GI Flashcards
1
Q
What is Grey-turners sign?
A
Bruising of the flanks and indicates intra-abdominal bleeding, consequently it is predictive of severe and acute pancreatitis
2
Q
What is Cullen’s sign?
A
Bruising around the umbilicus, it is also indicative of intra-abdominal bleeding and predictive of acute pancreatitis
3
Q
What does coffee ground haematemesis mean?
A
Upper GI bleeding, for example due to a peptic ulcer, or use of NSAIDs/SSRIs
4
Q
What are some possible causes of epigastric pain?
A
Pancreatitis, peptic ulcer disease, aortic aneurysm, perforated oesophagus, MI
5
Q
What are some possible causes of RUQ (hypochondrial) pain?
A
Biliary colic, cholecystitis, renal, hepatitis, peptic ulcer, carcinoma, subphrenic abscess, duodenal ulcer
6
Q
What are some possible causes of LUQ (hypochondrial) pain?
A
Peptic ulcer, suphrenic abscess, renal, carcinoma, ruptured spleen, pneumonia
7
Q
What are some possible causes of loin pain?
A
Renal colic, pyelonephritis, perforated bowel, referred pain, pancreatitis, ruptured spleen
8
Q
What are some possible causes of LLQ (iliac fossa) pain?
A
Diverticulitis, volvolus, colon cancer, pelvic abscess, IBD, UTI
9
Q
What are some possible causes of RLQ (iliac fossa) pain?
A
Appendicitis, UTI, volvolus, colon cancer, pelvic abscess, IBD, crohns ileitis
10
Q
What are some possible causes of pelvic pain?
A
Pregnancy, UTI, carcinoma, mnestruation
11
Q
What are some causes of generalised pelvic pain?
A
Gastroenteritis, IBS, constipation, peritonitis
12
Q
What is an ileus?
A
Lack of movement in the intestines leading to build up and blockage
13
Q
What is Gilbert’s syndrome?
A
A harmless inherited condition in which the liver doesn’t produce the enzyme to break down bilirubin, so it builds up causing jaundice
14
Q
What is tenesmus and when is it common?
A
The sensation of incomplete emptying after defecation, commonly experienced in IBS
15
Q
What is rebound tenderness and what usually causes it?
A
Pain upon removal of pressure from the abdomen, commonly caused by peritonitis
16
Q
What is Rovings sign?
A
Palpation of the left lower quadrant produces pain in the right lower quadrant - this is indicative of appendicitis
17
Q
What is Murphy’s sign?
A
Pain on taking a deep breath, when the examiner is pressing down on the right upper quadrant - this is indicative of cholecystitis
18
Q
What is McBurneys point?
A
A point that lies one-third of distance laterally on a line drawn from the umbilicus to the right anterior superior iliac spine - this is where the appendix lies
19
Q
In a GI exam, which organs should descend on inspiration?
A
Liver, spleen, kidneys
20
Q
What are the two layers of the peritoneum?
A
Parietal (lines the abdominal wall)
Visceral (covers organs)
21
Q
At what level does the oesphogus pass through the diaphragm?
A
T10
22
Q
Where does the stomach receive its blood supply from?
A
Coeliac trunk of common hepatic artery
Gastric arteries
23
Q
What causes dysphagia?
A
Mechanical block (malignancy, GORD, extrinsic pressures) Motility disorders (achalasia - failure of LOS to relax due to degeneration of myenteric plexus, stroke, MS, MND, parkinsons)
24
Q
What cancers occur in the oesophagus?
A
Adenocarcinoma (from Barret’s)
Squamous cell carcinoma
25
What is the role of the duodenum?
1. Takes in secretions from the pancreas and gallbladder, by producing CCK and secretin
2. Slows gastric emptying
3. Increases pancreatic activity
26
What is the role of the jejunum?
Lots of villi to increase surface area, involved in nutritional absorption and regular peristalsis
27
What is the role of the ileum?
Absorption of vitamin B12 and bile salts and whatever products of digestion were not absorbed by the jejunum
28
What are taeniae coli?
Three separate longitudinal ribbons of smooth muscle on the outside of the ascending, transverse, descending and sigmoid colons. They contract lengthways to produce haustra
29
What is the role of the large intestine?
1. Absorption of water and minerals
2. Mass movement (peristalsis twice an hour)
3. Defaecation
30
What is peritonitis?
Perforation of a peptic/duodenal ulcer, diverticulum, appendix, bowel or gallbladder
31
What are the signs of peritonitis?
Prostration (lying flat), lying very still, shock, rebound tenderness, guarding, rigidity, absent bowel sounds
32
How is peritonitis managed (tests and treatment)?
Tests - FBC, CRP, U&E, amylase, LFT, ABG, urinalysis, erect CXR (gas), AXR, USS
Treatment - Laparoscopy
33
What are the symptoms of acute appendicitis?
Periumbilical pain that moves to the RIF
Anorexia
Vomiting (often from the pain)
Constipation/diarrhoea
34
What are the special tests to diagnose appendicitis?
Rosving's sign - pain > in RIF when you press on LIF
Psoas sign - pain on extending hip if retrocaecal appendix
Cope sign - pain on flexion and internal rotation of right hip
35
Which is the gold standard imaging for acute appendicitis?
CT - only downfall is it takes time
36
How is acute appendicitis treated?
1. Metronidazole + cefuroxime
| 2. Laparoscopic appendicectomy
37
A girl has acute abdominal pain radiating to the shoulder tip. What are your two main differentials and how do you differentiate between the two?
Acute cholecystitis - vomiting, jaundice, fever, rigors
| Ectopic pregnancy - vaginal bleeding following weeks of amenorrhoea
38
What are the symptoms of intestinal obstruction?
Vomiting (faeculant = severe)
Colicky pain
Constipation (ask about flatulence)
Distenstion
39
What are the main causes of obstruction of the small bowel?
Adhesions
| Hernias
40
What are the main causes of obstruction of the large bowel?
Colon cancer
Constipation
Diverticular structure
Volvolus
41
What is an ileus?
A functional obstruction of the bowel from reduced motility - painless, bowel sounds will be absent
42
What would you hear on auscultation of a mechanical obstruction?
Tinkling bowel sounds
43
How is an obstruction managed?
NGT and IV fluids to replenish electrolytes
| Surgery
44
What is leukoplakia and what causes it?
Oral mucosal white patch - premalignant, HIV
45
What are aphthous ulcers and what causes them?
Shallow painful ulcers on the tongue/oral mucosa - trauma, crohn's, coeliac, behect's, erythema multiform, lichen plans, infections
46
What is candidiasis and what causes it?
White patches on buccal mucosa - fungal, antibiotics, immunusuppresion
47
What is angular stomatitis and what causes it?
Fissuring of the mouth corners - denture problems, candidiasis, iron deficiency
48
What is gingivitis and what causes it?
Gum inflammation and hypertrophy - poor oral hygiene, drugs, pregnancy, vitamin c deficiency, leukemia
49
What is oral pigmentation and what causes it?
Perioral brown spots - Peutz-Jehjers disease, Addison's
50
What are the symptoms of peptic ulcer disease?
```
ALARMS
Anaemia
Loss of weight
Anorexia
Recent symptoms
Malaena/haematemesis
Swallowing difficulties
```
51
How can you differentiate duodenal and gastric ulcer by their symptoms?
DUODENAL - Gnawing epigastric pain BEFORE meals or at night, which is relieved by eating
GASTRIC - Gnawing epigastric pain AFTER meals
52
How are H.pylori peptic ulcers treated?
Triple therapy:
- Amoxicillin
- Clarithromycin
- Omeprazole/lansoprazole
53
How can you test for presence of H.pylori?
Non-invasive - 13C breath test
| Invasive - CLO test (rapid urease test)
54
What are the risk factors for peptic ulcer?
H.pylori, smoking, NSAIDS, reflux, delayed gastric emptying, stress
55
What is GORD?
Reflux of stomach contents, causing over 2 episodes of heartburn a week (aka. waterbrash)
56
Prolonged reflux can lead to what?
Benign oesophageal stricture
Oesophagitis
Barret's oesophagus (sqaumous --> columnar)
57
What are the risk factors for GORD?
```
Hiatus hernia
Loss of peristaltic function
Abdominal obesity
Gastric acid hyper secretion
Slow gastric emptying
Smoking/alcohol
Pregnancy
Drugs
```
58
What are the symptoms of GORD?
```
Heartburn
Belching
Acid/waterbrash
Odynophagia
Nocturnal asthma/cough
```
59
How can GORD be managed?
Antacids/alginates/PPIs for symptomatic relief
60
What is the Rockall score?
A scoring system for upper GI bleeds, based on:
- Age
- BP
- Pulse
- Comorbidity
- Diagnosis
- Signs of recent haemorrhage on endoscopy (NB full resuscitation must be done before attempting this)
61
What is the main cause of upper GI bleeds?
Peptic ulcer, mallory-weiss
62
How should an acute GI bleed be managed?
Acute - ABC, 500ml fluid challenge over 5 minutes, surgery
| Long-term - PPI (heal ulcer), antibiotics (h.pylori) to prevent rebleed
63
What are the main causes of lower GI bleeds (and the risk factors)?
Small bowel mucosal damage (NSAID/aspirin)
Diverticular bleeding (NSAID/aspirin)
Colorectal cancer (weight loss)
Ischaemic colitis (preceding hypovolaemia)
Aorto-colic fistulae (previous vascular surgery)
Radiation proctitis (previous malignancy)
Haemorrhoids (bright red blood)
64
What are the indications for surgery for an GI bleed?
- Severe bleeding, despite transfusion
- Active/uncontrollable bleeding at endoscopy
- Rockal score (>3 at start, or >6 after endoscopy)
65
What are oesophageal varices?
Dilated sub-mucosal veins, due to portal hypertension and cirrhosis (often related to alcohol abuse)
66
How are varices managed?
1. Propanolol to reduce portal hypertension
| 2. Endoscopic banding ligation (tie off varices to prevent bleeding)
67
What are the diagnostic indications for upper GI endoscopy?
Haematemesis, new dyspepsia, suspected cancer, persistent vomiting
68
What are the diagnostic indications for colonoscopy?
Rectal bleeding, persistent diarrhoea, biopsy of lesion seen on barium enema, assessment of IBD, suspected cancer
69
What are the diagnostic indications for duodenal biopsy?
Coeliac disease, malabsorption
70
What is IBS?
A group of non-specific abdominal symptoms for which no organic cause has been found (likely due to a disorder of intestinal motility)
71
What are the symptoms of IBS?
Abdo pain relieved by defecation, altered stool form or bowel frequency and 2 of:
- Urgency
- Tenesmus
- Bloating
- Mucous PR
- Symptoms worse after eating
72
What exacerbates IBS?
Stress, menstruation, gastroenteritis
73
How is IBS managed?
Conservative - healthy diet, limit stress
| Medical - stool softeners if constipated (isphagula, lactulose), bulking agents if diarrhoea, bloating (mebeverine)
74
What is IBD?
An immune-mediated chronic intestinal condition, made up of Crohn's and UC
75
What is UC?
Relapsing and remitting inflammation of the colonic mucosa
76
Where does UC affect?
Anywhere proximal to the ileocaecal valve (often anal sparing)
77
Describe the inflammation in UC
Uniform and continous, confined to the mucosa, crypt abscesses
78
What are the symptoms of UC?
Crampy abdo pain, bloody diarrhoea, fatigue, systemically unwell during attacks, mouth ulcers (secondary to malabsorption)
79
What are the complications of UC?
- Perforation
- Toxic megacolon
- Venous thrombosis
- Colon cancer
80
How is UC treated?
Mild - sulfasalazine (DMARD) PO
Moderate - prednisolone PO
Severe - IV hydrocortisone
81
What are the indications for a stoma in UC?
Perforation
Massive haemorrhage
Toxic megacolon
Failed medical therapy
Needed in about 20% of patients
82
Where does Crohn's affect?
Mainly terminal ileum and proximal colon, but can affect anywhere in the gut (often rectal sparing)
83
Describe the inflammation in Crohn's disease?
Transmural, skip lesions (unaffected bowel between areas of active disease)
84
What are the symptoms of Crohn's disease?
Abdominal pain, diarrhoea, fatigue, mouth ulcers (primary) systemically unwell
85
What are the complications of Crohn's?
- Small bowel obstruction (due to narrowing and thickening)
- Abscess formation
- Fistulae
- Perforation and rectal haemorrhage
- Anal strictures
- Colon cancer
86
How is Crohn's treated?
Mild: prednisolone PO
Severe: hydrocortisone IV
87
How can you tell if a stoma bag is an ileostomy or colostomy?
Ileostomy - protect skin due to enzymes, right sided
| Colostomy - ok to touch skin, left sided
88
What causes bloody diarrhoea?
UC, gastroenteritis (campylobacter, shigella), colorectal cancer, polyps, ischaemic colitis
89
What causes mucus diarrhoea?
IBS, colorectal cancer, polyps
90
What causes steatorrhoea?
Pancreatic dysfunction
91
What is loperamide used for?
Diarrhoea - bulking agent
92
If colorectal malignancy is suspected, what imaging should be done?
Barium enema
| Colonoscopy
93
What are the different types of laxatives used to treat constipation?
```
Stimulant - senna, glycerol
Bulking agents (increased faecal mass to stimulate peristalsis) - loperamide
Isphagula husk
Stool softeners - docusate sodium
Osmotic laxatives - lactulose, macrogol
```
94
What are the different types of laxatives used to treat constipation?
```
Stimulant - senna, glycerol
Bulking agents (increased faecal mass to stimulate peristalsis) - loperamide
Ispaghula husk
Stool softeners - docusate sodium
Osmotic laxatives - lactulose, macrogol
```
95
What is the classical triad of mesenteric ischaemia?
1. Acute severe abdominal pain
2. No other abdominal signs
3. Shock
96
What are some causes of mesenteric ischaemia?
ASK ABOUT CARDIOVASCULAR HISTORY
- Thrombus/emboliv (usually in superior mesenteric artery)
- Venous
- Trauma
- Vasculitis
- Strangulation (volvolus/hernia)
97
How is staging investigated for GI cancers?
CT
PET (radioactive)
Laparoscopy
Endoscopic ultransound
98
What causes oesophageal cancer?
Smoking, alcohol, diet, Barret's, achalasia
99
What causes gastric cancer?
Diet, H.pylori, smoking, alcohol, FAP, Barret's, pernicious anaemia
100
What is the main type of:
a) oesophageal cancer?
b) gastric cancer?
BOTH adenocarcinoma
101
What are the 2WW criteria for upper GI?
- Dysphagia, obstructive jaundice, upper abdo mass
- Dyspepsia with weight loss, anaemia or vomiting, at any age
- All dyspepsia > 55 years for 6 weeks
- Dyspepsia with over 2 first degree relatives with upper GI cancer, Barrett's, pernicious anaemia
- Previous peptic ulcer surgery
102
Describe the epidemiology of colorectal cancer
3rd most common cancer, and 2nd most common cancer deaths
103
What causes colorectal cancer?
IBD, poor diet, smoking, alcohol, genetic predisposition (FAP, HNPCC)
104
What are the specific symptoms of left sided colorectal cancer?
Looser stools, tenesmus, bleeding
105
What are the specific symptoms of right sided colorectal cancer?
Iron deficiency anaemia, weight loss, abdo pain, palpable mass
106
What are the specific symptoms of rectal cancer?
Rectal bleeding, tenesmus
107
What is FAP?
An inherited disorder causing numerous polyps to form in the epithelium of the large intestine
108
What is HNPCC/Lynch syndrome?
Lynch syndrome (HNPCC or hereditary nonpolyposis colorectal cancer) is an autosomal dominant genetic condition that has a high risk of colon cancer
109
What is the 2WW criteria for lower GI cancer?
- >40yo rectal bleeding and looser/frequent stools for >6weeks
- >60yo rectal bleeding >6weeks alone
- >60yo looser/frequent stools >6weeks alone
- Any age with right lower abdo or rectal mass
- Any age unexplained iron deficiency anaemia
110
What is CEA?
Carcinoembryonic antigen - this is raised in many patients with CRC and indicates a worse prognosis
111
How are GI cancers staged (what criteria)?
Upper GI - TNM
| Lower GI - TNM, Dukes
112
What screening tests are available for colon cancer?
Between 50-75 yrs:
1. Faecal occult blood testing (check for hidden blood in stools)
2. Flexible sigmoidoscopy
3. Colonoscopy
Looks for adenomatous polyps (80% of cause)
113
What is the difference between diverticulum, diverticulosis, diverticular disease and diverticulitis?
Diverticulum - outpouching of gut wall
Diverticulosis - outpouchings are present
Diverticular disease - outpouchings are symptomatic
Diverticulitis - outpouchings are inflamed, causing colicky pain in the LLQ
114
Where do most diverticuli occur?
Sigmoid colon
115
What are the complications of diverticulitis?
Perforation - peritonitis and shock
Haemorrhage - sudden and painless
Fistulae - need surgery
Abscess - pus in rectum (if not could be subdiaphragmatic)
116
What is a hiatus hernia, and what are the two types?
When part of the stomach moves up through the chest through a hole in the diaphragm:
- Sliding (80%) - gastro-oesophageal junction slides up into the chest, causes reflux
- Rolling (20%) - junction remains in abdomen but a bulge of stomach herniates up into the chest, no reflux
117
What is a hernia?
The protrusion of a viscous through the wall of the cavity into an abnormal position
118
What is an incarcerated hernia?
It means that the contents of the hernial sac are stuck inside by adhesions
119
What is a strangulated hernia?
This means the hernia has become ischaemic, bowel sounds will be absent, and the patient becomes toxic --> URGENT SURGERY
120
What is an indirect inguinal hernia?
Passes through the internal inguinal ring and out through the external ring (75%)
121
What is a direct inguinal hernia?
Pushes directly forward through the posterior wall of the inguinal canal into a defect in the abdominal wall
These are more likely to strangulate than direct hernias
122
Where are the deep and superficial inguinal rings located?
Deep - midpoint of the inguinal ligament
| Superficial - superior and medial to the the pubic tubercle
123
What is a femoral hernia and where is it felt?
Bowel enters the femoral canal and points down the leg - common in middle aged woman, likely to be irreducible and strangulate
The neck of the hernia is likely to be felt inferior and lateral to the pubertal tubercle
124
Name 6 different types of hernia
```
Inguinal
Femoral
Hiatus
Paraumbilical
Epigastric
Incisional (through previously made incision)
Lumbar
Spigelan (rectus sheath)
Richter (part of the bowel protrudes through abdo wall, can cause gangrene)
```
125
What values are measured using the MUST tool?
Height, weight (now and 6 months ago), BMI, acute disease effect
```
0 = low risk
1 = medium
2 = high
```
126
If conventional values can't be used, what can you measure in a MUST tool?
- Mid upper arm circumference (muscle mass)
- Triceps skinfold thickness (fat stores)
- Grip strength (functional status)
- Waist cicrumference (fat stores)
127
When is parenteral nutrition used?
If gut is inaccessible or non-functioning, or if oral/enteral feeding is inadequate or unsafe
128
What does parenteral nutrition contain?
Glucose
Amnio acids
Fat emulsion
Vitamins and trace elemtents
129
What are the complications of parenteral nutrition?
- Line sepsis
- Vomiting and diarrhoea
- Glucose intolerance
- Thiamine depletion
- Refeeding syndrome
130
What is refeeding syndrome?
Fluid and electrolyte shifts with consequent metabolic implications in malnourished patients undergoing re-feeding
131
What systemic features are associated with IBD?
Clubbing
Apthous ulcers
Erythema nodosum (nodular red rash on shins)
Pyoderma gangrenosum (necrotic leg tissue)
Conjunvitivits/iritis
Large joint arthritis
Ankylosing spondylitis (HLA-b27 connection)
