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1
Q

INTESTINAL OBSTRUCTION
Define intestinal obstruction

A

Blockage of the lumen of the gut

Arrest of onward propulsion of intestinal contents

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2
Q

INTESTINAL OBSTRUCTION
Name 3 broad types of causes of intestinal obstruction

A
  1. Intraluminal obstruction = something in the bowel
  2. Intramural obstruction = something in the wall of the bowel
  3. Extraluminal obstruction = something outside of the bowel
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3
Q

INTESTINAL OBSTRUCTION
Give 3 causes of intraluminal obstruction of the intestine

A
  1. Tumour - carcinoma, lymphoma
  2. Diaphragm disease
  3. Meconium ileus
  4. Gallstone ileus
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4
Q

INTESTINAL OBSTRUCTION
What is diaphragm disease?

A

Mucosa/submucosa fold due to fibroid diaphragm leaving a pinhole lumen

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5
Q

INTESTINAL OBSTRUCTION
What is thought to cause diaphragm disease?

A

NSAIDs

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6
Q

INTESTINAL OBSTRUCTION
Give 3 causes of intramural obstruction of the intestine

A
  1. Inflammatory disease = Chron’s, Diverticulitis
  2. Tumours
  3. Neural = Hirschsprung’s disease
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7
Q

INTESTINAL OBSTRUCTION
Describe how Crohn’s disease can cause intestinal obstruction

A

Crohn’s disease –> fibrosis –> contraction –> obstruction

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8
Q

INTESTINAL OBSTRUCTION
Describe how diverticular disease can cause intestinal obstruction

A

Out pouching of mucosa –> faeces trapped –> inflammation in bowel wall –> contraction –> obstruction

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9
Q

INTESTINAL OBSTRUCTION
What is Hirschsprung’s disease?

A

A congenital condition where there is a lack of nerves in the bowel –> no ganglion cells –> no contraction –> distal obstruction and gross dilation of the bowel

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10
Q

INTESTINAL OBSTRUCTION
Give 3 causes of extraluminal obstruction of the intestine

A
  1. Adhesions
  2. Volvulus
  3. Peritoneal tumour
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11
Q

INTESTINAL OBSTRUCTION
What are adhesions?

A

Fibrous bands stick 2 bits of bowel together so bowel is pulled and distorted

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12
Q

INTESTINAL OBSTRUCTION
What causes adhesions?

A

Often formed after abdominal surgery (pelvic, gynaecologist, colorectal)

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13
Q

INTESTINAL OBSTRUCTION
What is volvulus?

A

Bowel twisting around each other cuts off blood supply/ lumen
Risk of ischaemia, necrosis and perforation

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14
Q

INTESTINAL OBSTRUCTION
Which areas of the bowel are most likely to be affected by volvulus?

A

Occurs in areas of bowel that have mesentery

Often in the sigmoid colon

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15
Q

INTESTINAL OBSTRUCTION
Give 4 common causes of small bowel obstruction in adults

A
  1. Adhesions
  2. Hernias
  3. Crohn’s disease
  4. Malignancy
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16
Q

INTESTINAL OBSTRUCTION
Give 3 common causes of small bowel obstruction in children

A
  1. Appendicitis
  2. Volvulus
  3. Intussusception
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17
Q

INTESTINAL OBSTRUCTION
What is intussusception?

A

One part of the intestine telescopes into another section of the intestine
Caused by force in-balances

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18
Q

INTESTINAL OBSTRUCTION
Give 5 symptoms of small bowel obstruction

A
  • vomiting more common
  • periumbilical
  • cramping and intermittent pain
  • lasts for a few minutes at a time
  1. Nausea and anorexia
  2. Early feculent vomit
  3. Diffuse colicky pain
  4. Late constipation
  5. Distention
  6. Tenderness
  7. bowel sounds
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19
Q

INTESTINAL OBSTRUCTION
Does abdominal distension occur more distal or proximal to an intestinal obstruction?

A

More distal = greater distension

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20
Q

INTESTINAL OBSTRUCTION
What investigations might you do in someone who you suspect to have a small bowel obstruction?

A
  • FBC
  • abdominal x-ray - shows central gas shadow that completely cross the lumen, distended loops of bowel proximal to obstruction, fluid levels seen
  • CT - gold standard to localise lesion accurately
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21
Q

What is the management/treatment for small bowel obstruction?

A
  1. Fluid resuscitation
  2. Bowel decompression
  3. Analgesia and antiemetics
  4. Antibiotics
  5. Surgery - laparotomy, bypass segment, resection
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22
Q

INTESTINAL OBSTRUCTION
Which is more common, small or large bowel obstruction?

A

Small bowel obstruction = 60-75% of intestinal obstruction

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23
Q

INTESTINAL OBSTRUCTION
What can untreated intestinal obstruction lead to?

A
  1. Ishcaemia
  2. Necrosis
  3. Perforation
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24
Q

GINTESTINAL OBSTRUCTION
ive 2 common causes of large bowel obstruction

A
  1. Colorectal malignancy - most common in UK

2. Volvulus - more common in Africa

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25
INTESTINAL OBSTRUCTION Where is the usual site of perforation in large bowel obstruction if the ileocaecal valve is competent?
Caecum
26
INTESTINAL OBSTRUCTION How long does acute presentation of large bowel obstruction last?
Average of 5 day of symptoms = abdominal pain and constipation
27
INTESTINAL OBSTRUCTION Give 5 symptoms of large bowel obstruction
- lower abdominal pain - less frequent pain - episodes last longer 1. Bloating/fullness/nausea 2. Late vomiting (more faecal like) - may be absent 3. Colicky pain - more constant than SBO 4. Distension 5. Blood in stool 6. constipation 7. palpable mass 8. bowel sounds normal then increase then quiet later
28
INTESTINAL OBSTRUCTION What investigations might you do in someone who you suspect to have a large bowel obstruction?
1. Digital rectal examination - empty rectum, hard stools, blood 2. abdominal X ray - peripheral gas shadows proximal to blockage, caecum and ascending colon distended 3. CT scan 4. FBC - low Hb
29
INTESTINAL OBSTRUCTION Describe the management for a large bowel obstruction
1. IV fluid replacement 2. Bowel decompression 3. Surgery - laparotomy 4. analgesia and antiemetic 5. antibiotics
30
HERNIA Define hernia
Abnormal protrusion of an organ into a body cavity it doesn't normally belong
31
HERNIA What are the risks of hernia's if left untreated?
Become strangulated
32
HERNIA Give 2 symptoms of hernias
1. Pain | 2. Palpable lump
33
COLORECTAL TUMOURS Describe the progression from normal epithelium to colorectal cancer
Normal epithelia --> adenoma --> colorectal adenocarcinoma --> metastatic colorectal adenocarcinoma
34
COLORECTAL TUMOURS Define adenocarcinoma
A malignant tumour of glandular epithelium
35
COLORECTAL TUMOURS What is familial adenomatous polyposis?
Autosomal dominant condition | - arise from mutation in APC gene- where you develop thousands of polyps in the duodenum and colorectal in teens
36
COLORECTAL TUMOURS What are precursors to colorectal cancer?
Polyploid adenomas
37
COLORECTAL TUMOURS Describe the epidemiology of colorectal cancer
Normally adenocarcinoma - majority in distal colon Incidence peaks around 60-65 years Males > females 2nd most common cause of cancer death in UK
38
COLORECTAL TUMOURS Give 5 risk factors for colorectal cancer
increasing age family history hereditary syndromes ethnicity (white) radiotherapy obesity diabetes mellitus smoking
39
COLORECTAL TUMOURS Give 3 reasons why bowel cancer survival has increased over recent years
1. Introduction of the bowel cancer screening programme 2. Colonoscopic techniques 3. Improvements in treatment options
40
COLORECTAL TUMOURS What can affect the clinical presentation of a colorectal cancer?
How close the cancer is to the rectum
41
COLORECTAL TUMOURS Give 2 signs of a left sided/sigmoid colorectal cancer
1. Altered bowel habit 2. diarrhoea 3. blood in stool 4. alternating diarrhoea and constipation
42
COLORECTAL TUMOURS Give 3 signs of a right sided colorectal cancer
1. assymptomatic until presenting with Iron deficiency anaemia 2. Right iliac fossa mass 3. Weight loss 4. low Hb 5. abdominal pain
43
COLORECTAL TUMOURS Give 4 signs of rectal carcinoma
- rectal bleeding and mucus - when cancer grows there will be thinner stools and tenesmus (cramping rectal pain) 1. Abdominal mass 2. Perforation 3. Haemorrhage 4. Fistulae
44
COLORECTAL TUMOURS What investigations might you do in someone who you suspect might have colorectal cancer?
- Faecal Immunochemical Test (FIT) >50 + bowel habit change / iron deficient anaemia >60 + anaemia - Colonoscopy + biopsy - Flexible sigmoidoscopy / barium enema / CT colonoscopy
45
COLORECTAL TUMOURS How can adenoma formation be prevented?
NSAIDs
46
COLORECTAL TUMOURS What screening programme is used to identify bowel cancer?
Faecal Immunochemical Test (FIT) - every 2 years from 56-75yrs | For over 65s+ve result = biopsy
47
COLORECTAL TUMOURS What is the management for colorectal adenocarcinoma?
- Surgical resection - endoscopic stenting for palliative care - radiation - chemotherapy - if duke's stage C
48
COLORECTAL TUMOURS What is the treatment for metastatic colorectal adenocarcinoma?
Chemotherapy and palliative
49
COLORECTAL TUMOURS Explain Dukes staging and prognosis
``` A = limited to muscularis mucosae = 95% 5-year survival B = extension through muscularis mucosae (not lymph) = 75% 5-year survival C = involvement of regional lymph nodes = 35% 5-year survival D = distant metastases = 25% 5-year survival ```
50
COLORECTAL TUMOURS What does the T mean for colorectal cancer staging?
``` T1 = invades submucosa T2 = Muscularis propria T3 = Bowel wall T4 = Peritoneum ```
51
COLORECTAL TUMOURS What does the N mean for colorectal cancer staging?
``` N1 = spread to lymph nodes N2 = spread to lymph nodes above the diaphragm ```
52
COLORECTAL TUMOURS What does the M mean for colorectal cancer staging?
M1 = surrounding structure involvement (liver)
53
GASTRITIS Name 5 things that can break down the mucin layer in the stomach and cause gastritis
1. Mucosal ischameia 2. H. pylori 3. Aspirin, NSAIDs - most common 4. Increased acid (stress) 5. Bile reflux 6. Alcohol
54
GASTRITIS Give 3 symptoms of gastritis
1. Epigastric pain 2. Nausea and vomiting (recurrent upset stomach) 3. Indigestion 4. Haematemesis 5. dyspepsia
55
GASTRITIS What investigations are done with someone you suspect has gastritis?
- Endoscopy (erythema) - Biopsy (histology change) - Blood tests (inflammation) - H.pylori testing - urea breath test, stool antigen test
56
GASTRITIS Describe the treatment for gastritis
1. Decrease alcohol and smoking 2. Antacid (magnesium carbonate) 3. PPI (omeprazole) 4. H2 receptor antagonist (ranitidine) 5. Enteric coated aspirin 6. decrease stress
57
GASTRITIS How do you treat H. pylori?
Triple therapy: Normal --> amoxicillin, omeprazole and clarithromycin/metronidazole Penicillin resistance --> clarithromycin, omeprazole and metronidazole
58
PEPTIC ULCERS Give 4 causes of peptic ulcers
1. NSAIDs 2. Mucosal ischaemia 3. Increased acid production (stress) 4. Bile reflux 5. Alcohol 6. H. pylori
59
PEPTIC ULCERS How does mucosal ischaemia cause ulcer formation?
Lack of blood flow to cells --> no mucin production = no mucosal protection --> ulcer formation
60
PEPTIC ULCER How does increased acid production (stress) cause ulcer formation?
Mucosa overwhelmed --> corrosion --> ulcer formation
61
PEPTIC ULCER How does NSAIDs cause ulcer formation?
Reduced prostaglandin synthesis due to salicylic acid release --> cell death --> no mucin production = no mucosal protection --> ulcer formation
62
PEPTIC ULCER How does bile reflux cause ulcer formation?
Mucosal cell damages --> no mucin production = no mucosal protection --> ulcer formation
63
PEPTIC ULCER How does H. pylori cause ulcer formation?
- causes decrease in HCO3- which increases acidity - H.pylori secretes urease - splits urea into CO2 and ammonia - ammonia + H+ forms ammonium which is toxic to gastric mucosa - Acute inflammatory reaction (neutrophils) with less mucosal defence
64
PEPTIC ULCER Give 3 symptoms of peptic ulcers
1. recurrent burning epigastric pain 2. pain relieved by antacids and is worse when hungry 3. pain occurs at night 4. nausea 5. anorexia and weight loss
65
PEPTIC ULCER What investigations might you do in someone who you suspect to have peptic ulcers?
H. Pylori Test (Urease breath test) | Endoscopy (if Over 55 or Red Flags Present)
66
PEPTIC ULCER How can you treat peptic ulcers?
- lifestyle changes - reduce stress, avoid irritating food, reduce smoking - Stop NSAIDs - H.Pylori eradication (triple therapy): - PPI - OMEPRAZOLE - 2 of following: - AMOXICILLIN - CLARITHROMYCIN
67
PEPTIC ULCER Name 2 complications of peptic ulcers
- Haemorrhage due to erosion to artery | - Peritonitis due to erosion through wall
68
MALABSORPTION Give 5 broad causes of malabsorption
1. Defective intraluminal digestion 2. Insufficient absorptive area 3. Lack of digestive enzymes 4. Defective epithelial transport 5. Lymphatic obstruction
69
MALABSORPTION what can cause defective intraluminal digestion?
1. Pancreatic insufficiency due to pancreatitis/CF - lack of digestive enzymes 2. Defective bile secretion due to biliary obstruction or ileal resection 3. Bacterial overgrowth
70
MALABSORPTION what can cause insufficient absorptive area?
1. Coeliac disease 2. Crohn's disease 3. Extensive surface parasitisation 4. Small intestinal resection or bypass
71
MALABSORPTION give an example of when there is a lack of digestive enzymes
Lactose intolerance - disaccharide enzyme deficiency
72
MALABSORPTION what can cause lymphatic obstruction?
1. Lymphoma | 2. TB
73
MALABSORPTION what are the risk factors?
- systemic disease - GI disease (IBD, coeliac) - pancreatic disease - surgery (bowel resection, pancreatectomy) - radiotherapy - trauma - parasitic infection - drugs - congenital (biliary atresia) - alcohol excess
74
MALABSORPTION what are the clinical features?
- bloating - nausea - increased flatulence - chronic diarrhoea - dry skin - fatigue - weight loss - hypotension - hair loss - fluid retention
75
MALABSORPTION what are the investigations?
BLOODS - FBC, iron studies, U&Es, zinc, megnesium, bone profile other investigations to consider - stool test - hydrogen breath test - sweat test - genetic testing - anti-TTG - bowel biopsy
76
MALABSORPTION what is the management?
- treat underlying cause - recognition + avoidance of triggers - treat symptoms e.g. anti-diarrhoeal tablets, anti-emetics - correct electrolyte imbalance - replace vitamins
77
CROHNS DISEASE Describe the distribution of inflammation seen in Crohn's disease
Patchy (skip lesions), granulomatous, transmural inflammation
78
ULCERATIVE COLITIS Describe the distribution of inflammation seen in Ulcerative colitis
Continuous inflammation affecting only the mucosa
79
CROHNS DISEASE What part of the bowel is commonly affected by Crohn's disease?
Can affect anywhere from the mouth to anus | Terminal ileum is most affected
80
ULCERATIVE COLITIS What part of the bowel is commonly affected by Ulcerative colitis?
Spreads proximally from the rectum but only affects the colon
81
ULCERATIVE COLITIS give 3 microscopic features that will be seen in ulcerative colitis
1. Crypt abscess 2. goblet cell depletion 3. mucosal inflammation - does not go deeper
82
CROHNS DISEASE what are the macroscopic features of crohn's disease?
- Deep ulcers and fissures --> cobblestone look - skip lesions - involved bowel often thickened and narrowed
83
IBD In Crohn's or UC is smoking a protective factor?
Ulcerative colitis
84
IBD Name 3 causes of IBD
1. Genetic 2. Stress/depression 3. Inappropriate immune response
85
ULCERATIVE COLITIS Give 4 signs and symptoms of Ulcerative colitis
1. Episodic/chronic diarrhoea +/- blood/ mucus 2. Abdominal pain - left lower quadrant 3. Systemic - fever, malaise, anorexia, weight loss 4. Clubbing 5. Erythema nodosum 6. Amyloidosis
86
CROHNS DISEASE Give 4 signs and symptoms of Crohn's disease
1. Diarrhoea - urgency 2. Abdominal pain 3. Systemic - weight loss, fatigue, fever, malaise 4. Bowel ulceration 5. Anal fistulae/stricture 6. Clubbing 7. Skin/joint/eye problems
87
IBD What investigations might you do in someone with IBD?
1. Bloods - FBC, ESR, CRP 2. Faecal calprotectin - shows inflammation but is not specific for IBD 3. Flexible sigmoidoscopy 4. Colonoscopy - biopsy to confirm 5. examination
88
CROHNS DISEASE What is the treatment induction of remission for Crohn's disease?
INDUCTION OF REMISSION MILD (1st presentation/1 exacerbation in 1yr) - 1st line = IV/PO glucocorticoid - 2nd line = aminosalicylate (MESALAZINE) - distal/ileocaecal disease = budesonide MODERATE (>2 exacerbations in 1yr) - 1st line = azathioprine or mercaptopurine - 2nd line = methotrexate SEVERE (unresponsive to conventional therapy) - 1st line = infliximab or adalimumab (anti-TNF) - 2nd line = other biological agents REFRACTORY - surgery
89
CROHN'S DISEASE what is the management for maintenance of remission in crohn's disease?
- 1st line = azathioprine or mercaptopurine - 2nd line = methotrexate - post surgery = consider azathioprine +/- methotrexate
90
ULCERATIVE COLITIS What is the treatment for Ulcerative colitis?
INDUCTION OF REMISSION PROCTITIS - 1st line = topical aminosalicylate (RECTAL MESALAZINE) - 2nd line = oral aminosalicylate - 3rd line = topical or oral corticosteroid PROCTOSIGMOIDITIS/LEFT-SIDED UC - 1st line = topical aminosalicylate - 2nd line = high-dose oral aminosalicylate or high-dose oral aminosalicylate + topical corticosteroid - 3rd line = stop topical treatment, add oral aminosalicylate + oral corticosteroid EXTENSIVE DISEASE - 1st line = topical aminosalicylate + high-dose oral aminosalicylate - 2nd line = stop topical treatment, add oral aminosalicylate + oral corticosteroid SEVERE DISEASE - should be treated in hospital - 1st line = IV steroids (IV ciclosporin if contraindicated) - 2nd line = add IV ciclosporin or consider surgery
91
ULCERATIVE COLITIS what is the management for the maintenance of remission in UC?
- proctitis = topical aminosalicylate or topical + oral aminosalicylate - left-sided + extensive disease = oral aminosalicylate - >2 exacerbations = oral azathioprine or mercaptopurine
92
ULCERATIVE COLITIS Give 5 complications of Ulcerative colitis
1. Colon --> blood loss, colorectal cancer, toxic dilatation 2. Arthritis 3. Iritis, episcleritis 4. Fatty liver and primary sclerosing cholangitis 5. Erythema nodosum
93
CROHNS DISEASE Give 5 complications of Crohn's
PERFORATION AND BLEEDING = MAJOR 1. Malabsorption 2. Obstruction --> toxic dilatation 3. Fistula/abscess formation 4. Anal skin tag/fissures/fistula 5. Neoplasia 6. Amyloidosis
94
COELIAC DISEASE Describe the pathophysiology of Coeliac disease
1. Gliadin from gluten deaminated by tissue transglutaminase --> increases immunogenicity 2. Gliadin recognised by HLA-DQ2 receptor on APC --> inflammatory response 3. Plasma cells produce anti-gliadin and tissue transglutaminase --> T cell/cytokine activated 4. Villous atrophy and crypt hyperplasia --> malabsorption
95
COELIAC DISEASE When does Coeliac disease usually present?
2 peaks - infancy and 5th decade
96
COELIAC DISEASE Give 5 symptoms of Coeliac disease
1. Diarrhoea and steatorrhoea (stinking/fatty) 2. Weight loss 3. Irritable bowel 4. Iron deficiency anaemia 5. Osteomalacia 6. Fatigue 7. abdominal pain 8. angular stomatitis 9. dermatitis herpetiform
97
COELIAC DISEASE What investigations might you do in someone who you suspect to have coeliac disease?
- anti-tTg antibody test - must keep gluten diet 6 weeks prior - Endoscopy - duodenal biopsy post 6 weeks gluten diet (gold standard)
98
COELIAC DISEASE What 3 histological features are needed in order to make a diagnosis of coeliac disease?
1. Raised intraepithelial lymphocytes 2. Crypt hyperplasia 3. Villous atrophy
99
COELIAC DISEASE What part of the bowel is mostly affected in coeliac disease?
Proximal small bowel (duodenum) | mean B12, folate and iron cannot be absorbed = anaemia
100
COELIAC DISEASE How do you treat coeliac disease?
- Lifelong gluten free diet - correction of mineral and vitamin deficiency - DEXA scan for osteoporosis risk
101
COELIAC DISEASE Give 3 complications of Coeliac disease
1. Osteoporosis 2. Anaemia 3. Increased risk of GI tumours 4. secondary lactose intolerance 5. T-cell lymphoma
102
OESOPHAGEAL CANCER What cells normally line the oesophagus?
Stratified squamous non-keratinising cells
103
OESOPHAGEAL CANCER Give 3 causes of squamous cell carcinoma
1. Smoking 2. Alcohol 3. Poor diet/obesity 4. coeliac disease
104
OESOPHAGEAL CANCER Name 2 types of Oesophageal cancer
1. Adenocarcinoma - distal 1/3rd of oesophagus | 2. Squamous cell carcinoma - proximal 2/3rds of oesophagus
105
OESOPHAGEAL CANCER What can cause oesophageal adenocarcinoma?
Barrett's oesophagus
106
OESOPHAGEAL CANCER Give 5 symptoms of oesophageal carcinoma
1. progressive dysphagia 2. Weight loss 3. Heartburn 4. Haematemesis 5. Anorexia 6. Pain
107
OESOPHAGEAL CANCER What investigations might be done on someone you suspect has oesophageal cancer?
upper GI endoscopy and biopsy = 1st line Barium swallow - to see strictures CT/MRI for staging
108
OESOPHAGEAL CANCER How can you treat oesophageal cancer?
- Surgical resection - best chance of cure if not infiltrated through oesophageal wall - Chemotherapy - Palliative care
109
GASTRIC CANCER Give 3 causes of gastric cancer
1. Smoked foods 2. Pickles 3. H. pylori infection 4. Pernicious anaemia 5. Gastritis 6. family history
110
GASTRIC CANCER Describe how gastric cancer can develop from normal gastric mucosa
Smoked/pickled food diet leads to intestinal metaplasia of normal gastric mucosa Several genetic changes lead to dysplasia and then eventually intra-mucosal and invasive carcinoma
111
GASTRIC CANCER Give 3 symptoms and signs of gastric cancer
1. Weight loss 2. Anaemia (pernicious) 3. nausea and Vomiting 4. Dyspepsia and dysphasia 5. palpable epigastric mass 6. Hepatomegaly, jaundice and ascites 7. Enlarged supraclavicular nodes 8. epigastric pain
112
GASTRIC CANCER What investigations might you do in someone who you suspect has gastric cancer?
1. gastroscopy - biopsy 2. endoscopic USS - depth of invasion 3. CT /MRI /PET
113
GASTRIC CANCER What is the advantage of doing a laparoscopy in someone with gastric cancer?
It can detect metastatic disease that may not be detected on USS/endoscopy
114
GASTRIC CANCER what is the management for gastric cancer?
Nutritional support Surgical resection Chemo
115
GASTRIC CANCER what are the red flag signs for upper GI cancer?
For people with an upper abdominal mass consistent with stomach cancer: - Dysphagia of any age - Aged ≥ 55yr + weight loss with any of the following: - Upper abdominal pain/(or) - Reflux/ (or) - Dyspepsia
116
GASTRIC CANCER What vitamin supplement will a patient need following gastrectomy?
They will be deficiency in intrinsic factor so will need vitamin B12 supplements to prevent pernicious anaemia
117
APPENDICITIS Give 3 causes of appendicitis
1. Faecolith 2. Lymphoid hyperplasia 3. Filarial worms
118
APPENDICITIS Describe the pathophysiology of appendicitis
Lumen of appendix is obstructed --> invasion of gut organism into appendix wall --> inflammation - if the appendix ruptures, faecal matter will enter the peritoneum resulting in peritonitis
119
APPENDICITIS Give 4 symptoms of appendicitis
1. Right sided pain located at McBurneys point 2. Anorexia 3. Nausea and vomiting 4. Constipation 5. Tenderness with guarding and rebound 6. Tachycardia
120
APPENDICITIS What investigations might be done in a patient you suspect has appendicitis?
- Blood tests = raised WCC, - CRP, ESR - USS - CT - gold standard
121
APPENDICITIS What is the treatment for appendicitis?
- Appendicectomy | - IV antibiotics pre-op
122
APPENDICITIS Give 2 complications of appendicitis
1. Ruptured appendix --> peritonitis 2. Appendix mass 3. Appendix abscess
123
DIVERTICULAR DISEASE Who is most likely to be affected by diverticular disease?
Patients over 50 and those with low fibre diets
124
DIVERTICULAR DISEASE Describe the pathophysiology of diverticulitis
Out-pouching of bowel mucosa --> faeces can get trapped here and obstruct the diverticula --> abscess and inflammation --> diverticulitis
125
DIVERTICULAR DISEASE What part of the bowel is most likely to be affected by diverticulitis?
sigmoid colon - smallest luminal diameter and highest pressure also descending colon
126
DIVERTICULAR DISEASE What is acute diverticulitis?
A sudden attack of swelling in the diverticula | Can be due to surgical causes
127
DIVERTICULAR DISEASE Describe the signs of acute diverticulitis
Pain in left iliac fossa region Fever and constipation Tachycardia signs and symptoms similar to appendicitis but on left side
128
GORD Give 3 causes of Gastro-oesophageal reflux disease (GORD)
1. Hiatus hernia - sliding or rolling hiatus 2. Smoking 3. Obesity 4. Alcohol 5. pregnancy
129
GORD Describe the pathophysiology of GORD
Lower oesophageal sphincter dysfunction --> reflux of gastric contents --> oesophagitis
130
GORD Name 3 oesophageal symptoms of GORD
1. Heartburn - retrosternal chest pain, after meals, worse when lying down, relieved by antacids 2. Bleching 3. Food/acid and water brash 4. Odynophagia - (painful swallowing) 5. Dysphagia - (difficulty swallowing)
131
GORD Name 3 extra oesophageal symptoms of GORD
1. Nocturnal asthma 2. Chronic cough 3. Laryngitis 4. Sinusitis
132
GORD What investigations are done for someone you suspect has GORD?
- Diagnosis can be made without investigations - Endoscopy (if red flags) - Barium swallow - 24hr oesophageal pH monitoring
133
GORD What is the treatment of GORD?
conservative - stop smoking - stop alcohol - lose weight - change sleep position medical - PPI (omeprazole) - H2 receptor antagonist (ranitidine) surgical - nissen fundoplication
134
IBS Give an example of a functional bowel disorder
IBS
135
IBS Describe the multi-factorial pathophysiology of IBS
The following factors can all contribute to IBS: - Psychological morbidity - trauma in early life - Abnormal gut motility - Genetics - Altered gut signalling (visceral hypersensitivity)
136
IBS Give 3 symptoms of IBS
1. Abdominal pain 2. Bloating 3. Change in bowel habit 4. Mucus 5. Fatigue 6. Backache
137
IBS Give an example of a differential diagnosis for IBS
1. Coeliac disease 2. Lactose intolerance 3. Bile acid malabsorption 4. IBD 5. Colorectal cancer
138
IBS What investigations might you do in someone who you suspect has IBS?
Rule out differentials 1. Bloods - FBC, U+E, LFT 2. CRP 3. Coeliac serology 4. Colonoscopy
139
IBS Describe the non pharmacological treatment of IBS
Education Resistance Dietary modification - reduce caffeine, plenty of fluids, increase fibre intake
140
IBS Describe the pharmacological treatment of IBS
1. Antispasmoidics for bloating - mebeverine, buscopan 2. Laxatives for constipation - Senna, Movicol 3. Anti-motility agent for diarrhoea - loperamide 4. Tricyclic antidepressants
141
CROHNS DISEASE what are the microscopic features of crohns disease?
- transmural inflammation - granulomas - increase in inflammatory cells - goblet cells - less crypt abscesses
142
CROHNS DISEASE what is the epidemiology of crohns disease?
- highest incidence and prevalence in Northern Europe, UK and N America - lower incidence than UC - female>male - 1/5 have 1st degree relative with disease - present mostly 20-40 yrs old
143
CROHNS DISEASE what are the risk factors for crohn's disease?
- genetic association - mutation on NOD2 (CARD15) gene on chromosome 16 - smoking - NSAIDs - family history - chronic stress and depression - good hygiene - appendicectomy
144
ULCERATIVE COLITIS what are the macroscopic features of ulcerative colitis?
- affect the colon only - begins in rectum and extends proximally - continuous involvement - no skip lesions - red mucosa that bleeds easily (friability) - ulcers and pseudo-polyps in severe disease
145
ULCERATIVE COLITIS what are the risk factors for ulcerative colitis?
- family history - NSAIDs - chronic stress and depression
146
ULCERATIVE COLITIS what is the epidemiology of ulcerative colitis?
- highest prevalence in Northern Europe, UK and N America - higher incidence than Crohn's - Male = females - present 15-30yrs - 3x more common in non-smokers/ex-smokers - 1 in 6 will have 1st degree relative with UC
147
ULCERATIVE COLITIS what are the different types of ulcerative colitis?
- proctitis = just affects rectum - left-sided colitis = rectum and left colon - pancolitis = affects entire colon up to ileocecal valve
148
COELIAC DISEASE what are the risk factors for coeliac disease?
- HLA DQ2/DQ8 - other autoimmune diseases e.g. T1DM, thyroid disease, Sjogren's - IgA deficiency - breast feeding - age of introduction to gluten into diet - rotavirus infection in infancy
149
COELIAC DISEASE what is the epidemiology of coeliac disease?
- 1% of population affected- peaks in infancy, and 50-60 years - 10% risk in 1st degree relatives and 30% risk in siblings
150
OESOPHAGEAL CANCER what are the risk factors for oesophageal cancer?
ABCDEF - Achalasia - Barret's oesophagus - Corrosive oesophagitis - Diverticulitis - oEsophageal web - Familial
151
OESOPHAGEAL CANCER what are the causes of adenocarcinoma of the oesophagus?
- smoking - tobacco - GORD - obesity - increases reflux
152
OESOPHAGEAL CANCER what is the epidemiology of oesophageal cancer?
- 6th most common cancer worldwide - mainly occurs 60-70yrs - poor prognosis (10% 5yr survival) - squamous = 5-10 per 100,000 in UK - male>female- incidence increasing in western world
153
APPENDICITIS what is the epidemiology of appendicitis?
- most common surgical emergency - males>females - high incidence 10-20yrs - rare before age of 2 - should be considered for all RHS pain if appendix is present
154
GORD what are the complications of GORD?
- peptic stricture | - barrett's oesophagus
155
INTESTINAL OBSTRUCTION how is intestinal obstruction classified?
- according to site - extent of luminal obstruction - according to mechanism - according to pathology
156
MALLORY-WEISS TEAR what is a mallory-weiss tear?
a linear mucosal tear occurring at the gastroesophageal junction
157
MALLORY-WEISS TEAR when do mallory-weiss tears happen?
- produced by a sudden increase in intra-abdominal pressure | - follows a bout of coughing or retching - classically seen after alcoholic dry heaves
158
MALLORY-WEISS TEAR what is the epidemiology of mallory-weiss tears?
- most common in males | - mainly 20-50 years old
159
MALLORY-WEISS TEAR what are the risk factors for mallory weiss tears?
- alcoholism - forceful vomiting - eating disorders - NSAID abuse - male - chronic cough
160
MALLORY-WEISS TEAR what are the clinical features of mallory-weiss tears?
- vomiting - haematemesis after vomiting - retching - postural hypotension - dizziness
161
MALLORY-WEISS TEAR what are the investigations for mallory-weiss tears?
Rockall score (assess blood loss: <3 = low risk) FBC, U&E, coag studies, group & save ECG & cardiac enzymes endoscopy to confirm tear
162
MALLORY-WEISS TEAR what is the treatment for mallory weiss tears?
- ABCDE - Terlipressin + Urgent Endoscopy - Rockall Score + Inpatient Observation - Banding/clipping, adrenaline, thermocoag
163
VARICES what are oesophageal varices?
Abnormal, enlarged veins in the oesophagus, that develop when normal blood flow to the liver is blocked by a clot / scar tissue
164
VARICES where do varices tend to occur?
- gastroesophageal junction - rectum - left renal vein - diaphragm - anterior abdominal wall
165
VARICES when do gastroesophageal varices tend to rupture?
when blood pressure in portal vein exceeds 12mmHg
166
VARICES what is the epidemiology of gastroesophageal varices?
- 90% of patients with cirrhosis develop varices over 10 years - 1/3 will bleed - bleeding likely in large varices - varices tend to develop in lower oesophagus and gastric cardia
167
VARICES what are the main causes of gastroesophageal varices?
- alcoholism - viral cirrhosis - portal hypertension
168
VARICES what are the risk factors for gastroesophageal varices?
- cirrhosis - portal hypertension - schistosomiasis infection - alcoholism
169
VARICES what is the pathophysiology of gastroesophageal varices?
- liver injury causes increased resistance to flow -> portal hypertension - hyperdynamic circulation -> formation of collaterals between portal and systemic systems - pressure >10mmHg start to bleed (rupture >12mmHg)
170
VARICES what is the clinical presentation of gastroesophageal varices?
- haematemesis/melena - abdominal pain (epigastric) - shock (if major blood loss) - fresh rectal bleeding - hypotension and tachycardia - pallor - splenomegaly - ascites - hyponatraemia - signs of chronic liver damage (jaundice, increased bruising)
171
VARICES what investigations should be undertaken for gastroesophageal varices?
1. Urgent endoscopy 2. FBC, U&E, clotting (INR), LFTs, group & save 3. CXR / ascitic tap / further Ix for PHT
172
VARICES what is the treatment for gastroesophageal varices?
- ABCDE - Rockfall Score (Prediction of Rebleeding and Mortality) - Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS - Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
173
VARICES how can gastroesophageal varices be prevented?
- PROPRANOLOL - reduce resting pulse rate to decrease portal pressure - variceal banding - liver transplant
174
IBS what is IBS?
a mixed group of abdominal symptoms for which no organic cause can be found
175
IBS what is the epidemiology of IBS?
- age of onset is under 40 - females>males - 1/5 western world experience symptoms
176
IBS what are the 3 different types of IBS?
- IBS-C with constipation - IBS-D with diarrhoea - IBS-M with constipation and diarrhoea
177
IBS what are the risk factors for IBS?
- previous severe diarrhoea - female - high hypochondriac anxiety and neurotic score at time of illness
178
IBS what are the causes of IBS?
depression, anxiety, stress, trauma, abuse GI infection eating disorders
179
IBS what is the pathophysiology of IBS?
dysfunction in brain-gut axis results in disorder of intestinal mobility and/or enhanced perception
180
IBS what are the extra-intestinal symptoms of IBS?
- painful periods - urinary frequency, urgency, nocturia, incomplete bladder emptying - back pain and joint hypermobility - fatigue
181
IBS what is the clinical presentation of IBS?
ABC - A = abdominal pain/discomfort - relieved by defecation - B = bloating - C = change in bowel habit 2 or more of following - urgency - incomplete evacuation - abdominal bloating/distention - mucous in stool - worsening of symptoms after food
182
COLORECTAL CANCER what are the red flag symptoms for GI cancers?
- unexplained weight loss - PR bleeding/blood in stool - family history of bowel or ovarian cancer
183
IBS what investigations should be undertaken for IBS?
diagnosis is made by ruling out differentials - bloods - FBC - ESR and CRP - coeliac serology - faecal calprotectin - colonoscopy
184
IBS what is the rome III diagnostic criteria for IBS?
- recurrent abdominal pain at least 3 days a month in last 3 months - associated with 2 of following: - onset associated with change in frequency of stool - onset associated with change in form (appearance) of stool
185
IBS what is the management of IBS?
- dietary/lifestyle modification = avoid alcohol, caffeine and fizzy drinks, small frequent meals, FODMAP diet - antispasmodics - MEBERVERINE or BUSCOPAN - laxatives - MOVICOL - antimotility agents - LOPERAMIDE - if no better try tricyclic antidepressants AMITRIPTYLINE - warn about drowsiness
186
what should be considered if you see atrial fibrillation and abdominal pain?
mesenteric ischaemia
187
DIARRHOEA what is the definition of acute diarrhoea?
diarrhoea lasting less than 2 weeks
188
DIARRHOEA what is the definition of chronic diarrhoea?
diarrhoea lasting more than 2 weeks
189
DIARRHOEA what are the causes of diarrhoea?
- viral (majority) - in children = rotavirus - in adults = norovirus - bacterial - Campylobacter jejuni - E.coli - Salmonella - Shigella - parasitic - Giardia lamblia - Entamoeba histolyitca - Cryptosporidium
190
DIARRHOEA what is the management for diarrhoea?
- treat underlying causes - bacterial treated with METRONIDAZOLE- oral rehydration therapy - anti-emetics - METOCLOPRAMIDE - anti-motility agents - LOPERAMIDE or CODEINE
191
GASTRITIS what are the effects of helicobacter pylori?
- inflammation - antral gastritis - gastric cancer - peptic ulcers
192
GASTRITIS what is the treatment for helicobacter pylori infection?
triple therapy - PPI - LANSOPRAZOLE / OMEPRAZOLE - 2 of the following: METRONIDAZOLE, CLARITHROMYCIN , AMOXICILLIN, TETRACYCLINE, BISMUTH
193
GASTRITIS what are the investigations for H.pylori infection?
urea breath test | stool antigen test
194
GASTRIC CANCER what is the epidemiology of gastric cancer?
● 4th most common cancer worldwide ● Second leading cause of cancer-related mortality ● Incidence increases with age ● Men > women ● More common in Japan and Chile, less common in USA ● 10% 5yr survival
195
COLORECTAL CANCER what is lynch syndrome?
hereditary non-polyposis colon cancer autosomal dominant condition caused by mutation in hMSH1 or hMSH2 genes, in highly repeated short DNA sequences
196
COLORECTAL CANCER what is the effect of lynch syndrome?
polyps form in the colon and rapidly progress to colon cancer
197
DIVERTICULAR DISEASE what is diverticulosis?
presence of asymptomatic diverticulum
198
DIVERTICULAR DISEASE what is diverticular disease?
diverticula are symptomatic in the absence of inflammation
199
DIVERTICULAR DISEASE what is diverticulitis?
inflammation of diverticulum
200
DIVERTICULAR DISEASE what is the clinical presentation of diverticulitis?
- abdominal pain - fever - change in bowel habit - nausea - anorexia - tachycardia - abdominal tenderness + guarding
201
DIVERTICULAR DISEASE what are the investigations for diverticulitis?
BEDSIDE - observations - urine dip - pregnancy test BLOODS - FBC, U&Es, LFTs amylase, CRP, group + save, clotting screen CT abdomen + pelvis
202
DIVERTICULAR DISEASE what is the management for diverticulitis?
ANTIBIOTICS - 1st line = co-amoxiclav (if penicillin allergic = ciprofloxacin/metronidazole) ANALGESIA - paracetamol SUPPORTIVE - high fibre diet SURGERY
203
DIVERTICULAR DISEASE what are the complications of diverticulitis?
fistula strictures diverticular bleed
204
VOLVULUS what are the clinical features of volvulus?
acute abdominal pain abdominal distention constipation nausea and vomiting tenderness on examination absent bowel sounds
205
VOLVULUS what are the investigations for volvulus?
FBC - leukocytosis U&Es = electrolyte disturbances VBG = lactate raised if ischaemic bowel abdominal XR - coffee bean sign CT scan
206
VOLVULUS what is the management for volvulus?
- endoscopic detorsion = rigid sigmoidoscopy and rectal tube - surgical intervention - fluid resuscitation - pain management
207
IBD what are the biliary complications of crohns disease vs ulcerative colitis?
crohn's = gallstones ulcerative colitis = primary sclerosing cholangitis
208
IBD what is the appearance of crohn's and colitis on X rays?
crohn's = string appearance colitis = lead-pipe sign
209
MESENTERIC ISCHAEMIA what is mesenteric ischaemia?
narrowed/blocked arteries restrict blood flow to small intestine it affects the SMA
210
MESENTERIC ISCHAEMIA what are the causes of actue mesenteric ischaemia?
thrombus (arterial or venous) embolism non-occlusive (hypo-perfusion)
211
MESENTERIC ISCHAEMIA what are the risk factors?
- older age - female - AF - atherosclerosis (HTN, smoking, hypercholesterolaemia, DM) - previous MI - hypercoagulable state - infective endocarditis - vasculitis - hypoperfusion
212
MESENTERIC ISCHAEMIA what are the clinical features?
SYMPTOMS - abdominal pain - N+V - diarrhoea +/- rectal bleeding - fever - weight loss SIGNS - absence of bowel sounds (late sign) - epigastric bruit on auscultation - rectal bleeding on PR - hypotensive and tachycardic
213
MESENTERIC ISCHAEMIA what is the abdominal pain like in acute vs chronic mesenteric ischaemia?
ACUTE - severe - out of proportion to abdominal signs CHRONIC - colicky - intermittent - post-prandial - described as 'intestinal angina'
214
MESENTERIC ISCHAEMIA what are the investigations for acute mesenteric ischaemia?
BLOODS - FBC - leucocytosis and neutrophilia - U&Es - pre-renal AKI (3rd spacing) - ABG - raised lactate and metabolic acidosis ECG - atrial fibrillation CT angiogram Erect pneumoperitoneum
215
MESENTERIC ISCHAEMIA how would you treat mesenteric ischaemia?
INITIAL - bowel rest (nil by mouth, NG tube) - IV fluids - IV broad spectrum abx - IV unfractionated heparin - prompt laparotomy DEFINITIVE - endovascular revascularisation (embolectomy/angioplasty) - laparotomy (open embolectomy, arterial bypass, resection)
216
MESENTERIC ISCHAEMIA what are the complications?
- bowel infarction and perforation - short bowel syndrome - strictures
217
DYSPHAGIA what is the physiology of swallowing?
Tongue presses against hard palate and forces hard bolus of food into oropharynx Tongue blocks off mouth and larynx and uvula rise to prevent food from entering lungs Upper oesophageal sphincter relaxes allowing food to enter oesophagus Constrictor muscles of the pharynx contract forcing food down Food moves down by peristalsis Gastroesophageal sphincter surrounding cardiac orifice opens and food enters stomach
218
DYSPHAGIA what are the causes of dysphagia?
Disease of mouth and tongue - tonsillitis Neuromuscular disorders - bulbar palsy, myasthenia gravis Esophageal motility - achalasia, scleroderma, DM Extrinsic pressure - goitre, mediastinal glands Intrinsic lesion - stricture, pharyngeal pouch
219
ACHALASIA what is achalasia?
Failure of esophageal smooth muscle to relax resulting in LOS remaining closed
220
ACHALASIA what are the clinical features of achalasia?
dysphagia of both solids and liquids regurgitation heartburn cough when lying down weight loss
221
ACHALASIA what are the investigations?
- upper GI endoscopy - oesophageal manometry (gold standard) - barium swallow
222
ACHALASIA what is the management?
- CCBs (nifedipine/verapamil) - laparoscopic Heller's cardiomyotomy - botox to LOS
223
PHARYNGEAL POUCH where do pharyngeal pouches occur?
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
224
BARRETTS OESOPHAGUS what is barrett's oesophagus?
Metaplasia of the lower esophageal mucosa (stratified squamous to columnar epithelium with goblet cells)
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BARRETTS OESOPHAGUS what are the causes/ risk factors of barrett's oesophagus?
``` GORD, Male (7:1), caucasian, FHx, Hiatus hernia, Obesity, Smoking, Alcohol ```
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BARRETTS OESOPHAGUS what are the clinical features of barrett's oesophagus?
Classic history: middle aged caucasian male with long history GORD & dysphagia
227
BARRETTS OESOPHAGUS what are the investigations for barrett's oesophagus?
OGD + biopsy
228
BARRETTS OESOPHAGUS what is the management for barrett's oesophagus?
- Lifestyle: weight loss, smoking cessation, reduce alcohol, small reg meals, avoid hot drinks/alcohol/eating <3hrs before bed, avoid certain drugs (nitrates, anticholinergics, TCAs, NSAIDs, K+ salts, alendronate) Endoscopic Surveillance with Biopsies High Dose PPI Dysplasia - Endoscopic Mucosal Resection, Radiofrequency Ablation Severe: oesophagectomy
229
OESOPHAGEAL CANCER which are the most common types of oesophageal cancer in the developing and developed world?
developing = squamous cell carcinoma developed = adenocarcinoma
230
OESOPHAGEAL CANCER where is adenocarcinoma of the oesophagus found?
lower 1/3 - near GO junction
231
OESOPHAGEAL CANCER where is squamous cell carcinoma of the oesophagus found?
upper 2/3
232
GORD what are the red flag symptoms for GORD that requires further investigation?
``` Dysphagia (difficulty swallowing) > 55yrs Weight loss Epigastric pain / reflux Treatment resistant dyspepsia Nausea and vomiting Anaemia Raised platelets ```
233
PEPTIC ULCERS what is the difference in presentation of gastric ulcers vs duodenal ulcers?
gastric ulcers = epigastric pain worse after eating, eased by antacids. haematemesis, weight loss, heart burn duodenal ulcers = epigastric pain before meals and at night, relieved by eating or milk. melaena, weight gain
234
PEPTIC ULCERS which drugs can cause gastric/duodenal ulcers?
NSAIDS SSRI corticosteroids bisphosphonates
235
GASTRITIS what are the causes/risk factors of gastritis?
``` autoimmune disease H.pylori bile reflux NSAIDS stress ```
236
DIVERTICULAR DISEASE what will imaging show in diverticulitis?
Imaging May Show Pneumoperitoneum Dilated Bowel Loops Obstruction Abscess
237
DIVERTICULAR DISEASE what are the causes/risk factors of diverticular disease?
low fibre diet obesity age >40
238
GASTRIC CANCER what are the 2 different types of gastric cancer?
type 1 = intestinal / differentiated (70-80%) - found in antrum and lesser curvature type 2 = diffuse / undifferentiated (20%) - found elsewhere
239
IBD what are the following features for crohns and ulcerative colitis? - location - inflammatory pattern - layers affected - granuloma - crypt abscesses - goblet cells
location - crohns = any part of GI tract - UC = colon only inflammatory pattern - crohns = skip lesions (cobblestone appearance) - UC = continuous layers affected - crohns = transmural - UC = mucosal granulomas - crohns = granulomas - UC = no gramulomas crypt abscesses - crohns = present - UC = present goblet cells - crohns = present - UC = depletion
240
DIARRHOEA what are the non-infectious causes of diarrhoea?
IBS IBD - crohns, ulcerative colitis bowel cancer
241
DIARRHOEA what are the causes of diarrhoea that are not related to disease or infection?
- stress - medication related - toxin ingestion
242
COELIAC which HLA is associated with coeliac disease?
HLA DQ2/DQ8
243
HAEMORRHOIDS what is the difference in presentation of internal and external haemorrhoids?
internal = painless bleeding with bowel movements external = pain and discomfort
244
DIVERTICULAR DISEASE what is the prevention for diverticulitis?
Regular exercise, avoid smoking, high-fibre diet, drink plenty of water
245
C.DIFF what is the clinical presentation of c.diff?
- watery diarrhoea with mucus/blood - abdominal distention, cramps - malaise - fever
246
C.DIFF what is the treatment for c.diff?
1st line = vancomycin orally for 10 days 2nd line = oral fidaxomicin 3rd line = oral vancomycin +/- IV metronidazole
247
C.DIFF what is the management of recurrent infection?
within 12 weeks of symptom resolution = oral fidaxomicin after 12 weeks of symptom resolution = oral vancomycin or oral fidaxomicin
248
C.DIFF what is the management of life-threatening infection?
ORAL vancomycin + IV metronidazole
249
PILONIDAL SINUS what is a pilonidal sinus?
abnormal pocket in the skin near the tailbone containing hair and skin debris
250
ISCHAEMIC COLITIS what is ischaemic colitis?
temporary restriction of blood supply to the large intestine due to vasoconstriction or low pressure flow
251
ISCHAEMIC COLITIS where does it affect?
large bowel occurs in 'watershed areas' e.g. splenic flexure (areas located at the border of territory supplied by SMA and IMA)
252
ISCHAEMIC COLITIS what are the risk factors for ischaemic colitis?
- age >60 - sex F>M - factor V Leiden - high cholesterol - reduced blood flow - HF, low BP, shock, DM, RA - previous abdominal surgery - heavy exercise - surgery on aorta
253
ISCHAEMIC COLITIS what is the clinical presentation?
transient, less severe abdominal pain bloody diarrhoea
254
ISCHAEMIC COLITIS what are the complications of ischaemic colitis?
- sepsis - bowel necrosis - death - fear of eating - unintentional weight loss
255
ISCHAEMIC COLITIS what are the investigations for ischaemic colitis?
colonoscopy = gold standard AXR - may show thumbprinting (due to mucosal oedema/haemorrhage)
256
ISCHAEMIC COLITIS how would you treat ischaemic colitis?
conservative surgery if conservative management fails/peritonitis/perforation/ongoing bleeding
257
VARICES what causes dark stools in oesophageal varices?
The bleeding varices can result in swallowing large amounts of blood, which causes black, tarry stools also known as melaena
258
ANAL FISSURES what is it?
tear in the lining of the anus or anal canal
259
ANAL FISSURES what are the different causes?
- primary (no clear underlying cause) SECONDARY (associated with underlying cause) - constipation - IBD - malignancy - STI - infections - anal trauma - pregnancy + childbirth
260
ANAL FISSURES what are the risk factors?
- chronic constipation - persistent diarrhoea - straining during bowel movements - passing hard or large stools - anal intercourse - IBD - pregnancy and childbirth
261
ANAL FISSURES what is the most common location?
posterior midline of the anal canal
262
ANAL FISSURES what are the clinical features?
SYMPTOMS - severe pain during + after bowel movements - bright red blood on toilet paper - itching around anus SIGNS - severe tenderness on DRE - visible tear - skin tag
263
ANAL FISSURES what are the investigations?
clinical diagnosis
264
ANAL FISSURES what are the differentials?
- haemorrhoids - perianal ulcers - fistulae - perianal abscess
265
ANAL FISSURES what is the management?
1st line: - dietary modifications - laxatives - topical GTN ointment - topical anaesthetics 2nd line - lateral internal sphincterotomy - botox injection
266
CONSTIPATION what is primary constipation?
constipation as a result of disordered or ineffective regulation of colonic and anorectal neuromuscular function or brain-gut neuroenteric function
267
CONSTIPATION what is secondary constipation?
constipation as a result of factors such as certain medications (opiates, antipsychotics), metabolic disturbances ( hypercalcaemia , hypothyroidism), neurological disorders or primary diseases of the colon
268
CONSTIPATION what are the risk factors?
- increasing age - lower socioeconomic status - medications (opiates, CCBs, antipsychotics) - metabolic (hypothyroidism, hypercalcaemia) - neurological (parkinsons, spinal cord lesions) - diabetes mellitus - colonic disease - IBS - sedentary lifestyle - reduced dietary fibre
269
CONSTIPATION what are the clinical features?
- difficult defecation - infrequent stools (<3 per week) - incomplete emptying - excessive straining - hard stools - overflow diarrhoea
270
CONSTIPATION what are the clinical signs?
- haemorrhoids/fissures - palpable mass on abo exam - hard stool on PR - urinary retention - delirium
271
CONSTIPATION what are the investigations?
- abdo exam - PR exam secondary investigations - bloods - FBC, U&Es, TFTs, bone profile, blood glucose - abdo x-ray - colonoscopy
272
CONSTIPATION what is the management for short duration constipation (<3 months)?
1st line - lifestyle advice (increase fibre, increase exercise, fluid intake) - bulking laxative (ispaghula husk) 2nd line - if hard stool, difficult to pass = osmotic laxative (macrogol, lactulose) - if soft stool, inadequate emptying = stimulant laxatives (senna, bisacodyl)
273
CONSTIPATION what is the management for faecal impaction?
1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna) 2nd line = suppository (bisacodyl/glycerol) 3rd line = enema (sodium phosphate)
274
CONSTIPATION what are the complications?
- pain - delirium - anal fissures - haemorrhoids - rectocele - megacolon
275
HAEMORRHOIDS what is it?
abnormally swollen vascular cushions that are located in the anal canal.
276
HAEMORRHOIDS what are the different types of haemorrhoids?
internal = proximal to dentate line external = distal to dental line
277
HAEMORRHOIDS what is the dentate line?
divides the upper two-thirds of the anal canal from the lower third of the anal canal - upper two-thirds = rectal columnar epithelium - lower third = stratified squamous epithelium (highly innervated)
278
HAEMORRHOIDS what is the pathophysiology?
Symptomatic haemorrhoids are thought to develop when supporting tissue with the anal cushions deteriorate It is the abnormal downward displacement of these cushions that leads to venous dilatation
279
HAEMORRHOIDS what are the risk factors?
- constipation - prolonged straining - diarrhoea - pregnancy - increasing age - prolonged sitting - anticoagulation use - pelvic tumours
280
HAEMORRHOIDS what are the clinical features?
- painless rectal bleeding - bright red blood on wiping - faecal incontinence - perianal irritation
281
HAEMORRHOIDS what are the investigations?
- clinical diagnosis - direct visualisation (proctoscopy)
282
HAEMORRHOIDS what are the differential diagnoses?
- anorectal polyps - anal fissure - cancer - fistula - diverticular disease - IBD - perianal abscess - rectal prolapse - STI
283
HAEMORRHOIDS what is the management?
LIFESTYLE - high fibre diet - adequate water intake - toilet training - analgesia (NSAIDs) - laxatives (bulk, stimulant, osmotic or softeners) MEDICAL - topical agents (anaesthetic + steroids) - venoactive agents - antispasmodic agents SURGERY - rubber band ligation - sclerotherapy - infrared coagulation - haemorrhoidectomy
284
HIATUS HERNIA what is it?
herniation (abnormal protrusion) of part of the stomach (or other organs) through an opening in the diaphragm
285
HIATUS HERNIA what are the different types?
- type 1 (sliding) = most common - type 2 (para-oesophageal) - type 3 (combined) - type 4 = severe + uncommon
286
HIATUS HERNIA what are the risk factors?
- increasing age - increasing BMI - increased intra-abdominal pressure (pregnancy, straining, coughing) - smoking
287
HIATUS HERNIA what are the clinical features?
- epigastric pain - heartburn - dysphagia - N+V - post-prandial fullness - bowel sounds audible on chest auscultation
288
HIATUS HERNIA what are the investigations?
CXR - stomach visible superior to diaphragm endoscopy others to consider: - barium swallow - manometry - CT thorax + abdomen
289
HIATUS HERNIA what is the management?
LIFESTYLE - small frequent meals - stop smoking - avoid lying down after eating MEDICAL - PPI e.g. omeprazole SURGERY - laparoscopic repair - Nissen's fundoplication
290
MALNUTRITION what is it?
a state of nutrition where there is a deficiency, excess or imbalance of macronutrients (fat, protein, carbohydrates) and/or micronutrients (vitamins and minerals)
291
MALNUTRITION what are the three broad causes?
- inadequate intake - impaired absorption - increased nutritional demands
292
MALNUTRITION what is kwashiorkor?
this is caused by inadequate protein intake despite normal energy (i.e. carbohydrate) intake it is characterised by muscle atrophy, distended abdomen + fatty liver disease
293
MALNUTRITION what is marasmus?
this is caused by a deficiency of all macronutrients. It is characterised by diffuse loss of muscle and fat tissue
294
MALNUTRITION what are the clinical features of vitamin A deficiency?
night blindness immune deficiency
295
MALNUTRITION what are the symptoms of iron deficiency?
- anaemia - impaired cognitive development
296
MALNUTRITION what are the clinical features of folate deficiency?
- anaemia - glossitis - cognitive impairment
297
MALNUTRITION what are the clinical features of iodine deficiency?
- hypothyroidism - growth restriction - impaired cognitive development
298
MALNUTRITION what are the clinical features of zinc deficiency?
- delayed wound healing - impaired taste - hair loss - immune deficiency
299
MALNUTRITION what are the risk factors?
- over 65 - low socioeconomic status - drug/alcohol abuse - chronic progressive conditions - cognitive impairment - mental illness
300
MALNUTRITION what are the clinical features of malnutrition?
- unintentional weight loss - fatigue and lethargy - muscle weakness - poor concentration - depression - cold intolerance - poor wound healing
301
MALNUTRITION what are the investigations?
MUST score blood tests (FBC, U&Es, TFTs)
302
MALNUTRITION what are the components of a MUST score?
- BMI - amount of unplanned weight loss in past 3-6 months - acute disease effect
303
MALNUTRITION what is the management?
- increase food intake - nutritional supplements - enteral tube feeding - TPN
304
MALNUTRITION what is the criteria for malnutrition?
any of the following: - BMI <18.5 - unintentional weight loss >10% in last 3-6 months - BMI <20 and unintentional weight loss >5% in last 3-6 months
305
MESENTERIC ADENTITIS what is it?
acute or chronic inflammation of the mesenteric lymph nodes.
306
MESENTERIC ADENTITIS what are the causes?
VIRUSES = most common - EBV - coxsackie - adenovirus BACTERIA - yersinia - streptococcus - staphylococcus - e.coli
307
MESENTERIC ADENTITIS what is the pathophysiology?
ingestion of organisms which reach the mesenteric lymph nodes this leads to local inflammatory responses, lymph node enlargement and abdo pain
308
MESENTERIC ADENTITIS what are the clinical features?
- abdominal pain (lower right quadrant/RIF) - N+V - diarrhoea - fever - rebound tenderness
309
MESENTERIC ADENTITIS what are the investigations?
- BLOODS - FBC, CRP - URINE DIP - abdominal USS (enlarged mesenteric lymph nodes) investigations to consider: - stool culture - abdominal CT
310
MESENTERIC ADENTITIS what is the management?
1st line - supportive care (self-limiting within 4 weeks) - antibiotics if bacterial (azithromycin) 2nd line - surgical intervention
311
ANAL FISTULA what is it?
abnormal connections between the epithelialised surface of the anal canal and the perianal skin
312
ANAL FISTULA what are the different types according to the Parks classification?
- extrasphincteric = outside sphincter complex - suprasphincteric = runs over the top of the puborectalis - trans-sphincteric = passes through external sphincter - intersphincteric = rns through the intersphinteric plane
313
ANAL FISTULA how are the different types categorised?
- using Parks classification
314
ANAL FISTULA what are the risk factors?
- history of anorectal abscess - chronic diarrhoea - IBD (crohns) - prior anorectal surgery - hydradentitis suppurativa - diverticulitis
315
ANAL FISTULA what are the clinical features?
- recurrent perianal abscesses - discomfort/pain in perianal area - faecal soiling or incontinence - foul smelling pus discharge from external opening
316
ANAL FISTULA what are the investigations?
- clinical history/exam - proctoscopy - MRI
317
ANAL FISTULA what is the management?
CONSERVATIVE - sitz baths - analgesia for pain control MEDICAL (for crohns) - infliximab SURGERY - seton technique - fistulotomy
318
ANAL FISTULA what are the complications?
- recurrence of fistula - anal incontinence - anal stenosis - persistent non-healing wound
319
PERIANAL ABSCESS
an acute and tender perianal swelling.
320
PERIANAL ABSCESS what are the risk factors?
- anal fistula - IBD - diabetes mellitus - immunosuppression
321
PERIANAL ABSCESS what are the clinical features?
- perianal swelling - perianal pain - malaise - pus discharge - erythema - fever
322
PERIANAL ABSCESS what are the investigations?
BLOODS - FBC, U&Es, CRP, HbA1c, virus screen MRI anal sphincter
323
PERIANAL ABSCESS what is the management?
incision + drainage if systemically unwell consider IV antibiotics
324
PERITONITIS what is it?
inflammation of the peritoneum
325
PERITONITIS what is primary peritonitis?
spontaneous bacterial invasion of the peritoneal cavity. Also known as spontaneous bacterial peritonitis. Seen in patients with pre-existing ascites
326
PERITONITIS what is secondary peritonitis?
peritoneal infection due to loss of integrity of the gastrointestinal or urogenital tracts. This leads to contamination of the peritoneal space. This is the cause in perforation
327
PERITONITIS what is tertiary peritonitis?
recurrent or persistent infection of the peritoneal cavity that typically occurs after secondary peritonitis. Less well defined and usually seen in patients who are immunocompromised
328
PERITONITIS what is the most common cause?
gastrointestinal perforation due to appendicitis, peptic ulcers, diverticulitis
329
PERITONITIS what is the pathophysiology?
The spillage of content from the gastrointestinal (or urogenital) tracts allows the entry of bacteria into the previously sterile compartment
330
PERITONITIS what are the clinical features?
- abdominal pain (worse on movement) - abdominal distention - anorexia - N+V - fever - sweating
331
PERITONITIS what are the clinical signs?
- tenderness on palpation - guarding - rigidity - percussion tenderness - absent/reduced bowel sounds - tachycardia
332
PERITONITIS what are the investigations?
- clinical diagnosis - CT abdomen - bloods - FBC, U&Es, LFTs, CRP, coagulation, group + save
333
PERITONITIS what is the management?
- urgent surgical exploration - IV antibiotics (co-amoxiclav, gentamicin, cefuroxime or metronidazole)
334
GI PERFORATION what is it?
hole that develops through wall of GI tract, resulting in leak into sterile peritoneal cavity leads to peritonitis
335
GI PERFORATION what is the pathophysiology?
- ischaemia - infection - erosions - physical disruption (trauma)
336
GI PERFORATION what are the common causes of gastric perforation?
- peptic ulcer - foreign body ingestion
337
GI PERFORATION what are the common causes of small intestinal perforation?
- crohns disease - cancer - trauma
338
GI PERFORATION what are the common causes of large intestinal perforation?
diverticulitis cancer trauma
339
GI PERFORATION what are the risk factors?
- trauma - instrumentation - infection - malignancy - ischaemia - obstruction
340
GI PERFORATION what are the clinical features?
SYMPTOMS - sudden onset, severe abdo pain - N+V - inability to pass flatus or stool SIGNS - fever - abdominal rigidity - abdominal tenderness - rebound tenderness - signs of shock: hypotension, tachycardia
341
GI PERFORATION what are the investigations?
- AXR = pneumoperitoneum, air under diaphragm, air on both sides of bowel - USS abdomen = free fluid - CT scan = pneumatosis intestinalis (gas in wall of bowel) - FBC/CRP - sepsis 6
342
GI PERFORATION what is the management?
- resuscitation (IV fluids, oxygen, analgesia) - broad spectrum antibiotics - emergency surgery
343
GI PERFORATION what are the complications?
- peritonitis - sepsis - adhesions + bowel obstruction - post-op infection/bleeding
344
ABDOMINAL WALL HERNIAS what are the different types of hernia?
- inguinal hernia - femoral hernia - umbilical hernia - paraumbilical hernia - epigastric hernia - incisional hernia - obturator hernia
345
ABDOMINAL WALL HERNIAS where are inguinal hernias found?
above + medial to pubic tubercle
346
ABDOMINAL WALL HERNIAS where are femoral hernias found? why are they dangerous?
below + lateral to pubic tubercle (more common in women) are at high risk of strangulation
347
VIRAL GASTROENTERITIS what are the common causes?
- norovirus - rotavirus - astrovirus - adenovirus
348
VIRAL GASTROENTERITIS what are the clinical features?
SYMPTOMS - vomiting - diarrhoea - abdominal cramps - fever - lethargy SIGNS - dehydration - electrolyte imbalance - hypotension - tachycardia - reduced urine output
349
VIRAL GASTROENTERITIS what are the investigations?
mild-moderate = no investigation to consider - FBC, U&Es - stool culture - stool microscopy - c.difficile toxin
350
VIRAL GASTROENTERITIS what is the management?
MILD-MODERATE - bland diet - oral rehydration SEVERE - IV fluids
351
BACTERIAL GASTROENTERITIS what are the common causes?
- e.coli - b.cereus - s.aureus - campylobacter - salmonella
352
BACTERIAL GASTROENTERITIS what is the typical presentation of e.coli infection?
- common amongst travellers - watery stools - abdominal cramps and nausea
353
BACTERIAL GASTROENTERITIS what is the typical presentation of giardiasis?
prolonged non-bloody diarrhoea
354
BACTERIAL GASTROENTERITIS what is the typical presentation of shigella infection?
- bloody diarrhoea - vomiting and abdominal pain
355
BACTERIAL GASTROENTERITIS what is the typical presentation of staph aureus infection?
- severe vomiting - short incubation period
356
BACTERIAL GASTROENTERITIS what is the typical presentation of campylobacter?
- flu-like prodrome followed by crampy abdominal pains, fever and diarrhoea which may be bloody - may mimic appendicitis
357
BACTERIAL GASTROENTERITIS what is the typical presentation of b.cereus infection?
two types of illness are seen - vomiting within 6 hrs - diarrhoeal illness occurring after 6 hrs
358
BACTERIAL GASTROENTERITIS what is the most common cause of travellers diarrhoea?
e.coli
359
BACTERIAL GASTROENTERITIS what are the most common causes of acute food poisoning?
- s.aureus - b.cereus - clostridium perfringens
360
PARALYTIC ILEUS what is it?
reduced peristalsis resulting in pseudo-obstruction
361
PARALYTIC ILEUS what are the clinical features?
- abdominal distention/bloating - abdominal pain - nausea/vomiting - inability to pass gas - inability to tolerate oral diet
362
PARALYTIC ILEUS what are the investigations?
it is important to check electrolytes (potassium, magnesium + phosphate) post-op as they can contribute to ileus
363
PARALYTIC ILEUS what is the management?
- nil-by-mouth initially - NG tube if vomiting - IV fluids - correct electrolyte disturbances - TPN (occasionally required for prolonged/severe cases)
364
GIARDIASIS what is it caused by?
giardia lamblia
365
GIARDIASIS what are the risk factors?
- foreign travel - swimming/drinking water from a river or lake - male-male sexual contact
366
GIARDIASIS what are the clinical features?
- often asymptomatic - non-bloody diarrhoea - steatorrhea - bloating - abdominal pain - lethargy - flatulence - weight loss - malabsorption and lactose intolerance can occur
367
GIARDIASIS what are the investigations?
- stool microscopy for trophozoite and cysts - stool antigen detection test
368
GIARDIASIS what is the management?
metronidazole

MY REVISION - ALL PHASES (36 decks)

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