GI Flashcards

Question

Investigations for Peptic Ulcers

Answer 1

FBC - looking for any iron deficiency anaemia Urea breath test to look for H.Pylori Endoscopy - IN some cases or to see extent of ulceration and bleeding

Answer 2

First presentation Over 55 years old Warning signs - ALARMS

Answer 3

Eradication of H.Pylori (Triple Therapy) o 2x Antibiotics - Clarithromycin and Metranidazole o PPI - Omeprazole Stop Smoking Stop NSAIDS Possible ablation of bleeding vessels Repeat endoscopy post treatment to confirm resolution

Answer 4

Indigestion Epigastric Pain related to hunger, certain food and time of day. A bloating and fullness after meals. Associated with heartburn

Answer 5

``` Non-ulcer dyspepsia GORD Oesophagitis Peptic Ulcer Duodenitis Gastritis ```

Answer 6

When showing ALARM signs ``` Anaemia Loss of weight Anorexia Recent onset/progression Melaena/Haematemsis Swallowing Difficulty ```

Answer 7

When the liver loses the ability to regenerate/repair and thus fails to function

Answer 8

``` Tuberculosis - But anti TB drugs can also cause hepatitis Alcoholic liver disease Primary Biliary Cirrhoisis Haemachromatosis - Accumulation of iron in the body Autoimmune hepatitis Alpha 1 anti trypsin deficiency Wilsons Disease Fatty liver disease HELLP Syndorme (Haemolysis, Elevated liver enzymes Infections o Viral Hepatitis - Hep B,C and Cytomegalovirus, Epstein-Barr o Yellow fever o Leptospirosis Drug Induced Causes o Paracetamol Overdose o Halothane - a GA o Isoniazid - TB treatment Toxins o Deathcap Mushrooms o Carbon Tetrachloride Venous Occlusion o Occlusion of hepatic portal vein o Occlusion of hepatic veins ```

Answer 9

Nausea Loss of appetite Fatigue Diarrhoea Bruising - Coagulation factors 1,2,5,7,8,9,10 made in liver Jaundice and pruritis - Unconjugated bilirubin and bile salt build up in skin Hepatic Encephalopathy Sweet, faecal smell on breath Leuconycia - hypoalbuminaemia Clubbing Palmar erythema Dupuytrens contracture - Alcoholic liver disease Hyper-dynamic circulation - increased circulatory volume Spider Naevi - >5 for indication of cirrhosis Hepatomegaly - Shrunk liver in late disease Ascites and peripheral oedema - Hypoalbuminaemia Kayser-Fleicsher rings - Copper rings around eyes in Wilson's disease Bronzed skin - caused by Haemachromatosis (iron overload) Polyuria Polydipsia

Answer 10

Do hepatic flap test and do a mini mental state examination

Answer 11

Ammonia build up in circulation as normally cleared by the liver. This enters the brain where it is converted to glutamine by astrocytes. This causes an osmotic imbalance. Fluid shifts into the brain causing cerebral oedema and causing the confusion.

Answer 12

``` Lesions in the brain/ cerebral infarction Intoxication Wernickes Encepalopathy Hypoglycemia Ketoacidosis Electrolyte imbalance Hypoxia Hypercapnia Renal failure/Heart failure - Oedema and Ascites ```

Answer 13

Bloods o FBC - Anaemia. signs of infection o U&E - Check for mineral levels (malnutrition) and renal function o LFTs and Serum Albumin - Raised ALP, AST, ALT, Gamma GT, bilirubin are indicative of liver disease and albumin will be low o Clotting - INR and PT will be prolonged due to deranged clotting factors o Paracetamol Levels - Check for an overdose o Virology - CMV, Hepatitis, Epstein Barr, HIV o Ferritin for Haemochromatosis o Copper for Wilson's Disease o Alpha 1 anti trypsin o Caeruloplasmin - Copper transport for Wilson's Disease o Autoantibodies - Primary Biliary Cirrhosis and autoimmune hepatitis o Immunoglobulins o Metabolic Syndromes - Thyrotoxicosis ()T3,4) and diabetes (Glucose) Coeliac Disease - Tissue Transglutaminase Test for parasites Blood Cultures Urine Cultures Paracentesis - take out peritoneal fluid, then culture and check neutrophil level Radiology o Chest X-ray o Abdominal Ultrasound o Doppler of portal vein and hepatic vein to check for block or Budd-Chaiari syndrome o Fibroscan to assess cirrhosis EEG for neurological Abnormalities

Answer 14

Lactulose - Keeps gut motility up and prevent ammonia from building up, reducing risk of encephalopathy Treat bleeds with fresh frozen plasma, platelet concentrates, antifibrinolytic drugs, prothrombin complex concentrates and/or recombinant factor 7 Ascites must be drained and collected for testing - and treat fluid build ups with spirinolactone (aldosterone antagonist) Monitor bloods Monitor weight - See how fast weight is coming off Liver transplant may be necessary depending on degree on encephalitis, age, and cause of liver disease. If caused by drug damage, may consider stopping some drugs

Answer 15

Stop alcohol intake - Treat withdrawal symptoms (Chlordiazepoxide), stop cravings (Acamprosate) and cause unpleasant drinking effects (Disulfaram) CBT and help groups for alcohol Vitamin and mineral replacement - Vit K and Pabrinex IV (contains important vitamins) Optimise nutrition - 40kcal/kg/day and >1.2g protein/kg/day Monitor bilirubin as a marker for improvement Prednisalone 40mg/day over 5 days

Answer 16

Normal Liver disease signs and symptoms Chronic Cholestasis (no bile flow through bile duct leading to gallstones) Patients more likely to have pruritits due to deposition of bile in the skin Right upper quadrant pain Very fatigued Steatorhea Dark urine (increased conjugated bilirubin in urine)

Answer 17

LFT's - ALP will be raised due to cholestasis Auto-antibody tests - Antimicrobial antibodies in >95% cases, Raised serum IGM, anti smooth muscle antibodies and antinuclear may be present Thyroid function tests - Patients often develop thyrotoxicsis (autoimmune) Ultrasound and Possible CT of gall bladder and liver

Answer 18

Sedating Antihistamines to treat pruritis Cholestryamine/Colestipol to sequester bile salts and also help with pruritits Ursodeoxycholic acid to slow disease progression Steroid to suppress autoimmune process of damage

Answer 19

A kind of cirrhosis caused by damage to the bile ducts in the liver. Unknown cause but thought to be autoimmune

Answer 20

Autosomal recessive disease that commonly presents in over 30's Patients have a deficiency in hepcidin (an iron regulatory hormone) which leads to increased intestinal iron absorption This increased iron then accumulates in tissues o Skin and pancreas often affected (bronzed diabetic) o Heart,gonads and joints may also be affected

Answer 21

``` Early Symptoms o Fatigue/Weakness o Arthropathy o Erectile dysfunction o Amenorrhoea - Absence of period o Heart Problems ``` ``` Advanced Symptoms o Diabetic Symptoms o Bronzed skin o Hepatomgeally o Cirrhosis o LIver Failure ```

Answer 22

Fasting transferrin saturation and serum ferritin | Genetic screening for human haemochromatosis protein

Answer 23

Venesection - Bleed the patient (500ml) every week to keep iron levels low and to prevent deposit (maintain ferritiin at <50Mg/L) Low iron diet may help Tea, coffee and red wine with meals to reduce absorption Serum Ferritin >1000ml risks cirrhosis

Answer 24

Autosomal recessive disorder, where copper is deposited in the liver. Leading to hepatitis and cirrhosis. Normally present and young age (early adult) Patients may also have psychiatric, neuro, renal problems, or rheumatoid pathologies as well a others.

Answer 25

``` Kayser-Fleicher rings - Copper deposits in the eyes, leading to a copper ring around iris (sign may also occur in bile excretion disorders as copper removed this way) Neurological Problems - Depression, Psychosis. Asymmetrical tremor (resting, postural or kinetic) Osteopaenia - Low bone density Osteoarthritis Myopathy, including cardiomyopathy Pancreatitis - Hypoglycemia Hypoparathyroidism Kidney Dysfunction Symptoms of liver failure ```

Answer 26

``` Primary biliary cirrhosis and other disease of cholestasis - Lead to copper build up as copper is excreted in bile Depression/anxiety disorders Hypothyroidism Diabetes Hepatitis and cirrhosis Huntington's/Parkinson's/MS ```

Answer 27

Caeruloplasmin (copper binding protein) level <0.1g/l diagnostic Check urine for copper excretion Liver Biopsy if other tests inconclusive Tests of exclusion for other causes of liver damage, renal impairment,hypothyroidism etc

Answer 28

Avoid alcohol and hepatotoxic drugs Low copper diet - Liver, chocolate, nuts mushrooms,. legumes and shellfish avoided annual examination of KF rings to see them disappear Chelating agents prevent copper absorption in the gut e.g. Zinc Acetate Test first degree family members as chance they have it too

Answer 29

Hepatitis caused by autoimmune antibodies. There are two types caused by different antibodies, With type 1 being most common (75%)

Answer 30

Screen for antibodies that cause autoimmune hepatitis Antinuclear antibodies(ANA) Anti smooth muscle antibodies (ASMA), Anti liver kidney miscrosmal 1 antibody(Anti-LKM-1) Antibodies against soluble liver antigen (Anti-SLA) Anti-mitochondrial antibody (AMA) Antiphospholipid antibodies Type 1 is associated with ASMA or ANA (75% patients). Type 2 is associated with presence of either anti-LKM-1 or anti-LC-1

Answer 31

``` Oral corticosteroids (prednisalone) to treat acute presentation Azathioprine to maintain remission ```

Answer 32

Autosommal recessive inherited disease, with a mutation in the SERPINA1 gene leading to reduced production of Alpha-1-Antitrypsin

Answer 33

Neonatal jaundice and hepatitis Older children develop hepatitis, cirrhosis and liver failure Obviously will have lung symptoms (symptoms of COPD)

Answer 34

Serum levels of Alpha-1-antitrypsin measured | LFT's and liver biopsy to see level of liver damage

Answer 35

``` Lower alcohol consumption and quit smoking Treat lung disease the same as COPD Give recombinant Alpha-1-antitrypsin May need liver transplant Screen for hepatocellular carcinoma ```

Answer 36

Accumulation of lipid in and around the liver due to impaired fatty acid metabolism in hepatocytes - may be due to G^PD or NAD+ deficiency There are two main categories - Alcoholic or non alcoholic fatty liver disease

Answer 37

``` Majority Asymptomatic Fatigue and malaise Right upper quadrant pain Advanced disease may present with cirrhotic symptoms such as jaundice and ascites Hepatomegally Splenomgally ```

Answer 38

Liver biopsy histopathology for diagnosis LFT's - show raised ALT in early disease (but normal in late). Also may be raised gamma GT if alcohol is the cause Fasting lipids are often raised Rule out other causes of hepatitis and liver failure by blood tests

Answer 39

Treat any alcoholism by abstaining and good healthy diet Treat withdrawal symptoms (Chlordiazepoxide), stop cravings (Acamprosate) and cause unpleasant drinking effects (Disulfaram) Lose weight Insulin sensitisers may give some benefit e.g. Metformin Consider stain therapy

Answer 40

Hepatitis caused by one of many different viruses including Cytomegalovirus. Epstein-Barr, Adenovirus, Herpes Simplex and Hepatitis ABCDE

Answer 41

In patients at higher risk of getting a viral infection ``` Anyone who has pierced skin o IV Drug Abuse o Tattoos with non sterile needles o Body piercings o Needle stick injury o Shared razors/toothbrushes Hepatitis A has faecal-oral transmission, raw shellfish from polluted water can cause problems Sexual transmission Vertical Transmission Insect bites ```

Answer 42

Signs of hepatitis and cirrhosis | Diarrhoea with Hepatitis A

Answer 43

Virology study on bloods when looking for cirrhosis and hepatitis

Answer 44

``` Symptom control Interferon Alpha may work in early disease - Antiviral Agent Antivirals/Retrovirals o Ribvarin for Hep C o Entecovir or Tenofovir for Hep B ```

Answer 45

Haemolysis - Increased RBC breakdown Gilbert's Syndrome - Congenital cause of occasional raised bilirubin Crigler-Najjar - Decreased conjugation due to enzyme defects

Answer 46

Viral Hepatitis Alcoholic Hepatitis Drug induced - NSAID, Steroid, amiodarone, some antibiotics Cirrhosis

Answer 47

Gallstones Biliary Strictures Tumours/Malignancy

Answer 48

Pre Hepatic o Raised LDH and unconjugated bilirubin o Low haemoglobin o Normal AST, ALT, ALP Hepatic o Raised ALT, ALP and Bilirubin o ALP>ALT Post Hepatic o Raised ALP, ALT and conjugated bilirubin o ALP>ALT

Answer 49

``` Liver Disease Nephrotic Syndrome (lost in urine) Poor long term nutrition ```

Answer 50

Raised levels indicate liver hepatocyte damage ALT is more specific to the live AST is a general muscle damage marker - Check Creatinine Kinase to exclude this as a cause for a raised result ALT>AST = Chronic Liver Disease AST>ALT = Cirrhosis AST:ALT>2 = Alcoholic Liver Disease

Answer 51

Liver disease causes increased Gamma GT Often more associated with bile duct disease o Cholescytits and ascending cholangitis o Gallstones

Answer 52

Alkaline Phosphatase is a marker of damage to the bile ducts | May be elevated in bone disease - check gamma GT as well to rule out this as the cause of raised ALP

Answer 53

The liver is the site of production for many clotting factors Raised prothrombin time/high INR is a good indicator of liver disease Obviously not useful if patient is on Warfarin/blood thinning drugs

Answer 54

Paracetamol is very toxic to the liver when taken in high doses and can cause acute liver failure A dose of >150mg/kg tends to have fatal effects Normally the liver metabolises paracetamol to NAPQI and then on to inactive metabolites by glutathione. However in high paracetamol doses glutathione is depleted and so NAPQI levels rise, leading to hepatocellular damage.

Answer 55

``` Asymptomatic for first 24 hours - May have non specific abdominal symptoms Hepatic necrosis begins at 24hrs Right upper quadrant pain Jaundice Encephalopathy Oliguria Hypoglycemia Renal failure Lactic acidosis ```

Answer 56

Paracetamol level - done >4hrs after overdose o Will not work for a staggered overdose o Results inaccurate <4hrs after taking Blood Tests o U&E, eGFR, Creatinine - Get baseline renal function and check for failure o LFT's - Generally raised specifically ALT o Glucose - Hypoglycemia is common o Clotting Screen - Prothrombin time is a good indicator of liver failure o ABG - Acidosis

Answer 57

Activated Charcoal o if <1hr since ingestion N-Acetyl Cysteine - Basically use the treatment graph o If paracetamol level is >100mg/l at 4hrs or >15mg/l at 10 hrs o If patient has had no bloods after 8hrs o Keep giving till paracetamol is under treatment level If patient arrives after 24hrs, necrosis has already begun and so very hard to treat

Answer 58

Stones formed in the gallbladder of many patients, not always symptomatic. Stones can be cholesterol, pigment or mixed.

Answer 59

``` Fat - BMI>30 Female Fertile Fair - White Forty+ ``` Increased cholesterol (excreted in bile) leads to increased bile formation, stasis occurs, and the bile becomes concentrated into crystals that form the stones.

Answer 60

Biliary Colic - RUQ pain that comes in waves due to transient obstruction of cystic duct - Exacerbated b y foods (especially fatty foods) as this causes the bile duct to contract against the stone while trying to release bile. Nausea and vomiting Steatorhea - Lack of bile salts entering intestine

Answer 61

Inflammation of the gall bladder due to stasis of bile and therefore infection. Inflammation may spread to the parietal peritoneum, leading to more generalised pain and peritonitis. E.coli and Klebsiella most common infective organism

Answer 62

``` Palpable Gall Bladder Positive Murphy's Sign Associated systemic response o Fever o Raised WCC o Nausea and Vomiting ```

Answer 63

Infection and inflammation of the bile duct, ascending from a point of bile stasis (caused by stones, tumours, strictures, stenosis, parasites, ERCP damage etc) . E.coli and Klebsiella most common infective organism

Answer 64

Charcots Triad - Jaundice, Fever, RUQ pain Mental confusion Septic Shock

Answer 65

Diagnostic Criteria - 1 of each letter A: Signs of systemic infection o Fever/Shaking/Chills o Evidence of inflammatory response - Raised CRP B: Signs of Cholestasis o Jaundice o Abnormal LFT C: Evidence on imaging o Biliary Dilation o Evidence of causative factor - stone, stricture, stenosis etc

Answer 66

Raised Bilirubin Raised CRP/ESR (erythrocyte sedimentation rate) and Leukocyte levels (WCC) Abnormal LFT's - increased ALP, AST, ALT and Gamma GT Imaging to show biliary dilation

Answer 67

``` Acute pancreatitis Appendicitis Bile duct strictures and tumours Pancreatic and hepatic tumours Courvoisers Law - In the presence of jaundice, a palpable, non tender gall bladder is unlikely to be gallstones ```

Answer 68

Bloods o FBC - Check for raised WCC o U&E, LFT and amylase -To rule out other differentials and gallstones can block the pancreatic and hepatic ducts leading to damage - raise ALP is common and does not necessarily indicate obstruction o Blood cultures in cases of fever o Send of any already taken bile drains for culture Ultrasound scan - Very sensitive and specific o View any cholestasis and see some causative factors o Allows evaluation of common bile and intrahepatic duct dilation MRCP - Shows static fluid and therefore cholecystitis, cholangitis and choledocholithiasis

Answer 69

Analgesia ECRP - Visualise and remove stones Cholecystectomy - Without removal likely to return

Answer 70

IV antibiotics - Co-amoxiclav for cholecystitis and cholangitis Endoscopic Biliary Drainage for cholestasis #May require resuscitation if Septic

Answer 71

Mucocele (cyst) - Failure to relive cystic duct obstruction leads to formation and may lead to necrosis if untreated (leading to perforation, peritonitis, sepsis and death) Empyema - Similar to mucocele but with a systemic response as infected Fistula Formation - May fistula between duodenum or colon - this may progress to gallstone ileus if a large stone enters lumen of either Mirrizi syndrome - Compression of common bile duct by large stone in Hartman's pouch ( junction of the neck of the gallbladder and the cystic duct) - leads to obstructive jaundice

Answer 72

Choledochlithiasis - Stone lodged in common bile duct - can lead to cholecystitis, obstructive jaundice, or cholangitis. Pancreatitis - Deranged LFT's and raised serum amylase (3x upper limit diagnostic)

Answer 73

Gall Stones - RUQ pain Cholecystitis - RUQ pain, Fever and Leucocytosis Cholangitis - RUQ pain, Fever and Leucocytosis and Jaundice +/- septic shock and confusion

Answer 74

GET SMASHED ``` Gallstones Ethanol Trauma Steroids Mumps and Malignancy Autoimmune Scorpion bite Hyperlipidaemia, Hypercalcaemia, Haemochromatosis ERCP Drugs - Thiazides, Valproate, Azathioprine, Corticosteroids ```

Answer 75

Left upper quadrant pain/Epigastric pain radiating to the back Nausea and vomiting Fever, tachycardia and malaise Jaundice may be present depending on cause (gallstones, malignancy or alcohol related) Paralytic Ileus may develop

Answer 76

Glasgow Criteria - PANCREAS 1 point for each, scores >2 mean severe pancreatitis ``` PO2 <8kpa Age > 55yrs Neutrophil count >15x10^9cells/l Calcium <2mmol/L Renal - Serum urea nitrogen >16mmol/L Enzymes - Serum Lactate dehydrogenase >600 or AST/ALT>200 Albumin <32g/l Sugar - Blood Glucose >mmol/l ```

Answer 77

Serum Amylase - 3x diagnostic Serum Lipase - Better than amylase in late presentation as amylase has short half life FBC, U&E, Glucose, CRP, LFT's, ABG - Used to assess prognosis - Raise ALT suggestive of gallstone cause, Hypocalcaemia is common Plain Abd Xray to exclude other causes CT scan - Diagnostic Ultrasound - Swelling, dilation of common bile duct indicates gallstone cause

Answer 78

Mild cases o Pain relief - Opiate>NSAID as NSAID can cause damage o NBM and IV fluids o Nasogastric tube/Anti Emetics for severe vomiting Antibiotics for specific infection Cather to monitor urine output Correct electrolyte imbalances o Hourly Obs - BP, urine output, RR, Blood sugar - EWS scoring o Alcohol withdrawal prophylaxis - Patients may have lied o Treat cause Severe Pancreatitis o IV antibiotics for pancreatic necrosis o Enteral Nutrition bypassing the duodenum to avoid pancreas o ERCP for removal of any stones/obstructive causes o Surgical debriment in infection/necrosis o Drain any pancreatic abscesses

Answer 79

Pancreatitis as a result of chronic inflammation of the pancreas leading to irreversible damage.

Answer 80

Chronic blockage of the outflow tract - leads to damage to the pancreas by its own enzymes Alcohol - can lead to protein precipitation in the pancreas, leading to damage, plus direct damage if alcohol Hereditary/familial Autoimmune disease

Answer 81

Severe abdominal pain - Epigastric radiating to back Nausea and vomiting Reduced appetite Exocrine dysfunction - malabsorption wit weight loss, diarrhoea, steatorrhea, and protein deficiency Endocrine dysfunction - diabetes in 30% patients (fatigued, polyuria, polydipsia, glycosuria on urine dip)

Answer 82

``` Cholecystitis or Cholelithiasis Peptic ulcer Acute Hepatitis Abdominal Aortic Aneurysm Pyelonephritis Acute Pancreatitis MI Pneumonia ```

Answer 83

Blood Tests - FBC, U&E, Creatinine, LFT's, Calcium, Amylase (normally normal in chronic, glucose, HBA1C Secretin Stimulation test - Give secretin IV and monitor fluids passed into the duodenum via NasoDuodenal tube - NBM 12hrs before, and a 60% reduction in pancreatic exocrine function if positive Imaging - Ultrasound first line, CT and Abdominal X-ray to show calcification, ERCP and MRCP for stones Pancreatic biopsy - Can confirm inflammation and fibrosis but high risk Reduced faecal elastase levels show pancreatic endocrine insufficiency

Answer 84

Analgesia - Opiates>NSAIDS as NSAIDS can cause damage Assess alcohol intake and counsel patient Psychiatric evaluation for depression if heavy drinker Treat any malabsorption by replacing pancreatic enzymes with CREON supplements Appropriate diabetic control Surgery o Pancreatic duct stenting in stricture o Resection to remove abnormal/damaged parts of pancreas Whipple's Procedure (Pancreatoduodectomy) for head involvement Distal pancreatectomy if tail involvement Total pancreatectomy if entire pancreas diseased

Answer 85

An inflammatory disorder of the large intestine (including rectum and anus) affecting the mucosa. The disease is continuous throughout the colonic mucosa and will never extend passed the ileocaecal valve, except in the case of a backwash ileitis where i can spread backwards. The disease goes through stages of relapse and remission, and is thought to be of immune origin, triggered by colonic bacteria so most treatments involve immunosuppresion

Answer 86

Diarrhoea - Many times per day, associated with urgency and tenesmus, often blood and mucous in the stool. If the disease is limited to the rectum and anus then you may have constipation and rectal bleeding instead Systemically unwell - Fever, malaise, weight loss, anorexia etc Tender, distended abdomen Tachycardia Dehydrated Anaemia ``` Extra-intestinal Symptoms Joint pain Mouth ulcers Clubbing Erythema nodosum - inflammation of fat cells under skin (commonly in shin) Pyoderma Gangrenousum - necrotic ulcer (often on legs) Fatty liver Primary Sclerosing Cholangitis Amyloidosis Conjunctivitis/Iritis and episcleritis ```

Answer 87

``` Crohns - Biopsy to differentiate Prolonged use of laxatives Infective colitis - Schistosomiasis, amoebiasis, tuberculosis C.Diff Irritable bowel syndrome - Mild colitis can mimic IBS Diverticulitis Colorectal Cancer Polyposis syndrome and colonic polyps Ischaemic and radiation colitis ```

Answer 88

Bloods o FBC - Looking for anaemia due to bleeding and looking for inflammation with raised WCC o CRP/ESR - Check for inflammation o U&E + eGFR - Check kidney function and electrolytes as patient may be malnourished or dehydrated o LFT's o Blood and stool cultures - Rule out pseudo membranous colitis (C.Diff) Faecal Calprotectin can help detect colonic inflammation - substance released in colonic inflammation Stool Microscopy, culture, and sensitivities to exclude any infective cause of diarrhoea e.g. E.coli, Camplyobacter, Shigella, C.Diff, salmonella Abdominal X-ray - Look for faecal shadows, mucosal thickening, colonic dilation or for perforation Barium enema - Shows ulceration and loss of haustra pattern Colonoscopy or flexible sigmoidoscopy - Shows extent of disease and allows for biopsy (also looks for inflammation, ulceration, crypt abscess)

Answer 89

Perforation and bleeding - sepsis and death Toxic Mega colon - Toxic dilation of colon (mucosal islands and colonic diameter >6cm on xray) Venous thrombosis (unknown cause) - Prophylactic Dalteparin Increased risk of colon cancer

Answer 90

Mild o 5-ASA preparations - such as sulfasalazine or mesalazine o Oral or topical steroid (prednisalone) to induce remission o Possible oral tacrolimmus to induce remission Moderate o Same as mild o Increase steroid dose (Prednisalone) o 2x daily steroid enemas ``` Severe - In hospital o NBM with IV Hydration o IV steroids (hydrocortisone) o Rectal steroids o If still not improving consider Colectomy or Rescue therapy (ciclosporin/infliximab) ``` Maintaining remission o 5-ASA preparation such as mesalazine and sulfasalazine will reduce relapse rate

Answer 91

Colectomy - Curative treatment | Restorative Proctolectomy with ileal pouch-anal anastamosis is the usual common procedure

Answer 92

Chronic inflammation of the bowel, including large and small intestine. It can be found anywhere in the bowels, from mouth to anus, and is not always continuos in nature. It goes through stages of remission and relapse. Some infectious agents have been implicated, though it is thought to be autoimmune and triggered by bacteria

Answer 93

Diarrhoea - With blood, urgency and tenesmus, patient may wake up night needing to empty bowels (not seen in UC) Patients may have constipation if proctitis Systemic symptoms - fever, malaise, night sweats, anorexia and weight loss Abdominal Pain and tenderness Vomitting Mouth Ulcers Anal and Perianal lesions - Abscess, skin tags and fistulae Extra GI symptoms Clubbing Erythema nodosum and pyoderma gangrenosum Conjunctivitis, episcleritis and iritis Large joint arthritis, sacroilitis, ankylosing spondylitis Fatty liver disease, primary sclerosing colangitis and cholangiocarcinoma Granulomata in many organs Renal Stones Osteomalacia Amyloidosis

Answer 94

Ulcerative Colitis - differentiated by possibility of inflammation in area's other than the large intestine and on biopsy Tuberculosis Gastroenteritis Bowel Carcinoma Diverticulitis Mild cases may be mistaken for Irritable bowel syndrome Ischaemic, radiation or drug induced colitis

Answer 95

Bloods o FBC - To check for anaemia, and white cells for inflammation o CRP - To check for inflammation o U&Es - Kidney Function (To check for dehydration) and to check for any mineral deficiency (as malnourishment is likely) o LFT's o Blood cultures to rule out infective causes Stool culture and Faecal calpotetctin Colonsocpopy to assess areas affected and take biopsies MRI can help to assess pelvic disease

Answer 96

The Crohns Disease Activity Index (CDAI)

Answer 97

``` Small Bowel Obstruction Toxic Dilation of colon - rarer than in UC Abscess formation Fistulae - Colovesical, Colovaginal, Perianal, Enterocutaneous Perforated bowel - Leading to peritonitis Rectal Haemorrhage Colon Cancer Fatty Liver Disease Primary Sclerosing Cholangitis Cholangiocarcinoma Renal Stones Osteomalacia Malnutrition Amyloidosis ```

Answer 98

Smoking Cessation Induce Remission o Prednisalone in mild attacks o Mesalazine (Can be used as enema if left sided colonic Crohns) o IV corticosteroids - Budesonide for Crohns in terminal ileum and ascending colon, Hydrocortisone for rectal Crohns o Azathioprine used as steroid sparing agent, but takes 6-8 weeks - so often used in combination with steroids o Methotrexate o Infliximab and anti-TNFa Maintenance of Remission o 5-ASA preparations such as sulfasalazine o Antibiotics (e.g. Rifaximin) used to prevent infections in abscesses and fistulae o Corticosteroids can be used in place of 5-ASA if ineffective

Answer 99

Smoking is a risk factor for Crohns Smoking is preventive in UC (UC = Use cigarettes)

Answer 100

Crohns can affect entire GI tract and is non-continuos (skip lesions) Ulcerative Colitis can only affects the colon and is continuous

Answer 101

In ulcerative colitis the mucous lining of the colon may have ulcers , but they do not extend below the inner lining. In Crohns the colon wall may be thickened and will have a cobblestone appearance. Ulcers are deep and extend into all layers of the bowel - transmural lesions

Answer 102

In Ulcerative colitis patients are less likely to wake in the night to empty bowels, and blood. and mucus in the stools are much more likely In Crohns patients are more likely to vomit, they are also more likely to develop anal fistulae, skin tags and abscesses. Crohns is more likely to develop granulomas.

Answer 103

An infection with Clostridium Difficile normally following removal of any other bacteria by antibiotic therapy

Answer 104

The 4 C's Co-amoxiclax Clindamycin Cephalosporin - Ceftriaxone, Cefotaxime Ciprofloxacin

Answer 105

``` Tends to be after antibiotic therapy More common in older patients Water Diarrhoea - 3+ stools within 24 hours and may contain mucous or blood Lower abdominal pain and cramping Low grade fever Nausea Anorexia Dehydration ```

Answer 106

``` Crohns and Ulcerative Colitis Ischaemic Colitis Other infections o Gastroenteritis o Camplylobacter o Salmonella o Shigella o Cholera o Amoebiasis ```

Answer 107

Bloods o FBC - Check for an elevated WCC and to check for CRP (as better marker in elderly patients) o LFTs - Hypoalbuminemia may be present Stool Sample/Culture - Look for C.Diff cytotoxin and can check faecal calpotetctin for UC and Crohns Sigmoidoscopy or Colonsocpopy with biopsy can confirm a diagnosis however fairly invasive so not normally performed Plain X-Rays to look for Toxic Megacolon (Septic) - Thumb printing and loss of Haustra/Valvulae seen as precursors

Answer 108

Isolate the patient and practice barrier nursing - Very infective spores Fluid resuscitation with an IV crystalloid Stop the causative antibiotics if possible - in 20% of patients this alone is curative, and if not possible to stop, replace with an alternative Use metronidazole or Vancomycin to treat the C.Diff infection Surgery to treat patients with toxic Megacolon or acute severe colitis (Basically if patient is septic)

Answer 109

Colonic dilation and distension, commonly caused by inflammatory bowel disease (More commonly Ulcerative Colitis) and some infections of the colon e.g. Clostridium Difficile

Answer 110

``` Abdominal pain and tenderness on palpation Distension of the abdomen Fever Tachycardia Dehydration Septic Shock Bowie Perforation Sepsis ```

Answer 111

X-Ray to show dilation of the bowel due to Megacolon - >6cm is diagnostic

Answer 112

Fluid Replacement and broad spectrum Antibiotics IV to treat any sepsis IV Hydrocortisone to reduce inflammation Decompress the bowel using long nasogastric tube to receive pressure NBM Subtotal colectomy if decompression is not possible within 2-3 days

Answer 113

A Bowel disorder with no known cause, leading to abdominal discomfort and GI symptoms. It is thought to be a disorder in smooth muscle activity and visceral hypersensitivity.

Answer 114

Boating and Distension Abdominal Pain or discomfort - May be relieved by defecating, and may have tender abdomen on examination Changes in bowel habit - Straining, tenesmus, urgency, and patient may have constipation, diarrhoea or a mix of the two Symptoms tend to be worse on eating Patients may have mucus in their stool Generalised symptoms - lethargy, nausea, heartburn, dysphagia, backache and bladder symptoms Relapses commonly in times of stress

Answer 115

Colon Cancer Inflammatory bowel disease - UC and Crohns Coeliac disease Gastroenteritis Diverticular disease Gynaecological problems with abdominal pain - Ovarian Torsion, Ovarian Cancer (Bloating and altered bowel habit) and endometriosis (cyclical pain on defecation and urination)

Answer 116

Bloods o FBC and CRP o Coeliac Screen o CA-125 in women if symptoms could be due to ovarian cancer Faecal calprotectin to rule out IBD Can use radiology and Colonsocpopy/Flexible sigmoidoscopy in order to confirm there is no other diagnosis

Answer 117

Lifestyle Factors o Healthy Diet o Fibre, lactose, fructose, wheat, starch, caffeine, sorbitol, alcohol and fizzy drinks may make it worse o Low fibre diet can cause other problems, so try water soluble fibre rather than more solid fibre types. o Drink lots of fluid Drug Therapy o Laxatives and bulking agents - Ispaghula, Bisacodyl and sodium picosulfate to treat constipation and Loperamide to treat diarrhoea o Antispasmodics may help with abdominal pain/discomfort - Mebeverine, alverine citrate, sometime, buscapon Cognitive Behavioural Therapy may help if the symptoms gets worse with stress

Answer 118

An adverse reaction to gluten leading to a range of symptoms and poor absorption in the intestines

Answer 119

``` Diarrhoea with steatorrhoea Bloating and flatulence Nausea and Vomitting Abdominal pain Weight loss Feeling tired all the time (Due to malnutrition and thus anaemia - so get signs of anaemia) Failure to thrive in children ```

Answer 120

Irritable Bowel Syndrome Lactose Intolerance Inflammatory bowel disease General Malabsorption

Answer 121

Blood tests for auto-antibodies (Tissue transglutaminase, endomyseal and anti-casein antibodies) - Give gluten diet for a week before test is taken Gene testing - HLA-DQ2 and HLA-DQ8 Biopsy of Jejenum as confirmation (While on gluten diet) - Will show subtotal villous atrophy compensated by crypt hyperplasia and lamina propria infiltration with lymphocytes and an increase in intraepithelial lymphocytes) FBC - To check for Anaemia

Answer 122

Eat a gluten free diet | Remove Wheat, rye, barley and possibly oats should be cut

Answer 123

Diverticulum form - Outpouchings forming in the gut wall (congenital or acquired). These can occur anywhere in the gut, but are most common in the ascending, descending and sigmoid colon. These outpouchings can act like mini appendicitis's and become inflamed (diverticulitis)

Answer 124

Most often asymptomatic (unless patient develops diverticulitis) and thus found on screening for other conditions e.g. colon cancer Lower left quadrant pain if diverticulae are on the left side of the colon (most common) and right lower quadrant pain if they are on the right hand side (more common in Asians) - Colic type pain relieved by defecation of flatulence. Fever and tachycardia Anorexia Nausea and Vomiting Localised tenderness possibly with mass on palpation PR Bleeding (fresh blood on stools)

Answer 125

Strictures - will cause an obstruction Abscesses - can cause peritonitis and sepsis Fistulae - can cause infection elsewhere in the body and will likely cause problems for the patient Haemorrhage is common in the lower GI tract (colon) – patient usually has abrupt, painless bleeding, often with the urge to defaecate beforehand

Answer 126

Other causes of acute abdominal pain, including acute appendicitis Irritable bowel syndrome Inflammatory bowel disease – Crohn's disease, ulcerative colitis Colorectal cancer Other forms of colitis – ischaemic, pseudomembranous, amoebic

Answer 127

Barium enema can be used to confirm diagnosis, rather than go all invasive with a colonoscopy Colnoscopy is usually the best way to look for diverticulae CT abdomen (CT colonoscopy) is best in the acute setting as a colonoscopy or enema may perforate the bowel - Can also be used to find out where a fistula leads to

Answer 128

Patient should be advised to eat more fibre in future, as a low fibre diet is thought to be the cause of diverticulum formation Mild attacks can be treated with a fluid diet and antibiotics Analgesia and NBM may be necessary if patients can't tolerate liquids IV antibiotics and fluids Surgery may be necessary for abscesses and for diverticulitis Resection of affected area of colon

Answer 129

Inflammation of an out pouching of the ascending colon, leading to epigastric pain Usually caused by obstruction, such as a faecolith which leads to obstruction thus stasis and bacterial colonisation. Causing infection and inflammation If the appendix ruptures it can lead to life threatening peritonitis

Answer 130

Acute, severe abdominal pain - Early periumbilical pain which moves over a period of hours/days towards the right iliac fossa. This pain wakes patient up and is aggravated by movement, deep breathing and coughing Tender to the touch in right iliac fossa Nausea, vomiting and anorexia Fever May have diarrhoea Tachycardia indicates peritonitis Palpation of left lower quadrant may increase pain in the right lower quadrant (Rovsing's sign) Extend hip and abduct thigh with patient on left side, if this causes pain then it indicates appendicitis (psoas sign)

Answer 131

Appendix may be abnormally positioned – Pain may therefore be located on the left rather than on the right, may be generalised or may be back pain. Also children may have abdominal pain that is milder than expected, they may not want to eat

Answer 132

All instances of acute abdominal pain

Answer 133

``` GI obstruction Constipation Diverticulitis Strangulated hernia Crohn's or Ulcerative Colitis Cholecystitis Peptic ulcer Gastroenteritis Pancreatitis Testicular torsion Renal calculi UTI Ectopic pregnancy – always pregnancy test in fertile women Ovarian cyst – rupture or torsion Pelvic inflammatory disease ```

Answer 134

Normally a clinical diagnosis Urinalysis – exclude UTI or stone Pregnancy test – exclude ectopic pregnancy Bloods Full blood count – may show leukocytosis, exclude bleed if no anaemia CRP – marker for inflammation Laparoscopic investigation and treatment tends to be the first line of investigation in suspected appendicitis Ultrasound may aid diagnosis however CT scanning is better X-ray can show if there has been any perforation of the peritoneum

Answer 135

Laparoscopic appendicectomy - with Pre-operative antibiotics to reduce risk of infection

Answer 136

Inflammation of the peritoneum, can be primary or secondary Primary peritonitis is inflammation of the peritoneum itself – bacterial infection from intraperitoneal dialysis is an example Secondary peritonitis occurs due to inflammation of an organ adjacent to the peritoneum – perforation of the viscera can cause secondary peritonitis

Answer 137

Abdominal pain - May be localised or widespread dependent on whether it is a local or general peritonitis Nausea and vomiting Anorexia Fever Tenderness on palpation, guarding, rigidity and rebound tenderness - Maximum tenderness over the area of pathology Bowel sounds might be absent

Answer 138

``` Neoplasms Perforation of the viscera Splenosis Peritoneal cysts Other causes of acute abdominal pain e.g. Appendiciti or Diverticulitis Abdominal aortic aneurysm Ectopic pregnancy Inflammation of other abdominal viscera - e.g. Pancreatitis, Pyelonephritis or Hepatitis ```

Answer 139

Bloods o FBC – leukocytosis, white blood cells o CRP o Liver function tests – ALP, AST, ALT, amylase and lipase, rule out pancreatitis or hepatitis causing peritoneal inflammation o U+Es – Rule out kidney inflammation as the cause of peritonitis Peritoneal fluid – culture and get amylase level Urinalysis to exclude renal pathology May want to do imaging studies – look for any areas of intestinal perforation or air under diaphragm Pregnancy test to rule out ectopic pregnancy

Answer 140

IV antibiotics – broad spectrum (cefotaxime) or a combination of two are normally used May want to drain ascites if present Monitor and protect renal function Surgery to close any perforations Treat any cause of secondary peritonitis Antibiotic treatment Removal of inflamed appendix, diverticula, etc.

Answer 141

``` Hepatocellular carcinoma most often caused by chronic liver disease o Hepatitis B and C viruses o Alcoholic liver disease and cirrhosis o Haemochromatosis o Primary biliary cirrhosis o Alpha-1-antitrypsin deficiency Diabetes Smoking Steroids ```

Answer 142

``` Right upper quadrant pain Pruritis (itching) and jaundice Hepatomegaly and splenomegaly Oesophageal and anorectal varices Spider naevi and caput medusae Abdominal distension – ascites Confusion – hepatic encephalopathy Weight loss ```

Answer 143

Those at high risk should be offered surveillance Cirrhotic patients Hep B, Alcohol related or Hep C cirrhosis Patients with high Hepatitis B virus concentration

Answer 144

Ultrasonography at 6-12 monthly intervals Alphafetoprotein testing – high levels may be indicative of carcinoma, >400ng/mL may be regarded as diagnostic

Answer 145

Ultrasound scan for focal lesions (>2cm) with raised Alpha-Fetoprotein is diagnostic CT chest, abdo, pelvis for local spread or for evidence of primary cancers in case hepatocellular cancer is a secondary metastasis (which is fairly common) Fine needle aspiration or biopsy can be used in unclear diagnosis LFTs will be consistent with cirrhosis, clotting may be deranged

Answer 146

Secondary metastasis to liver (30x more common than primary hepatocellular carcinoma) - Likely from colon, breast, pancreas, stomach, lung, ovary or melanoma Cirrhosis and its causes Lymphoma of liver

Answer 147

Treat complications of cirrhosis/liver failure Surgical resection – more viable in patients without cirrhosis Transplantation Ablation in early stage cancer Chemotherapy direct to tumour via hepatic artery Investigate for primary tumour

Answer 148

Exocrine tumours (infiltrating ductal adenocarcinoma) make up ~90% of pancreatic cancer

Answer 149

Smoking High BMI Low fruit and veg intake Diabetes High alcohol intake Chronic pancreatitis gives a 5-15x increased risk - Hereditary pancreatitis gives an up to 70x increased risk Family history of pancreatic cancer, as well as known BRCA1 or BRCA2 mutations (breast cancer oncogenes) FAP/gardner's syndrome and peutz-jegher in family are risk factors Multiple endocrine neoplasia type 1 is a risk factor, especially for insuloma development History of IBD and peptic ulcer disease

Answer 150

Early symptoms are very non-specific o Epigastric pain and dull backache - Often worse lying down and eased by sitting forward, however pain may be felt solely as a dull back-ache o Painless, progressive, obstructive jaundice – RED FLAG o Pale stools (lack of bilirubin), dark urine (high bilirubin) and pruritis – due to conjugated bilirubin in urine (and not being present in stool) o Courvoisier's sign – palpable, non-tender gall bladder with painless jaundice is very unlikely to be gallstone pathology o Patients may develop an acute pancreatitis thus showing signs (Fever, nausea, vomiting, epigastric pain, etc.) o Unexplained weight loss and anorexia o Steatorrhoea due to malabsorption – lack of pancreatic enzymes o Patients may have constipation, nausea and vomiting due to obstruction at the duodenum - More likely to be constipated due to lack of pancreatic enzymes leading to sticky stool and thus distal intestinal obstruction syndrome (DIOS) In late disease, an epigastric mass will be palpable, Virchow's node may also be palpable (troisier's sign) Palpable gall bladder (see courvoisier's law/sign) Paraneoplastic signs/symptoms such as thrombotic events and hypercalcaemia

Answer 151

Abdominal pain o Gallstones (but remember courvoisier's non-tender gall bladder) o Peptic ulcers – will be exacerbated by feeding o Gastric or colorectal cancers – haemoptysis and melaena likely o Oesophagitis, gastritis o Hepatitis o Liver abscess o Liver tumours o Chest pathology – pneumonia or PE – would have dyspnoea o Abdominal aortic aneurysm (also radiates to back) Obstructive jaundice o Bile duct stricture – will tend to follow previous pathology, eg. gallstones o Gallstones – only if lodged in the common bile duct o Ascending cholangitis o Pancreatitis o Cancer of gallbladder

Answer 152

Blood tests o Full blood count for anaemia and thrombocytosis – to rule out haemolytic anaemia as jaundice cause o LFTs to confirm jaundice and look for potential cause - ALT/AST up in liver pathology or ALP and Gamma-GT up in bile duct pathology o Tumour markers if we suspect cancer - CA19-9 for pancreatic cancer, CEA for colorectal cancer, Alpha-fetoprotein for hepatocellular carcinoma o Ultrasound of the abdomen o ERCP may aid in biopsy o High resolution/helical CT with contrast chest, abdo, pelvis for staging o Remember to take U+Es to check renal function is OK before administering contrast

Answer 153

Surgical resection of tumour and regional lymph nodes in low stage cancer (only 10-20% suitable for resection) o Whipple's procedure – proximal pancreaticoduodenectomy, with (modified Whipple's) or without pylorus preservation o Distal pancreatectomy for tumours of body and tail Adjuvant chemotherapy commonly recommended following surgery Palliative care for non-resectable disease - Stenting of any ducts blocked by the cancer, however surgical bypass may be needed in severe obstruction Palliative chemotherapy and radiotherapy Pain management – opiates or coeliac plexus nerve block for severe cases Creon supplements to treat malabsorption Antiemetics for nausea and vomiting

Answer 154

Most commonly squamous cell or adenocarcinoma

Answer 155

Tobacco and alcohol increase risk Barrett's oesophagus (and GORD before it) is likely to progress to adenocarcinoma Achalasia is a risk factor for squamous cell carcinoma Chronic inflammation – oesophagitis Family history of oesophageal cancer Family history of hiatus hernia also shows correlation with increased risk

Answer 156

``` Think ALARMS Anaemia Loss of weight Anorexia Rapid onset/progression Melaena/haematemesis Swallowing difficulty – dysphagia (difficult swallowing), odynophagia (painful swallowing) ``` +++ Hoarseness Retrosternal or epigastric pain Intractable hiccups Lymphadenopathy

Answer 157

Oesophageal stricture Compression of oesophagus from external (extramural) source – lung/bronchial carcinoma, aortic aneurysm, lymph gland enlargement Achalasia – oesophageal muscles unable to relax leads to blockage Gastric cancer

Answer 158

Bloods o Full blood count – look for anaemia, iron deficiency especially (hypochromic, microcytic) o U+Es, eGFR and LFTs for metastatic disease o CRP for inflammation – oesophagitis or Crohn's disease could be cause of haematemesis Urgent endoscopy in patients >55years old with dyspepsia or those with ALARMS symptoms Barium swallow may be more viable in high risk patients Chest X-ray or chest, abdo, pelvis staging CT to look for metastatic disease PET scan can help Endoscopic ultrasound can increase accuracy of staging

Answer 159

Endoscopic mucosal resection and submucosal dissection Photodynamic therapy or laser treatment via endoscope Oesophagectomy (Ivor Lewis procedure) for advanced cancer - Will remove lymph nodes and maybe even part of the stomach, then affected oesophagus is removed and stomach is moved up through diaphragm to allow for anastamosis with proximal oesophagus Abdominal lymphadenectomy may be beneficial Pre-operative chemoradiotherapy may be beneficial in adenocarcinoma Palliative care in late stage disease o Radiotherapy and chemotherapy or ablation to reduce tumour bulk and bleeding o Stenting to assist swallowing o Pain relief

Answer 160

Increasing age Male gender Low socio-economic status H. pylori infection can double the risk of gastric cancer A history of ulceration is likely to increase the risk Diet – diets with low fruit and veg intake or high levels of salt or preserved food intake Smoking Gastritis Family history Hypogammaglobulinaemia

Answer 161

Often patients only have symptoms of uncomplicated dyspepsia (indigestion) ALARMS likely to only occur in late disease Anaemia Loss of weight Anorexia Rapid onset/progression Melaena/haematemesis Swallowing difficulty – dysphagia (difficult swallowing), odynophagia (painful swallowing) ``` In Late DIsease o Epigastric mass o Hepatomegaly o Jaundice o Ascites o Enlarged Virchow's node (Troisier's sign) ```

Answer 162

GORD Peptic ulceration Acute gastritis Gastroenteritis

Answer 163

Urgent endoscopy referral within 2 weeks if ALARMS symptoms or 55+ with dyspepsia Full blood count for anaemia and LFTs for possible liver mets Endoscopy and biopsy of the stomach and possibly the duodenum Staging CT of chest and abdomen or PET scan

Answer 164

Treat pain, nausea and vomiting Surgical resection of stomach – more useful in palliative care Total gastrectomy may be necessary Lymphadenectomy often necessary Palliative care o Remove obstruction through chemo/radio-therapy or resection o Manage pain o Subtotal gastrectomy or gastroduodenectomy may be relevant o Endoscopic laser therapy may be of some use

Answer 165

``` Vague ill health and weight loss Acute or chronic obstruction of the intestine – patient not passing faeces or flatus Perforation and peritonitis Bleeding Anaemia Tenesmus (feel of incomplete voiding) ```

Answer 166

``` Bleeding Change in bowel habit Urgency Incomplete evacuation Wet wind Tenesmus Colic Sacral root pain ```

Answer 167

Right sided cancer Less likely to be obstructive in nature due to the faeces in that part of the colon being more liquid Blood in the stools is less likely to be fresh and is more often mixed in with the faeces Faecal occult blood screen will pick it up Often painless Left sided cancer Bowel obstruction common, tenesmus and change in bowel habit likely Bleeds are more likely to coat the stool rather than being mixed with it Colicky pain common

Answer 168

Feel for abdominal masses PR/DRE to feel for a mass Inspect finger for any blood after exiting anus

Answer 169

Chest/abdominal x-ray to look for: o Gas build-up in intestine due to obstruction, proximal to the obstruction o Gas under diaphragm, suggesting perforation CT colonography Bloods – FBC for anaemia, LFTs to check for metastatic liver damage - Colon cancer likely to metastasise to liver and lungs Endoscopy/Colonoscopy/Flexible Sigmoidoscopy and biopsy Liver ultrasound and CT or MRI are useful in staging Chest/Abdo/Pelvis staging CT to look for colonic cancer as well as liver and lung mets

Answer 170

Direct, through bowel wall Lymphatic, based on stage Blood stream – to liver via hepatic portal vein

Answer 171

Dukes classification

Answer 172

A = confined to muscle (94% 5 year survival) ``` B = through muscle (76% 5 year survival) C = into lymph nodes (32% 5 year survival) ``` C1 is into the lymph nodes, but the highest (apical node) is not involved C2 is into the lymph nodes, with involvement of the apical node D = distant metastases (liver and lungs likely, 6.6% 5 year survival)

Answer 173

Surgery Right hemicolectomy for right sided cancer, left hemicolectomy for left Rectum cancer can be removed with an anterior resection (if >5cm from the anus) or an abdomino-perineal resection with end colostomy if <5cm from anus Must take blood supply from whatever part of colon is taken as well Radiotherapy Adjuvent – after surgery in an attempt to reduce recurrence Neo-adjuvent – before surgery in an attempt to shrink the tumour before removal

Answer 174

A one off flexible sigmoidoscopy is currently being trialled and is offered to everyone aged 55 Men and women aged 60-74 are screened every 2 years - Patients wipe a sample of poo onto the sample kit, send it off and it is tested for faecal occult blood

Answer 175

Cancer below dentate line will often be squamous cell carcinoma Above the dentate line the epithelium is mucosal

Answer 176

Lymph drainage from squamous cells is to the inguinal, femoral and external iliac nodes Lymph drainage above the pectinate line (mucosa) is to the internal iliac lymph nodes Lymph drainage below the pectinate line (skin) is to the superficial inguinal lymph nodes It is important to know the difference in lymph drainage for sentinel node biopsy in staging

Answer 177

Human papillomavirus – genital warts - 50% of tumours contain viral DNA, also Anal intercourse and promiscuity increase the risk Increased risk in HIV patients – 2x as common in HIV+ homosexual men Other forms of immune suppression such as in transplant patients Smoking Previous malignancy

Answer 178

``` Perianal pain and bleeding Palpable lesion Faecal incontinence Tenesmus Rectovaginal fistula in women Weight loss and malaise ```

Answer 179

Piles/Haemorrhoids – especially non-reducible (grade 4) Large rectal cancers or cervical cancers Fissure or Fistula in anorectal area - However Both are more likely to form in anal cancer anyway

Answer 180

DRE and proctoscopy to see the size of the mass Sigmoidoscopy or flexisig to take a Biopsy to confirm this is cancer, sentinel node biopsy is also helpful CT, MRI or PET can be used for staging Test for relevant infections such as HIV - If HPV or HIV are suspected causes then you may want to test for other blood-borne viruses

Answer 181

Chemotherapy and radiotherapy are recommended as first line treatments o 5-fluorouracil and mitomycin C o Chemotherapy allows for reduced dose of radiation, allowing for reduced radio-load o Radiotherapy to both tumour and affected lymph nodes o If unsuccessful consider surgery Surgery – Anterior resection - excision of anus, rectum and part of the large bowel with insertion of a colostomy

Answer 182

An autosomal dominant genetic condition that has a high risk of colon cancer. It is a type of cancer syndrome.

Answer 183

Colorectal cancer – seen most commonly (80% lifetime risk) - 2/3rds appear in the proximal colon (right sided cancer) Endometrial carcinoma Digestive adenoma – gastric, pyloric and duodenal adenomas Ovarian serous cystadenocarcinoma

Answer 184

Genetic Testing in patients who met the Amsterdam criteria (identifies high risk patients)

Answer 185

Other first degree relatives should also be tested Colonoscopy at least every 2 years from age 25 onwards Consider prophylactic total colectomy Patient should be made aware of how other (non-colon) cancers will present, so that they can be tested should any red flag symptoms arise

Answer 186

A polyp within the colon is an abnormal growth of cells forming from the mucosa of the colon. Each polyp holds a small risk of becoming malignant – most patients will develop cancer by age 30 In familial adenomatous polyposis (also known as Gardner's syndrome), patients have many polyps (adenoma=benign tumour) and therefore the risk of malignancy is greatly increased

Answer 187

Singular polyps are normally asymptomatic Patients who do present, most commonly present with rectal bleeding or iron deficiency anaemia Occult blood may be detected in the stools

Answer 188

In FAP, due to the increased amount of polyps, patients are more likely to be symptomatic Obstruction and constipation Diarrhoea, abdominal pain and mucous discharge Gastric polyps may form, leading to epigastric pain, dyspepsia, vomiting and haemoptesis Duodenal polyps may cause obstructive jaundice Rectal polyps may be detectable by the patient, feeling similar to haemorrhoids -May lead to blood on wiping or tenesmus Patients with FAP are more likely to have extra teeth, odontomas and non-erupted teeth Thyroid carcinoma is more common in patients with FAP Epidermoid cysts are more common in patients with FAP

Answer 189

Any Causes of lower GI bleeds ``` Haemorrhoids Ulcerative colitis and Crohn's Colorectal cancer Anorectal cancer Diverticulitis ```

Answer 190

Bloods o Full blood count for anaemia and white cells (to rule out infection/inflammation) o LFTs to look for damage caused by liver metastases o Carcinoembryonic antigen (CEA) testing for colorectal carcinoma Faecal occult blood (microscopic blood, not normally seen by patient in stool) CT chest, abdomen and pelvis to look for tumours and metastases Colonoscopy and endoscopy with biopsies of any polyps viewed Genetic testing for the adenomatous polyposis coli gene and the mutY DNA glycosylase (MUTYH) gene Non-bowel manifestations of FAP o Thyroid function tests o Dental X-rays, chest x-rays and skull x-rays to look for osteomas, jaw lesions and supernumary teeth

Answer 191

FlexiSig every 1-2 years in early cases of FAP (at ages 10-12) to document the onset of any polyp formation Children will require colonoscopic polyp removal in early disease until they are old enough to handle a colectomy both physically and emotionally/psychologically If no polyps are found by age 20 then patients will have colonoscopy every 5 years after that Curative treatments normally involve resection of the colon or parts of the colon-This will likely require ileostomy or ileo-rectal anastomosis and Restorative proctolectomy with ileal pouch anal anastomosis is most often used Patients will still need to be reviewed every 3-6 months for rectal or ileal pouch polyps following surgery - These polyps will need ablation Endoscopy every 1-3 years following surgery to look for upper GI polyps - Can ablate these if necessary COX2 inhibitors such as aspirin or calecoxib can help to reduce rates of recurrence

Answer 192

Could be epistaxis (nose bleed) cause Oesophageal causes – mallory-weiss tear, tumour, varices (from liver pathology) Stomach pathology – tumour, ulcer, ingestion of foreign object (especially batteries) Duodenum – ulcers, haemobilia (bleeding into biliary tree)

Answer 193

``` Small bowel Tumours Ulceration Inflammatory bowel disease (Crohn's) Meckel's diverticulum ``` Large bowel/anus Tumours Diverticular disease Radiation damage – eg. Prostate, ovary or bladder radiotherapy AV malformation/angiodysplasia Inflammatory bowel disease – Crohn's or Ulcerative colitis Varices (liver pathology) Haemorrhoids (piles) – much less blood than in other conditions

Answer 194

Always look for signs of liver disease as this can easily lead to varices (oesophageal or colonic/rectal) Always do a PR exam to assess the anus, rectum and whether the patient has any melaena or blood in their stools

Answer 195

``` Oesophago-gastro-duodenoscopy/endoscopy to look for ulceration and upper GI tumours in patients: o Presenting 1st time over age 55 o Showing ALARMS symptom o In patients with warning signs - Iron deficiency anaemia - Chronic blood loss - Weight loss - Progressive dysphagia - Persistent vomiting - Epigastric mass felt on examination Urea breath tests for H pylori infection to see if present and causing ulceration FBC for iron deficiency anaemia LFTs for hepatic cause of varices ```

Answer 196

Endoscopic ulcer intervention – ablation of bleeding ulcer Resuscitation and stabilisation of patients who may have lost a lot of blood and are therefore in shock

Answer 197

Resection Resuscitation and stabilisation of patients who may have lost a lot of blood and are therefore in shock

Answer 198

Endoscopic variceal ligation or sclerosis Resuscitation and stabilisation of patients who may have lost a lot of blood and are therefore in shock

Answer 199

Blatchford score for risk assessment Rockall score can be calculated post-endoscopy

Answer 200

Minute bleeding can give way to a major haemorrhage very quickly, therefore it is important to get early IV access and take blood for group and save/crossmatch

Answer 201

FBC, U+Es, clotting and cross match Endoscopy or sigmoidoscopy (left bowel only but takes less prep) or colonoscopy. Can use Capsule endoscopy instead – camera in a non-digestible capsule is swallowed, allowing visualisation of entire bowel to look for cause of bleed Radiology mesenteric angiogram (a Radiolabelled red scan) red blood cells are taken, radiolabelled and re-infused, we then wait to see where they pool in the bowel after they bleed into it, telling us the location of the bleed

Answer 202

``` Resuscitation o 2 large bore cannulae o IV fluids, have blood on hand o Urinary catheterisation o Oxygen ``` Non-operative – best to treat conservatively until a cause is found Operative – only once a cause of the bleeding has been found

Answer 203

Upper GI – ulcers, tumours Small bowel – tumours, foreign bodies, obstruction, trauma Large bowel – diverticular disease, cancer, obstruction, inflammatory bowel disease, iatrogenic

Answer 204

Abdominal pain Peritonitis – generalised excruciating abdominal pain with guarding on examination (If a patient has peritonitis, always be aware that it may be perforate) Shock

Answer 205

FBC, U+Es, clotting, crossmatch Arterial blood gas ECG – monitor heart function due to shock and SIRS Chest X-ray to look for gas under the diaphragm CT scan abdomen for similar

Answer 206

Resuscitation o IV fluids – have blood on hand o Oxygen o Urinary catheterisation o IV antibiotics (peritoneal cavity likely to become infected) o Analgesia – analgesic ladder (probably opiates though) Conservative management is indicated in patients without generalised sepsis/peritonitis o Omentum may cover the perforation, preventing leak of contents and major contamination o Treat with antibiotics and rest the bowel (parenteral feeding) o Give PPIs in upper GI perforations to reduce acid damage and leak Surgical management o Possible to sew omentum over the area of perforation, stitching it to the perforated structure (upper GI generally) o Resection of areas of perforated small bowel or colon – generally leads to stoma being necessary

Answer 207

A stoma is an opening made in the bowel to allow faecal material out into a stoma bag in patients for whom the bowel distal to that point has been removed due to its inviability

Answer 208

Colostomy – opening made in the large intestine (colon), bypassing the anal canal Ileostomy – opening in the ileum of the small intestine, bypassing the large intestine Gastrostomy and jejunostomy are used for enteral feeding tubes

Answer 209

Inflammatory bowel disease Neoplasia (cancer) Diverticular disease

Answer 210

Colostomies are flat to the skinand are fairly big, like the large intestine (colon) Whereas ileostomies are spouted and comparatively small (like the small intestine)

Answer 211

Above skin level Red and moist – pallor suggests anaemia, dark suggests ischaemia No separation between musculocutaneous edge and skin No erythema, rash, ulceration or inflammation (obviously should not be present)

Answer 212

Ileostomy Produce faeces roughly 4 hours after a meal Increased output over normal defaecation Colostomy will produce faeces roughly 8-12 hours after a meal

Answer 213

Patients may need to change their diet to reduce output rate or reduce output of flatus (flatus filters available) Risk of dehydration, best for patients to avoid fizzy drinks and alcohol and drink more fluid than normal (roughly an extra litre a day)

Answer 214

Possibility of prolapse, narrowing or blockage of the stoma - Stenosis can be recognised by thin, ribbon-like stools and high pitched flatus and will require surgical correction Mucocutaneous junction may become detached, partially or fully - However good wound care will lead to reattachment Parastomal hernias which may need surgery to resolve

Answer 215

Tend to be caused by mucosal problems e.g. Inflammation – infection, diverticulitis, inflammatory bowel disease

Answer 216

The bowel should be scoped – | colonoscopy best

Answer 217

Tends to be obstructive

Answer 218

CT to look for obstructed areas of bowel

Answer 219

Assessment of the anus and rectum for haemorrhoids, etc. Patient will likely need colonoscopy Take bloods to look for anaemia

Answer 220

Abdominal pain – colicky, every 4-5 minutes (with contractions, longer wait in large bowel) Faeculant vomiting – brown, offensive smelling vomit that has been caused by stasis of bowel material and bacterial partial breakdown of digested material. This is different from faecal vomiting, which will occur in long-standing large bowel obstruction where peristalsis will work the material back up Vomiting is less conspicuous in large bowel obstruction as there is more bowel for the faeculent material to build up in Obstipation – severe or complete constipation, not passing motions for dayswith an inability to pass flatus Abdominal distention and bloating Abdominal tenderness Visible peristalsis Visible hernias Rectal examination may reveal a mass in large bowel/rectal obstruction High pitched, tinkling bowel sounds Dehydration and hypotension with tachycardia Fever

Answer 221

Slow gut – can be present from birth, some patients may always be constipated Neurological deficit or muscle weakness Issues with the pelvic floor muscles

Answer 222

Adhesions (fibrous tissue from previous surgery, trauma or intra-abdominal infection) Herniae (external and internal) Compression by tumour of another structure Liver, pancreas, gall bladder, ovary, uterus

Answer 223

Inflammation + oedema eg. Crohn's Polyp or tumour of the intestine – carcinoma, lymphoma, carcinoid tumour Left sided carcinoma is more likely to cause constipation Strictures Diverticular disease Ileus – Non-mechanical obstruction caused by paralysis of the intestine and therefore a lack of peristalsis

Answer 224

Faecal impaction Foreign bodies and bezoars (hair or fibre balls) Large gallstone Volvulus – The transverse colon, sigmoid colon and caecum are non-retroperitoneal (intraperitoneal) sections of the large bowel, allowing movement and therefore twisting on their mesenteries (Elderly patient, chronic constipation, megacolon are risk factors)

Answer 225

``` Gastrointestinal stromal tumours (GIST) Carcinoid tumours Lymphomas Metastatic o Ovarian o Colorectal (metastasises to small bowel) o Stomach o Most likely malignant cause of small bowel obstruction is a carcinoma of the large bowel at the ileocaecal junction Large polyps ```

Answer 226

Blood tests o Full blood count, clotting screen and group and save (in case surgery is needed) o Urea and electrolytes (patient may be malnourished) o Liver function tests o Arterial blood gas Radiology o Abdominal/chest x-ray – look for evidence of perforation (air under diaphragm) o Look for where gas ends in bowel – will show the rough area of obstruction o CT scan o Barium meal and follow-through and MRI in patients with chronic symptoms

Answer 227

Resuscitation Urinary catheter Nasogastric tube placement may help to relieve some pressure Non-operative may be fine as adhesional obstructions will resolve most of the time Operative to remove non-adhesional obstruction or to resolve adhesional obstruction which has caused: o Fever o Tenderness and guarding, indicative of peritonitis o Evidence of a perforation on imaging o Failure of resolution

Answer 228

Resuscitation Urinary catheter Sigmoid volvulus can normally be resolved via colonoscopy to give it a nudge back into position Operative removal of lesion causing blockage or stenting of strictures

Answer 229

Inguinal (groin) o direct (through hesselbach's triangle in the inguinal canal) o ndirect (through deep inguinal ring) Femoral Incisional – from incisions, likely from previous abdominal surgery Umbilical Hiatal

Answer 230

A hernia arising from a defect in the posterior wall of the inguinal canal and then passes through the superficial inguinal ring Inguinal hernias may enter the scrotum, especially indirect hernias

Answer 231

A hernia that passes through the deep inguinal ring, along the inguinal canal and out through the superficial inguinal ring Inguinal hernias may enter the scrotum, especially indirect hernias

Answer 232

Anterior wall – external oblique aponeurosis and internal obliques Posterior wall – transversalis fascia Roof – transversalis fascia, internal oblique and transversus abdominis Floor – inguinal ligament, lacunar ligament and iliopubic tract

Answer 233

Due to narrowness of the femoral ring

Answer 234

Medial – Lacunar ligament Lateral – Femoral vein Anterior – Inguinal ligament

Answer 235

A hernia that develops along the scar tissue of a surgical incision, most often due to weakness in the abdominal wall due to incisions in the muscles

Answer 236

A hernia protruding through the umbilicus, most often due to congenital malformation

Answer 237

A Hernia in the epigastric region, more commonly congenital than acquired

Answer 238

Half-way between the ASIS and the pubic symphysis - Femoral pulse should be palpable here

Answer 239

The mid-inguinal point

Answer 240

Half-way between ASIS and pubic tubercle The deep inguinal ring is roughly half an inch superior to this point and so helps to determine a direct or indirect inguinal hernia

Answer 241

Superior and medial to the pubic tubercle

Answer 242

Ultrasound or X-rays with contrast agent injected into the peritoneum will help to be sure of the type of hernia A CT scan may need to be performed to see what is going on in abdominal herniae and in obese patients

Answer 243

Strangulated herniae are a medical emergency and require immediate surgery Lichtenstein technique – Mesh can be inserted to cover the weakness in the abdominal wall and prevent re-perforation once reduced Bassini's technique – Apposition of the surrounding musculature, transversus abdominis and transversalis fascia and lateral rectus sheath, to the inguinal ligament, closing off openings through which hernias in the groin could perforate Femoral sacs surrounding femoral hernias may need to be dissected to allow for reduction followed by closure between the inguinal and pectineal ligaments Laparoscopic repair is possible Patients can wear a truss if surgery is inadvisable or refused

Answer 244

Differentiating femoral from inguinal (direct or indirect) herniae is a matter of location Femoral herniae are found infero-lateral to the pubic tubercle (below inguinal ligament) Femoral hernia are firmer than inguinal hernias More common in women (but still less common in women than inguinal) ``` Inguinal herniae are found supero-medial to the pubic tubercle (above inguinal ligament) Inguinal herniae (especially indirect) may enter the scrotum whereas femoral herniae will not ```

Answer 245

Direct pass through only the superficial inguinal ring A reduced indirect inguinal hernia will protrude on coughing even if the deep inguinal ring is blocked by an examiner's finger Indirect pass through the deep and superficial inguinal canal A reduced indirect inguinal hernia will not become apparent again on coughing if a finger is used to block the deep inguinal ring (at the midpoint of the inguinal ligament)

Answer 246

Saphena varix – varices of the saphenous vein however Often patients will have other varicoso veins, leading to a raised suspicion for saphena varix, a history of DVT will also support diagnosis Femoral aneurysm Inguinal lymphadenopathy

Answer 247

Varices of the saphenous vein As with herniae, a saphena varix will become uncomfortable after prolonged periodsand a saphena varix will reduce on lying down as this will remove gravity from the equation, allowing for ease of draining

Answer 248

Non-tender Fluctuant Has a cough impulse Infero-lateral to the pubic tubercle – Like a femoral hernia Bluish tinge Easily reducible and will reappear as soon as a finger is removed Disappears as soon as the patient lies flat – only seen on standing examination Often patients will have other varicose veins, leading to a raised suspicion for saphena varix History of DVT will also support diagnosis

Answer 249

The lump will be felt best at the mid-inguinal point (midway between ASIS and pubic symphisis) The lump will be pulsatile A fluctuant lump

Answer 250

A solid lump – this differentiates it from other groin lump pathologies May be pulsatile if overlying an artery May be warm and tender

Answer 251

Infective causes – HIV, tuberculosis, lower limb infection Neoplastic causes o Lymphomas o Leukaemias o Metastases from lower limb and external genitalia - Scrotum, skin of penis, vulva, anus (below pectinate line), perineum and buttocks - But remember that the testes drain to para-aortic nodes

Answer 252

Vascular cushions at the rectal boundary, that have a sensory function in feeling when the rectum is full and whether it contains gas, liquid or solid – allows us to fart without worry of following through. In low residue diets with straining to evacuate hard and solid faeces,damage to the haemorrhoids can occur, causing bleeding and possible prolapse Constipation is a big risk factor Piles lead to a lot of pain and discomfort for the patient

Answer 253

Grade 1 – Small swellings in the lining of the anal canal Can't be seen or felt from outside of the anus Grade 2 – larger, may slightly protrude from the anus when passing motions Reduce spontaneously on finishing defaecation Grade 3 – hang out of the anus when passing motions Felt as small, hard lumps hanging from the anus Can be pushed back up with a finger Grade 4 – permanently hang from the anus, unable to be pushed back in

Answer 254

Patients may notice fresh blood in the bowl or on the paper when they wipe - Bleeding may be painless Anal itching and irritation due to irritation of the perianal skin by mucous discharge Patients may feel the prolapsed haemorrhoids Patients may have tenesmus Patients may have impaired continence External haemorrhoids may be painful due to strangulation or thrombosis On PR examination, the swollen haemorrhoids will be felt Can ask patient to strain to see if their haemorrhoids prolapse to help with grading and confirm diagnosis

Answer 255

``` Anal carcinoma Colorectal cancer Inflammatory bowel disease Rectal prolapse Adenomatous polyps Anal fissure Anorectal abscess Anal fistula ```

Answer 256

Proctoscopy – may need referral to secondary care | If nothing seen on proctoscopy, consider other differentials, patient may need colonoscopy

Answer 257

Improve stool consistency o Increase fluid and fibre intake and reduce intake of refined foods (eat wholemeal instead) o Bulk forming laxatives (eg. Ispaghula husk) or fibre supplements may be needed to treat constipation Pain and symptom relief o Simple analgesia (paracetamol, NSAIDs) – avoid opiates as they will lead to worse constipation o Topical anaesthesia can also be used and topical corticosteroids will help to reduce inflammation Non-surgical treatments o Rubber band ligation of haemorrhoids – haemorrhoid will necrose and drop off o Injection sclerotherapy – phenol injection at base of haemorrhoids, leading to atrophy due to fibrosis of the blood vessels Surgical treatments – reserved for large haemorrhoids that will not respond to other treatments o Haemorrhoidectomy – painful but effective long-term o Haemorrhoidal arterial ligation – cut off blood supply so they necrose and drop off

Answer 258

Tears in the anus normally caused by constipated patients passing big motions which stretch the anus and lead to tears Tears lead to pain and can become infected leading to further problems Tears will take a long time to heal, as repeated defecation will lead to inflammation and anal spasm and therefore slowed healing Blood supply to area reduced by spasms

Answer 259

Pain on defecation, often described as feeling like passing nails or glass A visible fissure on examination of the anus Look for any signs of infection Ask the patient about constipation as this is likely the underlying cause and must be treated Acute fissures will be extremely painful to the touch and will lead to anal spasm

Answer 260

Advice on fibre, liquids and fewer refined foods (more whole grain) to soften stools Consider prescription of laxatives (bulk forming) Simple oral analgesia (avoid opiates as they will cause constipation) or topical analgesia Consider GTN ointment which will relax the anal sphincter, preventing spasm and improving healing Botox can also be used to relax the anus Surgery – Lateral sphincterotomy

Answer 261

Patients with multiple fissures may have formed them due to Crohn's disease Large, non-healing fissures may have been caused by anal cancer

Answer 262

A collection of pus in the anal/rectal region caused by infection of an anal fissure, as a result of STIs or blocked anal glands If left untreated they can lead to necrotising fasciitis, which is a medical emergency

Answer 263

Painful, hardened tissue in the perianal area -Pain is usually constant, throbbing and worse on sitting down Discharge of pus from the rectum and tenderness around the anus Lumps and nodules Fever, constipation or pain associated with bowel movements

Answer 264

DRE usually enough for diagnosis – pus on finger STI screen may be relevant Proctoscopy/sigmoidoscopy to rule out malignant cause MRI will show location of fistulae and locations of deep abscesses

Answer 265

Connection between anus or rectum and the skin allowing a leak of faeces to the skin Associated with diverticular disease, IBD, malignancies, tuberculosis and actinomycosis Patients will have faecal leak without feeling that they are defaecating

Answer 266

Surgical drainage of abscesses Analgesia Antibiotics only relevant if the patient is diabetic or immunosuppressed Best treatment for anal fistulae is to lay them open by cutting between them and the skin- This can lead to problems with continence as the anus and rectum may have to be cut

Answer 267

Gastric band surgery | Gastric bypass

Answer 268

Reduction of stomach capacity leads patients to feel fuller, sooner and therefore reduces their overall calorie intake Creates an additional stomach pouch, which acts as a smaller stomach which will hold much less food Size can easily be adjusted to allow for more or less of an effect Fewer complications than gastric bypass

Answer 269

Reducing length of small bowel – Leads to malabsorption of food, thus reducing overall calorie intake, also has a hand in reducing the total concentration of gut peptides, thought to lead to reduced hunger response A loop of jejunum is attached to the stomach allowing food to bypass the duodenum and proximal jejunum Greater weight loss than gastric band but greater risk of complications Patients will likely require multivitamin supplementation due to the reduce absorption of key vitamins from their small bowel

Answer 270

BMI≥40 or ≥35 with significant comorbidity that could improve with reduced weight e.g. Type 2 diabetes or Severe hypertension Failure of non-surgical management to achieve and maintain any clinically beneficial weight loss for 6 months Patient must be fit enough for surgery and anaesthesia Patient must have shown willingness to lose weight by following previous guidance on diet and exercise regimes Patient must be willing to continue these regimes The patient must be well informed and motivated to lose weight