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Flashcards in GI Deck (149):
1

What is boerhaave's syndrome

Oesophageal wall rupture due to vomiting.

2

What area of the GIT does crohn's affect

Anywhere from mouth to anus.

3

Syx of Crohn's disease

Abdo pain
Loss of appetite
Weight loss
Diarrhoea
Passage of blood / mucus rectally

4

Most common cause of painless rectal bleeding

Haemorrhoids

5

Syx of an anal fissure

Streaks of blood on toilet paper
Pain on defecation

6

What is cholestyramine and what is it used for?

Bile acid sequestrant
Used in primary biliary cirrhosis

7

What is goodpastures syndrome

Anti-glomerular basement antibody disease
Leading to glomerulonephritis and lung haemorrhage

8

What is primary sclerosing cholangitis

Disease of bile ducts.
Progressive inflammation and fibrosis of intra and extra-hepatic bike ducts.

9

Symptoms of primary sclerosing cholangitis

Fatigue
Jaundice
Pruritus
Malabsorption + steatorrhoea
Dark urine
RUQ pain (hepatomegally)
Weightloss
Fever / rigors

10

Diagnosis of primary sclerosing cholangitis

Raised bilirubin
Raised alkaline phosphatase / GGT
Endoscopic retrograde cholangiopancreatography
80% have p-ANCA

11

What is Primary biliary cirrhosis

Chronic inflammatory liver disease
Progressive destruction of intrahepatic bile ducts
Probably autoimmune

12

Symptoms of Primary biliary cirrhosis

Pruritus
Fatigue
Weightloss
Arthralgia
Jaundice
RUQ pain (hepatomegally)
Xanthelasma
Hyperpigmentation

13

What is biliary colic

Severe RUQ/epigastic pain - radiate to scapula
Related to cholecystitis and gallstones
Lasts several hours
May be precipitated by fatty meal
+/- n+v

14

What is cholangitis

Infection of the common bile duct

15

What is Wilson's disease

Autosomal recessive condition leading to reduced biliary excretion of copper
Accumulates in liver and brain

16

Management of Wilson's disease

Penicillamine = chelating agent

17

Symptoms of Wilson's disease

Liver infiltration --> jaundice, easy bruising, variceal bleeding, encephalopathy
Neuro --> dyskinesia, rigidity, tremor, dysarthria, dementia, ataxia
Psych syx

18

Signs of hepatocellular carcinoma

Weightloss
Lymphadenopathy
Nodular hepatomegally
Jaundice
Ascites
(Liver bruit)

19

Signs of alcohol excess

Malnourished
Palmar erythema
Dupuytrens contracture
Facial telangiectasia
Parotid enlargement
Spider naevi
Gynaecomastia
Testicular atrophy
Hepatomegally
Easy bruising

20

Symptoms of alcoholic hepatitis?

Mild illness
Nausea
Malaise
Epigastric or R hypochondrium pain
Low-grade fever
Jaundice
Ascites
Peripheral oedema
GI bleed

21

When do Kayser fleischer rings occur?

Wilsons disease

22

Clinical features of pancreatitis?

Epigastric pain radiating to the back
Nausea and vomiting
Previous episodes
Known gallstones
(Tachycardia, Hypotension)

23

Standard diagnostic test for pancreatitis?

Serum amylase

24

What is courvoisiers law?

In painless jaundice palpable gallbladder is unlikely to be gallstones

25

What is a choledocholithiasis

Gallstone in the common bile duct

26

Risk factors for hepatocellular carcinoma?

Increasing age
Male
Hepatitis B
Cirrhosis

27

Risk factors for developing acute cholangitis

Choledocholithiasis
Biliary stricture
Tumours
ERCP

28

Treatment of acute cholangitis

Antibiotic
Remove cause

29

What is Charcots triad

Fever, jaundice and abdominal pain
Associated with acute cholangitis

30

What is the acute cholangitis

Bacterial infection in conjugation with obstruction of the biliary tree
Commonly due to gallstones

31

Symptoms of acute cholangitis?

Epigastric pain
Right upper quadrant pain
Vomiting
Fever
Peritonism

32

What is Gilbert's syndrome?

Raised unconjugated bilirubin
More marked in fasting or illness
Autosomal recessive

No long-term sequelae

33

Features of an amoebic liver abscess

Entamoeba histoltica
90% Are solitary
Commonly involves right liver lobe
Treated by aspiration

34

Types of pancreatic Cancer

80% = adenocarcinoma
Rest = adenosqamous And mucinous cystadenocarcinoma

75% in head/neck of pancreas
15% in body
10% in tail

35

Symptoms of pancreatic cancer

Anorexia
Weight loss
Malaise

Later jaundice and epigastric pain

36

Symptoms of acute pancreatitis

Severe epigastric pain radiating to the back
Relieved by sitting forward
Worse on movement
Anorexia
Nausea and vomiting

37

What is Cullens sign?

Discolouration around the umbilicus inpatients with acute pancreatitis

38

What is grey-turners sign?

Bruising of the flanks
Can occur in a severe attack of acute pancreatitis

39

Features of amoebiasis

Pain
Bloody diarrhoea.
Flask-shaped ulcers on colon
PAS +ve trophozites + ingested RBC

40

Features of congenital toxoplasmosis

Jaundice
Hepatomegally
Hydrocephalus
Choroidoretinitis
necrosis of brain, liver, heart, lung, retina

41

Features of toxoplasmosis in adults

Sub clinical infection
Mild lymphadenopathy

42

Weightloss plus anaemia in a patient with a change in bowel habit and PR bleeding suggests what?

Colorectal carcinoma

43

Paroxysmal Flushing, wheezing, abdominal pain, diarrhoea and bronchospasm suggests what?

Carcinoid syndrome

44

What is a Hartman's procedure?

Primary resection of a lesion leaving a temporary colostomy and oversewing the rectum.
For later re-anastomosis.
Emergency procedure.

45

Complications of stomas

Fluid loss
Odour
Skin ulceration
Leaking
Stenosis
Herniation
Prolapse
Ischaemia
Psychosocial / sexual

46

Where do haustrae occur

Large bowel
Not full width

47

Where do valvulae coniventes occur?

Small bowel
Complete width

48

Symptoms of intestinal obstruction

Pain
Vomiting
Distension
Absolute constipation - no flatus or faeces

49

Causes of bowel obstruction

Adhesions
Hernias
Tumours
Gall stone ileus
Sigmoid or caecal volvulus

50

Features of spontaneous bacterial peritonitis in a patient with ascites

Generalised abdominal pain
Worsening ascites
Vomiting
Fever
Rigor

51

Most common causative organisms in spontaneous bacterial peritonitis

E. coli
Klebsiella

52

Portal hypertension causes varices where

Oesophagus
Rectum
Umbilical veins

53

Management of Oesophageal variceal bleeding

Therapeutic endoscopy
Banding or sclerosis of varices

If unresponsive haemostasis is achieved with balloon tamponade
= sengstaken-blakemore tube

54

Secondary prophylactic measures to reduce the risk of variceal rebleeding

Elective endoscopic variceal banding/sclerotherapy
Propranolol to reduce portal Venous pressure

55

Clinical features of hepatic encephalopathy

Reversed sleep pattern
Asterixis
Constructional apraxia
Agitation
Reduced consciousness
Coma
Death

56

Precipitants of hepatic encephalopathy

High protein diet
Upper GI bleeding
Hypokalaemia
Alcohol
Benzodiazepines
Diuretics

57

Treatment of hepatic encephalopathy

Correct underlying cause
Low protein diet
nurse patient in light room
Lactulose (osmotic laxative)

58

What is hepatorenal syndrome

Acute renal failure despite normal kidneys in a patient with cirrhosis and portal hypertension

59

What is the odynophagia

Pain on Swallowing

60

Symptoms of GORD

Heartburn
regurgitation
dysphagia
(Atypical symptoms= Retrosternal chest pain, hoarseness, hiccups, ear pain, loss of dental enamel, night sweats, chronic wheeze, globus sensation, hypersalivation, halitosis)

61

Complications GORD

Oesophageal inflammation
Erosions
Ulceration
Stricture
Metaplasia of lower oesophagus (Barrett's oesophagus)

62

Management GORD

Lifestyle - Weight loss, smoking cessation, avoid late night meals, avoid spicy food, elevate head of bed
Medical - Ranitidine (H2 antagonist), omeprazole (PPI), metoclopramide (Prokinetic)
Surgical - fundoplication

63

Most common causes of small-bowel obstruction

Post-op adhesions
Incarcerated hernia
Malignancy
Less common (diverticulitis, gallstone ileus, IBD)

64

What is familial adenomatous polyposis

Autosomal dominant
Hundreds of adenomatous polyps in early adulthood
Malignant transformation by age 50

65

What causes pseudomembranous colitis

Overgrowth of clostridium difficile
Most occurs following antibiotic use
Treatment is oral Metronidazole

66

Complications of diverticular disease

Diverticulitis
Abscess formation
Fistula
Bleeding
Perforation

67

Features of anorectal abscesses

Constant throbbing pain
Discharge of pus per rectum
Rectal lump/nodule

68

What type of stoma has a spout

Ileostomy

69

What is an end colostomy and when is it used

End colostomy is required after abdomino-perineal resection of a low rectal or anal canal tumour.
It has a single opening.
Usually found in the left iliac fossa - contents will be solid.

70

What is a Hartman's procedure and when is it used

Hartman's procedure is done after emergency resection of rectosigmoid lesions
When primary anastomosis is unfavourable.
The diseased segment is resected, the proximal end of bowel is made into an end colostomy.
The distal segment of bowel / rectal stump, is oversewn to remain closed.
Secretions from the rectal stump still pass through the anus.
Later once inflammation settled the two ends are rejoined.

71

How can you tell the difference between Hartman's procedure and an AP resection

Digital rectal examination - AP. procedure leave no rectum

72

What is an end Ileostomy and when is it used

End ileostomy is an end stoma using distal ileum.
Often created after resection of the colon and rectum, e.g for IBD.

Ileostomies usually found in RIF
Contents will be liquid.

Once outside abdominal wall - small bowel is everted to create a spout to protect the abdominal wall skin from the irritation.

73

What is a defunctioning ileostomy and why is it used

Defunctioning ileostomy is a temporary stomas created to protect distal anastomosis at risk of leakage or breakdown.
Allows bowel time to rest.

Commonly used in difficult low rectal anastomoses and in emergency resections.

Reversal of the temporary stoma at about 3-4 months.

74

What is a loop stoma and when is it used

Temporary stomas are usually loop stomas.
E.g. Defunctioning stomas

A loop of bowel is brought to the surface.
The loop is supported by a 'bridge' beneath it (between bowel and skin) to prevent the loop slipping back in.
The bridge is removed after a few days once wound healed.

Bowel wall is partially cut to create two openings: an afferent limb and an efferent limb.
The afferent limb leads to the functioning part of the bowel and allows stool and gas to pass out.
The efferent limb leads into the non-functioning part of bowel and secretes mucus. This is the mucous stoma.

75

What is a urostomy and when is it used?

Urostomies are used for diversion of the urinary system.

Used for bladder cancers, urinary incontinence not anemable to other treatments, and neuropathic bladders.

Requires an ileal conduit = a segment of ileum open at 1 end + closed at the other.
Ureters are implanted into this.
The open end is used to create a spout similar to an ileostomy

It allows urine collection in a stoma bag.

76

Classic presentation of acute pancreatitis

Epigastric pain
Radiating to the back
Hx of gallstones, alcohol

77

Causes of raised serum amylase in an acute abdomen

Acute pancreatitis
Perforation
Cholecystitis

78

What is murphy's sign

Place hand on RUQ and ask patient to breathe in. Causes pain as gallbladder contacts hand. --> arrest of inspiration.
Repeat on LUQ.
+ve = pain on RUQ palpation and not on L.
Indicates acute cholecystitis

79

Presentation of small bowel obstruction

Early onset vomiting - bilious not faceculant
Late onset distension
Abdominal pain - colicky

80

Presentation of large bowel obstruction

Early onset distension
Late onset vomiting - faeculant
Abdominal pain - colicky

81

Presentation of a duodenal ulcer

Epigastic pain relieved by eating or milk
Worse at night

82

Presentation of a gastric ulcer

Epigastric pain worse on eating

83

RF for duodenal ulceration

H. Pylori
Chronic NSAID use

84

Classic presentation of appendicitis

Central colicky abdominal pain
Shifts to RIF once peritoneum inflamed
Rebound tenderness

85

Is it crohn's or UC that is transmural

Crohn's

86

Crohn's can occur anywhere from mouth to anus but which area does it favour

Terminal ileum

87

Surgical repair of a AAA is indicated at what diameter?

>5.5cm

88

Presentation of gastric carcinoma

Persistent dyspepsia
Mass above L clavicle
Weight loss
Fatigue (anaemia)
Ascites if advanced

89

Right sided colon cancers (caecum / ascending colon) commonly present with...

Weight loss
Anaemia
RIF mass

90

Left sided colon cancers (sigmoid / rectum) commonly present with...

Change in bowel habit
PR bleeding

91

In a patient >40yo presenting with features of acute appendicitis it is important to consider the diagnosis of....

Caecal carcinoma

92

Features of a pancreatic pseudocyst

Abdominal discomfort
Nausea
Early satiety

Usually due to acute or chronic pancreatitis

110

Causes of a hard liver edge

Liver metastasis
Hepatocellular carcinoma
Conditions causing macronodular cirrhosis (Viral hepatitis B or C. Wilson's disease. Alpha-1-antitrypsin deficiency)

111

Presentation of haemochromatosis

Lethargy
Arthralgia
Features of chronic liver disease
Bronze diabetes
(Dilated cardiomyopathy)

112

Classical patient with haemochromatosis

Male
Middle aged

113

Inheritance of haemochromatosis

Type 1 = autosomal recessive
Mutation of HFE gene
Disorder of iron metabolism

114

Signs of chronic liver disease

Spider naevi
Gynaecomastia
Testicular atrophy
Clubbing
Leuconychia
Dupuytrens contracture
Palmar erythema
Parotid enlargement

115

What is a green-ish brown ring at the corneo-scleral junction best seen with a slit lamp called. And when does it occur

Kaiser-fleischer ring
Pathognomonic of Wilson's disease

116

Management of Wilson's disease

Long term penicillamine
(Copper-chelating agent)

117

When is alkaline phosphatase raised

Biliary tract diseases

118

When is serum bilirubin raised

Hepatic and post hepatic disease

119

When are alanine transaminase and aspartate transaminase raised

Hepatocellular disease

120

When is alkaline phosphatase raised

Biliary tract diseases

121

When is serum bilirubin raised

Hepatic and post hepatic disease

122

When are alanine transaminase and aspartate transaminase raised

Hepatocellular disease

123

Features of crigler-Najjar syndrome

Congenital hyperbillirubinaemia
Unconjugated jaundice
Causes severe brain damage in early years

124

Intermittent RUQ pain exacerbated by fatty foods is likely to be due to...

Biliary tract obstruction
Commonly due to gallstones

125

Diagnostic test for Wilson's disease

Ceruloplasmin level (low)

126

Diagnostic test for hereditary haemochromatosis

Raised ferritin
Reduced total iron binding capacity

127

What antibody is commonly found in primary biliary cirrhosis?

Antimitochondrial antibody

128

Diagnostic tests for primary biliary cirrhosis

+ve for anti-mitochondrial antibody
Hepatic USS
ERCP

129

Management of primary biliary cirrhosis

Symptomatic relief
Cholestyramine to treat pruritus
ursodeoxycholic acid for ascites and jaundice

Liver transplant (or death within 2 years of jaundice onset)

130

What may precipitate episodes of carcinoid syndrome

Stress
Caffeine
Alcohol

131

Management of proctitis in UC

Steroid foam enema
Mesalazine suppositories

132

Management of UC

- Aminosalicylates: - Mesalazine (= 1st line for induction + maintenance of remission in mild cases - topical then oral), olsalazine, balsalazide, sulfasalazine (more SE)
-Corticosteroids: induce remission in relapses. No role in maintenance. Topical - suppository, liquid, foam enema. Oral or iv.
- Thiopurines: - Azathioprine (if intolerant of steroids).
- Ciclosporin: salvage therapy - severe refractory colitis.
- Infliximab: effective in inducing remission in refractory to conventional treatment
- Stool bulking agents: - distal transit is rapid but proximal transit is slowed --> proximal constipation.

133

Causes of pancreatitis

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion / snake
Hyperlipidaemia / hypercalcaemia / hypothyroidism
ERCP / embolism
Drugs (azathioprine, steroids, Thiazide diuretic, COCP)

Pregnancy

134

What causes pain in pancreatitis

Autodigestion of the pancreas by trypsin.
Fat necrosis by lipases

135

Presentation of acute pancreatitis

Acute onset epigastric pain
Radiates to the back
Severe and constant
Relieved by sitting forwards
Nausea and vomiting
Fever
+/- Shock
+/- Peritionitis

136

Intermittent RUQ pain exacerbated by fatty foods is likely to be due to...

Biliary tract obstruction
Commonly due to gallstones

142

What x-ray feature may suggest acute pancreatitis

Sentinel loop of small bowel on a-Xr

Due to localised ileus

144

Symptoms of irritable bowel syndrome

Abdominal pain - relieved by defection
Bloating
Change in bowel habit
(Diagnosis of exclusion)

145

What are gallstones made of

<10%-pure pigment (Bilirubin breakdown products)
75% - Cholesterol
15% - Mixed

146

What percent of gallstones are radiopaque

10%

147

Predisposing factors to gallstone formation

Female
obesity
Haemolytic anaemia
Hyperlipidaemia
Crohn's
(Lithogenic bike - innate tendency to form stones)

148

Complications of gallstones

Chronic cholecystitis
Biliary colic
Acute cholecystitis (empyema/biliary peritonitis/abscess)
Mucocele
Gallbladder carcinoma
Obstruction of the common bile duct --> jaundice
Cholangitis
Pancreatitis
Gallstone ileus

149

Features of mesenteric ischaemia

Severe central abdominal pain that occurs soon after eating

153

Causes of pre-hepatic jaundice

Increased bile production- Haemolysis
- hereditary spherocytosis
- haemolytic transfusion reactions
- thalassaemia
- pernicious anaemia

Gilbert's syndrome (underactive conjugating enzyme)
Crigler-Najjar syndrome (rare autosomal recessive disorder of bilirubin metabolism)

154

Features of peutz-jeghers syndrome

Multiple blue-black Freckles around the lips nose oral mucosa and fingers.
GI hamartomatous polyps (benign)
Polyps predispose to GI bleeding and intussusception

155

Syx of diverticulitis

Central domino pain, localises to LIF
Vomiting
Diarrhoea
Fever
Local guarding
Leucocytosis
Risk of perforation or fistula formation

156

Hepatic causes of jaundice

- Viral hepatitis - A / B / leptospirosis / brucellosis / Coxiella burnetii/ glandular fever
- Alcoholic hepatitis.
- Autoimmune hepatitis
- Drug-induced hepatitis: paracetamol, rifampicin, isoniazid, allopurinol, amitryptilline, amiodarone, phenytoin
- Hepatotoxic chemicals: phosphorous, carbon tetrachloride, phenol.
- Decompensated cirrhosis.

157

Is hepatic jaundice Unconjugated or conjugated

Mixed

158

What is the mechanism behind hepatic jaundice?

Impaired bile conjugation and excretion

164

Isolated hyperbilirubinaemia in an asymptomatic patient indicates what

Gilbert's syndrome

165

What is achalasia
+ features

Progressive failure of relaxation of the lower oesophagus. Degeneration of the ganglia.
Dilated, tortuous, hypertrophy of the oesophagus.
Barium swallow shows a dilated tapering oesophagus

166

What is Zollinger-Ellison syndrome

Peptic ulceration secondary to gastric secreting adenoma (gastrinoma) in pancreas, stomach or small bowel.

167

What is glossitis + what causes it

Smooth, red, swollen, painful tongue

Iron deficiency
Folate deficiency
B12 deficiency

168

What is a meckels diverticulum

Embryological remnant
Variable length
Usually ~5cm from the ileo-caecal valve

169

Symptoms of a meckels diverticulum

Asymptomatic
Haemorrhage
Intestinal obstruction
Diverticulitis
Perforation

170

What is diverticulosis

Presence of diverticulae
Without symptoms

171

What is Diverticular disease

diverticula with symptoms
E.g. Haemorrhage / infection / fistulae

172

What is Diverticulitis

Evidence of diverticular inflammation
Lower quadrant pain h
- fever, tachycardia

173

Management of rectal prolapse

If partial - excise redundant prolapsed mucosa
If complete (involves muscle) - surgical lifting of prolapse. E.g. De lormes procedure

174

What is goodsalls rule?

Anterior anal fistulae track directly into the anal track - straight line.
Posterior anal fistulae track around and open in the posterior midline = curved line

175

Managment of an anal fistula

If not through the puborectalis muscle - lay open the fistula track.
If it goes through the puborectalis muscle you shouldn't lay it open as this damages the muscle + causes incontinence - insert a seton (non absorbable) and tie - gradually cuts through the muscle and allows it to heal by scarring

176

What is chaga's disease + it's symptoms

Parasitic disease from S America.
Skin nodule @ site of inoculation
Fever, anorexia, lymphadenopathy
Long time later - dysphagia + cardiomyopathy

177

Where and what age are diverticula most common

Descending and sigmoid colon
Elderly.
Rare before 40

178

Long term complications post gastrectomy

Gastrectomy syndrome - rapid gastric emptying
B12 deficiency
Iron deficiency
Osteoporosis (reduced calcium absorption)

179

Investigation of blood in stool

digital rectal examination
Proctoscopy / sigmoidoscopy
FBC
Clotting studies
LFTs if liver disease is suspected
Colonoscopy

180

When to refer suspected bowel cancer

2 week wait for:
- Rectal bleeding plus change of bowel habit for six weeks and are aged 40 years or older.
- Palpable rectal or right-sided lower abdominal mass.
- Iron-deficiency anaemia without any obvious cause
Refer patients aged over 60 under 2 week rule if:
- Rectal bleeding without anal symptoms for six weeks.
- Change in bowel habit for six weeks without rectal bleeding.