General Surgery Flashcards
(332 cards)
1
Q
What isa perianal fistula?
A
Abnormal connection between the anal canal and perianal skin
2
Q
What is the relationship between anorectal abscess and perianal fistula
A
Around 25-40% of abcesses lead to fistular formation
3
Q
What is an anorectal abscess?
A
Collection of pus in the anal or rectal region
4
Q
Who is most affected by anorectal abscesses
A
20-60 y/o
Men
5
Q
What are the causes of anorectal abscess?
A
Infection in cyrptoglandular epilithelium
Crohns
6
Q
How would a patient with anorectal abscess present
A
Severe throbbing or stabbing pain, localised swelling, itching or discharge
fever, malaise, constipation , bleeding
7
Q
What are the sites for anorectal abcesses
A
Supralevator
Ischiorectal
Ischiosphincteric
Perianal
8
Q
What is the most common site of an anorectal abcess
A
Perianal
9
Q
What would you find on examination of a perianal abscess
A
Erythematous, fluctuant, tender perianal mass.
10
Q
How do you a treat a perianal abscess?
A
Incision and draining, either using a cruciate or elliptical incision. Then proctoscopy should be performed to check for fistula
11
Q
When would you prescribe IV antibiotics for an anorectal abscess
A
I.v antibiotics indicated in the following situations:
Immunosuppressants
Valvular heart disease
Prosthetic devices
Sepsis or extensive cellulitis
Crohns disease
12
Q
What are the risk factors for perianal fistula ?
A
IBD
Systemic diseases
History of trauma
Previous radiation therapy
13
Q
What is a complex perianal fistula?
A
above or passing through the external sphincter, involving > 30%
14
Q
How does a perianal fistula present?
A
Hx of recurrent abscess
leaking faeces
Pain
15
Q
What would you see on examination of an anorectal fistula
A
External opening visible
Erythema
Proctoscopy–> internal opening
16
Q
What is the Goodsall rule?
A
If the external opening is posterior to the transverse anal line, the fistula tract will follow a curved course to the posterior midline
If the external opening is anterior to the transverse anal like, the fistula tract will be in a straight line to the denate line
17
Q
Where are the sites of anorectal fistula?
A
Extrasphincteric
Suprasphincteric
Transsphincteric
Intersphincteric
Submucosal
18
Q
What sites of anorectal fistula are simple and which are complex
A
Simple- intersphincteric and low-lying transsphincteric, submucosal
Complex- Suprasphincteric
Extrasphincteric or high fistulas
Fistulas with multiple tracts
Recurrent fistulas
Fistulas related to IBD, infection or radiation
19
Q
What is a simple anorectal fistula
A
minimal or no involvement of external sphincter or puborectalis
20
Q
How do you treat a simple anorectal fistula?
A
Fistulotomy (laying it open)
21
Q
How do you treat a complex anorectal fistula?
A
Placement of a seton through the fistula attempts to bring together and close the tract
22
Q
Define abdominal aortic aneurysm
A
Dilatation of the abdominal aorta greater than 3cm
23
Q
Where are most AAAs situated?
A
Below the renal arteries - infrarenal.
24
Q
Thinking of the tunica layers in arteries, what is AAA usually due to?
A
Degeneration of the tunica media - specifically the elastin and collagen.
25
How do AAA present?
Asymptomatic. PMH of atherosclerosis, trauma, infection, connective tissue disease, inflammatory disease. Pulsatile mass felt in the abdomen above the umbilicus.
26
How do ruptured AAA present?
Persistent abdo AND back pain. Dizzy, syncopal, LOC, SOB, shock. Sudden CVS collapse
27
How are AAAs investigated?
Screening programme in 65th year for men. US confirms Dx, CT with contrast is then done to check surrounding anatomy and to plan for elective surgery.
28
What advice can you give someone who has AAA?
Improve BP control, smoking cessation, exercise, weight loss, statins and aspirin therapy
29
Who would be suitable to have AAA surgery?
If AAA is 5.5cm1cm/year or if symptomatic
30
What surgical treatments are available for AAA?
Open repair or endovascular repair (keyhole).
31
What can serum calcium be helpful for looking at/diagnosing?
Acute pancreatitis, Clotting, cardiac function
32
What is peritonitis?
Inflammation of the lining of the abdomen
33
How do femoral hernias present?
Groin lump, inferior to inguinal ligament and inferior and lateral to the pubic tubercle.
34
How do strangulated femoral hernias present?
Similar to bowel obstruction. Nausea and vomitting, colicky abdo pain, slightly distended abdo
35
What are the RF for gallbladder carcinoma??
Hx of gallstones or chronic cholecystitis
Porcelain gallbladder
Smoking
Obesity
Primary sclerosing cholangitis
UC/crohns colitis
Oestrogens
Occupational exposure
36
How does gallbladder carcinoma present?
Usually presents late with vague symptoms of abdo pain
37
What are ddx for a patient with dyspepsia?
GORD, peptic ulcer, gallstones, gastritis, gastric cancer, NSAID associated erosions
38
What is painless jaundice a sign of?
Pancreatic cancer
39
A man is 60 years old and has a recent diagnosis of DM. He has lost a stone and has a yellow tinge to his skin. What may he have a diagnosis of?
Pancreatic cancer - recent onset of DM over age of 60. Painless jaundice is a clue too.
40
What is the most common type of gastric cancer?
Adenocarcinoma
41
What are 4 risk factors for developing gastric cancer?
Any 4 of male, H. pylori infection, increasing age, smoking, positive fhx, alcohol consumption, increased dietary salt, pernicious anaemia
42
How would a patient with gastric cancer present?
Specific: Dyspepsia, early satiety, vomiting and dysphagia.
General cancer sx: anorexia, weight loss, anaemia
43
What is trosiers sign?
Presence of palpable left supraclavicular node- sign of metastatic abdominal cancer (usually gastric)
44
A 43 year old patient presents with early satiety, what are your differentials?
Ovarian cancer, GORD, gastritis, peptic/duodenal ulcer, gastric cancer
45
Why is gastric cancer so hard to diagnose?
Vague and non-specific symptoms
46
What are differentials to consider when meeting a patient with dyspepsia, early satiety, anorexia and vomiting?
Gastric cancer, peptic ulcer disease, gallstone disease, pancreatic cancer
47
As well as trosier's sign, what are other signs of metastatic gastric cancer?
Hepatomegaly, ascites, jaundice, acanthosis nigricans
48
What imaging would you do in a patient with a suspected gastric cancer?
Upper GI endoscopy (OGD) with anyone who has new onset dysphagia or >55yrs with weight loss and either: upper abdo pain, reflux or dyspepsia
49
Why do you perform an OGD in a patient with suspected gastric cancer?
For visualisation and biopsy
50
On histology what would the appearance of cells be for a patient with gastric cancer?
Signet ring cells
51
What is the purpose of CT abdo-pelvis and laparoscopy in a patient with confirmed gastric cancer?
CT is used to make the treatment plan and the laparoscopy is used for staging
52
How do you treat early gastric tumour?
T1a- endoscopic mucosal resection is used
53
What is the curative management of gastric cancer?
Surgery- offered to fit enough patient, with peri-operative chemo.
Proximal gastric cancer- total gastrectomy
Distal gastric cancer- subtotal gastrectomy
54
What are the palliative treatment options for gastric cancer?
May incl chemo, best supportive care and stenting
Palliative surgery can be used when stenting fails
55
What are the two types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma
56
What are the demographics and affected areas for the different types of oesophageal cancer?
Squamous call carcinoma-more common in the DEVELOPING world, middle and upper thirds of the oesophagus, associated with smoking and drinking
Adenocarcinoma- more common in the DEVELOPED world, lower 3rd of the oesophagus, associated with Barretts oesophagus
57
What are the RF for oesophageal squamous cell carcinoma?
Chronic achalasia, low vit A
58
What are the RF for oesophageal adenocarcinoma?
GORD, obesity and high fat intake
59
How do patients with oesophageal cancer present?
Progressive dysphagia, weight loss due to dysphagia or cancer, odynophagia, hoarseness
60
How would a patient with oesophageal cancer look on examination?
Evidence of recent weight loss, cachexia, signs of dehydration, supraclavicular lymphadenopathy, signs of mets (ascites, jaundice, hepatomegaly)
61
What are the red flag symptoms that would make you request a 2WW endoscopy?
Any patient with new onset dysphagia OR >55 years with weight loss AND one of: dyspepsia OR upper abdo pain OR reflux
62
How do you investigate a ?oesophageal cancer
OGD- to visualise the malignancy
CT CAP and PET-CT for distant mets
Endoscopic US- to measure T-stage (penetration into oesophageal wall)
Staging laparoscopy- look for intraperitoneal mets
If there are any palpable cervical lymph nodes, may be investigated via FNA
Hoarseness and haemoptysis- investigate via bronchoscopy
63
How do you treat a squamous cell oesophageal cancer ?
Hard to operate, definitive chemo and radiotherapy
64
How do you treat Adenocarcinoma off the oesophagus?
Neoadjuvant chemo or chemo-radiotherapy followed by oesophageal resection
65
What are the risks associated with surgical treatment of oesophageal cancer?
Anastomotic leak, reoperation, pneumonia and death
66
What does palliative treatment for oesophageal cancer consist of?
Symptom control:
Patient has difficulty swallowing--> oesophageal stent
Radiotherapy and/or chemo to help reduce tumour size to reduce sx
Nutritional support--> disease progression can lead to significant dysphagia and cachexia--> thickened fluid and nutritional supplements should be offered
RIG inserted if cannot tolerate enteral feeds
67
Define a hernia
Protrusion of a whole or part of an organ through the wall of a cavity that contains it into an abnormal position
68
What is a hiatus hernia?
Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.
69
Which organ usually protrudes in a hiatus hernia?
Stomach. (Small bowel, colon or mesentery rarely herniate).
70
What are the two sub classifications of hiatal hernias?
Sliding or rolling.
71
Define a sliding hiatus hernia
Sliding = cardia of stomach moves upwards or slides upwards through the diaphragmatic hiatus into the thorax.
72
Define a rolling hiatus hernia
Upward movement of the fundus of the stomach, so it lies alongside the gastro-oesophageal junction. This creates a 'bubble' of stomach in the thorax. Has a peritoneal sac = so a true hernia!
73
Name a risk factors of hiatus hernia
Age - age related loss of diaphragmatic tone, increased abdominal pressure, increased size of hiatus, pregnancy, obesity, ascites.
74
How does a hiatus hernia present?
Mainly asymptomatic!!!
Symptoms include GORD, vom, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties.
75
What are differentials of hiatus hernia?
Cardiac chest pain, gastric or pancreatic cancer (if early satiety or weight loss), GORD.
76
What investigations might you do for suspected hiatus hernia?
Oesophagogastroduodenoscopy = gold standard. This would show upward displacement of GO junction.
Can be diagnosed incidentally - CT or MRI scan. Contrast swallow can also diagnose.
77
How is hiatus hernia managed conservatively?
Conservatively - PPI - reduces gastric acid secretion. Lifestyle modification - weight loss, low fat diet, earlier meals, smaller portions, sleep with head raised. Smoking cessation, reduce alcohol intake.
78
How is hiatus hernia managed surgically?
If symptomatic, if increased risk of strangulation, nutritional failure. Can do Cruroplasty and Fundoplication.
79
What are complications of hiatus hernia surgery?
Recurrance, abdominal bloating, dysphagia, fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted).
80
What are complications of hiatus hernias?
Incarceration, strangulation, gastric volvulus.
Presents as Borchardt's triad
81
What is Borchardt's triad
Severe epigastic pain, retching without vomiting, unable to pass NG tube.
82
What is a direct inguinal hernia?
Bowel enters the inguinal canal through a weakness in Hesselback's triangle (posterior wall).
83
What is an indirect inguinal hernia?
Bowel enters the inguinal canal via the deep inguinal ring.
84
Why may a direct inguinal hernia come about?
Secondary to an increased abdominal pressure or abdominal wall laxity.
85
Why may an indirect inguinal hernia come about?
From incomplete closure of processus vaginalis.
86
Name a RF for an inguinal hernia?
Male, raised intra abdominal pressure, obesity, increased age
87
How does an inguinal hernia present?
Lump in groin. Bowel obstruction. Mild-moderate discomfort which worsens with activity or standing.
88
What investigations would you carry out for suspected inguinal hernia?
Usually diagnosed by clinical features. USS recommended as first line imagining. CT imaging required if there are features of obstruction or strangulation.
89
How are inguinal hernias managed?
Surgical intervention - open or laparoscopic repair. Open repairs are preferred for primary inguinal hernias. Lapro is preferred in bilateral or recurrent hernias.
90
What are complications of inguinal hernia?
Incarceration, strangulation, obstruction
91
What are post op complications of inguinal hernia repair?
Pain, bruising, haematoma, recurrence, chronic pain, damage to vas deferent or testicular vessels.
92
What is the pathophysiology of femoral hernias?
Abdominal viscera or the abdominal omentum pass through the femoral ring, and into the potential space - the femoral canal
93
What are risk factors of having a femoral hernia?
Female, pregnancy, raised intra abdominal pressure from heavy lifting etc, increasing age.
94
How do femoral hernias present?
Small lump in groin but otherwise asymptomatic usually. Can present as an emergency. Found medial to the femoral pulse and inferno-lateral to the pubic tubercle.
95
What investigations would you do for a suspected femoral hernia?
USS. CT abdo-pelvis. Lump to be explored surgically.
96
How is a femoral hernia managed surgically?
Managed within 2 weeks of presentation, due to high risk of strangulation. Managed by surgical reduction and narrowing the femoral ring.
97
What are complications of femoral hernia?
Risk of strangulation.
Risk of obstruction.
Increased morbidity and 20 times higher mortality.
Risk of bowel resection, wound infection and cardioresp complications - if acute femoral hernia.
98
What is the pathophysiology of an incisional hernia?
Surgical incision of anterior abdominal wall means they become weakened and disrupted. Contents of abdominal herniate through this weakness.
99
What are RF for incisional hernia?
Emergency surgery, BMI>25, midline incision, post op wound infection, DM, steroid use, connective tissue disorders, increasing age, smoker.
100
How does an incisional hernia present?
Reducible, soft, non-tender swelling near site of previous surgical wound. Can be tender, painful and erythematous if incarcerated. Mass is palpable, may be reducible into abdominal cavity.
101
What investigations would you carry out for suspected incisional hernia?
Diagnosis made on clinical picture. CT imaging done to confirm.
102
How is incisional hernia managed?
Case-by-case different. Surgery is only usually for symptomatic hernias. Can do suture repair, open or laparoscopic repair, abdominal wall reconstruction.
103
What is an umbilical hernia?
Part of abdomen protrudes through opening in abdominal muscles near to the navel, causing belly button to swell.
In babies if opening that umbilical cord passes through does not close properly.
104
How does an umbilical hernia present?
Infants. Protrusion of soft swelling at the navel. Protrudes further on infant crying, straining or coughing. Painless.
105
What are RF for umbilical hernias?
Premature babies, low birth weight. Increased abdominal pressure (in adults).
106
Why is umbilical hernia at risk of incarceration?
Narrow neck of umbilicus = higher risk.
107
What is achalasia?
Failure of the LOS to relax
108
How does achalasia present?
Gradual onset of dysphagia of food and liquids
Regurg of food
Aspiration
Heartburn that often does not respond to PPI
109
What can achalasia lead to?
It is a risk factor for oesophageal squamous cell carcinoma
110
How does large bowel obstruction present?
Abdominal pain
Bloating
Absolute constipation
Nausea and vomiting
111
What are the causes of large bowel obstruction?
Colonic tumour
Volvulus (sigmoid or caecal)
Hernias
Adhesions
112
What investigations would you do for a large bowel obstruction?
Abdominal xray
CT abdo to establish a cause
113
What are red flag symptoms for Colorectal cancer?
Change in bowel habit, rectal bleeding, weight loss, iron deficiency anaemia, tenesmus
114
What are the risk factors for anal fissures?
Constipation and pregnancy (particularly in 3rd trimester and delivery)
115
How do you manage anal fissures?
Treatment of constipation- laxatives/fibre in diet
Topical analgesics- lidocaine cream/jelly
Topical vasodilators- nifedipine or nitroglycerine
Second line treatment incl topical CCB (diltiazem)
116
What are tympanic sounds in the abdomen?
Occurs over the air filled structures- should sound this way in the midline of the abdomen. It sounds long, high pitched and loud
117
What are the features of chronic pancreatitis?
Epigastric pain that radiates through to the back (exacerbated by fatty food/alcohol and relieved by sitting back), steatorrhoea, weight loss and diabetes mellitus.
118
A patient comes in with jaundice, upon investigation, the cause is post- hepatic. What are your ddx?
acute cholangitis, cholecystitis, bile duct strictures, obstructive choledocholithiasis, external compression from extra- billiard tumour, pancreatic tumour, primary biliary cirrhosis and primary sclerosing cholangitis
119
You meet a 68 year old M, who has chronic alcoholism . He has come in with lethargy and jaundice, what are you ddx?
Alcoholic liver disease, viral hep, hepatocellular carcinoma,hepatocellular adenoma,
120
What is the most sensitive blood test for diagnosis of acute pancreatitis?
Lipase! NOT amylase - as can rise and fall quickly, so can lead to false -ve.
121
A patient comes in and has unexplained microcytic anaemia and weight loss. What is your next investigation?
Colonoscopy/lower GI tract investigation as could have colorectal cancer.
122
How would you manage post-op ileus?
Conservatively - insert NG tube for stomach decompression for symptom control. Place pt on NBM regime to allow bowel to rest. Reduce opiate analgesia as reducing bowel motion. Do daily bloods as could have electrolyte abnormalities and AKI can develop. Encourage mobilisation.
123
What is post operative ileus?
A deceleration or arrest in intestinal motility following surgery. Classified as a functional bowel obstruction and is v common after abdominal or pelvic oath surgery.
124
How does post operative ileus present?
Failure to pass faeces or wind. Sensation of bloating and distension. Nausea and vomiting. On examination, there is abdominal distension and absent bowel sounds.
125
What is Buerger’s disease?
Non atherosclerotic vasulitis in small and medium sized arteries. Usually young male, smoker, Mediterranean origin
126
How does Buerger’s disease present
Acutely ischaemic limb without peripheral claudication
127
What is the management of gallstones?
Asymptomatic patients will be treated without investigation
Patients with symptoms or complications can be treated with cholecystectomy
128
What conditions increase risk of anal carcinoma?
HPV, Chrons, HIV
129
Patient presents with lower Gi bleed. What are the your differentials?
Chrons, UC, haemorrhoids, anal fissure, colorectal cancer, anal cancer, diverticula disease, colonic polyps.
130
What is a serious complication of total parental nutrition?
Refeeding syndrome
131
What does ischaemic colitis usually present with?
Acute rectal bleeding due to tissue necrosis.
132
How does mesenteric ischaemia present?
Sudden serve abdo pain out of proportion with clinical exam. N&V, signs of shock, metabolic acidosis on ABG, PR bleed seen in advanced ischaemia
133
How can diverticulitis present?
Left lower quadrant pain, fever, N and Vom. PR bleeding and pain
134
What are the symptoms of gallstone disease?
Can be asymptomatic
RUQ pain
Biliary colic
Nausea
Vomitting
Pale urine
Dark stools
Fever
Jaundice
135
What are the risk factors of gallstone disease?
Fair, fat, forty, family history, fertile
Poor diet
Oral contraceptives
Pregnancy
Malabsorption
Ethnicity- Native American and hispanic
136
What is biliary colic?
Stone is temporarily obstructing the neck of the gall bladder, impeding drainage
137
What are the symptoms of biliary colic?
Severe colicky RUQ pain
Often triggered by fatty meals
Nausea and vomitting
138
What is the most likely picture of LFTs when a patients presents with biliary colic?
Raised ALP, raised bilirubin
139
What is the first line investigation for patients who have suspected gallstone disease?
Ultrasound (trans abdominal)- helpful in identifying any gallstones in the gallbladder, gallstones in the ducts, bile duct dilatation, acute cholecystitis (thicken GB wall, or sludge in the gallbladder with fluid around the gallbladder)
140
What is the indication of MRCP in suspected gallstone disease?
Investigate further if ultrasound doesn't show the presence of stones, but there is dilatation of the bile duct or raised bilirubin which suggests obstruction
141
What is acute cholecystitis?
Gallstone blocking the cystic duct or neck of the gallbladder causing the gallbladder to become inflamed.
142
What are the signs and symptoms of acute cholecystitis?
Pain in the RUQ
Fever
Nausea
Vomiting
Tachycardia and tachypnoea
Murphy's sign positive
143
What is Murphy's sign?
Hand on the RUQ and apply pressure, ask patient to take a deep breath in, the gallbladder will move downwards and come in contact with your hand and cause pain for the patient.
144
What is the first line investigation for acute cholecystitis?
Abdo ultrasound showing thickened gallbladder wall, stones or sludge in gallbladder, fluid around the gallbladder
145
What is the management of acute cholecystitis?
Conservative includes, Nil by mouth, Co-amoxiclav +/- metronidazole, antiemetics
Laproscopic cholecsytectomy is performed usually during the acute admission (within 72 hours) and sometimes delayed by 6-8 weeks to allow for the inflammation to subside
146
What is acute cholangitis?
Biliary outflow obstruction and infection
Due to gallstone which fully stops bile flow, causing stasis and then infection
ERCP, infection introduced
147
What is Charcot's triad?
Presentation of acute cholangitis
RUQ pain
Fever
Jaundice
148
What are the most common organisms causing acute cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
149
How would a patient with acute cholangitis behave on examination?
Confused
RUQ tenderness
Jaundice
Hypotension
Tachycardic
150
Why is acute cholangitis a surgical emergency?
Due to the risk of sepsis and septicaemia
151
What would investigations find in acute cholangitis?
FBC- leukocytosis
LFTs-elevated ALP +/- GGT & bilirubin
blood cultures - not always positive
ultrasound buliary tract - duct dilation
152
How is acute cholangitis managed?
risk of sepsis- fluid resuscitation, routine bloods,
blood cultures, broad spectrum Abx
(co-amoxiclav + metronidazole)
definitive managment:
endoscopic biliary decompression using ERCP
cholecystectomy maybe required if
gallstones the underlying cause
153
What is thumbprinting indicative of?
large bowel thickening usually caused by oedema
154
Why is opiate analgesia a RF for anal fissures?
Opiates cause constipation —> stool is hard and patient will strain —> increases the risk of tearing skin of anal canal
155
What is the triad of Acute mesenteric ischaemia?
severe abdominal pain, unremarkable abdo exam and shock
156
What is oedematous bowel indicative of?
It is a non-specific sign but indicates an inflammatory process, e.g. necrotic bowel
157
What are differentials of right iliac fossa pain?
acute appendicitis, mesenteric adenitis, crohns, diverticulitis (but usually on the left), inflamed Meckel's diverticulum, ovarian torsion, ectopic pregnancy, ovarian cyst, testicular torsion, pyelonephritis, ureteric colic
158
What are the causes of small bowel obstruction?
Adhesions, incarcerated hernias, crohns disease, appendicitis, malignancy, gallstone ileus, foreign body ingestion
159
How does peripheral arterial disease present?
Walking impairment,
pain in buttocks and thighs that are relieved by rest, pale cold leg,
hair loss,
weak pulses,
ulcers
poorly healing wounds
160
How does chronic limb ischaemic present?
Cramping pain in the calf after walking, which is relieved by rest.
161
What is the significance of polyps in the colon?
10% progressive from benign adenomas to invasive adenocarcinoma
162
What is the APC gene?
It is present in FAP (familial Adenomatous polyposis) and is a tumour suppressor gene, results in the growth of polyps
163
What is the HNPCC gene and what condition does it give you?
It is a mismatch repair gene, giving you Lynch syndrome and increases your chance of colorectal cancer
164
What are the risk factors for colorectal cancer?
Male, increasing age, family hx, low fibre diet, increased processed meat intake, smoking, alcohol excess
165
How does colorectal cancer present?
Weight loss, change in bowel habit, PR bleeding, abdominal pain, iron deficiency anaemia.
166
How does presentation of colorectal cancer differ on location?
Right sided (ascending colon)- FUNGATING, change in bowel habit happens later on, abdo pain, iron deficiency anaemia, palpable mass in the R iliac fossa- presents later at diagnosis
Left sided (descending colon)- STENOSING, change in bowel habit early on, rectal bleeding, palpable mass in the LIF, tenesmus, presents earlier
167
When would you refer via 2 WW with suspected colorectal cancer?
40 years or more with unexplained weight loss and abdo pain
50 years or more with unexplained rectal bleeding
60 years or more with iron deficiency anaemia or change in bowel habit
168
What lab investigations would you do for a suspected colorectal cancer?
FBC, LFTs and Clotting
May show a microcytic (iron deficiency anaemia)
169
What is your first line investigation for a suspected colorectal cancer?
Colonoscopy with biopsy
If unable to do a colonoscopy, CT colonography
170
What is the role of alternative imaging (CT, MRI etc.) in colorectal cancer?
CT TAP, once diagnosed for staging and distant mets
MRI rectum for rectal tumours- to see tumour depth
Endo-anal ultrasound for T1/2 rectal tumours to determine suitability for trans-anal resection
171
How do you approach management of colorectal cancer
Discussion with the MDT
Very small tumours may be suitable for endoscopic resection
Surgery is the main curative treatment
R.Sided tumour- right hemicolectomy
L.Sided tumour- left hemicolectomy
Sigmoid colon tumour- Sigmoidectomy
High Rectal tumour- Anterior resection with loop ileostomy
Low Rectal tumour- Abdominoperineal resection
CHEMO- used Neo-adjuvant or adjuvant, usually in patients with advanced disease
RADIOTHERAPY-used more in rectal cancer
172
What is the aim of palliation in colorectal cancer?
Reduce cancer growth and focus on symptom control
173
What is a cholangiocarcinoma?
Cancer of the biliary system
174
What is a Klaskin tumour?
A tumour at the bifurcation of the L and R hepatic duct. It is a slow growing tumour which invades local lymph nodes
175
What are the risk factors for cholangiocarcinoma?
Primary scerlosing cholangitis
UC
Infective causes (liver flukes, HIV, hep)
Airplane and rubber fumes
Congential
Alcohol excess
DM
176
What are the clinical features of cholangiocarcinoma?
usually asymptomatic until later stages
post hepatic jaundice
pruritus
pale stools and dark urine
Less commonly- RUQ pain, early satiety, weight loss, anorexia and malaise
177
How does cholangiocarcinoma present on examination?
Jaundice and cachexia and courvoisiers rule applies
178
What is courvoisiers law?
Palpable gallbladder with painless jaundice--> pancreatic or biliary pathology should be suspected
179
What do you expect to be present on LFTs in a cholangiocarcinoma?
Obstructive jaundice, elevated bilirubin, ALP, y gamma transferase
180
What is the gold standard imaging for cholangiocarcinoma?
MRCP
ERCP can be used to obtain samples
181
What is the most common aim of treatment with cholangiocarcinoma?
Palliative
182
What is the definitive cure of cholangiocarcinoma?
Surgery
183
How do you treat a Klaskin tumour?
Partial hepatectomy and reconstruction of biliary tree
184
What are the palliative treatment options for cholangiocarcinoma?
Stenting- to relieve the obstruction
Bypass surgery- to bypass the obstruction, stenting doesn't work
Palliative radiotherapy- to prolong survival some chemo agents may be used with radiotherapy
185
What are some conditions that can predispose you to hepatocellular carcinoma?
Viral hep B and c
Hereditary haemochromatosis
Primary biliary cirrhosis
186
What are some risk factors for hepatocellular carcinoma?
Male
Over 70
Fhx liver disease
High alcohol intake
aflatoxin poisoining
smoking
viral hep b and c
187
How do patients with hepatocellular carcinoma present?
Similar to liver cirrhosis
Vague and non-specific symptoms: leathery, weight loss, fatigue, fever
Dull ache in RUQ is uncommon but if present can be suspicious of malignancy
188
What are the examination findings of a patient with hepatocellular carcinoma?
Large, craggy, tender and irregular liver-->v suggestive of malignancy
189
What are the blood abnormalities in a patient with hepatocellular carcinoma?
LFTs deranged
Low platelets and clotting due to liver failure
Alpha fetoprotein should be measure as is raised in 70% of cases, and is good indication of treatment progress
190
What investigative imaging do you use in hepatocellular carcinoma?
US. Mass >2cm, with raised alpha fetoprotein (AFP) is virtually diagnostic of hepatocellular carcinoma
Rising AFP with nodular liver--> MRI
191
What is the name of the staging criteria for hepatocellular carcinoma?
Barcelona Clinic (no need to know the different stages_)
192
When can transplantation be considered in hepatocellular carcinoma?
Milan Criteria is used and needs to be fulfilled:
One lesion less than 5cm or 3 lesions are smaller than 3 cm
No extra hepatic manifestations
No vascular infiltration
193
When would surgery be indicated in a patient with hepatocellular carcinoma?
Good baseline function and no cirrhosis
194
What are the non-surgical treatment options fo hepatocellular carcinoma?
Image guided ablation- low grade tumours
Alcohol ablation
Transarteril chemoembolisation
195
Which organs metastasise to the liver most frequently?
bowel, breast, stomach, pancreas and lung
196
Whats the most common type of tumour is in pancreatic cancer?
ductal carcinoma, which is from the exocrine part of the pancreas
197
Where do pancreatic tumours arise from?
Head- 60-70%
Body and tail - 20-25%
Diffuse- 10-20%
Body and tail tumours more likely to be diagnosed at advance stages compared to head
198
What are the risk factors for pancreatic tumours?
Smoking
Chronic pancreatitis
Poor diet- high red meat and low fruit and veg
late onset DM
Fhx
199
What is the presentation of pancreatic cancer?
Usually non-specific
Can get:
obstructive jaundice
weight loss
non-specific abdo pain
200
How does a patient with pancreatic cancer appear on examination?
Cachexia
jaundiced
malnourished
courvoisiers law applies
201
What is a RF for appendicitis?
In 20s-30s. FHx. Caucasian. Seasonal RF - summer.
202
How does appendicitis present?
Generalised peri-umbilical pain which later localises in the RIF. Vomiting, nausea, diarrhoea/constipation,
203
What is found on examination of a pt with appendicitis?
Guarding, rebound tenderness, percussion over McBurney's point. Rovsing's sign - pain in RIF when palpate LIF. Psoas sign - RIF pain with extension of the right hip.
204
Name four investigations you might do for suspected appendicitis
Urinalysis - check pregnancy and urological causes. Bloods - FBC, U+Es, CRP, serum beta-hCG.
US and CT, laparoscopic investigation.
205
How is appendicitis managed?
Laparascopic appendectomy, open appendectomy with a Lanz incision. Appendix to be sent to histopathology to look for malignancy. May need abs and percutaneous drainage. Analgesia.
206
Name a complication of appendicitis
Perforation. Surgical site infection. Abscess formation.
207
What are RF for Chrons? And what are RF for UC?
Chrons - smoking, Fox, environment. UC - caucasian, genetics, environment
208
How does Chrons present?
Episodic abdo pain. D-, stools may have mucus and blood. Malabsorption. Oral aphthous ulcers, perianal disease, arthritis, erythema nodosum, uveitis, renal stones, hepatobillary problems.
209
How does UC present?
Bloody diarrhoea, gradual onset, PR bleeding, mucus discharge, frequency and urgency of defecation, malaise, anorexia, low grade pyrexia, arthritis, erythema nodosum, uveitis, primary sclerosing cholangitis
210
What investigations would you do for suspected IBD (Chrons, UC)?
FBC, CRP, faecal calprotein, LFTs, stool sample, colonoscopy, CT abdo and pelvis. For Chron's - MRI, proctosigmoidoscopy. For UC - AXR or CT for toxic megacolon or bowel perforation and to see mural thickening, thumb printing or lead pipe colon.
211
How is remission induced in Chrons?
Fluid resus, nutritional support, prophylactic heparin (as flare ups are a prothrombotic state), corticosteroid treatment, immunosuppressive treatments - mesalazine.
212
How is remission maintained in Chrons?
Azathioproine - 1st line monotherapy. Smoking cessation. Colonoscopic surveillance if had disease for over 10yrs with more than 1 segment affected. Refer to specialist nurse and nutritional support.
213
How is UC managed presenting to hospital ?
Fluid resus, nutritonal support, prophylactic heparin. Induce remission with steroids and immunosuppressive agent.
Need to maintain remission too with immunomodulatord.
Colonoscopic surveillance.
Refer to specialist nurse.
214
How is Chron's surgically managed?
ileocaecal resection - where you remove the terminal ileum and caecum with primary anastomosis. Small or large bowel resection. Surgery for peri-anal disease.
215
How is UC surgically managed?
Total proctocolectomy is curative. Initially, pt may have subtotal colectomy.
216
Name 2 complications of Chron's
Fistula,
strictures,
recurrent perianal fistulas,
GI malignancy,
malabsorption - leading to growth delay.
Osteoporosis,
increased risk of gall stones and renal stones
217
What is a complication of UC?
Toxic megacolon, colorectal carcinoma, osteoporosis, pouchitis (inflame of ilea pouch).
218
What are diverticula?
Outpouchings of mucosa through weaker areas of the bowel wall.
219
Distinguish between diverticulosis, diverticular disease and diverticulitis
Diverticulosis = presence of diverticula. Diverticular disease = symptomatic diverticula. Diverticulitis = inflammation of the diverticula
220
What are RF for diverticula?
Age, low fibre diet, obesity, Fox, NSAID use.
221
How does diverticular disease present?
Intermittent lower abdo pain. Colicky. Pain relived by defecation, nausea, flatulence
222
How does acute diverticulitis present?
Acute abdo pain, sharp and localised to LIF. Worsened by movement. Localised tenderness, reduced appetite, pyrexia, nausea.
223
What is the pathophysiology of acute diverticulitis?
Bacteria grow in the outpouchings - causes inflammation. Can be simple, where its just inflam or complicated, where there is an abscess or perforation.
224
How may diverticular bleed present?
Painless PR bleed in diverticulosis. Painful PR bleed in diverticulitis.
225
How is diverticular disease managed?
Simple analgesia, increased fluid intake, colonoscopy to exclude malignancy.
226
What are complications of diverticular disease?
Acute diverticulitis, diverticular bleed.
227
What is conservative management of acute diverticulitis?
Abx, IV fluids, analgesia. Sx should improve in 2-3 days.
228
What surgical interventions are available for acute diverticulitis?
Hartmann's procedure - sigmoid colostomy with formation of end colostomy.
229
What is a complication of acute diverticulitis?
Recurrance, strictures, fistula formation, diverticular bleed.
230
How is diverticular bleed managed?
Self limiting. Can do flexible sigmoidoscopy to check for malignancy.
231
Name a cause of intraluminal intestinal obstruction?
Gallstone ileus, foreign body, faecal impaction.
232
Name a cause of mural intestinal obstruction
Malignancy, strictures, intussusception, mocker's diverticulum, lymphoma.
233
Name a cause of extraluminal intestinal obstruction
Hernia, adhesions, peritoneal mets, volvulus
234
What is the most common cause of small bowel obstruction?
Adhesions, hernias
235
How does small bowel obstruction present?
Abdo pain, vomiting, abdo distension, absolute constipation
236
What would be seen on examination for small bowel obstruction?
tinkling bowel sounds, focal tenderness.
237
What imaging would you do for small bowel obstruction? And what would you see?
AXR - see centrally dilated bowel >3cm. Valvulae conniventes are visible. Can do CT scan with IV contrast. Can do CXR - see pneumoperitoneum if perforated.
238
What initial management options would you discuss for small bowel obstruction?
Urgent fluid resus, catheter to monitor fluid output, pt NBM, insert NG tube to decompress bowel
239
When is surgery indicated for small bowel obstruction?
Intestinal ishaemia, closed loop bowel obstruction. If hernia is present and strangulated - need surgical correction.
240
What are complications of small bowel obstruction?
Bowel ischaemia, bowel perforation, dehydration and renal impairment
241
What are most common causes of large bowel obstruction?
Malignancy, diverticular disease, volvulus
242
What is seen on AXR of large bowel obstruction?
Peripherally dilated bowel. Haustral lines visible.
243
How do oesophageal varices present?
Haemetemesis, Malena, light headedness, LOC. Can also have associated signs: jaundice, ascites, raised JVP, bruising (sign of impaired coag due to liver disease), caput medusa
244
A pt has presented with hematemesis. You suspect oesophageal varices; what questions may you ask in the Hx?
Alcohol intake? Hep B/C?
245
What investigations would you do for definitive diagnosis of oesophageal varices?
OGD. or CT w/ contrast if patient is unstable for OGD or the OGD is unremarkable
246
During OGD, how can oesophageal varices be managed?
Endoscopic banding. Prophylactic AB and somatostatin analogues. Sengstaken- Blackmore tube/balloon tamponade. TIPS considered if band ligation does not work.
247
How are bleeding oesophageal varices initially managed?
A-E. Wide bore cannulas. Major haemorrhage protocol - bloods, platelets, clotting factors. May need platelet transfusion. Blood transfusion if low Hb or unstable. Coag reversal if on blood thinners.
248
What red flag in Hx would warrant an urgent OGD?
Adult with alcohol Hx presenting with haematemesis. Or adult who has haematemesis that is v unstable.
249
How does peptic ulcer disease present?
General symptoms - epigastric or retroperitoneal pain, nausea, bloating, and affected by eating —>Gastric ulcer - worse on eating. Duodenal ulcer - intermittint abdominal pain, relieved by eating.
Can present with complications of ulcers - bleeding, perforation, gastric obstruction.
250
What might you ask about when a pt presents with a peptic ulcer?
NSAID use, steroid use, if they have had a H pylori test. Have they had previous epigastric pain? Previous bypass surgery?Physiological stress?
251
Name a differential of peptic ulcer disease
ACS, GORD, Gallstone disease, gastric malignancy, pancreatitis.
252
What causes Mallory-Weiss tear?
Severe or recurrent vomiting, followed by minor haematemesis. Tear in epithelial lining of oesophagus - so get small bleed.
253
How does Mallory-Weiss tear present?
Haematemesis after retching, Malena, light headedness, dizzy, abdo pain.
254
What investigation would you do for suspected Mallory Weiss tear?
OGD if worsening or prolonged haematemesis .
255
How is Mallory-weiss tear managed?
Endoscopy. Clip with or without adrenaline. Or thermal coagulation with adrenaline. Or thrombin or fibrin with adrenaline.
256
Define oesophagitis
Inflammation of the intraluminal epithelial layer of the oesophagus. this can be due to - GORD, infections like thrush, meds like bisphosphonates, radiotherapy, ingesting toxic substances and Chrons.
257
How does oesophagitis present?
Pain in the abdomen and chest (can be severe), nausea, heartburn, acidic taste in mouth, bloating/belching, symptoms worse after a meal, cough, sore throat, hoarseness of voice.
258
How may Meckel's diverticulum present?
Bright red blood in stools. Child with rectal bleeding ++.. Malena. Obstruction.
259
How is Meckel's managed?
Resection of diverticulum.
260
What are the three classes of lower GI bleeding
Occult, Moderate and Massive
261
What do we mean by occult lower GI bleed?
Presents with anaemia
262
What do we mean by moderate lower GI bleed?
Rectal bleeding - fresh, dark or Malena BUT pt is haemodynamically stable.
263
What is a massive lower GI bleed?
Large amounts of fresh blood loss. Shock - systolic BP below 90mmHg. Bleeding for over 3 days, or rebleed in a week. Need a transfusion of 2+ units of blood. Hb is less than 6g/dl, initial drop in haematocrit.
264
What are two common causes of a lower GI bleed?
Diverticular disease, diverticulitis, UC, Chrons, Infective colitis, Haemmorhoids, Colorectal malignancy, Angiodysplasia, Ischaemic colitis.
265
How can haemorrhoids be classified?
1st degree - remain in rectum. 2nd degree - prolapse through rectum on defecation and spontaneously reduce. 3rd degree - prolapse on defectation and are manually reduced. 4th degree - persistently prolapsed
266
How are 1st and 2nd degree haemorrhoids managed?
Rubber band ligation
267
How can 2nd and 3rd degree haemorrhoids be managed?
Haemorrodial artery ligation (id the main vessel of the haemorrhoid through Doppler and tie it off —> haemorrhoid infarcts and falls off).
268
In which classifications of haemorrhoids would haemorrhoidectomy be considered?
3rd and 4th degree
269
Name two differentials for haemorrhoids
IBD, malignancy, diverticular disease, anal fissure (in ano), perianal abscess, external piles
270
How can R sided colorectal malignancy present?
Abdo pain, iron deficiency anaemia, palpable mass in the RIF, present later than L sided
271
How can L sided colorectal malignancy present?
Rectal bleeding, change in bowel habits, tenesmus, palpable mass in the LIF or on PR exam.
272
Describe/write out the modified Glasgow criteria to assess the severity of pancreatitis
score >3= severe pancreatitis neeeds high
dependency care
P pO2 <8kPa
Age>55
Neutrophils >15x109/L
Calcium <2mmol/L
Renal function (urea) >16 mmol/L
Enzymes LDH>600U/L OR AST >200u/l
Albumin <32g/L
Sugar (blood glucose) >10mmol/L
273
How is acute pancreatitis managed?
Treat underlying cause if appropriate - urgent ERCP and cholecystectomy.
Supportive measures - IV fluid resus, NG tube if vomiting, catheterise, opined analgesia
274
How do anal fissures present?
Pain on defecation - passing shards of glass. Bleed bright red on loo roll.
275
How des anal cancer present?
Pain, bleeding, anal discharge, pruritus, palpable mass, increasing pt age, incontience or tenesmus
276
What may you ask a pt about if you suspect anal cancer? (RF)
HPV infection in past - 16 and 19. Smoking. Immunosuppresision. Immunosuppressive drugs, hx of cancer, older age, many sexual partners, Chrons
277
How does ischaemic colitis present?
Generalised abdo pain +++, not explained by findings; diffuse and constant in nature. Nausea and vomiting.
278
What is found on examination of pt with ischaemic colitis?
Non-specific tenderness. If perforated - signs of peritoneum - tachycardia, low bp, guarding, laying v still.
279
How is ischaemic colitis managed (definitive)?
Excision of necrotic bowel if unable to revascularise. Revascularisation of the bowel.
280
What are differentials of ischaemic colitis?
Peptic ulcer disease, bowel perforation, Symptomatic AAA.
281
What is involved in a colonostomy?
Colon is brought to the surface of the skin. Located in the LIF. contents are more solid as water is reabsorbed in LI. Flat to the skin.
282
What is involved in a Ileostomy?
Ileum brought to the skin, located at RIF. Spout created as contents are liquid.
283
Describe a loop stoma
Loop of bowel is taken through the abdo wall - proximal and distal ends are left open. . Temporary colostomy to allow distal portion of the bowel and anastomosis to heal after surgery. Usually reversed 6-8weeks later.
284
Name four complications of a stoma
Local skin irritation,
Parastomal hernia
Psycho-social impact
High output = dehydration and malnutrition
Stenosis
Obstruction
Retraction
Prolapse
285
Describe the Hartmann's procedure
A sigmoid colectomy, proximal colon used to form a temporary end colostomy. The distal bowel is sewn over as a rectal stump. This is used in an emergency (i.e. bowel obstruction, ischaemia, toxic megacolon, or perforation
286
What is a rare but serious complication of gallstone disease?
Gallstone ileus
287
What is gallstone ileus?
Gallstone passing into the intestinal system via a biliary-enteric fistula causing distal obstruction
288
What is Zenker's Diverticulum?
Pharyngeal pouch- it is a diverticulum of the mucosa of a the pharynx
289
How does Zenker's diverticulum present?
dysphagia, regurgitation of food, sensation of food being stuck in the throat, halitosis. Key finding is gurgling sounds found in the neck
290
What investigations are done for Zenker's diverticulum?
Video fluoroscopy
291
What are some complications of Zenker's diverticulum?
Aspiration pneumonia, fistulas into trachea--> obstruction or into major blood vessels--> bleeding
292
How does a large bowel obstruction look on X-ray?
Peripherally dilated loops of bowel
293
What is a krukenberg tumour?
Development of mets to the ovaries
294
what is the embryo sign on AXR?
Caecal volvulus
295
What are some complications of ERCP?
Haemorrhage
Perforation
Acute Pancreatitis
Aspiration pneumonia
Ascending cholangitis
296
What is Courvoisier's law?
What can you infer about the diagnosis from this?
Courvoisier's law = Painless jaundice with a palpable gallbladder means the diagnosis is unlikely to be stones
Conclusion: Will need to be obscuring the common bile duct (e.g. stricture / pancreatic mass) to cause jaundice. Can often cause fever and pain too
297
Give an example of when you might use an MRCP and another example of when an ERCP would be more appropriate
MRCP - diagnostic tool e.g. suspect gall stone blocking CBD
ERCP - investigation + intervention. e.g. carcinoma of head of pancreas - place stent to open up duct
298
Treatment of chronic anal fissure?
Topical glyceryl trinitrate
299
Complications of gastrectomy? (stomach removal for stomach cancer)
B12 deficiency (need 3 month B12 injections)
dumping syndrome
re-operation
Death
Anastamotic leak
300
Differentials for generalised acute abdominal pain?
Peritonitis
Ruptured AAA
Intestinal obstruction
Ischaemic colitis
301
Differentials for RUQ pain?
Biliary colic
Acute cholangitis
Acute cholecystitis
302
Differentials for Epigastric pain
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA
303
Differentials for periumbilical pain?
Ruptured AAA
Intestinal obstruction
Ischaemic colitis
Early sign of appendicitis
304
RIF pain - differentials?
Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel's diverticulum
305
Differentials for LIF pain?
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
306
Suprapubic pain - differentials?
Lower UTI
Acute urinary retention
PID
Prostatitis
307
Loin to groin pain - differentials?
Renal colic - kidney stones
Ruptured AAA
Pyelonephritis
308
Testiular pain - differentials?
Testicular torsion
Epididymo-orchitis
309
Sigmoid volvulus RF?
Older patients
Chronic constipation
Chagas disease
Neuro conditions- parkisons, Duchenne muscular dystrophy
psych conditions e.g. schizophrenia
310
Clinical features of sigmoid volvulus?
Constipation
abdo bleeding
abdo pain
nausea and vomitting
311
Axr of sigmoid volvulus?
Large bowel obstruction and coffee bean sign
312
Management of sigmoid volvulus?
Rigid sigmoidoscopy with rectal tube insertion
313
Management of caecal volvulus?
usually operative, right hemicolectomy is often needed
314
abdominal pain, vomitting and bloating post bowel surgery?
post-operative ileus
315
causes pancreatitis?
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridaemia
ERCP
Drugs
316
Presentation of pancreatitis?
Severe epigastric pain radiating to back, relieved when leaning forward
Vomiting
Abdo tenderness
Systemically unwell
317
Investigations in pancreatitis?
FBC- to see WCC
U&Es- urea
LFTs- albumin and transaminases
CRP
Calcium
VBG for PaO2 and blood glucose
Amylase- 3x upper limit of normal
318
Complications of pancreatitis?
Pseudocyst
Pancreatic necrosis
Abscess formation
chronic pancreatitis
319
What is the most likely operation in a patient with a loop ileostomy and an anus?
In a loop ileostomy 2 bowel ends are visible. The patient is likely to have had an anterior resection (for high rectal cancer >5cm from anus) with formation of a temporary loop ileostomy (to allow for healing of the distal anastomosis).
320
What are the early complications of a stoma?
mechanical and functional
Early mechanical - bowel ischaemia/necrosis, bowel retraction, and para-stomal abscess formation.
Early functional -poor stoma function and high output stoma.
321
What are the late complications of stoma?
mechanical, functional and psychosocial.
Late mechanical - para-stomal hernia formation, bowel stenosis and prolapse, adhesion formation leading to bowel obstruction, and para-stomal dermatitis.
Late functional -bowel dysmotility (leading to constipation/diarrhoea) and malabsorption (e.g. if the terminal ileum is removed this can cause B12 deficiency).
Psychosocia -difficulties with body image and sexual activity.
322
What is the best initial management for patients with high output stomas (4 points)?
Restrict oral hypotonic fluid intake, advise dextrose-saline solution, prescribe oral loperamide and omeprazole
323
What criteria are involved in the Glasgow-Blatchford score?
Anaemia, urea, BP, HR, melaena, syncope, hepatic disease, cardiac failure
324
What are the causes of an upper gastrointestinal bleed?
Variceal haemorrhage
Inflammation - oesophagitis, gastritis
Peptic ulcer disease
Malignancy
Mallory-Weiss tear
Dieulafoy's lesion
Aorto-enteric fistula
325
causes of lower GI bleeding?
Vascular causes include angiodysplasia and ischaemic colitis.
Inflammatory causes include inflammatory bowel disease (Crohn's disease and ulcerative colitis).
Infective causes include infectious colitis.
Neoplastic causes include colorectal cancer and anal cancer.
Anatomical anorectal causes include haemorrhoids and anal fissure.
Anatomical small bowel/colon causes include diverticular disease, Meckel's diverticulum and colonic polyps.
Note that upper GI bleeding may cause a lower GI bleed (due to rapid transit).
Non-GI causes include endometriosis.
326
What is the difference between the use of the Glasgow-Blatchford score and the Rockall score?
The Glasgow-Blatchford score is used pre-endoscopy and the Rockall score can be used in patients post-endoscopy.
327
What does the Rockall score involve?
age, systolic blood pressure, pulse rate, comorbidities (before endoscopy) and diagnosis and signs of recent haemorrhage (after endoscopy)
328
Pt has occult GI bleeding and bloods show iron deficiency anaemia. What are next steps in managing this?
Pt needs colonoscopy and endoscopy
329
Pancreatic cancer lab investigations?
FBC- anaemia or thrombocytopenia and LFTs- raised bilirubin, raised ALP, gamma GT
CA19-9 to assess response to treatment
330
Imaging used for pancreatic cancer?
Abdo USS- may show pancreatic mass or dilated biliary tress
CT- gold standard preliminary diagnosis
CT TAP- good for staging
Biopsy
331
contraindications to laprascopic surgery
Absolute contraindications:
- haemodynamic instability/shock
- raised intracranial pressure
- acute intestinal obstruction (i.e. dilated bowel loops (e.g. > 4 cm)
- uncorrected coagulopathy
Relative contraindications:
- cardiac or respiratory failure
- recent laparotomy (within 4-6 weeks)
- abdominal aortic aneurysm (increased risk of vascular rupture)
- pregnancy (risk of injury to uterus)
- extensive adhesions from previous bowel surgery
332
complications of laprascopic surgery
include:
- general risks of anaesthetic
- vasovagal reaction (e.g. bradycardia) in response to abdominal distension
- extra-peritoneal gas insufflation: surgical emphysema
- injury to gastro-intestinal tract
- injury to blood vessels e.g. common iliacs, deep inferior epigastric artery
