbilical hernia

Answer 21

E.g Congenital hernia = omphalocele or Infantile
Adult- e.g. 90% acquired in women in pregnancy

If present over 4 yrs, then repair

Question 22

Gallstones + biliary colic

Answer 22

Fair, Fat, Fertile, Female + Forty
Biliary colic: Stones made in GB → symptomatic with cystic duct obstruction, or if passed into CBD
⇒ Sudden RUQ pain – often following food
⇒ Radiating to R.Shoulder
⇒ Persists for 15 mins
⇒ Better with analgesia
⇒ A/w nausea + vomiting

x	Fever (suggests cholecystitis or cholangitis) 
x	Jaundice (suggests cholangitis)

Question 23

Cholecystitis

CF:
what sign?

IVX

Treatment:

Answer 23

GB becomes inflamed following stone impaction at neck of GB
CF: Constant or colicky RUQ pain (biliary colic) –> Radiates to Back or R.Shoulder
Worse when eating Fatty Foods, GB mass at RUQ (gall stone), RUQ tender
⇒ Murphy’s sign (palpate RUQ, breathe in, ↑pain)
Fever, Nausea + Vomiting, bloating, NON peritonitic ± Obstructive Jaundice (if stone moves to CBD)

NB: pain is similar to biliary colic, but much more severe

IVX: Bloods, USS abdo to visualise stone
TX:
1. Analgesia, rehydrate, NBM
2. Abx – Co-Amoxiclav
3. Laparoscopic cholecystectomy – within 1 week!!
4. Open cholecystectomy – if GB perforation

Chronic: MRCP

Question 24

Portal hypertension

Caused by?

Signs

Answer 24

Abnormally high pressure in hepatic portal vein (often caused by liver cirrhosis)

Portal HTN → oesophageal varices + HYPO-perfusion of kidneys + water/salt retention (→ascites, transudative pleural effusion, splenomegaly) + ↑CO

sings:
Ascites – can be detected clinically ≥ 1.5 litres
Caput medusae – veins radiating from umbilicus
Splenomegaly
Oesophageal varices → upper GI bleed

Question 25

``` Viral hepatitis A B C D E ``` TREATMENTS?

Answer 25

HEP A: Faeco-oral: fever, malaise, Nauesea --> jaundice TX: Metocopramide + Chorphenamine HEP B: Blood products (IVDU + sex), incubation 1-6 months. Jaundice, malaise, urticaria TX: Metocopramide + Chorphenamine - Peg interferon + active immunisation to high risk HEP C: Blood, IVDU. Often acute --> chronic. Early infection mild. Jaundice. High risk hepatocelluar carcinoma. TX: PEG interferon and ribbavarin HEP D: Need HBV --> may need liver transplant HEP E Feaeco-oral, always acute. High risk in pregnancy. TX: metoclopramide, chlorphenamine.

Question 26

Cirrhosis CF decompensated Signs: Score for severity of Cirrhosis? TREATMENT for pruritis? for ascites?

Answer 26

Diffuse hepatic inflammation characterised by fibrosis CF: Often asymptomatic (compensated) until obvious complications of liver disease (decompensated) Initially vague systemic symptoms: Fatigue + Malaise + Anorexia, Nausea + Weight loss + Jaundice + hair loss Spider naevi, Leukonychia (↓Alb), Clubbing, Dupuytren’s contracture, Palmar erythema, Hepatomegaly Hypogonadism: testicular atrophy or amenorrhoea, Gynaecomastia and Xanthelasma Kayser-Fleischer ring – Wilson’s Decompensated: Oedema + Ascites , Jaundice Easy bruising due to coagulopathy Oesophageal variceal rupture Spontaneous bacterial peritonitis Hepatic encephalopathy (Liver flap, Confusion, Drowsy, ↓GCS) Bloods: LFTS, albumin, PT, INR Liver USS, viral serology, genetic Child-pugh score = severtiy of cirrhosis Management: stop alcohol, treat cause PRUTITIS --> COLESTERYRAMINE SPIRONONELACTONE for ascites

Question 27

Ascites Cause CF IVX Management:

Answer 27

Excessive accumulation of fluid in abdominal cavity Cause: Cirrhosis or malignancy CF: Abdo distension and discomfort, weight gain, nausea and dyspnoea IVX: Exam patient. lying down look for stigmata of cirrhosis: : jaundice, muscle wasting, spider naevi, gynaecomastia, caput medusae, leukonychia, palmar erythema Virchow’s node – L side supraclavicular node, upper abdo malignancy Shifting dullness – change in resonance, repeat both side Fluid thrill – large ascites only FBC: LFTS detramhed, increased INR as lower alb Imaging: Abso USS 1st line Diagnostic ascetic tap / paracentesis FBC + clotting U+E Abdo USS: Microscopy + albumin/ protein level Management: Fluid and salt restriction = SPIRONOLACTONE Therapeutic paracentesis to relieve resp distress

Question 28

Inflammatory bowel disease UC CF IVX signs test ? Treatment 1. Initiate remission 2 Maintain

Answer 28

UC- Colonic and recla mucosa only, relapsing remitting CF: diarrhoea, abdo pain Left Lower Quadrant, Aneamia, large joint arthritis IVX: AXR- thumb priting, lead pipe and mucosal islands feaecal calcprotectin +ve for intestinal inflammation Colonoscopy: continous red colon crypt abcesses Biopsy: Plasma cells and mucosal base 1. Induce remission Management: RECTAL Mesalazine + topical/po Prednisolone 2. Mesalasie +-/ Infliximab to maintain If failed = Proctocollectomy + ileostomy

Question 29

Diverticular disease Severity classification ?

Answer 29

↑Intraluminal pressure → mucosa herniates through muscle layers of gut wall --> infected becomes diverticulitis common Descending large colon (left) CF: Altered bowel habit – constipation Abdominal colic – LEFT sided ⇒Relieved by defecation (do not confuse with IBS), Bleeding, Nausea + Flatulence Diverticulitis: all features above + systemic pyrexia, anoreoxia, tender colon, bleeding stool IVX: Bloods, CT colonography HINCHY score = severity classification Management: high fibre diet, analgeisa + abx Acute: Hospital admission + segmental resection

Question 30

Appendicitis Symtoms? Key sign? IVX ABX Treatment

Answer 30

Obstruction of appendix lumen - 10-20 yrs CF: General central/peri-umbilical, colicky abdominal pain, Aggravated by movement, coughing etc, Nausea + Vomiting + Diarrhoea, Fever (mild) + Fatigue, Voluntary guarding Flushed face LATE: McBurney’s RIF pain (intense) Involuntary guarding (absent in retrocaecal appendix) Rovsing’s sign – palpate LIF and RIF pain Psoas sign – pain on extending hip if retrocaecal IVX: Urinalysis, Bloods, USS Management: NBM, IV fluids, IV prophylactic Cefuroxime and metronidzaole TX: Laparoscopic appendectomy

Question 31

Intestinal Obstruction CF: IVX: CXR: Management:

Answer 31

Simple, Closed loop or strangulated Causes: adhesions, hernias, voluvulus, malignancy divertiuclar disease, faecal impaction, intussusception CF: N+V- feaculant, constipatio Dehydration, abdo distension, colicky abdo pain IVX: DRE, examinae herinal orrifices, AXR - small bowel: >3 cm, vulvulae conniventes cross lumen completely - large bowel: >6 cm haustra do not completely cross lumen CXR erect for pneumoperiteum Bloods + contrast enema CT MANAGEMENT: Drip and suck NGT, avoid prokinetic drugs Emergency surgery if closed loop

Question 32

Ileus

Answer 32

Non-mechanical obstruction (ileus), commonly paralytic i.e. absence of peristalsis → adynamic bowel Causes: Post-abdo surgery, pancreatitis, hypokalaemia also ↓Mg+/↓Ca2+, uraemia, peritonitis, drugs (TCAs, Opioids) - Painless distension! - Bowel sounds absent entirely!! - No bowel movement or flatus

Question 33

Colorectal carcinoma RF CF: Staging Screening?

Answer 33

RF: IBD, HNPCC, pout-jegghers, obesity CF: weight loss, anaemia, mass, colicky pain, tenesmus, change in bowel habit IVX: Colonoscopy, FBC, LFT, tumour markers 2 week refer over 40 with rectal bleeding/ change in bowel habit for 6 + weeks DUKES STAGING! Management: Surgery, radiotherapy and chemo Bowel cancer screening 60-74 yrs every 2 yrs

Question 34

Irritable bowel syndrome IVX to do? Treatment:

Answer 34

- Relapsing functional bowel disorder - Pain and discomfort ass with defecation or change in bowel habit CF: exacerbated by stress, menstruation and gastroenteritis 6 month history of change in bowel, bloating and abdo pain IVX: ca-125 to rule out ovarian Ca, faecal calprotein, bloods FBC Managment: CBT, Loperamide, antispasmodics,

Question 35

Rectal prolapse

Answer 35

- Weak anal sphincter, prolonged straining RF: elderly, multiparous CF: mass protruding through anus after bowel movement -> can need manually replacing, pin, faecal incontinence, ulceration IVX: DRE, barium enema, stool microspy and sweat test MAnagement: high fibre diet, mild laxative, surgery

Question 36

haemorrhoids

Answer 36

Disrupted and dilated anal cushions → piles CF: Painless rectal bleed, bright red, often coasts stools/on tissue - Anaemia/ fatigue due to bleed IV: Abdominal + PR exam, palpate 3 cushions, prolapsing piles are obvious but internal are not palpable Proctoscopy to visualise internal haemorrhoids Management: 1. Fluid, fibre and good anal hygeine, topical analgesia = sterods - Surgery rubber band ligation

Question 37

Perianal abcess

Answer 37

Abscess (collection of pus) located in anal or rectal region - Caused by Infection (E.Coli or Staph), STI or blocked anal glands - RF: DM, Immunoscomp, CD, Diverticulitis, Anal sex CF: painful, hardened tissue, swollen, lumps, discharge from pus from rectum, fever ivx: DRE< proctologist's-sigmoidoscopy Management: Surgical incision + drainage, Analgesia,

Question 38

Anal fissure

Answer 38

Painful tear in squamous mucosa of lower anal canal Causes: constipation, hard feaces, spasms, Crohns, Anal cancer CF: Anal pain, exacerbation by pooping: feels like passing shards of glass, fresh bright red blood during pooping Management: Analgesia- paracetemol + BULK forming laxative Soak in shallow warm bath

Question 39

Sigmoid volvulus

Answer 39

Chronic constipation → colon becomes distended with gas → twists on mesenteric pedicle → closed loop obstruction CF: Acute abdo pain colicky, gross abdo distensison, constipation, vomiting, palpable mass IVX: DRE, AXR, = coffee bean, erect CRR air under diaphragmm Management: Decompression=- sogmoidscope into rectum and pass flatus tube into obstructed loop - leave in for 24 hrs Surgical: Resection of redudent sigmoid colon if recurrent

Question 40

2- Achalasia Syx Gold standard test? Management>

Answer 40

Disorder of motility of the lower oesophageal or cardiac sphincter SYX: Dysphagia of solid foods regurgitate, chest pain, heartburn IVX: CXR: gastric air bubble small, signs of inhalation, dialted oesophagus behind heart Barium swallow - contrast material passes slowly into stomach - Manometry of oesophagus gold standard !! - Mangement: CCB (nimfedipine) and nitrates to reduce pressure in lower sphincter

Question 41

2- Gastritis

Answer 41

- Inflammatiion of stomach lining making it swollen and painful Cause: infection eg h. pylori or alcohol or drugs such as NSAIDs SYX: Dyspepsia, pain, loss of appetitie, bloating, N+V IVX: bloods, gastroscopy, Management: eat small meals, avoid irritating foods, reduce stress --> Ranitadine + PPI if H.pylori triple therapy clarithromycin, amoxicillin and PPI

Question 42

2- Chronic pancreatitis CF Management:

Answer 42

Syx: Epigastric pain – severe, Radiates to back, Relieved sitting forwards/hot water bottle on back, Bloating, Steatorrhoea IVX: US, CT, glucose test Management: analgesia, coeliac plexus block, lipase eg CREON, Fat soluble vitamins (ADEK), insulin Low fat diet no alcohol

Question 43

2- Chronic hepatitis Symptoms

Answer 43

Inflammatory disease of the liver lasting >6 months 2 types: chronic persistent (no cell necrosis) and chronic active (cell necrosis) Cause: viral help, metabolic, alcoholic fatty liver disease Syx: fatigue, anorexai, muscle pain, arthralgia, weight loss, abdo distension, ankle swellling, haematemesis, pruritis, gynaecomastia IVX: bilirubin, urobiillogen, LFTs,

Question 44

ALP

Answer 44

Hepatobillary tree and bones

Question 45

ALT

Answer 45

Hepatocellular damage

Question 46

The complete Rockall Score

Answer 46

estimates mortality in patients with active upper GI bleed who have had endoscopy.

Question 47

Murphys sign

Answer 47

Gall bladder hits hand on palpation --> cholecystitis

Question 48

AST

Answer 48

muscle

Question 49

** Upper GI Bleed IVX Treatment

Answer 49

``` Endoscopy immediately afterr resuscitations for unstabel patients FBC every 4-6 hours cross match 2-6 unuts Coag profile CXR Erect and supine AXR] ``` Admit; if shocked, aged >60 Major ulcer bleed = ompereazole Terlepressin 2mg IV if vasrices suspected

Question 50

2- Subphrenic abcess Cause by? CF:

Answer 50

Localised collections of pus underneath the right or left hemi-diaphragm Often caused bu Generlaised Peritonitis following appendicitis, peptic ulcer or bowel surgery CF: Swinging fever, N+V, malaise, abdo tenderness subcostal + dyspnoea if causes pleural effusion IVX:WCC HIGH - US or CT abdo - CXR shws high diaphragm

Question 51

IBS: CHRONS CF IVX INDUCE REMISSION?

Answer 51

Transmural inflammation mouth to anus CF: Weight loss, FTT, lethargy, diarrhoea, abdo pain, anal structures Lage join arthtitis + erythema nodosum IV:X: faecal calprotectin +ve, AXR strictures, small bowel enema, colonoscopy, COBBLESTONE muscosal appearance, skip lesions Gobley cells ``` Management: 1. INDUCE REMISSION = PREDNISOLONE 2. KEEP REMISSION = Azathoprine Consider Infliximab / methotrexate Surgery if limited to distal ileum ```

Question 52

Liver abcess

Answer 52

Cause: infection --> collection of pus CF: R upper quadrant pain, tenderness, hepatomegaly, Swinging fever, Night seats, N and V Management: Metronidazole, drainage USS

Question 53

Perianal haematoma

Answer 53

Acutely painful condition with onest after straining at stool Syx: Blue-black bulge in the skin near the margin of the anus, Pain

Question 54

Fistula in ano

Answer 54

Abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin * Previous anorectal abscess * Ass with diverticular disease, IBD, malignancy, TB and actinomycosis CF: perianal dischange, pain, swelling

Question 55

UC + chrons treatment 1. remission 2. maintinaing remission

Answer 55

UC 1. MESALASINE 2. MESALASINE --> AZIATHROPINE if doesnt work CHRONS 1. STEROIDS 2. AZIATHROPINE

Question 56

Primary billiary cirrhosis Primary sclerosing cholangitis

Answer 56

``` Autoimmune chronic liver disease 1. igM 2.anti Microbial antibodies 3. middle aged females = affectes the billiary tree ``` (Primary sclerosing cholangitis = UC = affects the duct (tube) like UC)

Question 57

PPIs side effects

Answer 57

Low Na and low Mg

Question 58

treat Hepatic encephalopathy

Answer 58

Lactulose!!! | Prevention = Rifaximin is a type of antibiotic

Question 59

surgical sievere

Answer 59

``` Vascular Infective Trauama autoimmune Metabolic Iatrogenic Neoplastic degenerative ```