Gastrointestinal Flashcards
(143 cards)
1
Q
Deficiency of vitamin:
1) B1
2) B12 and folate
3) K
4) D
5) C
A
1) Thiamine - Wernicke’s encephalopathy
2) Macrocytic anaemia
3) Bleeding disorder
4) Osteomalacia and rickets
5) Easy bruising and bleeding (scurvy).
2
Q
Causes of malabsorption
A
Poor dietary intake
Defective digestion or lack of digestive enzymes (e.g. pancreatic insufficiency)
Poor absorption or transport ability (e.g. coeliac)
3
Q
Blood group association with gastric and duodenal ulcers
A
Gastric = A Duodenal = O
4
Q
2 barriers which prevent gastro-oesophageal reflux
A
Lower oesophageal sphincter (LOS) Crural diaphragm (external sphincter)
5
Q
Classification criteria for GORD
A
Montreal
6
Q
Risk factors for GORD
A
Obesity
Hiatus hernia
Agents which relax LOS e.g. caffiene, nitrate drugs, CCB, fat.
Smoking
7
Q
Presentation of GORD
A
Heartburn - retrosternal pain Regurgitation - acid taste in mouth and sensation of content coming up to pharynx Belching Dysphagia Chronic cough
O/E:
Enamel erosion on teeth
8
Q
Managing GORD
A
If no red flag symptoms (GI bleed) - trial PPI with no investigations.
1) OTC e.g. Gavison and other alginates / antacids and LIFESTYLE ADVICE.
2) 4-8wks of PPI e.g. Omeprazole, Lansoprazole. If symptoms persist after trial continue pt on PPI at the lowest therapeutic dose.
3) Add an H+ 2 Receptor Antagonist e.g. Ranitidine (usually taken before bed).
4) Surgical intervention - laparoscopic fundoplication
9
Q
Investigating GORD in secondary care
A
Endoscopy - oesophagitis, erosions and ulcerations. Ambulatory pH monitoring. Oesophageal manometry (measure LOS pressure)
10
Q
Complications of GORD
A
Barrett’s oesphagus
Oesophageal adenocarcinoma
Oesophageal stricture
11
Q
Barrett’s oesophagus
A
Squamous epithelium replaced by columnar epithelium.
Ix - endoscopy and biopsy.
Rx - surveillance and regular biopsies if low-grade. High grade = ablation, resection
12
Q
Risk factors for oesophageal cancer
A
Male sex GORD/Barrett's oesophagus changes (squamous to columnar) Obesity Achalasia Hiatus hernia Hx FHx
HPV, achalasia, smoking and alcohol more risk for squamous cell carcinomas than adenocarcinomas.
13
Q
Histology of oesophageal cancer
A
Majority are adenocarcinoma, minority are squamous cell carcinomas
14
Q
S+S of oesophageal cancer
A
GORD symptoms - heartburn, regurgitation. Dysphagia Dyspepsia Pain on swallowing Weight loss Haematemesis
More advanced disease: hoarse voice and cough.
15
Q
Investigating suspected oesophageal cancer
A
Urgent Upper GI endoscopy and biopsy (2 week wait).
16
Q
Managing oesophageal cancer
A
Endoscopic resection
Oesophagectomy
Chemotherapy before and after surgery
17
Q
Mallory-Weiss tear
A
Non-variceal upper GI bleed.
RFx - recurrent vomiting/retching, hiatus hernia.
CFx - Haematemesis, melena, dizzy.
Ix - FBC, U+E, group + save, clotting profile, LFTs, CXR.
Mx - Resusitation (A-E, warm fluid, blood products, oxygen), endoscopy when stable.
18
Q
Red flag symptoms for referral for endoscopy
A
If over 55, dypepsia and (ALARM) Anaemia Loss of weight Anorexia Recent onset Melena
19
Q
2 types of peptic ulcers
A
Gastric ulcers
Duodenal ulcers
20
Q
Which peptic ulcer has greater association with H.pylori?
A
Duodenal
21
Q
Name 4 drugs which can cause peptic ulcer disease
A
NSAIDS Aspirin Crack cocaine Alcohol Tobacco/smoking
22
Q
Zollinger-Ellison syndrome
A
Hypersecretion of gastrin due to gastric NET.
Multiple peptic ulcers, diarrhoea + steatorrhoea, weight loss, and hypercalcaemia.
23
Q
S+S of peptic ulcer disease (1 difference in presentation between DU and GU)
A
Upper abdominal burning pain Dyspepsia Nausea Weight loss/anorexia Symptoms are related in meal times
GU pain occurs on eating
DU pain occurs post-prandial (1-3hrs) and can be relieved by eating.
24
Q
Investigating peptic ulcer disease
A
H.pylori - carbon-13 urea breath test or stool antigen test.
FBC
Upper GI endoscopy (not routine!)
25
Drugs taken before testing for H.pylori
No PPI for 2 weeks.
| No ABx for 4 weeks.
26
H.pylori eradication treatment
1 x PPI + 2x ABx 7 days.
e.g. Lansoprazole + amoxicillin + clarithromycin
27
Management of peptic ulcer disease
Review drugs
If H.pylori -ve: PPI
If H.pylori +ve: eradication therapy
If assciated with NSAIDs: 2 months PPI.
28
Management of an acute GI ulcer bleed
```
A-E assessment and resusication.
A - airway manoeuves
B - Oxygen
C - 2x large bore cannulas, warm fluids, take bloods (esp clotting profile and crossmatch), blood products
D - assess GCS
```
Activate major haemorrhage protocol.
Consider platelet transfusion and FFP.
29
Causes of an acute GI bleed
```
Mallory-Weiss tear
Peptic ulcer
Stricture
Malignancy
Oesophageal varices
```
30
Oesophageal varices
Ax - Portal HTN and liver cirrhosis. Local dilation of veins.
CFx - UPPER GI HAEMORRHAGE, features of liver disease (ascites).
Ix - endoscopy.
Mx - A-E and resuscitation. Drug - Terlipressin.
31
Risk assessment of patients with upper GI bleed
Glasgow-Blatchford bleeding score at first assessment.
| Rockall score after endoscopy.
32
Some causes of oesophageal motility dysfunction
Achalasia
Systemic sclerosis
Diffuse oesophageal spasms
33
How to test for H.pylori
Carbon-13 urea breath test or a stool antigen test. After eradication therapy NICE recommends using Carbon-13 urea breath test as test of cure rather than stool antigen.
34
Causes and types of gastritis
Acute and chronic.
Erosive and non-erosive.
Acute, non-erosive = H.pylori.
Acute, erosive = long-term NSAID use.
Atrophic gastritis -
Autoimmune gastritis - antiparietal cell antibodies.
35
2 types of inflammatory bowel disease
Crohn's disease
| Ulcerative colitis
36
Pathophyisology and histology of Crohn's disease
Transmural, granulomatous inflammation which can affect any part of the GI tract from mouth to perianal area and has a relapsing-remitting course.
```
Submucosal oedema.
Cobblestone appearance
Longitudinal, linear ulcers
Apthlous ulcers
Discontinuous epithelium involvement = skip lesions.
```
37
Most common sites for Crohn's disease
Terminal ileum and proximal colon.
38
Genes associated with Crohn's disease
CARD15
| NOD2
39
S+S of Crohn's disease
Abdominal pain
Prolonged diarrhoea including nocturnal diarrhoea and urgency.
Weight loss.
Fever
Fatigue
Perianal lesions e.g. fistulas, skin tags, abcess.
```
EXTRA-INTESTINAL:
Arthritis
Erythema nodosum
Aphthous mouth ulcers
Uveitis
```
40
Investigations for Crohn's disease
```
Lab tests:
FBC - anaemia
CRP and ESR - raised
U+E - dehydration from chronic diarrhoea
LFT + albumin
B12, folate, vitamin D, ferritin - signs of malabsorption.
Faecal calprotectin - raised.
Coeliac test (IgA-tTG and EMA), stool sample - exclude as differential.
```
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
41
What not to prescribe in suspected IDB
Anti-diarrhoeal drugs - may precipitate toxic megacolon in UC patients.
42
Management of Crohn's disease
Induce remission and maintenance.
Induce = steroids e.g. Prednisolone
If more distal disease or steriods are CI use Budesonide.
Maintenance = Azothioprine, Mercaptopurine or Methotrexate
Biological therapy = Infliximab (anti-TNF)
Surgery = for distal ileum patients only.
43
Pathophysiology and histology of Ulcerative Colitis
Diffuse and continuous, superficial inflammation of rectum and extending proximal up the colon.
Continuous inflammation of the mucosa only (no deep inflammation).
Crypt abcesses
44
When can ulcerative colitis not be confined to the rectum and colon?
'Backwash ilitis' - backwash of caecal contents into distal ileum can cause features of UC in that area.
45
S+S of UC
Blood in stool
Diarrhoea urgency, frequency, incontinence, nocturnal.
Abdo pain (left lower quad)
Pre-defaecation pain, relieved on passing stool.
Fever, malaise, fatigue, weight loss.
Uveitis, arthritis, aphthous mouth ulcers.
46
Investigating UC
```
Lab tests:
FBC - anaemia
CRP and ESR - raised
U+E - dehydration from chronic diarrhoea
LFT + albumin
B12, folate, vitamin D, ferritin - signs of malabsorption.
Faecal calprotectin - raised.
Coeliac test, stool sample - exclude as differential.
```
Imaging/Secondary care:
Colonscopy + biopsy for histology.
CT to stage.
Abdo USS - bowel wall thickening.
47
Management of UC
Induce remission and maintenance.
Induce = topical aminosalicylate (suppository/enemaformula) can give oral at patient request. +/- steroids if severe.
Maintenance = low dose aminosalicylate
2nd line = methotrexate/azothioprine.
3rd line = biologics e.g. antiTNF infliximab
48
Examples of aminosalicylates
Mesalazine
| Sulfasalazine
49
Causes of small bowel obstruction
```
Adhesions from surgery
Inguinal hernias
Intestinal malignancy
Appendicitis
Crohn's disease inflammation and strictures.
```
50
More common causes of small bowel obstruction in children
Appendicitis
Intussusception
Volvulus
Intestinal atresia
51
S+S of small bowel obstruction
Colic pain
Vomiting
Absolute connstipation -
no stool or flatus. overflow diarrhoea
O/E
Distended bowel
Tinkling bowel sounds (accuracy is in question)
Palpable mass (tumour, stools)
52
Investigations for small bowel obstruction
ABX - Dilated loops of small bowel (normal diameter = 3cm, located central on ABX).
Coil-spring appearance of valvulae conniventes. Air-fluid levels.
CT abdo.
FBC, urea, U+Es - indicate severity/necrosis, volume depletion.
53
Management of small bowel obstruction
NG tube and IV fluids = decompression.
Analgesia
Anti-emetic
Surgery - correct underlying cause.
54
Causes of large bowel obstruction
Colorectal malignancy
Colonic volvulus
Benign stricture e.g. diverticular.
55
S+S of large bowel obstruction
```
Colic abdo pain
Faeculant vomiting
Hx of bowel habit changes
O/E
More marked abdo distension
Tympanic on percussion (gas)
Empty rectum or very hard faeces on DRE
```
56
Investigations for large bowel obstruction
AXR - Dilated loops of large bowel (>6cm for colon or >9cm for caecum). Air fluid levels.
Abdo CT
FBC, U+E, creatinine, group + save.
57
Management of large bowel obstruction
NG decompression
IV fluids
Treat cause - stenting.
58
Difference between UC and Crohn's
Crohns - can be found anywhere in GI tract, transmucosal inflammation, 'skip lesions' of discontinuation, granulomas, smoking is bad, more likely to develop fistulas or strictures.
Ulcerative colitis - confined to rectum and colon, superficial mucosal imflammation, continuous inflammation, no granulomas, more likely to see blood and mucus in stools, smoking is protective.
59
Complications of IBD
```
Malnutrition
Intestinal strictures
Fistualas
Toxic megacolon - esp UC
Colorectal cancer
```
60
Brief outline of the blood supply to the gut
Small intestine - braches of the pancreaticoduodenal and superior mesenteric arteries.
Large intestine - Midgut: superior mesenteric artery and Hindgut: inferior mesenteric artery
61
Causes of bowel ischaemia
Emboli from left side of heart
Thrombus from atherosclerosis of artery
Abdo tumour or mass compression
Vasculitis, SLE, RA.
62
Areas at high risk in bowel ischaemia
Watershed areas - supplied by the distal parts of two arteries, susceptible to iscahemia e.g. splenic fissure and rectosigmoid junction.
63
S+S of bowel ischaemia
```
Abdo pain which is out of proportion to clinical findings. Often after a meal. Can be intermittent.
Fever
Nausea
Diarrhoea
Anorexia
```
```
O/E
Pallor
Abdo distension
Abdo tenderness and guarding
Abdominal bruit
```
64
Investigations for bowel ischaemia
```
FBC - high WCC
Coagulation profile
ABG + lactate - metabolic acidosis
CT angiogram
ECG
ABX
CXR - free air under diaphragm = performation
Stool culture
```
65
Management of bowel ischaemia
A-E resuscitation (airway manoeuvre, oxygen supplementation, 2xlarge bore cannulas, warm crystalloid fluids)
Antibiotics (gentamycin + metronidazole).
Papaverine infusion.
Interventional radiology for thrombolysis or angioplasty.
Surgery - bowel resection
66
Irritable bowel syndrome definition
Chronic and relapsing disorder of the lower GI tract, with no discernible structural or biochemical cause (therefore is a diagnosis of exclusion).
67
Risk factors or potential causes of IBS
Females
Antibiotics
FHx
Dietary e.g. spicey foods, caffiene
68
S+S of IBS
```
Chronic - at least 6 months of symptoms!
Change in bowel habit - diarrhoea,constipation, frequency.
Abdo pain esp related to defaecation.
Abdo bloating
Lethargy
Nausea
Back pain
```
69
Investigation IBS
Exclude other causes - FBC, ESR, CRP, coeliac serology (IGA-tTG, EMA).
70
3 gastro and 3 systemic differentials for IBS
IBD (Crohn's or UC)
Coealiac
Gastroenteritis
Hyperthyroidism
Premenstrual symptoms
Laxative misuse
71
Management of IBS
Dietary advice (regular, healthy meals, avoid spicey food).
Education and information.
Antispasmodic e.g. dicyclomine.
Bulk-forming laxative for persistent constipation e.g ispaghula.
Diarrhoea relief with loperamide.
Tricyclic antidepressant trial e.g. Amitriptyline.
72
Definition of
1) Diverticulosis
2) Diverticular disease
3) Diverticulitis
4) Diverticular
1) presence of diverticular
2) diverticular cause symptoms
3) inflammation of diverticular
4) herniation of mucosa through thickened colonic muscle
73
Common areas for diverticular disease
Sigmoid and descending colon
74
Risk factors for diverticular development
```
Age (over 55yrs)
Low fibre diet
Smoking
Obesity
NSAIDsm opioids, corticosteroids.
```
75
S+S of diverticular disease
Left lower quadrant abdo pain. Exacerbated on food, relieved on defaecation or flatus.
Bloating
Occasional large rectal bleeding.
Diarrhoea and constipation.
O/E
Fever
Left lower quad tenderness
76
Complications of diverticular disease and divertiuculitis
```
Diverticular haemorrhage.
Diverticulitis:
Abscess
Perforation + peritonitis
Stricture formation
Intestinal obstruction
```
77
Investigating diverticular disease
Imaging:
Rule of malignancy with colonoscopy + biopsy (CRC).
CT colongraphy to diagnose presence of diverticula.
Contrast enema
Laboratory:
FBC (high WCC in diverticulitis)
78
Management of diverticular disesae
Assess if complication e.g massive GI bleed and resus if there is one!
Lifestyle advice - increase fibre in diet, avoid NSAIDs.
Diverticular disease Rx - bulk forming laxative e.g. Ispaghula, paracetamol.
Diverticulitis Rx - co-amoxiclav, paracetamol. Clear liquids only and reintroduce solids over 2-3 days.
79
Appendicitis
Acute inflammation of the appendix.
Causes = obstruction due to faecolith, bacteria overgrowth, lymph hyperplasia (viral infection).
S+S = Early periumbilical pain (T10 level) which moves to right iliac fossa. Shallow breathing, nausea, anorexia, vomiting, low grade fever. O/E - peritonitis rebound tenderness, guarding, +ve Rovsing's.
Ix = clinical, explorative laproscopy. pregnancy test, urine dip, FBC and CRP - to rule out other causes.
Mx = Laparoscopic appendicectomy. Analgesia and fluids.
80
Where is site of max tenderness in appendicitis
McBurney's point = 2/3 along the line from umbilicus to anterior superior iliac spine.
81
Name a sign positive in appendicitis
Rovsing's sign = palpation of left lower quadrant increases pain in right lower quadrant.
82
Meckel's diverticulum
Congenital malformation of small bowel.
Failure of vitelline duct to obliterate during 5th week in utero.
Asymptomatic but at risk of bowel perforation, bleeding, obstruction.
83
Volvulus
Malrotation of the intestine.
| Occur during embryonic development.
84
Name of smooth muscle relaxant used in bowel ischaemia
Papaverine.
| Vasodilator and smooth muscle relaxor
85
Vasoactive drug for oesophageal varicies bleed
Terlipressin
86
Achalasia
Loss of ganglionic cells in the Auerbach's plexus, leading to impaired peristalsis.
S+S: dysphagia, regurgitation, chest pain.
Ix: barium swallow (BIRD BEAK) dilation of oesophagus with distal narrowing. CXR (dilated oesophagus), Manometry.
Mx: CCB or nitrates (can lead to GORD), Endoscopic balloon dilation.
87
Slowing in peristalsis not due to mechanical obstruction.
Ileus.
Commonly post-ado surgery also can be due to narcotics.
Paralytic ileus - bowel inactivity.
88
Non-mechanical obstruction but acute intestinal pseudo-obstruction associated with massive dilation, usually of the colon but also of the small intestine.
Ogilvie's syndrome
89
Sigmoid volvulus
Sigmoid colon wraps around itself and its own mesentery, causing a closed-loop obstruction.
S+S: Abdo distension, abdo pain, absolute constipation, nauseam vomiting, anorexia, empty rectum on DRE.
Ix: COFFEE BEAN sign on AXR, CT.
Mx: resuscitation. decompression with sigmoidoscope.
90
Some causes of intra-abdominal sepsis and abscesses
Upper GI: peptic ulcer perforation.
Lower GI: appendicitis, ischaemic bowel.
Liver etc: cholecystitis
GU: PID.
91
Presentation of abdominal abscess
Pain, diarrhoea, ileus, feverish.
| Swinging/spikey temperatures.
92
Psoas muscle abscesses
Flank pain, radiating to groin.
93
S+S of peritonitis
Peritonitic pain, anorexia, nausea, vomiting.
O/E:
High fever, TC, tenderness on palpation, guarding, rebound tenderness, knees flexed most comfortable position.
94
Investigations for peritonitis
```
FBC
U+E
LFT
Urinalysis
Blood cultures
PERITONAL FLUID mc+s
Abdo XR.
```
95
Management of peritonitis
IV fluids
ABx - IV metronidazole + cefotaxime
Surgical drainage or surgery
96
Common bacteria to cause peritonitis with bowel perforation
E.coli
| Gram -ve rod
97
Toxic megacolon
Causes: IBD, ischaemic colitis, Salmonella, Shigella, C.difficule colitis.
Dilation of the colon (>6cm on AXR)
+
Systemic toxicity (fever, TC, anaemia, leukocytosis, dehydration, hypotensive, electrolyte imbalance).
Ix: AXR
Mx: A-E, NG decompression, IV ABx (tazocin), surgery.
98
Hirschsprung's disease
Loss of ganglionic cells from myenteric and submucosal plexus of rectum - causes contracted lumen and functional obstruction.
Diagnosed in first year of life.
Associated with Down's syndrome.
S+S: vomiting, explosive passage of foul smelling diarrhoea, abdo distension, delayed passage fo meconium after birth, fever, failure to thrive.
Ix: AXR, rectal biopsy.
Mx: bowel irrigation, surgery within 1st week of life.
99
Name a gram +ve rob
C.difficile.
Can cause pseudomembranous colitis - esp after cephalosporin use.
Rx = metronidazole and Vancomycin if severe
100
Defintion of
1) Irreducible hernia
2) Incarcerated hernia
3) Obstructed hernia
4) Strangulated hernia
1) Can not be pushed back into correct location through weakened wall.
2) Contents of the hernia sac are stuck.
3) In GI hernias where contents of GI tract can no longer pass.
4) Ischaemia of tissue inside hernia - EMERGENCY.
101
6 locations for hernias
Inguinal - weak point above inguinal ligament, in inguinal canal.
Femoral - below inguinal ligament, in femoral canal.
Incisional - at previous surgical site.
Umbilical - near navel.
Epigastric - between sternum and navel.
Diaphragmatic - e.g. hiatus hernia, protruding into thorax.
102
Risk factors for inguinal hernias
```
Male sex
Obesity
Heavy lifting
Fix
Chronic cough/COPD
Older age
Marfan syndrome, Ehlers-Danlos syndrome.
```
103
Direct and indirect inguinal hernias
Direct - protrudes through posterior wall of inguinal canal. mostly due to adult weakening of wall.
Indirect - passes through internal deep inguinal ring, passing lateral to inguinal artery. mostly congenital.
104
Contents of the inguinal canacl
Spermatic cord in males / Round ligament in females
Ilioinguional nerve
NB: spermatic chord contents = - testicular, cremasteric and ductus deferens arteries.
- external spermatic, cremasteric and internal spermatic fascial layers.
- genital branch, sympathetic fibres and ilioinguinal nerves.
105
Mid-inguinal point
Halfway between pubic symphysis and the anterior superior iliac spine. Can palpate femoral artery here.
106
S+S of inguinal hernia
Palpable lump in groin area.
Pain in groin area, worse on coughing.
Lump will move in on coughing if its a direct hernia.
Signs of acute abdomen if strangulated.
107
Ix and Mx of inguinal hernias
Clinical diagnosis is sufficient.
If ? USS of groin, CT scan.
Mx: Open-mesh repair.
108
Which hernia is more common in females than males
Femoral - high rate of strangulation so surgical repair all femoral hernias.
109
Types of hiatus hernia
```
Sliding = gastro-oesophageal junction (and LOS) + part of stomach slide above diaphragm into chest cavity.
Rolling = bulge of stomach above diaphragm and gastro-oesophageal junction remains below.
```
110
Ix for hiatus hernia
Upper GI series - gold standard.
CXR
Upper GI endoscopy.
111
Mx for hiatus hernia
Sliding hernias - PPI, H2RA (Ranitidine), may not need surgery.
Rolling hernias - surgical repair.
112
Types of laxatives
Bulk forming - increase faecal mass and aid peristalsis e.g. Ispaghula.
Stool softener - decrease surface tension e.g docusate
Stimulant - increase intestinal motility e.g. Senna. CI in obstruction!
Osmotic - draw fluid into the bowels and keep it there e.g. Lactulose
Enema for rapid evacuation of stools.
113
4 GI causes and 4 systemic/non-GI causes of diarrhoea
GI = IBD, diverticular disease, overflow constipation, coeliac.
Systemic = hyperthyroidism, antibiotics (cephalosporins = C.diff), alcohol, non-beta pancreatic islet cell tumour / vipoma.
114
Haemorrhoids
= Piles
Abnormal swelling of vascular mucosal anal cushions. Internal = above dentate line and painless. External = below dentate line and painful.
RFx = pregnancy, constipation + straining, heavy lifting, ageing, chronic cough.
S+S = bright red, painless rectal bleeding, anal itchy, rectal discomfort/fullness/incomplete defaecation.
Ix = DRE, anoscopic exam, FBC.
Rx.= lifestyle advice and constipation avoidance (high fibre, good hydration, perianal hygiene). Paracetamol analgesia, topical steroids (hydrocortisone). Rubber band ligation in secondary care/
115
Pilondial sinus
Hair follicles become inserted into the skin (usually around natal cleft), creating a sinus tract and inflammation.
RFx = male, 15-40yrs, coarse hair, poor hygiene, obesity.
S+S = discharge, pain, swelling.
Cx = abscess, sinus, sepsis, chronic pain.
Rx = hair removal e.g. laser therapy, local hygiene advise, surgical treatment if severe symptoms.
116
Perianal haematoma
Dilated vascular plexus.
Pain on straining at defaecation.
O/E: blue/black buldge under skin
Rx = expectant, excise under LA
117
Anorectal abscess
Infection of soft tissue around anus. Commonly E.coli, Enterococcus.
RFx = male, DM, immunocompromised, anal sex.
S+S = pain, swelling, itch, general malaise, fever, urinary retention, sepsis (rare). Tender, erythematous mass O/E.
Ix = DRE, MRI for fistula.
Rx = drainage, ABx, analgesia.
118
Difference between anal fissure and fistula
```
Fissure = tear in mucosa of anal canal. Bright red blood in stool, MASSIVE pain in defaecation.
Fistula = communicating tract from skin to anorexia-rectal canal.
```
119
Criteria for functional GI disorders e.g. IBS, dyspepsia
Rome IV Criteria (esp IBS).
120
Alternative to steroids in induction of remission for Crohn's
Budesonide
121
Risk factors for gastric cancer
```
H.pylori
Male gender
Smoking
Alcohol consumption
EBV
Blood group A
Pernicious anaemia
Radiation exposure
Genetic = CDH-1
```
122
Histology of gastric tumours
Majority are adenocarcinomas.
| Other types include small cell carcinomas, stromal tumours, NET, lymphoma.
123
S+S of gastric cancer
```
Dyspepsia
Weight loss
Anorexia
Early Satiety
Junctional tumours = dysphagia and pain on swallowing.
```
O/E:
Supraclavicular lymphadenopathy at Virchow's node.
Periumbilical lympadenopathy at Sister Mary Joseph's nodule.
124
Investigating suspected gastric cancer
Upper GI endoscopy + multiple biopsies.
CT scan of chest, abdo pelvis-for metastases.
Endocopic US for staging/invasion depth.
125
Mx of gastric cancer
Education and advice - nutritional/dietician input.
Surgery:
Low staged = endoscopic mucosal resection.
High staged = total/subtotal gastrectomy + preoperative chemotherapy e.g. 5-fluorouracil..
126
Mucosa-associated lymphoid tissue
Also known as extra-nodular marginal zone B-cell lymphomas.
Subtype of non-hodgkin's lymphoma, proliferation not in lymph nodes.
Common site = distal ileum and gastric and is associated with H.pylori.
RFx = female, 60yrs.
S+S similar to gastric cancer
Ix similar to gastric cancer.
Rx = H.pylori eradication, Rituxumab, surgical resection.
127
Most common type of cancer in duodenum and jejunum and major RFx
Adenocarcinoma.
| Crohn's disease.
128
Inheritance of familial adenomatous polyposis
Autosomal dominant.
129
Most common type of CRC and most common location
Adenocarcinoma
71% in colon
29% in rectum.
130
Risk factors for CRC
```
AGE
FHx
Obesity
Ulcerative colitis
Low fibre diet
Smoking
Radiation exposure
```
131
2 genetic diseases which predispose to CRC
Familial adenomatous poylposis
| Hereditary non-polyposis colorectal cancer.
132
S+S of colorectal cancer
Change in bowel habit (increase frequency, loose stools)
Rectal bleeding + anaemia
Right sided = weight loss anaemia, occult bleeding.
Left sided = colic pain, bowel obstruction symptoms, tenesmus.
O/E:
Palpable rectal mass on DRE
Palpable mass in abdo
133
Ix for colorectal cancer
```
DRE
Colonoscopy + biopsy
Barium enema
FBC
LFT
Faecal occult blood
Liver USS or CT to look for met.
```
134
Common place for CRC met
Liver
135
Criteria for 2 week wait for ?CRC
- Aged 40yrs and over with unexplained weight loss and abdominal pain.
- Aged 50 and over with unexplained rectal bleeding.
- Aged 60 and over with:
>Iron-deficiency anaemia or
>Changes in their bowel habit.
- Tests show occult blood in their faeces
136
Describe the staging classification for CRC
```
Duke's.
A = in mucosa
B = in muscular propria
C = spread to at least 1 lymph node.
D = Met to other areas e.g. liver.
```
137
Criteria for hereditary non-polyposis colorectal cancer
Amsterdam criteria.
138
Screening for CRC
Offered to every 2 years to people aged 60-74 years.
Faecal occult blood test.
If +ve = colonoscopy.
139
Mx of colorectal cancer
Surgical - colonectomy + lymph node clearance.
| Adjuvant chemotherapy.
140
Which hormone suppresses gastric acid secretion and where is itself secreted from
Somatostatin from D cells.
141
What cells secrete gastric acid and what else do these cell secrete?
Parietal cells.
| Also secrete intrinsic factor.
142
What is the very first line investigation/gold standard (according to NICE) for coaelaic
IgA-tTG
143
How to differentiate between dysphagia caused by
1. Oesophageal cancer.
2. Oesophageal cancidiasis.
3. Achalasia
4. Pharyngeal pouch
5. Systemic sclerosis
6. Myasthenia gravis
1. weight loss, anorexia, vomiting on eating. Hx of GORD, smoking and alcohol.
2. Hx of HIV or steroid inhaler.
3. Both liquids and solids from onset of symptoms. Regurgitation of food - aspiration pneumonia.
4. Old men.
5. calcinosis nodules, telangiectasia, sclerodactylyl, raynauds too.
6. At end of meal, liquids and solids.
