Flashcards in General Gastro Deck (144):
What are the two types of hiatus hernias?
Sliding and paraoesophageal hernia
what is achalasia?
when the lower gastro-oesophageal sphincter doesn't relax. This can lead to dysphagia, regurgitation and aspiration
where do we look for in palmar erythema?
redness in hypothenar is > than in the thenar of the hand
which side do we roll the patient with ascites to test for shifting dullness?
the side away from organomegaly
what kind of cirrhosis is alcohol?
what kind of cirrhosis is caused by viral hepatitis?
where do we look for cachexia?
look at the masseter, temporals, vastus medals, thenar muscle for cachexia
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
what is specific to alcoholic cirrhosis in terms of liver size?
left liver lobe hypertrophy
what are 10 causes of cirrhosis?
3. Viral hep B and C
4. Drugs- methotrexate
9. Sclerosing cholangitis
10. alpha 1 antitrypsin deficiency
How do we determine leukonychia?
In the nails- loss of lunules (creamy crescent shape seen at the bottom of normal nails)
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
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
what features do we want to comment upon upon palpation of the liver?
describe the liver edge and the surface of the liver
what are 3 causes of ascites related to chronic liver disease??
1. bacterial periotinitis
2. cirrhosis- portal hypertension
3. malignant ascites ( due to hepatoma)
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
what are the top 3 causes of epigastric pain?
3. duodenal ulcer
what question do you want to ask the patient with epigastric pain?
is the pain aggravated at meal times?
how do we look at the synthetic function of the liver?
Albumin, INR (clotting profile)
what do we perceive as a cholestatic LFT pattern?
High ALP and GGT
what do we look at to assess the excretion function of the liver?
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
what are the top causes of cirrhosis in Aus?
1. Alcohol, 2. hep c, 3. Nash, 4. hep b, 5. other
what are some general causes of ascites?
Budd Chiari syndrome
Massive hepatic metastases
what does recanalisation of ligamentum vein mean on ultrasound?
what do you worry about with ascites?
Spontaneous bacterial peritonitis
Prophylaxis for oesophageal varices?
banding + beta blockers
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
what do you think when a patient comes in with recurrent epigastric pain?
describe zollinger ellison syndrome?
gastrin secreting tumour in the pancreas stimulates parietal cells that release HCL--> leading to ulceration
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
what is the macroscopic appearance of bowel infarction?
why did the abdominal X-ray show wall thickening for bowel infarction?
blood through the mucosa
what infections target the terminal ileum?
amoebic colitis, TB, yersinia
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
what is another condition that has similar clinical and histological symptoms to coeliac disease?
how much fluid does the stomach make per day?
approx 3 litres a day.
if there is a high gastric output- what do you need to replace?
Potassium. Potassium is lost in the kidneys due to the alkalosis
what can cause large bowel obstruction?
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.
what do you think if albumin is low?
why do we put in a nasogastric tube for bowel obstruction?
to remove gas from the GIT
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
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
what is budd chiari syndrome?
occlusion of the hepatic vein causing acute hepatic damage which can lead to chronic cirrhosis over time
how is Wilson's disease inherited?
autosomal recessive on Chromosome 13
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
how does unconjugated bilirubin travel in the blood?
attached to albumin
what are the 4 inherited conditions that can impair bilirubin metabolism?
2. Crigler Najjar
3. Dubin Johnson
treatment for achalasia?
• Botox injection
• Calcium channel blockers
• Endoscopic balloon dilatation
what are some causes of steatorrhea?
coeliac, troprical sprue, giardia
what do we give for prophylaxis oesophageal varicoele bleeding?
Complications of GORD
strictures, chronic cough, adenocarcinoma secondary to barrett's metaplasia
what is the pathophysiology of achalasia?
T cell mediated destruction of myenteric ganglion cells
what sort of cancer does barrett's oesophagus progress to?
adenocarcinoma of the oesophagus
how do we diagnose helicobacter pylori infection?
1. Radiolabelled urea breath test
what is the pathophys of autoimmune gastritis?
auto antibodies against gastric proton pump in parietal cells
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
how do we assess severity of acute pancreatitis?
Ranson score- calculated at admission and at 48 hrs post admission
what is the triple therapy and quadruple therapy for helicobacter pylori
4. bismuth subsalicylate
both for 7-14 days
how might we ix possible helicobacter pylori induced PUD?
urease breath test, urea breath test, stool antigen, serology for IgG antibodies against h pylori
what is the cause of most duodenal ulcers
Non bacterial acute inflammatory condition of the pancreas characterised by pancreatic enzyme activation and auto digestion.
what are the 2 main ix required to dx appendicitis
CT abdo and explorative laparoscopy
if you do an open explorative laporoscopy in the abdomen, and you see a normal appendix with gynae problem, do you take it out?
sensation of blockage or obstruction in the oesophagus
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)
2 mechanisms of dysphagia in patients with sliding hiatus hernias
1. oesophagitis (oesophageal angina)
2. prolonged inflammation--> stricture
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.
how do we measure the pressure of the lower oesophageal sphincter?
what can we suggest the patient do to reduce lower oesophageal sphincter pressure?
low fat diet
reduce caffeine intake
substitute anti-cholinergic drugs
early evening meal
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
What examination findings would you look for a patient with dysphagia?
lymphadenopathy (supraclavicular nodes)
hyper expanded chest
how might we ix dysphagia
how long is the small intestine?
which drugs cause oesophagitis/oesophageal ulcerations
what do you think if see linear ulcerations in the oesophagus from endoscopy?
what is barrett's mucosa?
endoscopic diagnosis where you have gastric epithelium lining the tubular oesophagus
what must you see on biopsy from endoscopy of an oesophagus that will dx barrett's oesophagus?
how might you treat strictures in the oesophagus?
dilate the oesophagus
start a PPI
Control obesity/smoking/alcohol etc
Describe Nissan wrap operation. Indication? Consequences?
Nissan Anti reflux operation
Wrap stomach around the oesophagus to increase sphincter pressure
Consequences= vagus nerve dysfunction
what does lymphadenopathy indicate in the setting of adenocarcinoma of the oesophagus?
cannot operate- palliative approach, as no longer surgically resectable
which do we do for pancreatitis lipase or amylase
LIPASE greater than 1000 is diagnostic for pancreatitis
why do we do a CXR for pancreatitis?
we are looking for an effusion
which can be therapeutic out of ERCP or MRCP?
what are 2 types of AAA?
(above or below the renal arteries)
how might we visualise the biliary tree?
how might we manage chronic pancreatitis?
abstinence from alcohol
surgery if possible (whipples or stent)
oral administration of enzyme replacement therapy
when would you not CT IVC for gallstones?
when there is too much bilirubin
when would you really want to do a CT IVC
when you're worried about a bile leak
what are the 2 types of gallstones
Cholesterol stones (supersaturation of cholesterol)
Vs. Calcium pigmented stones (due to build up of unconjugated bilirubin)
describe biliary colic
episodic RUQ dull constant pain after eating fatty meals.
f you incidentally find gallstones in an asymptomatic patient, would you proceed to do remove the gallbladder
no. watch and wait. If symptomatic, yes
how to manage cholecystitis? how does this differ from management of cholangitis?
Admit patient, NBM, fluids
IV antibiotics- metronidazole and ceftriaxone
Admit patient, NBM, fluids
ERCP, or bile duct exploration under laparoscopy
Types of colitis
Infectious, vascular, autoimmune/inflammatory, radiation
Where do we normally find diverticulitis?
What are you looking on CT for diverticulitis?
Any signs of perforation
Look for abscess
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
why is toxic mesocolon 'toxic'?
bacterial infiltrate makes it 'toxic'
where do we normally see bezoar obstruction?
ileocaecal valve (narrowest point of the GIT)
what do we think when the colicky bowel obstruction pain becomes constant?
may indicate ischaemia
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
what is pseudobstruction?
obstruction without a mechanical cause
types of appendix? (think position)
Retrocaecal, pelvic, retroilial appendix
Symptoms of appendicitis
• LOSS of appetite
• N+ V (sometimes)
• Low grade fever
• Occasional diarrhoea
• 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
what causes appendicitis?
: Obstruction of the caecum/appendix orifice--> faecalith, lymphoid hyperplasia (mostly during puberty), cancer, worms--> infection
Primary cancers of the appendix? how do you manage?
carcinoid- tip of the appendix
Hemicolectomy + removal of the appendicitis + removal of lymphnoid drainage (if staged)
what causes a positive rovsing's sign
lifting the right leg--> stretching of the peritoneum--> irritation, peritonitis from appendicitis
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
where is the appendiceal artery located?
in the free edge of the mesentary leading from caecum to appendix
What is the management for terminal ilietis?
IV antibiotics and analgesia
wait for the symptoms to relieve
then do a scope
What do you ask for a patient with mesenteric adenitis
previous viral illness
where is the cancer causing LBO usually located in the Large bowel?
left sided in rectosigmoid area
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,
when would you do a CT abdo pelvis for a patient with LBO?
elderly patients or patients with high suspicion of malignancy
how do we manage confirmed sigmoid volvulus?
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
What is a hernia?
Abnormal protrusion of a viscus
What is a fistula
Abnormal communications between two epithelial lines
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
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.
ddx for ascites?
• Cirrhosis + portal hypertension
• Heart failure
• Nephrotic syndrome
• Malnutrition- Kwashiokor
• Acute liver failure
What is a polyp
Abnormal outgrowth of a mucosa into a lumen
what antibiotic is clostridium diff pseudomembranous colitis mostly associated with?
what do the two toxins of clostridium difficult do?
• Toxin B= cytotoxin
• Toxin A= cause osmotic diarrhoea
what are some causes of portal HT
Budd chiari syndrome
right heart failure
what ix marker is a good indicator of severe pancreatitis?
CRP > 150 at 48 hrs= good chance of severe pancreatitis
where should patients with severe pancreatitis be admitted?
what is the ranson score for severe pancreatitis?
what is the clinical dx of pancreatitis?
Diagnosis= any 2 of:
• Raised Lipase
• Epigastric pain
-CT evidence of pancreatitis
what medication can we use for chronic pancreatitis
CREON zygomatic enzyme replacement therapy
what blood Ix would we be sending off to dx pancreatitis?
FBE looking for raised WCC
U and E looking for hypocalcemia
LFT looking for any obstructive derangement
Blood sugar levels
why do gallstones form?
1. supersaturation of cholesterol
2. biliary stasis
3. infection of the gallbladder
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
what are Ix we want to order to differentiate between PBC and PSC?
PBC: Anti mitochondrial antibodies, liver biopsy, ALP
PSC: ERCP/MRCP, pANCA
What are the causes of chronic pancreatitis?
1. Alcohol abuse
2. Cystic fibrosis
what are some associations with coeliac disease?
• IgA deficiency
• Autoimmune thyroid disease
• Type 1 diabetes mellitus
Iron deficiency anaemia
how do gallstones form?
Supersaturation of bile with cholesterol and stasis of bile in gallbladder leads to gallstone formation typically in the gallbladder
What are the 5 components of the Child Pugh Score? what are the classes?
Class A= 5,6
Class B= 7-9
Class C= 10-15
Do they use the Child Pugh score for transplant listing and assessing stage of chronic liver disease?
no. they use the MELD score
prophylaxis for oesophageal varices?
treatment of bleeding oesophageal varices?
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
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