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FACEM Written > GI > Flashcards

GI Flashcards

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1
Q

SBO causes

A

COMMON

  • Adhesions (postoperative) 50–80%
  • Hernias (external) 5–15%
  • Malignancy (peritoneal) 5–15%
  • Crohn’s disease <7%

OTHER

  • Bowel wall lesions (causing intussusception)
  • Intra-luminal mass: foreign body, gallstone ileus
  • Extrinsic inflammatory lesions (appendiceal)
  • Internal hernia
  • Congenital malformation
  • Superior Mesenteric Artery syndrom
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2
Q

Large Bowel Obstruction

A

Tumor (usually sigmoid carcinoma)
Volvulus (sigmoid, cecal)
Fecal impaction
Diverticulitis
Benign stricture (e.g. post-operative, inflammatory bowel disease)
Abscess

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3
Q

BO vs Ileus

A
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4
Q

Dysentry

A

Bacterial

  • Gram positive – Clostridium Difficile
  • Gram negative – Shigellosis, Enterohaemorrhagic E.coli, Salmonella, Yersinia enterocolitica

Protozoa

  • Entamoeba histolytica
  • Balantidium coli

Helminths

  • Schistoma (S. mansion or S. japonicum)
  • Ascariasis
  • Trichuriasis

Non-infectious

  • Inflammatory bowel disease
  • Colorectal cancer
  • Polyps
  • Ischaemic colitis
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5
Q

Mackler’s Triad (oesophageal rupture)

A
  1. Chest pain
  2. Vomiting
  3. SC emphysema

Pathognomic for spontaneous oesophageal rupture - < 50% presentations

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6
Q

CXR oesophageal rupture

A

Abnormalities in up to 90% (none if early)

Pneumomediastinum

Right pl effusion - upper third rupture

Left pl effusion with distal third rupture

SC emphysema

Mediastinal widening

Pulmonary infiltrates

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7
Q

Oesophageal narrowings (4)

A
  1. C6 - cricopharyngeus muscle
  2. T4 - aortic arch
  3. T6 - bifurcation of trachea
  4. T11 - gastrooesophageal junction
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8
Q

Dysphagia - Neuromuscular

A

VASCULAR

  • CVA

IMMUNOLOGICAL

  • Dermatomyositis
  • MS
  • Myaesthenia gravis
  • Polio
  • Scleorderma

INFECTIOUS

  • Botulism
  • Diptheria
  • Polio
  • Rabies
  • Sydenham’s chorea
  • Tetanus

METABOLIC

  • Lead poisoning
  • Mg deficiency

OTHER

  • Alzheinmer’s
  • Amyotrophic lateral sclerosis
  • Brain tunmour
  • Depression
  • Diabetic neuropathy
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9
Q

Dysphagia - Obstructive

A
  • Aortic aneurysm
  • Oesophageal dysmotility
  • Oesophageal - rings, webs, stricture
  • Oesophagitis
  • FB
  • Hypertrophic cervical spurs
  • Mediastinal mass
  • Left atrial enlargement
  • Thyroid enlgargment
  • Vascular anomalies
    *
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10
Q

Dysphagia - other

A
  • Alcoholism
  • Decreased saliva production - Sjogren’s, radiation SE
  • DM
  • GORD
  • Post-op
  • Functional
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11
Q

Internal Hernia Locations

A
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12
Q

Haemorrhoid grades

A
  1. Painless, no prolapse
  2. Prolapse afters straining, spontaneous reduction
  3. Prolapse, require digital reduction
  4. Prolapse, irreducible
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13
Q

GI bleeding Risk Factors

A
  • Medications
    • Antiplatelets
    • Anticoagulants
    • NSAIDS
    • Steroids
  • PMHx
    • PUD
    • Chronix liver Dx
    • Cirrosis
  • Age >60yrs
  • ETOH
  • Smoker
  • Comorbidities
    • CCF
    • DM
    • Renal failure
    • Malignancy
  • AAA graft
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14
Q

UGI Bleed Mimics

A
  • Epistaxis
  • Hemoptysis
  • Dental Bleeds
  • Red Food Colouring
  • Bismuth/Iron supplements
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15
Q

LGI bleed mimics

A
  • Vaginal Bleeding
  • Gross Hematuria
  • Red Foods (BEETS)
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16
Q

Glasgow Blatchford Score

Screens need for intervention - Transfusion and OGD

NOT FOR VARICEAL BLEEDS

Study These Flashcards
A

Score

0 - Rx as OP

1-6 - should have OGD within 24 hrs

Score >6 suggest high risk bleed and 50% need intervention

7-12 - MUST have OGD within 24 hrs

>12 - MUST have ODG within 12 hours

Must have OGD in 6 hours
* suspected variceal bleed
* Unstable
* High volume

17
Q

Jaundice differential

Study These Flashcards
A

UNCONJUGATED HYPERBILIRUBINAEMIA

Pre-HEPATIC (overproduction of heme)
* Haemolysis - Haemolytic anaemias,
* Congenital - Gilberts, Crigler-Najar Syndrome
* Thalassaemia
* Trauma
* Severe CCF
* G6PD deficiency + oxidative drugs

HEPATIC (reduced hepatocyte Br uptake)
* Chronic hepatic cirrhosis
* Infection
* Viral / Bacterial / Protozoal
* Sepsis
* Drugs
* Toxins
* Alcohol
* Autoimmune

CONJUGATED HYPERBILIRIBUINAEMIA

POST-Hepatic (decreased excretion of Br)
* Hepatocellular (dec hepatocyte function)
* Hepatitis - viral, toxic, alcohol, AI
* Cirrhosis
* Drugs - paracetamol, methyldopa, pheyntoin
* Intra-hepatic
* Hepatitis
* Primary Biliary Cirrhosis
* Intrahepatic cholestasis
* Drugs - indomethacin, erythromycin, chlorproamzine, isoniazid, flucloxacillin, OCP
* Extra-hepatic
* Intraluminal - CBD stone, stenosis/ scarring PBC, PSC
* Pancreatitis
* External - Carcinoma - GB. pancreas, Ampullary

PREGNANCY

  • Pre-eclampsia
  • HELLP
  • Acute fatty liver
  • Hyperemesis gravidarum
  • Cholestasis of pregnancy
18
Q

Jaundice - Critical Causes

Study These Flashcards
A

Hepatic
* Fulminant hepatic failure
* Toxin
* Viral
* Alcohol
* Ischaemic insult
* Reye’s syndrome

Biliary
* Ascending Cholangitis

Systemic
* Sepsis
* Heatstroke

Cardiovascular
* Obstructing AAA
* Budd Chiari
* Severe CCF

Haematological
* Transfusion reaction

OBS
* PET
* HELLP
* Acute fatty liver of pregnancy
* Cholestasis of pregnancy

19
Q

Spontaneous Bacterial Peritonitis

Study These Flashcards
A

Ascitic fluid infection without intra-abdominal surgically treatable source

Consider in Ascites + AP OR ascites + acute deterioration

+ve ascitic fluid bacterial culture + PMN count >250 cells/mm3

Cirrhosis or peritoneal dialysis patient (improper asepsis or contaminated dialysate)

Consider SBP versus secondary bacterial peritonitis

Orgs:

  • E. coli
  • Klebsiella
  • Strep
  • Enterococci
  • Anaerobes

Rx

  • Cextriaxone 2g IV
  • If already on prophylaxis - Tazocin
20
Q

SBP vs Secondary Bacterial Peritonitis

Study These Flashcards
A

Ascitic fluid analysis

Spontaneous Bacterial Peritonitis
* No surgically treatable source
* Glucose <2.8mmol/L
* Serum protein-ascitic fluid gradient >1.1g/dL
* Total protein <1g/dL
* LDH not as high as bacterial
* Usually single organism
* No radiological abnormality

Bacterial peritonitis
* Surgically treatable source
* Glucose >2.8mmol/L
* Serum protein-ascitic fluid gradient <1.1g/dL
* Total protein >1g/dL
* LDH higher c.f. SBP
* Multiple organisms
* Radiology confirms obstruction, perforation, abscess

21
Q

Hepatic Encephalopathy

Study These Flashcards
A

State of cerebral and NM dysfunction secondary to increased ammonia levels

Severity doesn’t correltate well with ammonia level

Consider ppte - GI bleeding, infection, electrolyte disorder, dehrdration, constipation, RF, non-compliance with meds

Also consider DDx for AMS

Stages

  • Stage I - apathy
  • Stage II - lethargy + asterixis
  • Stage III - stupor
  • Stage IV - coma

Treatment

  • Lactulose
  • ABx - neomycin or metronidazole
22
Q

Diarrhoea

Study These Flashcards
A

TOXIN mediated - onset < 6hrs

  • S. aureus - egg/mayo
  • Bacillus cerues - fried rice
  • E.colie - classic travellers diarrhoea
  • Clostridium perfringens - meat/poultry
  • Scombroid - dark meat fish - histamine
  • Ciguatera - carvivorous fish - neuro

Invasive - delayed onset

  • Salmonella - undercooked eggs/chicken
  • Shigella - febrile - dysentry
  • Campylobacter - chicken
  • Yersinia - farm animals /chicken
24
Q

Pancreatitis Scoring Systems

Study These Flashcards
A

Mortality from Pancreatitis

  • Ranson’s
    • Admission + 48hrs
  • Glascow-Imrie
    • 48 hrs post admission
  • BISAP
    • <48hrs
25
Ranson's Criteria for Pancreatitis
[https://www.mdcalc.com/calc/89/ransons-criteria-pancreatitis-mortality#use-cases](https://www.mdcalc.com/calc/89/ransons-criteria-pancreatitis-mortality#use-cases) Glucose > 11.1mmol/l Age > 55 yrs LDH > 350 AST > 250 WCC > 16 Best = Base deficit > 4mml/l Biomarkers = Blood urea > 5 mmol/l rise For = Fluid sequastration > 6L Calculating = Ca < 2.0mmol/l High = Hct drop > 10% Pancreatitis = PaO2 <60 mmHg (Severity) Pts = mortlality risk 2= 1% 4 = 15% 6 = 40$ 7 = 100%
26
Bilirubin metabolism
1 Creation of Bilirubin Reticuloendothelial cells take up RBCs Metabolised into individual components; haem and globin. Globin broken down into amino acids which are subsequently recycled. Haem broken down into iron and biliverdin by **haem oxygenase**. The iron gets recycled, while biliverdin is reduced by **biliverdin reductase** to create unconjugated Br. 2 – Bilirubin Conjugation In the bloodstream, unconjugated Br binds to albumin to facilitate its transport to the liver. Once in the liver, glucuronic acid is added to unconjugated bilirubin by the enzyme **glucuronyl transferase**. This forms conjugated Br, which is soluble. Excreted in bile to duodenum. 3 – Bilirubin Excretion Once in the colon, colonic bacteria deconjugate bilirubin and convert it into urobilinogen. Around 80% of this urobilinogen is further oxidised by intestinal bacteria and converted to stercobilin and then excreted through faeces. It is stercobilin which gives faeces their colour. Around 20% of the urobilinogen is reabsorbed into the bloodstream as part of the enterohepatic circulation. It is carried to the liver where some is recycled for bile production, while a small percentage reaches the kidneys. Here, it is oxidised further into urobilin and then excreted into the urine.
27
Urine Dip in Biliary Disorders
28
Fulminant Hepatic Failure
Rapid onset of hepatic synthetic failure + encepaholopathy Causes Drugs - Paracetamol, NSAIDS, amanita, ABx, dapsone, halothane Alcohol Viruses - EBV, CMV< HIV, Hep B/C, HSV Extras - Obstetric - HELLP, acute fattyl iver of pregnancy - Autoimmune - a1-antitrypsin - Vascular - Budd-Chiari Sepsis Ix FBC, UEC. LFTs, CMP Hepatitis, HIV, EBV, CMV screen Bloods cultures Urine Drug screen ANA, SMA Serum protein electrophoresis Serum copper, caeruloplasmin Mx Supportive - A - intubate if encephalopathic - B - ventilation, may have pleural effusions - C - IVF and Na+ restriction + diuretics - D - BGL monitoring - E - nutrition, correct electrolyte imbalances Antidotes Liver Transplant Paracetamol - pH < 7.3 / INR > 6.5 **OR** Cr > 300 **OR** > gd III encephalopathy Complications Cerebreal oedema COagulopathy GIH Renal failure Hypoglycaemia Electrolyte abN Resp failure: impaired ventilation, coma, pl effusions, ARDS, aspiration, sepsis
29
Caecal vs Sigmoid Volvulus
30
BISAP Score
Blood Urea > 8.92mmol/l Impaired Mental State > SIRS criteria Age > 60 yrs Pleural effusion 0 points < 1% risk of mortality > 1 point increases risk of mortality
31
UC - Truelove & Witt Score
32
King's College Criteria
INR > 6.5 Arterial pH < 7.3 Creatinine > 300umol/l Grade III or more encephalopathy Lactate > 3.5 mmol/l after fluid resus PO4 > 1.2mmol/l Features Associated with Poorer prognosis * Unknown aetiology * Toxin associated (other than paracetamol) * 10 yrs < Age > 40 yrs * Jaundice > 1 week prior to encephalopathy * INR > 3.5 * Creatinine > 300umol/l * Br > 300 * pH < 7.3

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