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Flashcards in General Gastro Deck (144):
1

What are the two types of hiatus hernias?

Sliding and paraoesophageal hernia

2

what is achalasia?

when the lower gastro-oesophageal sphincter doesn't relax. This can lead to dysphagia, regurgitation and aspiration

3

where do we look for in palmar erythema?

redness in hypothenar is > than in the thenar of the hand

4

which side do we roll the patient with ascites to test for shifting dullness?

the side away from organomegaly

5

what kind of cirrhosis is alcohol?

micronodular

6

what kind of cirrhosis is caused by viral hepatitis?

macronodular

7

where do we look for cachexia?

look at the masseter, temporals, vastus medals, thenar muscle for cachexia

8

why do we see changes in body hair in men with chronic liver disease?

lack of body hair and changes in pubic hair distribution due to reduced testosterone production. There would also be testicular atrophy

9

what is specific to alcoholic cirrhosis in terms of liver size?

left liver lobe hypertrophy

10

what are 10 causes of cirrhosis?

1. alcohol
2. NAFLD
3. Viral hep B and C
4. Drugs- methotrexate
5. autoimmune
6. haemachromatosis
7. Wilson's
8. Idiopathic
9. Sclerosing cholangitis
10. alpha 1 antitrypsin deficiency

11

How do we determine leukonychia?

In the nails- loss of lunules (creamy crescent shape seen at the bottom of normal nails)

12

What might we see in hepatocellular carcinoma? What tumour marker do we test for?

A venous hum over liver may be present.
We look for alpha feto protein

13

What are some classic features of alcoholic liver disease?

macrocytic anemia, left liver lobe hypertrophy, hepatic foetor, hepatic flap, encephalopathy, raised GGT, parotid gland hypertrophy

14

what features do we want to comment upon upon palpation of the liver?

describe the liver edge and the surface of the liver

15

what are 3 causes of ascites related to chronic liver disease??

1. bacterial periotinitis
2. cirrhosis- portal hypertension
3. malignant ascites ( due to hepatoma)

16

when is elevated bilirubin clinically apparent? e.g. when you see jaundice

This can usually be detected clinically if the serum bilirubin level is > 50 μmol/L

17

what are the top 3 causes of epigastric pain?

1. pancreatitis,
2. cholecystitis/choledokolithasis
3. duodenal ulcer

18

what question do you want to ask the patient with epigastric pain?

is the pain aggravated at meal times?

19

how do we look at the synthetic function of the liver?

Albumin, INR (clotting profile)

20

what do we perceive as a cholestatic LFT pattern?

High ALP and GGT

21

what do we look at to assess the excretion function of the liver?

bilirubin

22

in portal hypertension, what would you see in the platelets of the LFTs? and how would this affect the INR?

reduced platelets due to being sequestered by the spleen. INR increased

23

what are the top causes of cirrhosis in Aus?

1. Alcohol, 2. hep c, 3. Nash, 4. hep b, 5. other

24

what are some general causes of ascites?

Cirrhosis
Alcoholic hepatitis
Cardiac failure
Pericarditis
Budd Chiari syndrome
Massive hepatic metastases

Nephrotic syndrome
Peritoneal tuberculosis
Serositis

25

what does recanalisation of ligamentum vein mean on ultrasound?

portal hypertension

26

what do you worry about with ascites?

Spontaneous bacterial peritonitis

27

Prophylaxis for oesophageal varices?

banding + beta blockers

28

what are the 3 reasons why a person with chronic liver disease may cause a coagulopathy?

1. thrombocytopenia due to platelets being sequestered in the spleen
2. reduced production of clotting factors 2, 7, 9, 10
3. reduced bile production--> reduced fat absorption--> vitamin K deficiency

29

what do you think when a patient comes in with recurrent epigastric pain?

peptic ulcer

30

describe zollinger ellison syndrome?

gastrin secreting tumour in the pancreas stimulates parietal cells that release HCL--> leading to ulceration

31

what do we think when we see a patient with sudden onset central abdominal pain, followed by nausea and vomiting. Now has mild abdominal pain. Hx of AF and MI

Bowel infarction secondary to emboli

32

what is the macroscopic appearance of bowel infarction?

haemorrhagic, dusky

33

why did the abdominal X-ray show wall thickening for bowel infarction?

blood through the mucosa

34

what infections target the terminal ileum?

amoebic colitis, TB, yersinia

35

what is gastroparesis? what can cause it?

Gastroparesis is when there is delayed gastric emptying, resulting in food being stuck in the stomach for a long time. Often results in regurgitation after a while. Can be caused by autonomic neuropathy secondary to diabetes or damage to the vagus nerve somehow. It can also be associated with scleroderma

36

what is another condition that has similar clinical and histological symptoms to coeliac disease?

tropical sprue

37

how much fluid does the stomach make per day?

approx 3 litres a day.

38

if there is a high gastric output- what do you need to replace?

Potassium. Potassium is lost in the kidneys due to the alkalosis

39

what can cause large bowel obstruction?

Cancer, vulvolus

40

what classically happens with pseudo obstruction?

loose stools- not complete absence of opening the bowels, previous hx of pelvic surgery, abdominal distension, on pain meds and often from low level cares.

41

what do you think if albumin is low?

infection

42

why do we put in a nasogastric tube for bowel obstruction?

to remove gas from the GIT

43

what is "drip and suck"?

refers to bowel obstruction management. Drip= IV fluids because usually the patient is NBM. Suck = nasogastric tube to relieve gas. They are NBM because the patient may need to go to surgery

44

what does TIPS stand for? What is it used for?

Transjugular intrahepatic portosystemic shunt. Used for cirrhosis and portal hypertension as a shunt is made between the portal vein and hepatic vein

45

what is budd chiari syndrome?

occlusion of the hepatic vein causing acute hepatic damage which can lead to chronic cirrhosis over time

46

how is Wilson's disease inherited?

autosomal recessive on Chromosome 13

47

Name the changes in stool colour and urine colour for pre, intra and post hepatic jaundice.

Pre hepatic- no changes to stool or urine colour
Intra hepatic- dark urine and normal stools
Post hepatic- dark urine and pale stools

48

how does unconjugated bilirubin travel in the blood?

attached to albumin

49

what are the 4 inherited conditions that can impair bilirubin metabolism?

1. Gilberts
2. Crigler Najjar
3. Dubin Johnson
4. Rotor

50

treatment for achalasia?

• PPIs
• Botox injection
• Calcium channel blockers
• Nitrates
• Endoscopic balloon dilatation

51

what are some causes of steatorrhea?

coeliac, troprical sprue, giardia

52

what do we give for prophylaxis oesophageal varicoele bleeding?

propranolol

53

Complications of GORD

strictures, chronic cough, adenocarcinoma secondary to barrett's metaplasia

54

what is the pathophysiology of achalasia?

T cell mediated destruction of myenteric ganglion cells

55

what sort of cancer does barrett's oesophagus progress to?

adenocarcinoma of the oesophagus

56

how do we diagnose helicobacter pylori infection?

1. Radiolabelled urea breath test
2. Biopsy

57

what is the pathophys of autoimmune gastritis?

auto antibodies against gastric proton pump in parietal cells

58

grades of haemorrhoids?

Grade 1: Remains in rectum
•Grade 2: Prolapse on defecation but spontaneous return
•Grade 3: As for second but requires manual reduction
•Grade 4: Remains persistently prolapsed

59

how do we assess severity of acute pancreatitis?

Ranson score- calculated at admission and at 48 hrs post admission

60

what is the triple therapy and quadruple therapy for helicobacter pylori

Triple therapy
1. Clarithromycin
2. Amoxycillin
3. Omeprazole

Quadruple therapy
1. Omeprazole
2. Metronidazole
3. tetracycline
4. bismuth subsalicylate

both for 7-14 days

61

how might we ix possible helicobacter pylori induced PUD?

urease breath test, urea breath test, stool antigen, serology for IgG antibodies against h pylori

62

what is the cause of most duodenal ulcers

helicobacter pylori

63

Describe pancreatitis

Non bacterial acute inflammatory condition of the pancreas characterised by pancreatic enzyme activation and auto digestion.

64

what are the 2 main ix required to dx appendicitis

CT abdo and explorative laparoscopy

65

if you do an open explorative laporoscopy in the abdomen, and you see a normal appendix with gynae problem, do you take it out?

yes generally

66

describe dysphagia

sensation of blockage or obstruction in the oesophagus

67

what symptoms indicate gastro-oesophageal reflux

• Nocturnal cough may indicate reflux
• Heart burn
• Waterbrash (increased salivary secretion)
• Altered taste sensation
• Morning nausea
• Laryngitis (hoarse voice)

68

2 mechanisms of dysphagia in patients with sliding hiatus hernias

1. oesophagitis (oesophageal angina)
2. prolonged inflammation--> stricture

69

describe oesophageal angina

after eating --> oesophageal spasm--> retrosternal chest pain radiating down both arms
- also responsive to nitrates

another symptom that is associated with oesophageal angina= they cannot drink anything without pain.

70

how do we measure the pressure of the lower oesophageal sphincter?

manometry

71

what can we suggest the patient do to reduce lower oesophageal sphincter pressure?

low fat diet
lose weight
stop cigarettes
reduce caffeine intake
substitute anti-cholinergic drugs
early evening meal

72

if you have helicobacter pylori infection and been treated with triple therapy, would you still get IgG antibodies to h pylori post therapy?

yes. for up to 6 months after eradication

73

What examination findings would you look for a patient with dysphagia?

weight loss
lymphadenopathy (supraclavicular nodes)
hyper expanded chest
fever

74

how might we ix dysphagia

barium swallow

75

how long is the small intestine?

4 metres

76

which drugs cause oesophagitis/oesophageal ulcerations

Slow K
Doxycycline
fosamax (bisphosphonate)
Nsaids

77

what do you think if see linear ulcerations in the oesophagus from endoscopy?

peptic ulcerations

78

what is barrett's mucosa?

endoscopic diagnosis where you have gastric epithelium lining the tubular oesophagus

79

what must you see on biopsy from endoscopy of an oesophagus that will dx barrett's oesophagus?

goblet cells

80

how might you treat strictures in the oesophagus?

dilate the oesophagus
start a PPI
Control obesity/smoking/alcohol etc

81

Describe Nissan wrap operation. Indication? Consequences?

Nissan Anti reflux operation
Wrap stomach around the oesophagus to increase sphincter pressure

Consequences= vagus nerve dysfunction

82

what does lymphadenopathy indicate in the setting of adenocarcinoma of the oesophagus?

cannot operate- palliative approach, as no longer surgically resectable

83

which do we do for pancreatitis lipase or amylase

LIPASE greater than 1000 is diagnostic for pancreatitis

84

why do we do a CXR for pancreatitis?

we are looking for an effusion

85

which can be therapeutic out of ERCP or MRCP?

ERCP

86

what are 2 types of AAA?

suprarenal
infrarenal

(above or below the renal arteries)

87

how might we visualise the biliary tree?

CT IVC

88

how might we manage chronic pancreatitis?

abstinence from alcohol
remove stones
surgery if possible (whipples or stent)
oral administration of enzyme replacement therapy

89

when would you not CT IVC for gallstones?

when there is too much bilirubin

90

when would you really want to do a CT IVC

when you're worried about a bile leak

91

what are the 2 types of gallstones

Cholesterol stones (supersaturation of cholesterol)
Vs. Calcium pigmented stones (due to build up of unconjugated bilirubin)

92

describe biliary colic

episodic RUQ dull constant pain after eating fatty meals.

93

f you incidentally find gallstones in an asymptomatic patient, would you proceed to do remove the gallbladder

no. watch and wait. If symptomatic, yes

94

how to manage cholecystitis? how does this differ from management of cholangitis?

Cholecystitis:
Admit patient, NBM, fluids
Analgesia
IV antibiotics- metronidazole and ceftriaxone
Lap cholecystectomy

Cholangitis
Admit patient, NBM, fluids
Analgesia
IV antibiotics
ERCP, or bile duct exploration under laparoscopy

95

Types of colitis

Infectious, vascular, autoimmune/inflammatory, radiation

96

Where do we normally find diverticulitis?

Sigmoid colon

97

What are you looking on CT for diverticulitis?

Fat stranding
Any signs of perforation
Look for abscess

98

how do you tell if a NGT tube is properly placed?

CXR, NGT should pass gastrooesophageal junction by 10cm
can auscultate and listen for wind going past when you inject air from the syringe

99

why is toxic mesocolon 'toxic'?

bacterial infiltrate makes it 'toxic'

100

where do we normally see bezoar obstruction?

ileocaecal valve (narrowest point of the GIT)

101

what do we think when the colicky bowel obstruction pain becomes constant?

red flag

may indicate ischaemia

102

why do we get vomiting as a late presentation of LBO?

if the ileocaecal valve is incompetent, large bowel contents move up to the oesophagus to be expelled

103

what is pseudobstruction?

obstruction without a mechanical cause

104

types of appendix? (think position)

Retrocaecal, pelvic, retroilial appendix

105

Symptoms of appendicitis

• LOSS of appetite
• N+ V (sometimes)
• Low grade fever
• Occasional diarrhoea
• Tachycardia
• Very unlikely for low blood pressure
• Sometimes you get microscopic haematuria and leukocytes on dipstick due to some irritation of the bladder. So can't just rule out appendicitis
• Some dysuria in particular due to pelvic appendicitis

106

what causes appendicitis?

: Obstruction of the caecum/appendix orifice--> faecalith, lymphoid hyperplasia (mostly during puberty), cancer, worms--> infection

107

Primary cancers of the appendix? how do you manage?

carcinoid- tip of the appendix
OR adenocarcinoma

Hemicolectomy + removal of the appendicitis + removal of lymphnoid drainage (if staged)

108

what causes a positive rovsing's sign

lifting the right leg--> stretching of the peritoneum--> irritation, peritonitis from appendicitis

109

Management of acute appendicitis?

Admit the patient
Gain IV access
Start antibiotics- ceftriaxone, Fluids
IF you have a high clinical suspicion for appendicitis NO NEED FOR CT. High radiation; but if other risk factors etc do CT for certain patients
Lap appendicetomy vs. Open appendicetomy
Uncomplicated- discharge the next day
Complicated- five days of IV antibiotics

110

where is the appendiceal artery located?

in the free edge of the mesentary leading from caecum to appendix

111

What is the management for terminal ilietis?

IV antibiotics and analgesia
wait for the symptoms to relieve

then do a scope

112

What do you ask for a patient with mesenteric adenitis

sick contacts
previous viral illness

113

where is the cancer causing LBO usually located in the Large bowel?

left sided in rectosigmoid area

114

how does management differ for a patient with clinical SBO with a hx of adhesive abdomen vs a patient with a virgin abdomen?

Virgin abdomen- CT and laparoscopy

           Adhesive abdomen- drip and suck,
-->manage conservatively

115

when would you do a CT abdo pelvis for a patient with LBO?

elderly patients or patients with high suspicion of malignancy

116

how do we manage confirmed sigmoid volvulus?

flexible sigmoidoscopy

117

what do we use a Sengstaken Blackmore tube for?

We use a Sengstaken Blackmore tube to tamponade bleeding from oesophageal varices in emergency situations. It is used when medication alone will not acute manage the bleeding

118

What is a hernia?

Abnormal protrusion of a viscus

119

What is a fistula

Abnormal communications between two epithelial lines

120

how do we tell the difference between ascites due to portal hypertension or not portal hypertension?

we tell this by calculating the SAAG gradient. From [Serum albumin]- [ascites albumin]. If it is greater than 11, then it is due to portal hypertension

121

how might we predict the level of cirrhosis by looking at the U and Es?

the level of hyponatremia correlates with the level of cirrhosis. This is because cirrhosis is associated with vasodilation leading to increased ADH production, causing increase water retention and diluted sodium levels.

122

ddx for ascites?

• Cirrhosis + portal hypertension
• Heart failure
• Nephrotic syndrome
• Malnutrition- Kwashiokor
• Acute liver failure
Cancer

123

What is a polyp

Abnormal outgrowth of a mucosa into a lumen

124

what antibiotic is clostridium diff pseudomembranous colitis mostly associated with?

clindamycin

125

what do the two toxins of clostridium difficult do?

• Toxin B= cytotoxin
• Toxin A= cause osmotic diarrhoea

126

what are some causes of portal HT

cirrhosis
Budd chiari syndrome
schistosomiasis
right heart failure

127

what ix marker is a good indicator of severe pancreatitis?

CRP > 150 at 48 hrs= good chance of severe pancreatitis

128

where should patients with severe pancreatitis be admitted?

ICU

129

what is the ranson score for severe pancreatitis?

3

130

what is the clinical dx of pancreatitis?

Diagnosis= any 2 of:
• Raised Lipase
• Epigastric pain
-CT evidence of pancreatitis

131

what medication can we use for chronic pancreatitis

CREON zygomatic enzyme replacement therapy

132

what blood Ix would we be sending off to dx pancreatitis?

LIPASE obviously
FBE looking for raised WCC
U and E looking for hypocalcemia
LFT looking for any obstructive derangement
Blood sugar levels
CRP levels

133

why do gallstones form?

1. supersaturation of cholesterol
2. biliary stasis
3. infection of the gallbladder

134

what is gallstone ileus? what do you see on AXR?

rare cause of SBO due to obstruction via a gallstone.

AXR- gallstone, pneumobilia and SBO

135

what are Ix we want to order to differentiate between PBC and PSC?

PBC: Anti mitochondrial antibodies, liver biopsy, ALP

PSC: ERCP/MRCP, pANCA

136

What are the causes of chronic pancreatitis?

1. Alcohol abuse
2. Cystic fibrosis
3. hereditary
4. idiopathic

137

what are some associations with coeliac disease?

• IgA deficiency
• Autoimmune thyroid disease
• Type 1 diabetes mellitus
Iron deficiency anaemia

138

how do gallstones form?

Supersaturation of bile with cholesterol and stasis of bile in gallbladder leads to gallstone formation typically in the gallbladder

139

What are the 5 components of the Child Pugh Score? what are the classes?

AABIE

Albumin
Ascites
Bilirubin
INR
Encephalopathy

Class A= 5,6
Class B= 7-9
Class C= 10-15

140

Do they use the Child Pugh score for transplant listing and assessing stage of chronic liver disease?

no. they use the MELD score

141

prophylaxis for oesophageal varices?

regular gastroscopes
banding
propanolol

142

treatment of bleeding oesophageal varices?

1. octreotide/terlipression
2. emergency gastroscope and banding
3. blood transfusion if required
4. can use sengstaken blackmore tube or inject varices (sclerotherapy)
5. Antibiotics to prevent bacterial infection

143

what is hepatorenal syndrome?

renal failure as a result of CLD.
less blood flow to kidneys as more blood flow within the portal venous system

144

what are the 4 histological grades of CLD?

F1= periportal fibrosis
F2= periportal fibrosis + septa
F3= numerous septa, no architectural distortion
F4= architectural distortion+ nodule formation