GI Flashcards
What is the most common micro organism is amoebic liver abscess?
Entamoeba histolytica
What happens in ascites?
Fluid leaks out of capillaries due to build up of pressure in the portal vein so fluid leaks out into abdominal cavity, increasing chance on infection.
What does the secretion of TGF do in cirrhosis?
Further stimulates stellate cells for a cascade of myofibroblasts proliferation which eventually produce matrix causing fibrosis.
What are the two types of gallstone?
Cholesterol and Bile pigment stones
How would IBD investigations differentiate between UC and Crohns?
Serology shows Crohns pANCA negative and UC is pANCA positive. Colonoscopy would show the different ulceration.
What is the treatment of a fistula in ano?
Drainage, antibiotics, fistulotomy and excision. May need a seton suture to maintain continence.
What causes refractory ascites?
Occurs secondary to metastatic malignancy caused by peritoneal infiltration by tumour, liver metastases and lymphatic obstruction, heart failure, advanced liver disease
What is treatment for hydatid abscess?
Albendazole and percuatnous aspiration, injection of scolicidal agent and re aspirate. (PAIR), surgery.
What is a 1st degree haemorrhoid and its treatment?
It remains in the rectum an treated with fluids, fibre, stool softener and topical analgesic.
What happens in hepatic pulmonary syndrome?
Endothelin 1 is secreted and binds to capillary cells and cause NO secretion for vasodilation, so not all will be replenished by o2 due to increase pressure, leucocytes also migrate to pulmonary capillaries to further stimulate NO secretion, causing insufficient o2 supply throughout the body, causing difficulty breathing
What causes an abscess?
Gut organisms, mainly in women, in the perianal area.
What are the ulcer management risk scales?
Pre endoscopy - Rockall score / Glasgow Blatchord Post endoscopy - Forest scale
What is extracorporeal shock wave uthotripsy?
A shock wave directed radio-logically or by US onto gallstones.
What are the causes of peritonitis?
blood borne or genital tract organisms, cirrhosis with ascites, ruptured appendicitis or diverticulitis, IBD, perforation, pancreatitis, surgery, spontaneous, PID, TB
What is midgut dysmotility and its symptoms?
Disordered motility and visceral sensation after the SI, causing abdominal pain from eating which is not relieved by opening the bowels, abdominal distension, postprandial fullness, nausea, anorexia, weight loss
Treatment of gastritis?
H. pylori - PPI, amoxicillin and clarithromycin, metronidazole Antacids or H2 receptor antagonists, PPI, Ranitidine
What main bacteria can cause infective diarrhoea?
salmonella (reptiles), shigella, campylobacter (puppies), Yersinia, E.coli, C.diff (antibiotics, in hospitals, community acquired, antimicrobials), mycobacterium avium complex (watery)
Symptoms of acute pancreatitis?
epigastric pain radiating to the back, nausea, vomiting, peri-umbilical and flank bruising
What symptoms are specific to amoebic liver abscess?
Diarrhoea, cough (anchovy paste suggesting broncho pleura fistula formation), history of travel to endemic areas in 5 month
What is an incisional hernia?
Weakness caused by a surgical repair that has not fully healed
What is used to detect scleroderma and what is the treatment?
Manometry or barium swallow, treat the reflux and the benign stricture.
How is fibrosis caused in liver cirrhosis?
Stellate cells and Kupffer cells are activated by cytokines and their receptors, reactive oxygen intermediates and paracrine and autocrine signals causing stellate cells to become swollen, lose retinoids, secrete cytokines (TNF-a, IL-6, IL-1B, TGF) and up regulate receptors for proliferative and fibrogenic cytokines via the CCL2 receptor e.g. PDGF and TGFB1.
What is diverticulitis and the symptoms?
When diverticulum in the intestines become inflamed from infection, LI pain, fever, constipation, diarrhoea, and decreased appetite. May be due to accumulation of pus from an abscess leading to perforation.
What is the treatment of Crohns disease?
Continued monitoring of complications, diet, TNF-a antagonists, methotrexate, colectomy, B12 and folate supplements, thrombosis prophylaxis, stop smoking, corticosteroids, antibiotics
What is an anal fissure and what is it caused by?
A tear in the sensitive skin liner lower anal canal, distal to the dentate line, causing pain on defecation. Caused by hard faeces or secondary to Crohn’s or ulcerative colitis. Spasm could also constrict the inferior rectal artery causing ischemia, making it difficult to heal.
Symptoms of ischaemic colitis?
Sudden abdominal pain, passage of bright red blood, shock, distended and tender abdomen, thumb printing seen a splenic flexure on x-ray
Symptoms of gastritis?
functional dyspepsia, red mucosa, epigastric pain, vomiting, haematemesis
What does Ranson’s criteria measure on admission of acute pancreatitis?
glucose, AST, LDH, Age, WBC
What are the investigations and results for peptic ulcer?
H.pylori test is a 13C urea breath test, stool antigen test, serological test and biopsy urease test. If younger than 55yrs and is H.pylori positive due to the tagged CO2 being present, start treatment immediately. If older than 55, may need endoscopic diagnosis and cancer exclusion.
What is ulcerative colitis called if it reaches the transverse colon?
Extensive colitis (20%)
What happens in hepatorenal syndrome?
No damage to kidney, but reduced kidney perfusion due to insufficient blood supply to kidneys from portal hypertension
What causes a peptic ulcer?
Can be caused by H.pylori infection, NSAIDs or corticosteroids as they reduce mucosal protection and cause mucosal ischaemia. This causes the mucosa to appear inflamed and friable with a fibrous base and increase in inflammatory cells. (rarer causes are hyperparathyroidism, Zollinger Ellison syndrome, vascular insufficiency, sarcoidosis and Crohn’s disease.)
Treatment of diffuse oesophageal spasm?
PPIs for reflux e.g. omeprazole, antispasmodics, nitrates, CCBs, GABA receptor agonists e.g. baclofen. Balloon dilation of longitudinal oesophageal myotmy.
What is the treatment for chronic pancreatitis?
Stop smoking, no alcohol, avoid high fat foods, analgesics, insulin therapy for diabetes, membrane stabalising agents e.g. pregabalin, duct drainage, pancreatic enzyme replacement therapy (PERT), multivitamin supplements, tricyclic antidepressants
What would liver biochemistry show in cirrhosis?
As severity increases, PT and creatinine increase and sodium decreases due to defect in free water clearance. Increase in ALP and aminotransferase. Look for viral markers, seum autoantibodies, immunoglobulins, iron, ferritin, coper, a, antitrypsin.
What causes varices?
Liver cirrhosis
Symptoms of varice?
Massive upper GI bleed (much more than Mallory Weiss tear)
Features of C.diff which make it suitable for infection?
Gram positive with terminal bulge due to spore, some hyper virulent strains e.g. ribotype 027, glucosyltransferases that target Rho family GTPases blocking their activation, toxin and b induce actin depolymerisation and cytoskeletal arrangement effecting epithelial tight junctions and permeability, spores allow persistence in environment, ingested by faeces-oral route, germinate in colon on exposure to bile salts
What would investigations show in IBD?
increased WBC, platelets, ESR, CRP, stools and c.diff toxin test to exclude infection, US shows inflammations and free fluid in abdominal wall
Which hiatus hernia is more painful?
Rolling due to volvulus and strangulation formed, so must be treated surgically.
Why dose liver cirrhosis cause itching?
Due to high levels of uric acid that can’t be cleared by the liver?
DD for diarrhoea?
Malaria, sepsis, IBD, IBS, mal absorption (coeliac), malignancy, overflow with constipation, medicine (PI as antivirals), throtoxicosis
What is acute cholangitis?
A bile duct duct infection mostly from gall stone obstruction, causing biliary sepsis and septicaemia
What is the treatment of primary biliary cirrhosis?
Ursodeoxycolic acid which improves bilirubin and ATL. Cholestyramine to control pruritus. Steroids improve biochemical and histological disease Fat soluble vitamin supplements Bisphosphonates for osteoporosis Rifampicin and naloxone hydrochloride for opioid antagonists Liver transplant.
What is a 4th degree haemorrhoid and its treatment?
It remains persistently prolapsed. Treated with excisional haemorrhoidectomy or a stapled haemohhoidopexy.
What causes hydatid liver abscess?
Food or water contaminated with dog faeces causing a multi-layered cyst with daughter cysts tat can calcify
What is acute pancreatitis?
inflammation of the pancreatic gland and parenchyma due to acute injury
What are the 3 types of liver abscess?
Pyogenic, amoebic and hydatid
Signs and symptoms of IBD?
diarrhoea, rectal bleeding, abdominal pain, tenesmus, weight loss, fever, vomiting, cramps, muscle spasms
Signs and symptoms of liver cirrhosis?
Astrexis (hepatic flap), parotid gland swelling, spider naevi, jaundice, gynocomastia, hepatomegaly, splenomegaly, ascites, caput medusa, testicular atrophy, nail changes, clubbing, pulmonary empyema, hypertrophic osteoarthropathy
What are the symptoms of chronic
epigastric pain radiating to back, relieved on sitting forward and worse when eating and heavy drinking, weight loss, mal absorption, diabetes, jaundice, oily foul smelling stools
Chronic pancreatitis causes malnutrition, what are some complication of this?
osteoporosis, vision loss, difficulty maintaining weight
What are the two types of hiatus hernia?
Sliding (95%) and rolling
What causes a rectal prolapse and how?
Straining excessively and constipation leading to ulceration of anterior rectal wall so that it bleeds and produces mucus on defaecation.
How are cholesterol stones formed?
By cholesterol crystallization, when there is an excess of cholesterol in the bile duct as there is reduced bile salt and phospho lipids which normally keep cholesterol soluble to form micelles and vesicles
Epidemiology of IBD?
Crohns is more common than UC, and females are more likely to get Crohns, whereas both are equally predisposed in UC. Onset occurs usually around 15-40 years.
What is primary biliary cirrhosis?
An autoimmune illness where T cells are destroying the bile ducts leading to impaired bile formation and impaired bile secretion causing cholestasis causing retained toxic material leading to cirrhosis
What is the treatment for diverticulosis?
Increased fibre, stool softeners
What is a fistula in ano?
Blockage of deep intramuscular gland ducts between the skin and the anal /rectal canal causing a abscess with discharge.
What is gastritis?
Inflammation of the stomach lining due to decreased prostaglandin production causing mucosal damage.
Complications of ulcerative colitis?
severe bleeding, toxic megacolon, rupture of bowel, colon cancer, osteoporosis, haemorrhage, primary sclerosing cholangitis
What is peritonitis?
Inflammation of the peritoneum and endothelial lining of the abdominal cavity and can be localised or generalised.
How does a rolling hiatus hernia occur?
Part of the fundus prolapses through the hiatus, alongside the oesophagus so the sphincter remains competent and below the diaphragm
What does Achalasia cause dysphagia for from onset and what other symptoms occur?
Solids and liquids. and regurgitation of food from dilated oesophagus, mainly at night, with spontaneous chest pains due to oesophageal spasm.
What does TNF-a do in cirrhosis?
Attract more neutrophils and T cells for inflammation causing necrosis and fibrosis.
What are factors influencing IBD?
antimicrobial peptide problems, autophagy, handling of bacteria, cytokines, diet, infection, stress, NSAIDs, smoking, antibiotics
What is a toxin mediated cause of infective diarrhoea?
Shiga toxin (bloody), B cereus and S aureus
What do clonochis sinensis and opisthorchis spp. cause?
relapsing cholangitis and cholangiocarcinoma
What happens in hepatic carcinoma and the symptoms?
Causes pain, sweating, hepatomegaly and weight loss. Cell apoptosis and uncontrolled multiplication of liver cells.
What are probiotics?
Live or attenuated bacteria or bacterial products for a significant health benefit in the host e.g. bifidobacterium infancts 35624
What is the difference between a micro and macro nodular in the liver and in what diseases would you see them?
Micro -
What is an appendicitis and what does if present with?
Inflammation of the appendix, causing umbilical pain, migrating to the right iliac fossa and tenderness with guarding, nausea, vomiting, anorexia and diarrhoea
What are the symptoms of peritonitis?
Generalised acute abdominal pain that can become localised, abdominal tenderness and muscle guarding, fever, decreased peristalsis, abdominal distension, pyrexia, chills, dizziness, inability to pass stool, nausea, anorexia, vomiting, sinus tachycardia, lie still with shallow breaths
Describe stage 1-4 of ascites
1 - detectable after careful examination/US 2 - easily detectable but of relatively small volume 3 - obvious but not tense 4 - tense and large
What is toxic megacolon?
dilated thin walled colon with >6cm diameter, gas filled and contains mucosal islands, risk or perforation and mortality
Complications of cirrhosis?
Increase in pressure from portal hypertension causes ascites, hepatic encelopathy, variceal haemorrhage, bacterial peritonitis, hepatic renal syndrome, portal hypertension gastropathy, hepatic hydrothorax, hepatopulmonary syndrome, portopulmonary hypertension, cirrhotic cardiomyopathy.
What is the treatment of an appendicitis?
laparoscopic surgery, IV fluids, antibiotics if mass, interval appendictectomy prevents further acute episodes
What causes intra hepatic portal hypertension and what investigation is needed?
Can be mild fibrosis if non cirrhotic portal hypertension or schistomsomiasis with extensive fibrosis or congenital hepatic fibrosis or nodular regenerative hyperplasia. Need a wedge liver biopsy.
What is a complication of biliary colic if it is not treated?
Acute pancreatitis
Complication of TIPS and variceal banding?
hepatic encephalopathy
Complications of primary biliary cirrhosis?
cirrhosis, osteoporosis, osteomalacia, polyneuropathy
What is the difference in histology between acute and chronic gastritis?
Acute has neutrophil infiltration and chronic has mononuclear cells, chiefly lymphocytes, plasma cells and macrophages.
Complications of gastritis?
Gastric outlet obstruction, pernicious anaemia, peptic ulcers, stricture formation, mucosa associated lymphoid tissue (MALT) lyphoma
What is Achalasia and how is it caused?
degeneration of the lower oesophageal sphincter and the nerves controlling the muscles causing impaired relaxation of the LOS, difficulty swallowing, chest pain and regurgitation of food. Thought to be caused by inflammation of myentreric plexus of the oesophagus with reduced ganglion cell number, reduced NO containing neurons and loss of inhibitory nitregic neurones.
What is biliary pain and what causes it?
Pain associated with temporary obstruction of the cystic duct and common bile duct, caused by a stone. Pain is in the RUQ and spreads to the right shoulder and scapula area.
What investigations would you conduct for liver cirrhosis?
Liver biopsy, liver function test, ultrasound, metabolic breath test (assesses functional reserve of the liver), hepatic venous pressure gradient, transient elastography (measure liver stiffness of fibrosis and oedema), CT shows hapatosplenomegaly and dilated collaterals, endoscopy detects varicies and portal hypertensive gasrtopathy
What is chronic cholecystitis, the signs and symptoms?
Chronic inflammation of the gall bladder wall associated with gallstones and IBD, causing flatulence, nausea, discomfort in right hypercondrium, fatty food intolerance and US shows small sunken gall bladder, Treat with cholecystectomy.
What is a common micro organism in peritonitis?
s.pneumoniae and other streptococci, staph aureus, E.coli, P.aeruginosa
What is portal hypertension?
Blockage of blood flow through the liver, causing a portal vein bypass, increasing portal vein pressure, resulting in backflow towards the gastro oesophageal vein and cause oesophageal-gastric varicies causing bleeding.
What is a pilonidal sinus?
An abscess near the anus caused by an obstructed hair follicle which has excited a foreign body reaction causing secondary tracks to open laterally forming foul smelling discharge.
What is shown in investigations for chronic pancreatitis?
raised serum amylase and lipase, decreases faecal elastase, mutations in genes, CT shows calcification, US and MRI, pancreatic stimulation test using secretin
What main viruses can cause infective diarrhoea?
Norovirus (contact with other cases) and rotavirus (small children), CMV (transplant)
What is the treatment of diverticulitis?
Drainage of abscess, surgery to remove affected colon segment (may need stoma), clear liquid diet, oral antibiotics (amoxicillin-clavulinic acid)
What is classed as diarrhoea?
6 loose bowel movements a day. More than 1 month is chronic. Less than 1 month means it could be infection.
What happens in the space of Disse in cirrhosis?
Collagen replaces the matrix and loss of endothelial fenestrations (openings) cause impairment of liver function. Increase in tissue inhibitors of metalloproteinases cause inhibition of collagen degradation.
What is the function of mucus in the stomach?
Acts as a barrier to acid
What are systemic complications of IBD?
conjunctivitis, iritis, mouth ulcer, fatty liver, liver abscess, thrombosis, large joint arthritis, erythema nodosum and pyodema gangrenosum due to cytokine release
How do gallstones cause acute pancreatitis?
They block the ampulla drainage, causing ductular hypertension and increase in ca2+, causing early activation of trypsinogen
How can bacteria get into the liver in pyogenic abscess?
Via portal vein (appendicitis, diverticulitis), biliary tract (cholangitis), hematogenous (bacteramia), trauma or infection of tumour/cyst
What do COX 1 enzymes do in the stomach?
Make prostaglandins in the mucosal lining of the stomach to protect it from the stomach
What are the main two types IBD and their main differentiation?
Crohns (discontinuous and patchy with skip lesions, transmura, granulomasl) and ulcerative colitis (continuous and restricted to the mucosa, moving distal to proximal with pseudopolyps, petichae exudates oedema, crypt abscesses, mucin depletion, goblet cell depletion)
What do investigations show in acute pancreatitis?
increased serum amylase and lipase, US and CT to look for cause, LFTs, FBC, MRI to assess pancreatic damage
DD for upper GI bleeds?
oesophageal varices, gastritis, peptic ulcers, malignancy, Mallory Weiss tear
What is gastropathy?
injury to gastric mucosa, associated with epithelial damage and regeneration with little of no accompanying inflammation
What is systemic sclerosis (scleroderma) and what does it cause?
Dimished peristalsis and oesophageal clearance caused by smooth muscle replacement with fibrous tissue. This decreases LOS pressure, causing reflux and mucosal damage, so deep strictures develop with dysphagia and heartburn.
What are parasitic causes of infective diarrhoea?
Giardia (well water), cryptosporidium (HIV or transplant or flooding), entamoeba (travellers)
Investigations in ascites?
serum ascites albumin gradient (SAAG), microscopy, diagnostic aspiration of ascitic fluid, cytology for malignant cells, amylase to exclude pancreatic ascites, neutrophil count, US and CT, protein count, sodium
Where are the most common places for ischaemic colitis to occur?
In watershed areas, in the splenic flexure and caecum
Complications of acute pancreatitis?
haemorrhage, DIC, ARDS, multi organ failure, necrosis
What is the treatment of an amoebic liver abscess?
Metronidazole and luminal agent, aspirate if large
What causes chronic pancreatitis?
CF, alcohol, malnourishment, pancreatic duct obstruction, genetic, autoimmune, smoking, elevated triglycerides, hereditary pancreatitis
What cause post hepatic portal hypertension?
Prolonged severe heart failure with tricuspid incompetence and constrictive pericarditis.
What does IL-8 do in the formation of peptic ulcers?
It is a cytokine that promotes inflammation
Treatment of acute cholangitis?
MRCP and ERCP for further assessment, biliary drainage and biopsy cultures. IV antibiotics (cefotaxime, metronidazole, amoxicillin, and gentamicin) and bile duct drainage with cholecystectomy, remove stones via balloon or basket catheter, if it can’t be removed, place a stent in the biliary tree. Mechanical lithotripsy.
Investigations for gastritis?
H.pylori urea breath test, endoscopy with biopsy of stomach lining, stool microscopy, urinalysis, blood, H.pylori antibody
What is a peptic ulcer?
A break in the superficial epithelial cells, penetrating down to the muscularis mucosa of the stomach or duodenum (mainly in duodenal cap or lesser curvature near incisura)
What is a Mallory-Weiss tear and what is it caused by?
A linear mucosal tear at the oesophageal junction caused by a sudden increase in intra abdominal pressure. Occurs after a bout of coughing, retching and after an alcohol dry heaves. It is the cause of 10% of upper GI bleeds.
Complications of ascites?
Spontaneous bacterial peritonitis e.g. E.coli, treat with antibiotics and liver transplant
What is the treatment of ulcerative colitis in a flare up?
5-AminoSalicylicAcid therapy e.g. sulfasalazine if mild, IV fluids, IV corticosteroids to reduce flare, IV antibiotics if all unresponsive
What are causes of acute pancreatitis and how?
Gallstones, alcohol (trauma, mumps, autoimmune disease, drugs, hyperlipidaemia, steroids) - an acute increase in pancreas intracellular calcium ions, causing an early activation of trypsinogen to trypsin and an impairment of trypsin degradation by chymotrypsin C, leading to cellular necrosis and haemorrhage.
Treatment of peptic ulcer if H.pylori negative?
PPIs to stop excess gastric secretion, stop the initiating factors, use selective COX2 inhibitors instead of NSAIDs in future to prevent recurrence, follow up with endoscopy and biopsy. Surgery of vagotomy or partial gastrectomy if uncontrolled haemorrhage, antacids
How do you diagnose infective diarrhoea?
Stool culture (SSYC and Shiga toxin), ova and parasite, Cryptosporidium and Giardia antigen, C.diff toxin A and B PCR, faecal leukocytes (inflammation), BMP and electrolytes if dehydrated., CT scan, colonoscopy, biopsy
What is 5-ASA?
It treat UC and is activated by bacteria in the colon as it breaks down azo bonds to release 5-ASA. Released in the microsphere and acts via PPAR-Y signalling pathway to induce and retain remission and reduce inflammation.
Treatment of dyspepsia?
Stop smoking and alcohol, reduce weight around stomach and gaviscon in the day to reduce reflux. PPI before dinner and breakfast. Stop NSAIDs. Check for red flags (weight loss, dysphagia, mass, vomiting) for malignancy. Anti-reflux surgery. If functional (non ulcer) have diet review and antidepressants.
How do you diagnose primary biliary cirrhosis?
Positive anti mitochondrial antibody (AMA), positive antigen M2 and increased GGT and alkaline phosphatase, liver biopsy shows portal tract infiltration of lymphocytes and pasma cells and granulomas in zone 1, increased IgM as failure to switch to IgG, increased serum cholesterol, US shows diffuse alteration in liver architecture
What is acute cholecytitis and its symptoms and signs?
Severe pain in the RUQ following the impaction of a stone in the cystic duct or neck of gall bladder causing fever, raised WCC, abnormal liver biochemistry, focal tenderness, muscle guarding and thicken gall bladder wall
Treatment of anal prolapse?
Increase fluids and fibre, stool softeners, and if severe, surgical rejection rectopexy.
What microorganisms commonly causes biliary disease?
E.coli, K.pneumoniae, Bacterioides (anaerobes), Enterococci, clonorchis sinensis, opisthorchis spp., fasciola hepatica
What is the treatment of pruritus ani?
Enhanced toilet hygiene, capsaicin, no spicy food, anaesthetic cream keeping the area dry, avoid perfumed soaps and moisturised creams..
Signs and symptoms of acute cholangitis?
Causes RUQ pain radiating to LUQ and epigastrium, fever, jaundice (dark urine, pal stools, itchy skin), rigors and can be tachycardia during an attack. Increased WBC, leucocytosis, abnormal liver biochemistry, increased serum bilirubin and alkaline phosphatase. U/S shows dilated common bile duct and the cause of obstruction. ATL and PTT increased, decreased potassium absorption
Treatment of cirrhosis?
Avoid alcohol, aspirin, NSAIDs, reduce salt intake, adjust medications, manage symptoms e.g. cramps, hernias, treat complications, liver transplant.
What is a hiatus hernia?
Part of the stomach herniating through the oesophageal hiatus of the diaphragm caused by obesity and constipation
Treatment of a pilonidal sinus?
Excision of sinus tract with pre op antibiotics, complex tracts can be laid open and packed individually or skin flap can be used to cover the defect, keep clean, remove hair, drain pus.
DD for appendicitis pain?
IBD, inflamed Meckels diverticulum, acute salpingitis in women, terminal ileitis from Crohn’s, mesenteric lymphadenitis
Treatment of peptic ulcer if H.pylrori positive?
Eradicate H.pylori with antibiotics, to increase healing and reduce recurrence, anti-secretary treatment if haemorrhage or perforation, antacids
What part is mainly affected in ulcerative colitis?
inflammation of rectal and sigmoid colon in 50% (proctitis)
What is a problem with probiotics?
Quality control and formulation restrict the clinical availability.
DD for RI pain?
Appendicitis, ectopic pregnancy, ovarian torsion, inguinal or femoral hernia
What makes up brown pigment stones, where are they found and when?
Calcium, salts of fatty acids and calcium bilirubinate. Found in bile stasis and biliary infection and cause recurrent bile duct stones post cholecystectomy.
In the presence of abdominal pain, what constitutes functional diarrhoea?
Passage of several stools in rapid succession, usually first thing in the morning A formed first stool, later ones are more mushy and watery Urgency of defecation Anxiety about bowel movement Exhaustion after defecation
What causes a fistula in ano?
Perianal sepsis, abscesses, Chron’s disease, TB, diverticular disease, rectal carcinoma, immunocompromised
DD for RL pain?
kidney stones, UTI, constipation
What is diffuse oesophageal spasm and its symptoms?
Severe oesophageal dysmotility causing retrosternal chest pain and dysphagia, can accompany GORD. Can cause marked contractions on swallowing in oesophagus, but can be asymptomatic.
Epidemiology of DU?
in 10% of adults, 2.3x more common than GU, more common in elderly and developing countries.
What does Ranson’s criteria measure after 48 hours of acute pancreatitis?
calcium, Hct, paO2, BUN, base defecit, sequestration of fluids (CHOBBS)
What are potential complications of hernias?
strangulation, incarceration, fistula formation, femoral are irreducible
How dose a mechanical lithotripsy work?
it facilitates fragmentation by increasing bile salt content to solubilise stones, uses oral chendeoxycholic acid and ursodeoxycholic acid
What would Achalasia show on investigations?
CXR - dilated pesophagus, fluid behing heart and absent fundal gas shadow Manometry - aperistalsis of oesophagus and failure of lower sphincter relaxation Oesophagoscopy and CT scan exclude carcinoma Barium swallow - lack of peristalsis and synchronous contractions inn oesophagus body with dilatation. Lower end shows bird beak due to lack of relaxation.
Treatment of varice?
IV Octreotide inhibits vasodilation and decreased bloodflow. IV Terlipressin restricts portal inflow by splenic arterial constriction (CI if IHD), somatostatin is similar Endoscopic banding around large veins to cut off blood supply. Transjugular intrahepatic porto systemic shunting to create a bypass with a metal stent between portal and hepatic venous circulation to relieve hypertension. Balloon tamponade with sengstaken Blakemore tube to prevent blood flow to bleeding point Injection sclerotherapy produces vessel thrombosis Endoscopic haemostasis by dilute adrenaline injection with coagulation of vessel, thermal therapy and mechanical dips to the vessel.
DD for RUQ pain?
Pancreatitis, Gastric ulcer, gallstones, biliary colic, acute cholangitis, acute cholecystitis
Treatment of biliary colic?
Analgesia, rehydrate, elective laproscopic cholecystectomy, may need a MRCP before if the liver biochemistry is abnormal
What is the treatment of functional diarrhoea?
Loperamide and an tricyclic antidepressant e.g. clomipramine
What part is mainly affected in crohns?
caecum and ileum (40%) SI (30%) - has skip lesions
Symptoms of ascites?
painful abdominal distension, SOB, nausea, vomiting, loss of appetite, constipation, cachexia, weight loss, jaundice
What causes diverticulosis?
low fibre, constipation, straining with bowel movements due to increased pressure causing the mucosa and sub mucosa to herniate through the weakened part, forming a diverticulum
What are common micro organisms in a pyogenic liver abscess?
E.coli, K.pneumoniae, Streptococcus milleri, bacterioides spp.
What causes pre hepatic portal hypertension?
Blockage of the portal vein due to thrombosis caused by secondary congenital portal venous abnormality.
How does H.pylori cause a peptic ulcer?
It is adapted to live in gastric mucus (antrum) as it has urease which generates ammonium to buffer acidity and neutralise it so H.pylori can move down to the epithelial cells and adhere. It then excretes Cag A and Vac A, breaking down the tight junctions of epithelial cells and induces inflammation by mononuclear and neutrophil cellular infiltrate in lamina propria so the HCl acid layer can reach the epithelial cells and damage them causing an ulcer. This promotes gastric acid secretion and spread to the duodenum.
What is the treatment for midgut dysmotility?
avoid narcotics, FODMAP diet, SSRI paroxetine and smooth muscle relaxant
What are the symptoms of a liver abscess?
Fever, weight loss, nausea, vomiting, leucocytosis, RUQ pain radiating to right shoulder and scapula, jaundice (more severe than in cholencytitis, tender hepatomegaly
What makes up black pigment stones and in what kind of patient would you find them?
Calcium biliruibinate, mucin glycoproteins and calcium carbonate, in haemolytic patients
What causes calcification in chronic pancreatitis?
The prolonged intra pancreatic enzyme activity, leads to precipitation of proteins forming plugs and a nidus for calcification and ductal obstruction and hypertension
Epidemiology of primary biliary cirrhosis?
90% are female, aged 35-55years
If H.pylori decreases gastric acid in a patient, what does this suggest?
Gastric cancer
What is a varice?
Elevated pressure in the portal renal system causes dilated veins to become engorged which can rupture if the pressure becomes more than >12mmHG, leading to haemorrhage
What is haemorrhoids and what is it caused by?
Disruption and dilation of the 3 anal cushions which line the anus to help with anal closure. Caused by gravity, pregnancy, pelvis tumour, CCF, portal hypertension, increased anal tone and straining at the stool.
What causes an amoebic liver abscess?
From food contaminated with faeces in endemic areas, swallow cyst into intestines, reaches caecum and grows and goes into mesenteric vein, portal vein and liver
Complications of diverticulosis?
Diverticulitis, abscess in pelvis from spreading pus which can erode into the urinary bladder causing bladder infection and passing of intestinal gas in the urine, colon obstruction, bacterial peritonitis, bleeding into colon, fistula formation
What factors would lead you to do surgery in varice treatment?
Severe bleeding or bleeding despite transfusing 6U if >60. Active of uncontrollable bleeding at endoscopy. Initial Rockall score >=3 or final Rockall score >6.
What can cause a false positive result in a Heliobactor test?
Previous Heliobacter treatment
What does the rate of cholesterol stone formation depend on?
Cholesterol supersaturation of bile, crystallization promoting factors in bile (mucus and calcium) and motility of gall bladder.
What is pruritus ani and what are its primary and secondary causes?
Itching and scratching of the perianal due to haemorrhoids or overactive sweat glands or secondary to threadworm, a fungal infection or perianal eczema.
What is type B chronic gastritis?
Caused by H.pylori infection, and is the most commo chronic cause
Treatment of hepatic encephalopathy?
Nursing, NBM, ranitidine to reduce acid secretion, sucralfate to decrease oesophageal ulceration post endoscope
What test would differentiate between amoebic and pyogenic liver abscess?
Stool microscopy, antigen (fresh), culture, serology EIA
What investigations would be used for a hernia?
Endoscopy, barium swallow, ultrasound
Diagnosis of peritonitis?
CXR shows free air and fluid under diaphragm and perforation, increased WBC, US and CT show location, peritoneal aspiration, serum amylase for pancreatitis
What are the symptoms specific to hydatid abscess?
asymptomatic until 5cm. The symptom depends on where the cyst is. Diagnose by serology ELISA
Treatment of acute cholecystitis?
NBM, IV fluids, opiate analgesia, IV antibiotics (Cefotaxime), drain if empyema, delayed cholecystectomy to allow symptoms to settle.
What are complications of Achalasia?
Aspiration pneumonia, increased risk of oesophagus squamous carcinoma and reflux esophagitis risk.
DD for lower GI bleeds?
haemorrhoids, diverticulitis, IBD, malignancy, polyps. angiodysplasia, infectious diarrhoea, anal fissure
What is a femoral hernia?
Weakness in the femoral canal, lateral and inferior to the pubic tubercle, more common in females, presenting with a mass in the groin.
Treatment of a Mallory-Weiss tear?
Can heal spontaneously, or can use surgery to over sew the tear. IV omeprazole to reduce re-bleeding rates and reduce the need for surgery.
Treatment of peritonitis?
NPO status, nasogastric tube to suction and decompress stomach, IV fluids, antibiotics, analgesics, oxygen and electrolyte replacement, surgery to identify cause and repair, drain peritoneal fluid, colon resection, antimicrobials, ascitic tap if >250PMN/uL and positive culture
What are some complications of acute cholecystitis?
Empyema (pus), perforation and peritonitis
What is the management of ulcerative colitis when there is not a flare up?
5-ASA therapy via rectal or oral and then oral prednisolone, colectomy
Treatment of infective diarrhoea?
Bacterial - fluoroquinolones, azithromycin, susceptibility testing C.diff - metronidazole or oral vancomycin Giardia - metronidazole or tinidazole Cryptosporidium - nitazoxanide Virus - self limited Amoebiasis - metronidazole and intraluminal agent e.g. paromycin or diloxanide
What do investigations show with diverticular disease?
Increased WCC, ESR, CRP and leucocytosis. CT shows paracolic abscess, colonic wall thickening, US shows thickened bowel and large pericolic collections
What is the difference between 2nd and 3rd degree haemorrhoids and what is their treatment?
2nd is prolapse through anus on defecation but spontaneously reduces and 3rd degree is the same but needs digital reduction. Treatment via rubber band ligation, scerolsant injection, infrared coagulation or cryotherapy.
How does smoking affect the two IBD?
Aggravates Crohns but protects against ulcerative colitis
DD for LUQ pain?
gastric ulcer, pancreatitis
DD for LI pain?
diverticular disease, IBD, ectopic pregnancy, ovarian torsion, inguinal or femoral hernia
What is an umbilical hernia?
Weakness in the umbilicus, mainly in males, and is self resolving.
What is skip lesions in the colon referred as?
Crohn’s colitis
Causes of liver cirrhosis?
Chronic viral hepatitis, alcoholic liver disease, hemochromatosis, autoimmune hepatitis, Wilson’s disease and coeliac disease
What is the pathogenesis behind genetic chronic pancreatitis?
There is a mutation in the PRSSI gene which codes for cationic trypsinogen (the main trysinogen produced by the pancreas).
