What is a colostomy?
A surgical opening into the large bowel
Where are colostomy bags usually found?
In the left iliac fossa
What should the contents of a colostomy be like?
Thick and solid as it has already been through the small bowel and had water reabsorbed
Which type of stoma has a spout and why?
An ileostomy
As the enzymes in faeces are toxic to the skin so a spout must be made from the section of bowel so the faeces can drain without touching the skin
What is a common complication of a stoma that will present with a palpable mass?
Parastomal hernia
More common with colostomy rather than ileostomy
Where are ileostomies usually found?
In the right iliac fossa
What is an ileostomy?
A surgical opening into the small bowel
What should the contents of an ileostomy be like?
Watery
What are some examples of when an ileostomy may be made?
In UC/ Crohn’s
FAP
What is the different between:
i) diverticulosis
ii) diverticular disease
iii) diverticulitis
i) presence of diverticula
ii) symptomatic diverticula
iii) inflammation/ infection of diverticula
What are some risk factors for GORD?
Age Male Obesity Smoking Alcohol Spicy or fatty foods Caffeinated drinks
What are some symptoms of GORD?
Burning retrosternal chest pain (worse on lying down and after eating)
Dysphagia
Chronic cough
Belching
How can GORD be managed?
Conservative: avoid precipitants e.g. coffee, avoid eating a few hours before bed, smoking cessation, weight loss
Pharmacological: PPI
Surgical: fundoplication
What is Barrett’s oesophagus?
Metaplasia of normal oesophageal lining from stratified squamous to simple columnar
Where does Barrett’s oesophagus usually occur?
Distal oesophagus
How is Barrett’s oesophagus managed?
PPI
Stop any NSAIDs
Routine endoscopy due to risk of progression to adencarcinoma (respect any premalignant lesions, if carcinoma an oesophagectomy may be indicated)
Which type of oesophageal cancer is more common in the developed world?
Adenocarcinoma
Where in the oesophagus does adenocarcinoma occur and why?
Lower third of the oesophagus, occurring when Barrett’s oesophagus become dysplasic and becomes malignant
How should a patient with ?oesophageal carcinoma be investigated?
Urgent OGD within 2 weeks
Biopsy any malignancy and send for histology
What is a Mallory Weiss tear and how are they often caused?
Rupture to the superficial mucosa of the oesophagus
Usually at the GOJ
Usually occur after a period of profuse vomiting
OGD
Usually self limiting
What is the difference between a sliding and rolling hiatus hernia?
Sliding: when the GOJ, abdominal part of the oesophagus and often the cardia of the stomach slide upwards through the oesophageal hiatus of the diaphragm
Rolling: when the funds of the stomach creates a pouch that sits next to a normal GOJ
What are some risk factors for a hiatus hernia?
Age
Pregnancy
Obesity
Ascites
How could a hiatus hernia be managed?
Conservatively: PPI, weight loss, dietary advice (smaller portion, alcohol reduction), smoking cessation
Surgical: fundoplication (wraps part of funds around the LOS), cruroplasty (reduces hernia back from thorax into abdomen)
Where are peptic ulcers most common?
In the first part of the duodenum (duodenal ulcer) or fundus of the stomach (gastric ulcer)
How would the symptoms differ between a gastric ulcer and a duodenal ulcer?
Epigastric pain in both.
Gastric ulcer pain would be exacerbated by eating.
Duodenal ulcer pain would occur a few hours after eating. It is often worst when fasting and is alleviated by eating.
Which vessels could a gastric ulcer erode?
Left gastric and splenic
Which vessels could a duodenal ulcer erode?
Gastroduodenal artery
How would you investigate a px with a suspected peptic ulcer?
If red flag symptoms: OGD and biopsy (can send biopsy for histology and H Pylori test)
If OGD not needed, test for H Pylori via urease breath test, stool antigen test, serum antibodies test
What is the cause of peptic ulcers?
Impaired defence of stomach through H Pylori/ alcohol excess/ prolonged NSAID use
How would a peptic ulcer be managed?
Conservative: weight loss, smoking cessation, reduce NSAID use, reduce alcohol use
If H Pylori +ve: amoxicillin, clarithromycin and PPI
If H Pylori -ve: PPI for 8 weeks
What are some signs for gastric cancer that would be visible on examination?
Enlarged Virchow’s node Hyperpigmentation of skin creases Palpable epigastric mass Signs of anaemia e.g. pale conjunctiva Jaundice/ hepatomegaly (can indicate liver mets)
What is Troiser’s sign?
Enlarged Virchow’s node
What are some symptoms of gastric cancer?
Dyspepsia Dysphagia Nausea Malena Vomiting Non specific cancer signs e.g. weight loss, anorexia, Anaemia (markers of late disease)
What is the difference between a direct and indirect hernia?
Direct: occurs within Hesselbachs triangle when bowel enters superficial ring by a weakness in the abdominal wall, medial to the epigastric vessels
Indirect: goes through the deep inguinal ring, lateral to epigastric vessels, outside Hesselbachs triangle
Indirect inguinal hernias are due to failure of which embryological part to close?
Processus vaginalis
What are some risk factors for an inguinal hernia?
Male
Age
Obesity
Increased intra abdominal pressure eg heavy lifting, chronic cough, constipation
What are the boundaries of Hesselbachs triangle?
Medial: rectum abdominus
Inferior: inguinal ligament
Lateral: inferior epigastric vessels
What are some risk factors for a femoral hernia?
Female
Age
Pregnancy
Increased intra abdominal pressure
What are the borders of the femoral triangle?
Superior: inguinal ligament
Medial: lateral border of adductor longs
Lateral: medial border of sartorius
What type of organism is Clostridium difficile?
Gram positive bacillus
Anaerobic
Spore forming
Produces exotoxins A and B which cause an inflammatory response in the bowel
How does a C Diff infection usually occur?
Following treatment by broad spectrum antibiotics
How is a C Diff infection treated?
Fluids
Oral metronidazole
If C Diff is unresponsive to metronidazole after 72 hours, which antibiotic could be used?
Vancomycin
What are some differentials for abdominal pain common in children?
Appendicitis
Mesenteric adenitis
What is Rovsing’s sign?
When RIF pain is elicited on palpating of the LIF
Seen in appendicitis
What is Psoas sign?
When RIF pain is elicited on extension of the right hip
Seen in appendicitis
What is an important first line investigation to do for any woman of child bearing age with abdominal pain/ symptoms?
Beta hCG
How do colorectal carcinoma usually form?
Adenocarcinoma sequence
Normal mucosa becomes an adenoma which can then become a carcinoma
What are some risk factors for colorectal cancer?
High red meat and processed intake Male IBD Low fibre diet Age Male
How is colorectalcancer screened for?
Every 2 years for men and women aged 60 to 75 using home stool testing kits for faecal occult blood
If they are positive, they are offered a colonoscopy
What is the tumour marker for colorectal cancer and when is it used?
CEA
Not secreted by all tumours and also raised in IBD so mainly used to monitor response to tx
How is colorectal cancer staged?
Dukes Staging
What is the classification of Dukes Staging?
A = confined to muscularis mucosa B = through muscularis mucosa C = regional lymph nodes involved D = distant mets
How does treatment differ if a rectal tumour is high or low?
High can undergo anterior resection
Low would have to abdominoperineal resection resulting in colostomy
What are common causes of small bowel obstruction?
Adhesions
Herniae
What are common causes of large bowel obstruction?
Malignancy
Diverticular Disease
Volvulus
What signs and symptoms can be seen with bowel obstruction?
Abdominal pain Absolute constipation Abdominal distension Vomiting Tinkling bowel sounds Rebound tenderness if ischaemic
Why would a venous blood gas be ordered in cases of possible bowel obstruction?
As high lactate indicates ischaemia
Px often acidaemic
How will small and large bowel differ on abdominal x Ray?
Small bowel: central, dilated more than 3cm, plicae circulares present
Large bowel: peripheral, dilated more than 6cm, haustra visible
How is bowel obstruction managed?
Conservative if no signs of ischaemia: drip and suck (IV fluids and NG tube), analgesics, fluid balance
Surgery: indicated if virgin abdomen, signs of ischaemia, closed loop obstruction, tumour
What is a Volvulus?
When the large bowel twist around its mesentery resulting in a closed loop obstruction
How will a sigmoid Volvulus typically appear on AXR?
Coffee bean sign arising from LIF
Signs of large bowel obstruction
What types of patients are associated with Volvulus?
Older patients
With constipation
And neurological conditions e.g. Parkinson’s
Or psychiatric conditions e.g. schizophrenia
How are volvuli managed?
Sigmoidoscope decompression
If this fails, or if perforated, then surgery is indicated (primary anastamosis or Hartmanns)
Where in the bowel is diverticular Disease most common?
Sigmoid colon
What is the difference between diverticulosis, diverticulitis and diverticular Disease?
Diverticulosis= presence of diverticula
Diverticulitis = inflammation of diverticulum
Diverticular Disease = symptomatic diverticulum
What is important in a patient on immunosuppressants or steroids who may have abdominal pathology?
Immunosuppressants and steroids can mask the symptoms of diverticulitis, even when perforated
What are some symptoms are diverticular Disease?
LIF colicky pain relived by defecation Flatulence Nausea Altered bowel habit PR bleeding
How would you want to investigate a px with diverticular Disease?
Routine bloods
Blood gas to assess lactate level (for sepsis or bowel ischaemia
Flexible sigmoidoscopy (NOT if suspected diverticulitis due to risk of perforation)
AXR to exclude bowel obstruction
CXR to exclude perforation
What is Hartmann’s procedure?
Emergency surgical procedure
Where the sigmoid colon is resected
End colostomy and closure of the rectal stump is formed
Anastomosis with reversal of end colostomy may be possible later
How can diverticular disease be managed?
Uncomplicated: at home with analgesic (paracetamol 1st line as opioids lead to constipation)! Abx, encourage fluids
Conservative: Broad spectrum Abx, fluids, analgesics, bowel rest (only clear fluids orally)
Surgery: only is unresponsive to conservative methods, have perforation or sepsis unresponsive to Abx
Elective surgery may be indicated if chronic disease or if immunosuppressed
What is the difference between an anorectal abscess, anal fissure and anal fistula?
Anorectal abscess is a collection of pus in the anal or rectal region thought to be due to plugging of the anal ducts causing bacteria overgrowth
Anal fissure is a tear in the mucosal lining of the anal canal
Anal fistula is an abnormal connection between the anal canal and perianal skin
Wheat are some risk factors for an anal fissure?
Constipation (as usually due to defecation of hard stool)
IBD
STIs
How would you manage an anal fissure?
Increased patients fibre intake Increase fluids Analgesia Stool softening laxatives GTN cream (to relax internal anal sphincter and increase blood supply to the area to promote healing) Surgery only if chronic
What are haemorrhoids?
Abnormal swelling or enlargement of anal vascular cushions
What is the most likely differential of passage of painless bright red blood (not mixed in with stool) in an elderly patient?
Haemorrhoids
How are haemorrhoids managed?
95% can be conservatively managed (increased fibre and fluid intake, laxatives, topical analgesics)
Rubber band ligation
Haemorrhoidectomy if symptomatic or haemorrhoid has prolapsed through so cannot be banded
Why should opioid analgesics be avoided for a patient with haemorrhoids?
As they can compound constipation
Are most liver cancers primary or metastatic?
Metastatic
What are the most common cancers that metastasise to the liver?
Bowel Breast Pancreas Stomach Lung
What is indicated by an AST: ALT ratio >2?
Alcoholic liver disease
What is indicated by an AST: ALT ratio of ~1?
Viral hepatitis likely
What are some causes of acute pancreatitis?
GET SMASHED Gallstones Ethanol Trauma Steroids Mumps/ malignancy Autoimmune Scorpion bits Hyperlipidaemia/ hypercalcaemia/ hyperparathyroidism ERCP Drugs
What is Cullen’s sign?
Periumbilical bruising sometimes seen in pancreatitis, indicates retroperitoneal haemorrhage
What is Grey Turners sign?
Flank discolouration that can be seen in pancreatitis, indicates retroperitoneal haemorrhage
How much would you expect amylase to be raised by in pancreatitis?
At least 3x the upper limit of normal
Other than pancreatitis, what else can amylase be raised in?
Ectopic pregnancy
Mesenteric ischaemia
Bowel perforation
DKA
What criteria can be used to assess the severity of a patients pancreatitis?
Modified Glasgow criteria
Does not use amylase in its score!
Sudden onset sever epigastric pain radiating to the back with nausea and vomiting is characteristic of what condition?
Acute pancreatitis
Why are Cullen’s sign and Grey Turners sign seen in acute pancreatitis?
Due to retroperitoneal haemorrhage as the inflamed pancreas can release its enzymes into the systemic circulation and this can lead to auto digestion of blood vessels
Why do hypocalcaemia form in cases of acute pancreatitis?
Enzymes are released from the inflamed pancreas which can cause autodigestion of fats, resulting in fat necrosis
Fat necrosis causes the release of free fatty acids which reacts with serum calcium to form chalky deposits, hence the hypocalcaemia
How would you manage a px with acute pancreatitis?
Supportive treatment of O2, fluids IV, NG tube if vomiting, analgesia
Treat any underlying causes e.g. urgent ERCP if gallstones are present
What local complications can acute pancreatitis lead to?
Pseudocyst
Pancreatic necrosis
What is the most common cause of chronic pancreatitis?
Alcohol
How would chronic pancreatitis appear on USS/ AXR/ CT?
Will have pancreatic calcifications
How is chronic pancreatitis managed?
Pancreatic enzyme supplements
Fat soluble vitamin supplements
Analgesia (TCAs recommended due to opioid dependence)
No alcohol and low fat diet
ERCP to extract any pancreatic duct stones
Endoscopic USS to drain any pseudocysts
What investigations would you do for chronic pancreatitis and what would they show?
BM for hyperglycaemia LFTs Amylase and lipase (raised but not as much as in acute disease) Faecal elastase will be low Abdominal USS Ct chest abdo pelvis ERCP can assess pancreatic duct
What are the fat soluble vitamins?
A, D, E, K
What are most types of pancreatic cancer?
Adenocarcinoma
What tumour marker can be used to assess response to tx for pancreatic cancer?
CA19-9
What is a Whipple’s procedure?
Removal of head of pancreas, antrum of the stomach, 1st and 2nd part of the duodenum, gallbladder and CBD
(As they are all supplied by the gastroduodenal artery)
How is pancreatic cancer treated?
Whipples proceudre
Adjuvant chemo
Palliative stenting and ERCP
What are some risk factors for gallstones?
5 F’s
Female, fertile, forty, fat, family hx
How do gallstones present?
Mostly asymptomatic
If synaptic: biliary colic
What is biliary colic?
Sudden, dull, colicky pain in the RUQ that may radiate to the right shoulder tip
Associated with nausea and vomiting
Precipitated by fatty foods
How does cholecystitis differ to biliary colic?
Cholecystitis is more constant, even despite pain relief
May also show signs of inflammation e.g. fever, raised WCC
What is Murphys sign?
Positive in cholecystitis
Pain elicited when pressure is applied in RUQ as the px inspires (this causes the diaphragm to come down and irritate the inflamed gallbladder)
What liver enzyme pattern on LFTs indicate obstruction of the biliary duct?
When ALP and bilirubin and higher than ALT
What imaging modality is 1st line in suspected cholecystitis?
USS
This will show gallstones and can also show gallbladder thickening and bile duct dilation
How is biliary colic managed?
Lifestyle: low fat diet, weight loss
Analgesia (NSAID with PRN opioid)
Antiemetic (eg cyclizine, metoclopramide)
Elective cholecystectomy
How is cholecystitis managed?
IV abx (co-amoxiclav, metronidazole) Fluids Analgesia Antiemetic Laparoscopic cholecystectomy
What is ascending cholangitis?
Bacterial infection of the biliary tree combined with biliary obstruction
What are the organisms commonly involved in ascending cholangitis?
E Coli
Klebsiella
Enterococcus
What is Charcot’s triad?
RUQ pain, fever and jaundice
Seen in ascending cholangitis
What is Reynold’s pentad?
For ascending cholangitis
Charcot’s triad + hypotension + confusion
What will indicate ascending cholangitis on a FBC and LFT?
Raised WCC, CRP
Raised bilirubin and ALP and GGT
What is the gold standard imaging for cholangitis?
ERCP
How is ascending cholangitis managed?
IV Abx (co amoxiclav + metronidazole)
Fluids
Bloods and cultures
ERCP to relieve any obstruction
What is the most common organism causing cholangitis?
E Coli
Then klebsiella, streptococcus, psuedonomas
In which type of jaundice (pre hepatic, hepatic and post hepatic) will ALT and AST be highest?
Hepatic
High ALT specific to intracellular hepatic damage
ALP will be most elevated in which type of jaundic: pre hepatic, hepatic or post hepatic?
Post hepatic (Raised most in biliary obstruction)
What is Reynolds pentad and what does it indicate?
Charcot’s triad (fever+jaundice+RUQ pain) + confusion and hypotension
Indicates biliary sepsis
What are some drug causes of acute pancreatitis?
Steroids Mesalazine Azathioprine Furesomide Bendroflumethiazide Sodium valproate
Whereabouts in the abdomen is pain usually felt in ischaemic colitis?
Left iliac fossa
Barium enema showing thumb printing is indicative of which pathology
Ischaemic colitis
How is mild to moderate ischaemic colitis managed?
Analgesia
Bowel rest (NBM)
IV Fluids