GI Flashcards
(505 cards)
1
Q
What are 3 emergency causes of haematemesis in order of frequency?
A
Duodenal ulcer
Gastric ulcer
Oesophageal varices
2
Q
What are 5 non-emergency causes of haematemesis?
A
Oesophagitis - reflux, bisphosphonates, toxins, Crohn’s, candida
Mallory-Weiss tear
Gastric carcinoma
3
Q
5 important questions in haematemesis history
A
Timing, frequency, volume Smoking, alcohol Medical history Dyspepsia, dysphagia, odynophagia Steroids, NSAIDs, bisphosphonates, anticoagulants
4
Q
Signs on haematemesis exam
A
Telangiectasia
Liver stigmata - jaundice, hepatosplenomegaly, spider naevi, ascites, palmar erythema
Epigastric tenderness (PUD, gastritis)
5
Q
Investigations haematemesis
A
FBC - anaemia, low platelets if hypersplenism from portal hypertension (varices)
High urea:creatinine ratio = upper GI bleed
LFT - liver damage
Group and save and 4u crossmatched
OGD - immediately after resus if emergency, in 24h if not
CT abdo with IV contrast if endoscopy unremarkable or too unwell
Erect CXR for perforated ulcer - pneumoperitoneum
H pylori - PUD
ABG - hypoperfusion
6
Q
What are the 2 scoring systems for upper GI bleed and what is it for?
A
Glasgow-Blatchford Bleeding score:
1. FBC - urea, Hb
2. Obs - pulse, systolic bp
3. Sx - melaena, syncope
4. Hx - known hepatic or cardiac failure
Associated with >risk of intervention need
Rockfall score - severity for GI bleed post-endoscopy
7
Q
Resus for haematemesis
A
Transfuse blood, platelets, clotting factors according to local massive bleed protocol
Platelet transfusion if <50 and active bleeding
FFP if active and APTT>1.5
Prothrombin complex if activebleeding and warfarin
Recombinant factor VIIa if all else failed
8
Q
Manage non-variceal upper GI bleed
A
Endoscopic: - Clips +- adrenaline - Or thermal coagulation with adrenaline - Or fibrin/thrombin with adrenaline PPI if stigmata of recent haemorrhage seen on endoscopy
9
Q
Manage variceal upper GI bleed
A
Terlipressin until haemostats is achieved or 5d
Abx prophylaxis if suspected
Band ligation for oesophageal, and TIPS if not successful
Endoscopic injection if gastric, then TIPS if not successful
Long term B blockers
10
Q
GI bleeding control and prevention if on anticoagulants
A
Continue low dose aspirin once haemostasis achieved
Stop NSAIDs during acute phase
Consider stopping clopidogrel - seek specialist advice
11
Q
Likely causes of diarrhoea with blood and mucus
A
Inflammation - UC, radiation, bacterial, pseudomembranous colitis
Acute gastroenteritis - campylobacter, shigella, E. coli
12
Q
Likely cause of pale and greasy stools
A
Malabsorption - SI disease, pancreatic insufficiency
- coeliac disease fhx
- alcohol
13
Q
Likely cause of diarrhoea with nausea and vomiting
A
Enteritis, chronic pancreatitis
14
Q
Likely cause of diarrhoea with joint pain, skin damage, uveitis
A
IBD
15
Q
Hypomotility and malabsorption in bowels
A
Scleroderma
16
Q
Jaundice and steatthoroea
A
Pancreatitis or pancreatic carcinoma
17
Q
Important drug history in diarrhoea
A
Colchicine, metformin, digoxin = GI ADR
Purgatives
Broad spectrum abx (penicillin, cephalosporins) = C diff - pseudomembranous colitis
18
Q
Important medical history in diarrhoea
A
Vagotomy in GI surgery = diarrhoea
GI resection = reduced motility and absorption
Radiotherapy on abdo/pelvis = GI ADR for years
Systemic conditions: DM - neuropathy, collagen, vascular disease
HIV = atypical infections ie cryptosporidium and CMV
19
Q
Diarrhoea and dehydration on exam
A
Acute onset
IBD
VIP-oma - lose electrolyte-rich fluid in large quantities
20
Q
Diarrhoea and pallor on exam
A
IBD/malignancy = blood loss
Anaemia of chronic disease
Iron and vit B/folate deficiency in malabsorption
21
Q
Weight loss and diarrhoea
A
Malignancy or malabsorption
22
Q
3 IBD findings on exam
A
Aphthous ulcers, pyoderma gangrenosum, uveitis
23
Q
1 thyrotoxicosis finding on exam
A
Proptosis or exophthalmos
24
Q
1 adrenal insufficiency finding on exam
A
Pigmentation
25
1 diabetes finding on exam
Peripheral neuropathy
26
Skin colour changes on GI exam for diarrhoea
Radiation enteritis
27
RIF mass on exam for diarrhoea
Crohn’s or caecel carcinoma
28
Diarrhoea and low urea
Malabsorption or malnutrition
29
Diarrhoea and high urea
Dehydrated or melaena
30
Urine dipstick for diarrhoea
5-hydroxyindoleacetic acid (5-HIAA) = metabolite of serotonin = carcinoid syndrome
31
LFT for diarrhoea
Pancreatic insufficiency or alcohol excess
32
Primary care investigations for diarrhoea
FBC (deficiencies - calcium, B12, folate, ferritin), coeliac screen (IgA tissue transglutaminase antibody (t-TGA) or IgA endomysial antibody (EMA)), U&E, LFT, thyroid, ESR, CRP, urine dipstick, stool culture
33
3 possible stool culture findings in diarrhoea
Ova and cysts in giardia - 3 specimens 2-3 days apart due to intermittent shedding
C diff if recent abx or nursing home resident
Viruses if immunosuppressed
34
Imaging for diarrhoea
Flexible sigmoidoscopy if <45y/o or colonoscopy if >45y/o, +- biopsy: mucosal inflammation, rectosigmoid carcinoma or polyps, melanosis coli in purgative abuse
Others:
Abdo x-ray for faecal impaction or megacolon (UC and very unwell)
Small bowel barium study/enema/colonoscopy if blood or anaemia - IBD
Duodenal biopsy if steatthorea and folate deficiency - coeliac
Breath test for bacterial overgrowth (H pylori) if steatthoea, low B12, normal folate
35
Red flag symptoms for diarrhoea
```
Unintentional or unexplained weight loss
Rectal bleeding
>6 weeks in >60y/o
Abdominal or rectal mass
Anaemia
Raised inflammatory markers
Family history or bowel or ovarian cancer
```
36
Diverticular disease - what is it and symptoms
Mucosal outpouchings in descending and sigmoid colon
| Painless heavy self limiting bleeds
37
Haemorrhoids - what is it and symptoms
Enlarged vascular cushions in the anal canal
Cause mass and priorities
Fresh blood separate from stool
Painful when thrombosed
38
Malignancy symptoms with rectal bleeding
Other GI symptoms, weight loss
Family history
No focal anal symptoms
dark red blood mixed with stool
39
6 questions in rectal bleeding history
Pain - wake at night, increase or decrease with defecation
Mucus
Previous episodes
Haematemesis
Family history of cancer or IBD
Nature - colour, duration, frequency, relation to stool
40
Rectal bleeding examination findings and suggestions
General - anaemia, cachexia, lymphadenopathy
Mass = constipation from haemorrhoid with fissure
LIF tenderness +- guarding = inflammed diverticulae
Perianal lesions or skin tags = thrombosed haemorrhoids
Discharge = IBD or anorectal carcinoma
Increased tone and pain on DRE = fissure
Mass on DRE = rectal polyp or carcinoma
41
Investigations for rectal bleeding and indications
Proctoscopy for position of haemorrhoids or anal fissure
Rigid sigmoidoscopy for suspicious lesions 15-20cm from anal margin - carcinoma, IBD
Flexible sigmoidoscopy for left colon malignancy
Full colonoscopy and angiogram to identify bleeeding vessel +- arterial embolisation
Emergency OGD and CT angiogram if haemodynamically unstable
Others: FBC, U&E, LFT, coag, g&s, stool culture
42
Where is the cause of rectal bleeding likely to be depending where blood is in relation to stool?
Mixed and dark red = higher up - polyps, cancer, angiodysplasia, inflammatory
Separate from stool = low rectal +- mucus - anorectal carcinoma, diverticular disease, haemorrhoids, IBD
Spotting = haemorrhoids, anal tear
43
8 symptoms of IBS
```
LIF pain, relieved by passing wind and defecation
Rectal dissatisfaction
Distension and sensation of bloating with no obstruction
Strain/urgency
Symptoms worse after meals
Mucus
Pain
Change in bowel habit
```
44
4 non-GI symptoms of IBS
Dysparaunia
Urinary symptoms
Fatigue
Anxiety and depression
45
Things to check in IBS history
No: weight loss, night symptoms, not acute onset, rectal bleeding, not >50y/o
46
3 IBS theories
Abnormal GI sensation or motility
Abnormal bowel flora
Altered GI serotonin signalling
47
Treat IBS: 4 advice and 4 medication
1. Reassure and explain
2. Try excluding certain foods
3. Increase fibre and fluids if constipated
4. Hypnotherapy, exercise and relaxation
1. Anti-spasmodic - mebeverine
2. Anti-motility - loperamide
3. Laxative - bisacodyl
4. Treat depression - TCA for pain
48
Blood supply to colon, 3 on each side
Right - ileocaecal, right colic, middle colic
| Left - marginal, left colic, sigmoid arteries
49
What are the brought categories of causes of jaundice and what form is the bilirubin in for each?
```
Pre-hepatic = unconjugated
Intra-hepatic = mixed
Post-hepatic = conjugated
```
50
What is the process of heme breakdown and where is it done?
Spleen/macrophages: heme + heme oxygenase = biliverdin
+ biliverdin reductase = bilirubin (unconjugated and insoluble, bound to albumin)
Through sinusoids to hepatocytes in liver
Unconjugated bilirubin + glucuronic acid = conjugated bilirubin (water soluble)
Through biliary system into SI, + bacterial proteases = urobilinogen
90% = reduced to sterocobilinogen/oxidised to stercobilin = pigment in faeces
10% through portal vein to liver, then to kidney = urobilin (pigment) and to urine
51
What is the enterohepatic urobilinogen cycle?
Conjugated bilirubin is metabolised by bacterial proteasese to 90% urobilinogen reduced to stercobilin, oxidised to stercobilinogen which is the pigment in faeces
52
What happens to urobilinogen as a result of biliary obstruction?
Less conjugated bilirubin enters SI so lower levels of urobilin and stercobilin. Conjugated bilirubin enters blood stream and secreted by kidneys, so dark urine and pale stools
53
What are 2 main causes of dark urine and pale stools?
Cholestasis - less conjugated bilirubin enters SI
| Reduced intestinal flora by broad spectrum abx - less conjugated bilirubin metabolised
54
What are 3 causes of reduced urobilinogen in urine?
Obstruction - reduce bilirubin in SI
Abx - reduced bacterial flora to metabolise bilirubin
Drugs that acidify urine ie ascorbic acid (vit c)
55
How are post-hepatic and hepatic causes of jaundice differentiated?
USS - dilated bile ducts = obstruction ie gall stones
56
What sign is seen on examination for haemolytic anaemia?
Haemosiderin deposits on lower legs
57
What localised conditions are associated with haemosiderin deposits? Name 4
Venous eczema
Venous ulcers
Dermatitis
DVT
58
Where is pre-hepatic jaundice caused?
Spleen and blood vessels
59
Name 4 causes of pre-hepatic jaundice and 2 causes of the main 2 categories
Immune
Burns
Infection
Mechanical
Transfusion
Haemolytic anaemia: thalassaemia, RBC membrane defects (spherocytosis)
Congenital hyperbilirubinaemia: Crigler-Najjar syndrome, Gilbert’s syndrome
60
Name 6 causes of intra-hepatic jaundice
```
Alcoholic liver disease
Hepatobiliary carcinoma
Hereditary haemochromatosis
Hepatitis - viral, EBV, CMV, AI
Intrahepatic cholestasis of pregnancy
Drugs - paracetamol, amoxicillin, flucloxacilin, valproate, TB drugs, allopurinol
```
61
Where is post-hepatic jaundice caused? Name 4 locations
Biliary tree: L and R and common hepatic arteries, cystic duct, common bile duct, ampulla of vater
62
Name 2 intra-hepatic causes of post-hepatic jaundice
Cholangiocarcinoma
| AI - PSC, PBC
63
Name 4 extra-hepatic causes of post-hepatic jaundice
Gall stones
Biliary stricture after lap chole
Chronic pancreatitis
Drugs causing cholestasis - Flucloxacillin, co-amoxicillin, steroids, nitrofurantoin
64
Relevant hepatitis hx (5)
```
Contact/area with A-E or EBV
Risky behaviours - sharing needles, sex
Seafood abroad
Alcohol
Farm/sewers = leptospirosis
```
65
Relevant jaundice PMH (2)
```
UC = PSC
Cholecystectomy = stricture or bile duct stone
```
66
Relevant jaundice fx (3)
Congenital hyperbilirubinaemia
Wilson’s disease
A1 antitrypsin deficiency
67
What law is looked for on jaundice exam?
Courvoisier’s law: palpable gall bladder, non tender is not gall stones
68
Jaundice with acute distension (2)
Acute hepatitis
| Hepatic vein thrombosis causing ascites
69
Jaundice with raised JVP and peripheral oedema
Heart failure = congested
70
Causes of generalised lymphadenopathy and jaundice (3)
EBV
CMV
Toxoplasmosis
71
5 signs of chronic liver disease
```
Palmar erythema
Spider naevi
Gynaecomastia
Ascites
Hepatosplenomegaly
```
72
Kaiser-Fleicher rings and jaundice
Wilson’s disease
73
Resp disease and jaundice
CF or a1 antitrypsin deficiency
74
Neuro signs and jaundice
Hepatolenticular degeneration in Wilson’s disease
75
AST:ALT raised
Viral hepatitis
76
AST:ALT >2
Alcoholic liver disease
77
Alkaline phosphatase raised
Biliary obstruction (or bone injury)
78
Gamma-GT raised
Biliary obstruction
79
What clotting study is abnormal in liver disease and why?
PT: vit K absorption reduced as it is fat soluble and there are fewer bile salts. Less factor 2, 7, 9, 10 (vit K dependent) so increased PT
80
FBC in alcoholic liver disease
MCV raised due to RBC damage (increased deposition of lipids and cholesterol on membrane surface, increasing size of RBC) - marrow toxicity, and B12/folate deficiency
81
Acute viral serology in liver screen
EBV, CMV, hepatitis A, B, C, E
82
Chronic viral serology in liver screen
Hep B, C
83
Acute non-infective markers in liver screen (4)
Anti-nuclear antibody - Sjogren’s, SLE, scleroderma
Paracetamol level
IgG subtypes increased in chronic active and alcoholic hepatitis and cirrhosis
Caeruloplasmin - carries copper, oxidises iron so it can be carried by transferrin, synthesised in liver - low in Wilson’s disease
84
Chronic non-infective markers in liver screen (5)
ANA (SLE, sjogren’s, scleroderma), AMA (PBC), Anti-SM (AI hepatitis)
Caerulosplasmin - low in Wilson’s disease
T-TGA - coeliac disease
Ferritin (increase) and transferrin (decrease) saturation - acute phase protein
A1 antitrypsin
85
Signs of Wilson's disease (5)
```
Keyser-Fletcher rings
Renal tubular acidosis
Hyperparathyroid
Infertility
Cardiomyopathy
```
86
Imaging for jaundice
USS
MRCP if USS inconclusive or limited, or obstructive (dilated ducts)
Biopsy
87
Urine test for jaundice (3)
Low urobilinogen and raised bilirubin = obstruction
Low bilirubin = unconjugated (pre-hepatic cause)
Haemosiderin = haemolysis
88
Manage complications of liver failure (3)
Vit K, treat hypoglycaemia, FFP
89
Manage encephalopathy (decompensated liver failure)
Laxative
| Neomycin/rifaximin - decrease ammonia producing bacteria in bowel
90
Obstructive jaundice management (surgery, med and symptoms)
ERCP, open surgery, cholecystectomy, bile duct stenting
Cholestyramine increases biliary drainage
Antihistamines for pruritis
91
Role of IgG
Secondary immune response - activates complement pathway: macrophages and neutrophils to phagocytosis, eosinophils and NK cells to extracellular targets
Internal body fluids, crosses placenta (Gestation)
Inhibited by staph a
92
Role of IgA
Most prevalent, produced in mucosae
Neutralises microorganisms in GI and resp tract
In breast milk
93
Role of IgM
Primary response (Meets), stays in circulation
94
Role of IgD
On B cells - antigen receptor
95
Role of IgE
Extracellular organisms - activates mast cells and basophils to release inflammatory mediators which attack parasitic worms
96
What is acute liver failure?
Massive hepatocyte necrosis
97
3 main causes of acute liver failure and survival rates
1) paracetemol toxicity 65%
2) idiosyncratic drug use 25%
3) acute hepatitis B 25%
98
Normal paracetamol metabolism
Mostly glucuronidation or sulfation, some with p450 to NAPQI, binds to glutathione to conjugate and makes cysteine and mercaptopuric acid conjugates
99
Paracetamol toxicity metabolism
Glutathione depleted (also in malnutrition) so more NAPQI which causes hepatocyte injury
100
Classification of acute liver failure?
From onset of jaundice to hepatic encephalopathy:
1) hyperacute <7d
2) acute 8-28d
3) subacute 29d-12w
101
Outcome of hyperacute liver failure
Cerebral oedema and RICP more likely
| Spontaneous resolution more likely
102
Definition of acute liver failure (3)
Hepatic encephalopathy
Jaundice
Coagulopathy INR>1.5
103
Hepatic encephalopathy grading and purpose
Grade at presentation is prognostic
On consciousness and physical signs
1) sleep reversible, reduced awareness, short attention span
2) personality changes, lethargy, poor memory; asterexis
3) somnolence, disorientated, confusion; rigidity, clonus, hyper-reflexia, nystagmus
4) stupor and coma
104
Risk factors for acute liver failure (7)
```
>40y/o, female
Pregnant
Poor nutrition
Paracetamol for chronic pain
Drug/alcohol/substance abuse
Chronic hep b
```
105
4 symptoms acute liver failure
Nausea and vomiting
Abdo pain
Malaise
Depression and suicidal ideation
106
4 signs of acute liver failure
Hepatomegaly (acute viral hepatitis, Budd-Chiari syndrome, CHF with congestion)
RUQ tenderness
Signs of cerebral oedema: abnormal pupillary reflexes, rigidity, decerebrate posturing
No signs of chronic liver disease - spider naevi, splenomegaly, ascites, palmar erythema
107
LFTs in Wilson’s disease
AST:ALT >2.2, alk phos:bilirubin <4
108
Role of U&E in acute liver failure
Renal failure predicts mortality - hepatomegaly syndrome, ATN, hypovolaemia
Correct K, phosphate and Mg
109
FBC in Wilson’s disease
Anaemia with Coombs test negative haemolysis
110
Role of ABG in acute liver failure
Paracetamol = metabolic acidosis, lactate increased = prognostic
111
Hepatitis viral serologies in acute liver failure - which ones?
Anti-A and E IgM
Anti-B core and surface IgM
Anti-C IgG
112
Imaging in acute liver failure
USS and Doppler for:
Hepatic vein thrombosis in Budd-Chiari
Nodularity in cirrhosis, or regeneration
113
Monitoring in acute liver failure (3)
Neuro status
Culture surveillance
Central venous pressure and pulmonary artery
114
Management of acute liver failure (6 points)
ICU as risk of rapid deterioration, sepsis, cerebral oedema, haemodynamic instability and renal failure
RICP: raise head, +- mannitol (requires good renal function or RRT)
RRT for optimal fluid management and electrolyte correction
Caution in IVi for fluid overload
Propofol and fentanyl as short half lives
Enteral nutrition
115
Manage acute liver failure due to paracetamol toxicity
NAC
116
Manage acute liver failure due to Budd-Chiari syndrome
Anticoagulation, hepatic vein stent or TIPS
117
Manage acute liver failure due to pregnancy
Caessarian
118
Manage acute liver failure due to AI hepatitis
If AST>10x or >5x with raised GGT = prednisolone
119
Manage acute liver failure due to Wilson’s disease
Plasmapheresis, continuous veno-venous haemofiltration
120
Contraindications to liver transplant (3)
Severe infection or septic shock
Extrahepatic malignancy
ARDS, severe cardiopulmonary disease or multi organ failure
121
Acute indications for liver transplant (3)
Post-operative
Trauma
Fulminant hepatic failure - paracetamol and others ie congenital biliary atresia in children
122
Chronic indications for liver transplant (5)
```
Cirrhosis due to alcoholism >6m abstinence
Chronic hepatitis
Hepatocellular carcinoma
PSC
PBC
```
123
Assessment for liver transplant score (2)
```
Child-Pugh score - determines severity and required treatment:
Bilirubin
Refractory ascites
Albumin
INR
eNcephalopathy
```
```
MELD score - stratifies severity of end stage liver disease for transplant planning:
Creatinine
Sodium
Bilirubin
INR
```
124
Post-op treatment for liver transplant (4)
Cefuroxime
Metronidazole
PPI
Immunosuppression - methylprednisolone, ciclosporin, azathioprine, tacrolimus, monoclonal antibodies
125
Early complications of liver transplant
Bleeding, hypothermia
CVS - haemorrhage, vasodilation
Resp - TRALI, hypoxia, atelectasis, pleural effusion
Neuro - encephalopathy, cerebral oedema
Small for size - raised bilirubin, ascites, portal hypertension
Biliary leak
Biliary duct stricture
Hepatic artery thrombosis = fever and raised LFT
Portal vein thrombosis = ascites and renal failure
126
Late complications of liver transplant
```
Chronic rejection
Renal failure
Sepsis from immunosuppression
Diabetes
Post-transplant lymphoproliferative disease - EBV
Disease recurrence
```
127
What is chronic liver disease?
Progressive destruction of liver parenchyma over >6m leading to fibrosis and cirrhosis
128
What are the 2 categories of hepatic encephalopathy?
Overt - defines decompensated liver failure
Covert -
- subtle neuropsychological signs, psychomotor slowness and difficulty with ADLs
- minimal and subclinical
- diagnose with psychometric testing
129
Sx of chronic liver disease for each region of body
```
Asterexis, Dupeytron’s contracture, palmar erythema, leuconychia
Fatigue and encephalopathy
Jaundice and fetor hepaticus
Spider naevi and gynaecomastia
Ascites, hepatomegaly and caput medusae
Polyneuropathy
```
130
What is non-alcoholic fatty liver disease and what causes it?
Microvesicular steatosis, AST
131
Which hepatitis can cause chronic liver disease?
B, C, D
132
What is the most common cause of chronic liver disease?
Alcohol - 25% of cirrhosis
133
What questionnaire assesses drinking?
CAGE:
Do you ever think you should Cut down?
Do people Annoy you criticising your drinking?
Do you ever feel Guilty about how much you drink?
Do you ever need a drink as an Eye opener in the morning? To calm nerves or a hangover
134
Sx of alcoholic liver disease (3)
Nausea and vomiting
Abdo pain
Diarrhoea
135
Extrahepatic sx of alcoholic liver disease
```
Porphyria cutanea tarda
Psychosocial - Wernicke-Korsakoff
Malnutrition
Cardiomyopathy, arrhythmia, HF
Gastritis and erosions
Proximal myopathy
Peripheral neuropathy
```
136
What is Wernicke’s encephalopathy? (4)
Confusion
Nystagmus
Ataxia
Opthalmoplegia
137
What is Korsakoff’s psychosis?
Short term memory loss
138
How is alcohol broken down?
Oxidised by cytochrome p450 or by alcohol dehydrogenase to acetaldehyde
By acetaldehyde dehydrogenase to acetate
139
How is the liver damaged by alcohol breakdown?
NADPH becomes NADP and NADH becomes NAD, releasing free radicals which cause hepatocellular damage
140
What are the 3 features of alcoholic liver disease?
Fatty change
Hepatitis
Fibrosis with nodular regeneration
141
Describe the fatty change seen in alcoholic liver disease
Ethanol is metabolised to fatty acids, which accumulate and cause cell destruction
142
When is fatty change seen except alcoholism? (4)
Diabetes, obesity
Starvation
Pregnancy
143
Describe hepatitis in alcoholic liver disease
Polymorphonuclear leukocytes and Mallory bodies (hyaline) infiltrate (also in chronic active hepatitis)
144
What is Zieve syndrome?
Triad of alcoholic hepatitis/cirrhosis, hyperlipidaemia and haemolytic anaemia, with unconjugated bilirubin (jaundice) and abdo pain. Caused by alcohol withdrawal. Treat with abstinence
145
FBC in alcoholic liver disease (3)
Macrocytosis
Thrombocytopoenia - toxic to megakaryocytes
Leukocytosis
146
Further investigations for alcoholic liver disease
USS - macronodular, irregular margin, fatty change
| Biopsy (trans jugular to minimise bleeding) - fatty change and cirrhosis
147
Manage alcoholic liver disease (4)
Abstinence increases 5y survival from 60-90%
Thiamine
Protein and calorie supplements
Withdrawal with benzodiazepines
148
What is haemochromatosis? Name 6 things it causes and investigation results
Excess iron absorption causing deposition in liver and organs
```
Cirrhosis
Diabetes
Heart failure
Arrhythmia
Hypogonadism
Skin discolouration
```
Iron, ferritin and transferrin saturation increased, seen on biospy
149
What is the treatment for haemochromatosis? (2)
Regular venesection or desferrioxamine
150
What is Wilson’s Disease? Name 6 things it causes and investigation results
Autosomal recessive accumulation of copper
```
Neuropsychiatric - Parkinsonism
Keyser-Fleicher rings
Arrhythmia
Cardiomyopathy
Cirrhosis
Renal tubular damage
```
Caeruloplasmin reduced, urinary copper increased
151
What is the treatment for Wilson’s disease?
Copper chelators - penicillamine
152
What is a1 antitrypsin deficiency and name 2 things it causes
A1-AT is a protease inhibitor which mediates inflammatory process. Deficiency causes excess breakdown of proteins in lungs and liver
Causes early onset basal lung emphysema and late onset cirrhosis
153
What are 5 genetic causes of chronic liver disease?
```
A1 antitrypsin deficiency
CF
Haemochromatosis
Wilson’s disease
Hereditary glycogen storage diseases
```
154
Who gets AI hepatitis and what is it associated with?
F>M, peaks in early 20s and perimenopausal
| Associated with thyroiditis, psoriatic arthritis, AI haemolytic anaemia
155
What are 3 causes of AI hepatitis?
Primary sclerosing cholangitis
Primary biliary cirrhosis
AI hepatitis
156
Sx of primary biliary cirrhosis (6)
```
Pruritis
Fatigue and lethargy
Dark urine and pale stools
Xanthelasma/xanthoma
Bone disease from reduced vit D absorption
Signs of chronic liver disease
```
157
Investigations for PBC (6)
```
LFT: alk phos +
Cholesterol +
AMA ++, ANA/antiSM +
IgM +
MRCP
USS for focal lesion, thrombosis, external compression
```
158
Complications of PBC (4)
Renal tubular acidosis
Cirrhosis
Osteoporosis
Osteomalacia and coagulopathies
159
Treat PBC (4)
Cholestyramine for pruritis
Ursodeoxycholic acid
Vit A, D, E, K and calcium
Bisphosphonates
160
What is primary sclerosing cholangitis?
Inflammation and fibrosis of intra/extra hepatic biliary ducts
161
6 sx of PSC
```
IBD symptoms (linked to UC)
Abdo pain, jaundice, pruritis
Fatigue and weight loss
Recurrent biliary infections
Features of CLD
Cirrhosis
```
162
Investigate PSC (4)
ANCA, AntiSM, ANA
LFT - high or normal
MRCP - bead like multiple strictures
Biopsy - progressive fibrous cholangitis
163
Complication of PSC
Cholangiocarcinoma
164
Treat PSC (6)
```
Ursodeoxycholic acid
Cholestyramine
Vitamins
Antibiotics if bacterial cholangitis
Stent/drain - balloon dilatation, sphincterotomy
Liver transplant
```
165
Presentations of AI hepatitis (3)
CLD +- jaundice
Acute hepatitis with jaundice
AI - fever, rash, arthritis, malaise
166
Investigations for AI hepatitis (3)
LFT - raised bilirubin, ALT, IgG
FBC - normocytic normochromic anaemia, thrombocytopoenia, leucopoenia
Anti-SM antibodies
167
Treatment for AI hepatitis (2)
Corticosteroids induce remission
| Azathioprine - antiproliferative immunosuppressant
168
Drugs which cause chronic liver disease and why (5)
Isoniazide - acute hepatitis
Methotrexate and amiodarone - cholestasis
Phenytoin and valproate - necrosis
169
Sarcoidosis and chronic liver disease, and treatment
Non-caseating granulomas, normally in lung, lymph nodes and skin
Treat with steroids and azathioprine
170
3 main areas of cirrhosis features
CLD stigmata
Endocrine
Neuro
171
Endocrine features of cirrhosis (5)
Loss of libido
Testicular atrophy, amenorrhoea
Parotid enlargement
Gynaecomastia
172
Cirrhosis investigations
LFT normal or all abnormal
Glucose high from pancreatic insufficiency
Dilutional hyponatraemia and albuminaemia
Raised PT
Macrocytic anaemia, B12/folate deficiency
173
Cirrhosis biomarker
A-fetoprotein for hepatocellular carcinoma
174
Secondary investigations for cirrhosis
USS - size, fatty change, fibrosis, carcinoma
Biopsy - macronodular = hepatitis B/C, micronodular = alcohol
Endoscopy for varicose - band or B blocker
175
4 complications of cirrhosis
Portal vein hypertension
Ascites
Encephalopathy
Hepatorenal syndrome
176
What causes hepatorenal syndrome?
Reduced intravascular volume activates RAAS, causing vasoconstriction of afferent arterioles, lowering GFR
Renal failure also from sepsis, diuretics or paracentesis reducing volume
177
What causes hepatic encephalopathy?
Toxic metabolites and ammonia from protein breakdown
178
What causes portal hypertension?
Collagen and fibrosis causes sinusoidal portal vascular resistance
Vasoactive substances from toxic metabolites ie nitric oxide cause vasodilation
Sodium retention causes increased plasma volume
179
How to treat vasodilation, increased plasma volume and varices in cirrhosis
Vasodilation - crystalloids and blood to replace intravascular volume; vasopressin analogue terlipressin to cause splachnic vasoconstriction and decrease portal flow
Plasma volume - spironolactone, loop diuretics, shunt (IJV, TIPS)
Varices - endoscopy and sclerotherapy, balloon tamponade, banding, TIPS, and B blockers
180
Cause of ascites in cirrhosis (2)
Vasoactive substances cause arterial vasodilatation - active RAAS - increase hydrostatic pressure - transudate
Hypoalbuminaemia decreases oncotic pressure
181
Sx and treatment of peritonitis
Nausea, abdo pain, fever, neutrophilia, clinical deterioration
Treat with fluroquinolone (ciprofloxacin)
182
How is iron absorbed?
Kept soluble by gastric acid, as ferrous and bound to gastroferrin. Binds to transferrin and undergoes endocytosis then is split, releasing iron into the blood where it is once again bound to transferrin
183
How are carbohydrates broken down in the intestine?
By a-amylase and bb enzymes to glucose
184
How is glucose absorbed?
Uses sodium gradient for active absorption using the SGLT1 cotransporter, into mucosal cells. Then diffuses through GLUT2 into ECF
185
How are fructose and lactose absorbed?
Through facilitated diffusion
186
What is in oral rehydration therapy and why?
Sodium and glucose - stimulates 2 osmotic gradients to increase water absorption
187
How is calcium absorbed?
Stimulated by PTH, uses vitamin D, to use Ca-ATPase pump for facilitated diffusion
188
How much calcium is absorbed compared to intake?
700mg absorbed of 6g consumed
189
How is B12 absorbed?
Binds to intrinsic factor to be absorbed in terminal ileum
190
What is absorbed in duodenum?
Water, HCO3- and iron
191
What is absorbed in jejunum?
Amino acids, fatty acids, carbs, vitamins, minerals, electrolytes and water
192
What is absorbed in large intestine?
Final water and salt
193
How much fluid is absorbed in SI?
14l to 1.5l
194
What happens when carbs are not absorbed?
Fermented by colonic bacteria to carbon dioxide, methane and hydrogen which causes bloating and distension
And fatty acids (acetate, lactate) which cause diarrhoea
195
What happens if fats are not absorbed? (2)
Trap fat soluble vitamins A, D, E, K - deficiency
| Unabsorbed bile salts causes water secretion into colon which causes diarrhoea
196
How does bacteria cause malabsorbtion?
Overgrowth causes deconjugation and dehydroxylation of bile salts, decreasing fat absorption
197
What is the mechanism of coeliac disease?
Gluten-sensitive T cells cause inflammatory response causing mucosal villus atrophy in SI
198
Diagnosis of coeliac disease (4)
```
T-TGA
Anti-EMA (endomysial antibody)
Iron deficiency (microcytic anaemia)
SI biopsy (D2) = villus atrophy, crypt hyperplasia, increased Intraepithelial cells
```
199
4 symptoms of coeliac disease
Failure to thrive
Anorexia
Apathy
Soft bulky clay-coloured offensive-smelling stools
200
8 signs of coeliac disease
```
Hypotonia
Muscle wasting
Pallor and sx of anaemia
Abdo distension
Glossitis
Angular stomatitis
Apthous ulcers
Dermatitis herpatiformis
```
201
Skin condition associated with coeliac disease
Dermatitis herpatiformis - intense pruritic papulo-vesicular rash. Symmetrical on elbows, knees, shoulders, buttocks, scalp - extensors
202
Complications of coeliac disease
Intestinal lymphoma and other GI malignancies
Reduced fertility and amenorrhoea
Vit D and calcium deficiency causing osteomalacia/poenia/porosis
203
What 3 conditions are linked with exocrine pancreatic insufficiency?
CF (90% of CF patients will have it)
Chronic pancreatitis
Diabetes (T1)
204
6 sx of exocrine pancreatic insufficiency
```
Weight loss
Anorexia
Diarrhoea
Abdo pain
Steatthoroea
Flatulence
```
205
Diagnosis of exocrine pancreatic insufficiency
Elastase in stool
Direct pancreatic output test (invasive)
ERCP (invasive), MRCP, USS, CT
206
Investigation for macrocytic anaemia and what is it caused by
B12 deficiency from damaged terminal ileum - Schilling test for pernicious anaemia
207
What is Zollinger-Ellison syndrome
Gastrinoma - islet cells or gastric producing duodenal cells
208
Laxative for soft faeces and route
Stimulant/irritant - Senna (bisocodyl) - excites nerve endings increasing intestinal motility
PO or suppository, or glycerol as rectal stimulant
Pre-op or impaction
Rapid (6-8h)
209
Initial ADR of bisacodyl (senna) (2)
Cramps
| Hypokalaemia
210
Long term ADR of bisacodyl (2)
```
Colonic atony
Melanosis coli (abuse)
```
211
CI to bisacodyl (2)
Obstruction
| Acute colitis
212
Bulking laxative?
Isphagula husk or fybogel
Add water in GI = increased peristalsis
Takes a few days
213
ADR of bulking laxatives (3)
Obstruction
Distension
Flatulence
214
CI to bulking laxatives (4)
Dysphagia
Atony
Obstruction
Impaction
215
Softener laxative and what for
Arachis oil enema - lubricates
| For fissure/adhesion/haemorrhoids and <3y/o
216
Osmotic laxatives (4)
```
Laculose
Movicol - 2-3D
Mg and Na salts - pre-op as rapid
Phosphate enema - pre-op as rapid
Retain fluid in bowel
```
217
How does laculose work and what is this useful for
Ferments with fructose and colonic bacteria to make acetic acid and lactic acid = osmotic diarrhoea
Causes low pH that discourages growth of ammonia-producing organisms
For hepatic encephalopahy
218
ADR of laculose (4)
Bloating
Cramps
Abdo discomfort
Flatulence
219
4 types of laxatives and an example of each
Stimulant - bisacodyl//senna
Bulking - isphagula husk or fybogel
Softener - arachis oil enema
Osmotic - laculose, movicol, Mg/Na salts, phosphate enema
220
IBS treatment - diet and medication
1. Reduce insoluble fibre if diarrhoea predominant
Fibre supplements if constipation predominant
+- probiotics for 4w
2. Anti-motility loperamide for diarrhoea
Anti-spasmodic mebeverine for pain
3. TCA
221
4 classes of anti-diarrhoeals
1. Codeine/loperamide - antimotilility to increase absorption anal tone and decrease defamation reflex
2. Bulker isphagula, or kaolin increases water absorption
3. Bile salt sequestrant cholestyramine - for Crohn’s, post-vagotomy when increased bile salts causes diarrhoea
4. Pancreatic enzymes Creon if malabsorption
222
ADR of anti-motility loperamide (3)
NV, constipation, drowsy
223
CI of anti-motility loperamide
Toxic megacolon
224
Treatment of GORD/oesophagitis - 3
Lifestyle
Antacid - ST buffer gaviscon or alginate - layers GI surfaces sucralfate
PPI omeprazole/lansoprazole if oesophagitis (to aid healing and maintenance) or proven GORD (initial healing)
225
Lifestyle changes for GORD - 7
```
Weight loss
Avoid trigger foods - coffee, tomatoes
Small meals, last 3-4h before bed
Stop smoking
Reduce alcohol
Raise head of the bed
Treat anxiety/stress
```
226
Causes of dyspepsia - 5
```
GU/DU
GORD/oesophagitis
Duodenitis/gastritis
Non-ulcer dyspepsia
Gastric malignancy
```
227
H Pylori treatment (3)
PAC triple therapy for 1-2w, 90% effective:
PPI lansoprazole
Amoxicillin - B lactate, strep, gram neg
Clarithromycin - macrolide, protein synthesis
Surgical lower oesophageal sphincter reinforcement
Vagus resection
228
How does H2 antagonist work
Stops amplification of ACH and gastric by histamine for 80% acid reduction
229
ADR of cimetidine - 4
Dizzy, rash, fatigue, gynaecomastia
230
What stimulates gastrin release (2)
Proteins/peptides
| ACh
231
What stimulates ACh release (3)
Post-ganglionic PSNS - cephalic phase
Distension - gastric phase
Amines on food buffer H+, decreasing acid (gastric phase)
232
What inhibits gastrin release (2)
Less food causing more acid (intestinal phase)
| Chyme leaves stomach, causing release of CCK and GIP (intestinal phase)
233
Where are chief cells in the stomach and what do they release?
Upper 2/3 = enzymes
234
Where are parietal cells in the stomach and what do they release?
Upper 2/3 = acid and intrinsic factor
235
Where are G cells in the stomach and what do they release?
Lower 1/3 = gastrin
236
Where are neck cells in the stomach and what do they release?
Lower 1/3 = mucous and HCO3- unstirred layer
237
What do PPIs do and when should they be taken?
Irreversibly inhibit ATPase so no acid is pumped
| 30m before breakfast
238
ADR of PPI (3)
NV, headache, gastric atrophy
239
Mechanism of vomiting - 4
Pyloric sphincter closes
Cardia and oesophagus relax
Diaphragm and abdo wall contract
Glottis closes
240
Where is chemoreceptor trigger zone?
Chemoreceptor trigger zone on floor of 4th ventricle in postrema area - part of medulla oblongata
241
What area activates vomiting?
Medullary centre in CTZ
242
How does 4th ventricle communicate with medullary centre?
Dopamine to D2
243
Where do domperidone and metaclopramide act and what other mechanism do they use?
Inhibit D2 in CTZ, and ACh for M1 receptors
| Pro kinetic - increase frequency and power of contractions to increase rate of emptying
244
7 uses for domperidone?
```
L-Dopa
Uraemia
Radiation
GI
Opioids
Migraine and post-op = metaclopramide
```
245
2 ADRs of domperidone and metaclopramide?
Extrapyramidal ADRs - dystopia, oculogyric crisis (young people)
Increased prolactin = galactorrhoea
246
How do ondansetron and granisetron work and what for?
Block serotonin from medullary centre - for CNS and GI stimulates ie cytotoxic drugs and post-op
247
What can enhance ondansetron?
Steroids increase effect
248
ADRs of ondansetron and granisetron - 3
Flushing
Headache
Constipation
- reduced vagal afferent nerve
249
What is cyclizine for?
Inhibits H1 in medullary centre - crosses BBB so sedative as well - good for acute NV, motion and morning sickness
250
ADR of cyclizine
Prolongs QT interval - CI = MI
251
What do hyoscine and scopolamine do?
Inhibit ACh between vestibular apparatus and medullary centre for motion sickness and post-op
Also antispasmodic and antisecretory
252
Why is hyoscine good for motion sickness?
Inhibits ACh from vestibular apparatus and short half-life
253
ADR of hyoscine and scopolamine - 4
Dry mouth
Blurred vision
Palpitations
Brady/tachycardia
254
DDI for hyoscine and scopolamine and why?
Prokinetic D2 antagonist metaclopramide and domperidone as anti-spasmodic
255
What 2 neurotransmitters communicate vestibular apparatus and medullary centre?
ACh and histamine
256
Initial treatment for severe vomiting
IV fluids
K replacement
Monitor electrolytes and fluid balance
257
What kinds of cancer are in the oesophagus and where are they?
SCC in upper 2/3, adenocarcinoma in lower 1/3
258
What blood vessels supply the oesophagus?
Inferior thyroid artery, thoracic aorta with oesophageal branches
Azygous vein
259
SCC of the oesophagus associated factors (5)
Developed countries
Smoking and alcohol
Vit A/riboflavin deficiency
Chronic alcoholism HPV
260
Adenocarcionoma of the oesophagus associated factors
Developed world
Barrett’s oesophagus = metaplastic epithelium = dysplasia = malignant
- long standing GORD, obesity, high density fat
261
Red flags for oesophageal carcinoma
Dyspepsia, dysphagia, weight loss and upper abdo pain
| >55y/o
262
Early sx of oesophageal carcinoma - 2
Restrosternal dyscomfort and dyspepsia
263
Late sx of oesophageal carcinoma - 5
Dysphagia - solids then liquids
Significant weight loss - dysphagia and anorexia
Odynophagia
Hoarse
Productive cough - aspirating pharyngeal secretions or oesopho-tracheal fistula
264
Exam for oesophageal carcinoma - 4
Weight loss/cachexia
Lymphadenopathy
Dehydration
Metastatic - jaundice, ascites, hepatomegaly
265
5 advanced investigations for oesophageal carcioma
OGD - biopsy and histology
CT neck thorax
Endoscopic USS and spiral CT for staging - penetration into wall
Staging laparoscopy for intraperitoneal masses
FNA for palpable cervical lymph nodes
266
Curative management of SCC in the oesophagus
```
Upper = chemoradiotherapy
Mid/lower = neoadjuvant CRT +- surgery
```
267
Curative management of oesophageal adenocarcinoma
Neoadjuvant chemo or CRT followed by resection
| If less fit, surgery only
268
How much of oesophageal cancer is palliative and what is the management - 5?
70% of patients
Oesophageal stent
RT/chemo to reduce size and bleeding
Photodynamic therapy - oxygen produced by light waves kills tumour
Nutrition - thickened fluid and supplements
Radiologically inserted gastrectomy
269
Complications of surgery for oesophageal carcinoma - 3
Pneumonia
Anastamosis leak
Death
270
Management of anastamotic leak following oesophageal surgery
CT CAP with PO contrast
NBM
Resuscitate
271
Post-op nutrition for oesophageal surgery
Feeding jejunostomy and small meals 5x/d as some of stomach is lost
272
Mechanism of surgery for oesophageal cancer
Ivor-Lewis resection: remove tumour, nodes and top of stomach and make stomach into tube to replace oesophagus
Very early cancer = endoscopic mucosal resection +- radiofrequency ablation
273
6 causes for malabsorption/digestion
1. Inadequate mixing/rapid emptying ie gastroenterostomy or gastrocolic fistula
2. Impaired transport ie pernicious anaemia or Addison’s
3. Acutely abnormal epithelium ie infection, alcohol or neomycin; Chronically abnormal epithelium ie Crohn’s, coeliac, ischaemia
4. Insufficient digestive agents ie cirrhosis, chronic pancreatitis, CF
5. Abnormal milieu ie bacterial overgrowth, Zollinger-Ellison, motility problem ie diabetes, scleroderma, high/low thyroid
6. Short bowel from resection or jejunoileal bypass for obesity
274
Investigate gastrinoma in pancreas/duodenal wall - 2
Gastrin serum level, CT/scintigraphy/PET scan
275
Treat gastrinoma - 3
PPI, surgery, chemo
276
FBC and sx of iron deficiency
Hypochromic microcytic anaemia
| Glossitis
277
FBC vit B12/folate deficiency
Macrocytic anaemia
278
Vit C/k deficiency 3 sx
Bleeding
Petechiae
Bruising
279
What vit deficiency causes peripheral neuropathy?
B1/6/12
280
What vit/min deficiency causes glossitis? (5)
B12, B2, folate, niacin, iron
281
What does calcium and magnesium deficiency cause?
Carbopedal spasm
282
What deficiencies can cause bone pain and fracture?
K, Mg, Ca, vit D
283
What sign does protein deficiency cause?
Oedema
284
8 risk factors for gastric cancer
```
H Pylori
Age
Smoking
IBD
Alcohol
Salt
Family history
Pernicious anaemia
```
285
What is H Pylori and how does it cause damage?
Gram neg helicobacter, releases urease which breaks urea down to carbon dioxide and ammonia. Ammonia neutralises acid producing an alkaline microenvironment for a cycle of damage to epithelial cell, causing inflammation, ulceration and neoplasia
286
Presentation of gastric cancer
Non specific and vague
Dyspepsia, dysphagia, NV, melaena, haematemesis
Cancer symptoms at late stage
287
Signs in advanced gastric cancer (6)
```
Anaemia
Epigastric mass
Jaundice
Hepatomegaly
Acanthosis nigricans
Troisier’s sign (supraclavicular/Virchow’s node)
```
288
3 initial investigations for gastric cancer
CEA (in 50%) - monitor progress and treatment
Endoscopy for polyps and biopsy
CLO breath test for H Pylori
289
What is found on biopsy of gastric cancer?
Ulcerating, fungating, linitis plastica (=infiltration)
290
2 investigations for treatment plan of gastric cancer?
Her2/neu protein expression for targeted monoclonal therapies
CT CAP and laparoscopy for staging and peritoneal masses
291
Where does gastric cancer spread to?
Through wall to duodenum, transverse colon, pancreas
| Transcoelomic to ovaries, peritoneum, liver, nodes
292
4 complications of gastric cancer?
Gastric outlet obstruction
Perforation
Iron deficiency
Malnutrition
293
Curative treatment options for gastric cancer? (3)
Endoscopic mucosal resection if confined to mucosa
Subtotal gastrectomy if distal (antrum or pyloris)
Total gastrectomy if proximal
And connect small bowel to oesophagus
+ neo/adjuvant chemo
294
Complications of total gastrectomy - 5
```
Anastamotic leak
Reoperation
B12 deficiency
Dumping syndrome
Death
```
295
What is dumping syndrome?
Early (10-30m) - sudden hypertonic contents in small intestine causes intraluminal fluid shift, causing distension, causing NV, diarrhoea, hypovolaemia which activate the SNS = tachycardia and sweating
Late (1-3h) - insulin surge = hypoglycaemia - avoid with small frequent meals
296
Nutrition for gastric cancer?
Nasogastric or radiologically inserted gastrotomy tube
297
Palliative management of gastric cancer (4)
Supportive
Chemo
Stent obstruction
Surgery - distal gastrectomy or bypass if no stent or bleeding
298
What are the 4 main types of gastric cancer?
Glandular adenocarcinoma - well differentiated glandular formation or mucous-secreting acini
Diffuse spreading fibrous adenocarcinoma = linitis plastica
Lymphoma from MALT (B cell non-Hodgkin’s)
Stromal - Interstitial cells of Cajun - uncommon and unpredictable, necrosis, mitosis and pleomorphism
299
What is the targeted therapy for stromal gastric cancer?
Imatinim to CD117 or CKit
300
What are 2 sx of gastric lymphoma and what’s the prognosis?
Night sweats
Raised LDH
Marrow involvement
80-90% survival with curative incision
301
What gastric cancer is associated with H Pylori?
Lymphoma - treat with abx first
302
How common is colorectal cancer?
Commonest GI cancer and 3rd most common cancer in the UK
303
What are 6 risk factors for colorectal cancer? How many cases are sporadic?
```
>60y/o
Family history
IBD
Low fibre
High processed meat
Smoking and alcohol
75% sporadic
```
304
What genetic mutations are related to colorectal cancer? (4)
Adenomatous polyposis coli (TSG) on chr5 - Familial Adenomatous Polyposis = increased adenomatous tissue growth
Kras, KBraf
Hereditary non-polyposis colorectal cancer - DNA mismatch repair
305
What is the timeline of progression from normal epithelium to colonic carcinoma?
Normal - abnormal - small adenomatous - large adenoma - colonic carcinoma
10-15y
306
What is found on microscopy of colorectal cancer?
Abnormal glands - signet cells, mucous cells - growing into muscle wall
307
What is found on macroscopy of colorectal cancer and what are the key symptoms with each side?
Right = fungating = abdo pain, occult bleeding, RIF mass
Left = stenosis = bleeding, change in bowel habit, tenesmus, LIF mass
Weight loss only if mets or obstruction
308
Where are most colorectal cancers?
60-70% rectosigmoidal
309
Primary investigation for colorectal cancer and when to do it?
Occult faecal blood test
>40 and unexplained weight loss or abdo pain
>50 and rectal bleeding
>60 and iron def anaemia or change in bowel habit
310
Imaging for colorectal cancer?
Colonoscopy and biopsy, unless comorbidities
Significant comorbidities = flexible sigmoidoscopy
CTCAP for staging
MRI for resection margin, tumour and node staging to predict recurrence
Endoanal USS to assess suitability for trans-anal resection
311
What is the staging system for colorectal cancer?
```
Duke’s staging:
A = confined to muscularis mucosa
B = extension through muscularis
C = regional nodes - 1 = close, 2 = apical
D = distant mets
```
312
What are survival rates for different stages of colorectal cancer?
```
A = 90%
B = 65%
C = 30%
D = <10%
```
313
Management for colorectal cancer?
Regional colectomy with margin and lymph node drainage, creating primary anastamosis or stoma
Neo/adjuvant CRT if rectum (15cm) or anus (8cm)
314
Blood supply to right side of colon?
Middle colic, right colic and ileocolic - off SMA
315
Blood supply to left side of colon?
Middle colic off SMA
| Left colic with superior and inferior branches - off IMA
316
Blood supply to sigmoid?
Superior rectal and sigmoidal off IMA
317
Difference between anterior resection and abdominal perineal resection?
```
Anterior = >5cm from anus, sphincter intact and anastamosis
APR = <5cm from anus, permanent colostomy
```
318
What is Hartmann’s procedure?
Emergency for obstruction/perforation - end colostomy and close stump
319
Palliative surgery for colorectal surgery?
Endoluminal stent if left sided and not rectal as = tenesmus
| Stoma if acute obstruction
320
Where are carcinoid tumours found? (3)
Appendix, terminal ileum, rectum
321
Presentation of carcinoid tumours (5)
```
Diarrhoea (secretory)
Flushing
Abdo pain
Obstruction
Liver mets
```
322
How is serotonin metabolised? (3)
Reduced by first pass metabolism
With bradykinin and histamine
In urine
323
Cardiac complications of carcinoid syndrome?
Right cardiac lesions - tricuspid regurgitation, pulmonary artery stenosis
324
Treat carcinoid tumour?
Resect or somatostatin analogue to reduce gut hormone release
325
3 types of anal cancer?
Squamous from below dentate line = 80%
Adenocarcinoma from upper canal epithelium and crypt glands = 10%
Melanomas and anal skin cancers = 10%
326
What is a precursor to anal cancer and how is it graded?
Anal Intraepithelial Neoplasia - in canal or perianal skin
Strongly linked with HPV
Graded by cytological atypia degree and depth
2-3 = premalignant and becomes invasive cancer
327
Risk factors for anal cancer? (6)
HPV 16/18, HIV, Crohn’s, age, smoking, immunosuppression
328
6 symptoms of anal cancer
Bleeding and pain (50%)
Discharge
Pruritis
Tenesmus and incontinence from sphincter involvement
329
Exam findings for anal cancer (4)
Lymphadenopathy
Wart like lesions on perineum, perianal and vulval/vaginal
Palpable mass on DRE - establish distance from anal verge and fraction of circumference
Fistula-in-ano and infection if locally invasive
330
7 areas of investigation for anal cancer
```
Examine - DRE, perianal area, nodes
Proctoscopy
Under anaesthetic for size and invasion
Biopsy
HIV
Smear test for CIN or VIN
Staging imaging: USS FNA palpable inguinal nodes, CT CAP, MRI pelvis for extent of local invasion (T of TNM)
```
331
What nodes do different parts of anus drain to?
Below dentate line = superficial inguinal nodes
| Above dentate line = para-aortic, mesorectal, paravertebral
332
Management of T1N0 anal cancer?
Local excision
333
Management of anal cancer? (2 lines)
CRT - external beam RT to anal canal and inguinal nodes
+ dual chemotherapy
Abdominoperineal resection if advanced or chemo failure
334
Short term complications of CRT for anal cancer? (4)
Dermatitis
Proctitis and cystitis
Diarrhoea
Leucopoenia and thrombocytopoenia
335
Long term complications of CRT for anal cancer? (4)
Fertility
Erecitile dysfunction and vaginal dryness
Faecal incontinence
Rectovaginal fistula
336
4 benign liver primaries
Hepatic adenoma
Bile duct adenoma/haematoma
Haemangioma
Focal nodular hyperplasia
337
Manage hepatic adenoma? What’s associated with it?
Resect due to risk of malignancy or rupture
Associated with OCP
Can cause intrahepatic bleeding
338
Diagnose haemangioma?
USS or angiography
339
Manage focal nodular hyperplasia?
No risk of malignancy, normal function, asymptomatic or RUQ pain
Mistaken for cirrhosis on radio/FNA
340
Who is most likely to get hepatocellular carcinoma? 6
```
>70 and male
Hepatitis - B and C
Aflatoxin
Alcohol
Smoking
Family history
```
341
What conditions cause hepatocellular carcinoma? (3)
Viral hepatitis - B
Chronic alcoholism
Hereditary haemochromatosis, PBC
- causing cirrhosis
342
Features of cirrhosis - groups of symptoms, 3 of signs
Fatigue, fever, weight loss, lethargy
RUQ dull ache - indicative of cancer in cirrhosis
Irregular enlarged craggy tender liver
Liver failure - jaundice, ascites (exudate +- blood)
Mets - lung and bone = pleural effusion and pathological fracture
343
Initial investigations for liver cancer (3)
LFT - normal or raised as necrosis, alk phos raised from bony mets
FBC - low platelets, abnormal clotting
a-Fetoprotein raised in 70%
344
Imaging for liver cancer - 4
USS: >2cm and raised afp = diagnostic
Staging CT
MRI and contrast CT angiography shows arterial hypervascularity
Biopsy and percutaneous FNA
345
Barriers to liver cancer biopsy - 3
Ascites
Deranged clotting
Risk of seeding
346
Liver cancer staging?
Barcelona Clinic Liver Cancer Staging System to determine which treatment: stage, liver function, physical status, cancer symptoms
347
Score for cirrhosis?
```
Child-Pugh: risk of mortality and effectiveness of treatment options
Bilirubin
Refractory ascites
Albumin
INR
ENcephalopathy
```
348
Score for end stage liver disease/transplant
```
MELD:
Bilirubin
Dialysis number
INR
Creatinine
Sodium
for likelihood of tolerating transplant
```
349
Management of liver cancer (4) and prognosis
<5% 6m survival
Surgery - if no cirrhosis and good baseline health, but 60% 5y recurrence
Transplant - if <5cm or 3x3cm and no vascular infiltration, and fulfil Milan criteria
Image guided USS or alcohol ablation causing necrosis - for small tumours and functioning liver
Trans-arterial Chemo embolisation if stage B multinodular - into hepatic artery causing ischaemia, preserves the majority of the liver
350
How common is secondary liver malignancy?
Most common cause of death in cancer patients
351
Where do liver mets come from? (5)
```
Bowel (portal circulation)
Breast
Pancreas
Stomach
Lung
```
352
What is there more of in secondary liver cancer than primary?
Ascites and hepatomegaly
Jaundice and RUQ pain
Non-specific cancer symptoms
353
ALP in secondary liver cancer?
Raised ALP from biliary obstruction
354
Management of secondary liver cancer?
Surgery if confined to liver and primary is controlled - TACE or internal radiotherapy
Palliative likely - most have other mets
355
What is hep B associated with? - sx and conditions
Arthralgia and urticaria
| Arthritis, glomerulonephritis, HCC
356
What sx from hep A?
Jaundice, abdo pain
Fever, headache
Vomiting, diarrhoea
357
What is Hep E associated with?
Pregnancy causing acute liver failure
358
Treatment for hep A and B?
```
A = self limiting
B = antivirals
```
359
Age group for pancreatic carcinoma
60-80y/o
360
Types of pancreatic carcinoma? (3)
90% ductal carcinoma with poor prognosis
Exocrine = pancreatic cystic carcinoma
Endocrine = islet cell
361
4 risk factors for pancreatic carcinoma
Smoking
Chronic pancreatitis
Recent or late onset diabetes (>50y/o)
Family history
362
Presentation of pancreatic cancer - 6
Vague and late presentation - jaundice, cachexia/malnourished
Rare = pancreatitis, thrombophlebitis migrans (hypercoagulable)
Epigastric mass
Courvoisier’s law - enlarged painless gall bladder (distal to cystic duct)
363
Where is the tumour likely to be in the pancreas if there is abdo pain and why?
Outer 2/3 - coeliac plexus invasion
364
Where is the tumour likely to be in the pancreas if there is back pain?
Middle 1/3
365
Where is the tumour likely to be in the pancreas if diabetic?
Outer 2/3
366
Biomarker for pancreatic cancer
Ca19-9 for treatment response
367
Investigations for pancreatic cancer (5)
Ca19-9
FBC = anaemia, thrombocytopoenia
LFT = raised alk phos, bilirubin and gamma GT = obstructive jaundice
USS = mass or dilated biliary tree, hepatic mass, ascites
CT for diagnosis and staging - assess respectability = arterial, pancreatic and portal vein phases
368
Management for pancreatic cancer - 4
Surgery - distal pancreatectomy if body/tail, pancreaticoduodenectomy/Whipple’s procedure if head
Adjuvant chemotherapy
Creon - with meals if exocrine insufficiency causing malabsorption and steatthoroea
Palliative = stent if obstructive jaundice, pruritis (ERCP or percutaneous)
369
What is Whipple’s procedure?
Pancreaticoduodenectomy for tumour at head of pancreas - also D1, D2, gall bladder, bile duct, stomach antrum
Tail and hepatic duct attached to jejunum and anastamosis to stomach
370
Complications of surgery for pancreatic cancer - 3
Fistula
Delayed gastric emptying
Pancreatic insufficiency
371
Endocrine tumours of pancreas?
MEN1/Wermer’s syndrome:
1) Hyperparathyroid
2) Endocrine tumour of pancreas
3) Pituitary tumour
372
What does endocrine G cell tumour make and cause?
Gastrin = gastric acid = Zollinger-Ellison = PUD refractory to treatment, diarrhoea, steatthoroea
373
What endocrine tumour can cause diabetes? What else does it cause?
A cells = glucagon = increase BM = diabetes, hyperglycaemia, necrolytic migratory erythema
Triad = weight loss, recent onset diabetes, unusual dermatitis
374
What endocrine tumour can cause hypoglycaemia? What else does it cause?
B cells = insulin = decrease BM = hypoglycaemia, neuroglycopoenia symptoms (dysphoria, irritability, emotional, unconscious)
375
What does d cell tumour cause (4)?
Somatostatin = reduce GH, TSH, prolactin and gastrin = mild diabetes, steatthoroea, gall stones (CCK), achlorhydria (reduced HCl in stomach
376
What does a non-islet cell pancreatic tumour do?
```
VIP = water and electrolytes into GI, relax enteric SM
Profuse watery diarrhoea
Hypokalaemia
Dehydration
= VIPoma = Verner-Morrison syndrome
```
377
What 2 conditions can cause an isolated increase in bilirubin?
Gilbert’s syndrome = unconjugated hyperbilirubinaemia
| Haemolysis = splenomegaly, anaemia
378
How is the cause of haemolysis with increased reticulocye count identified?
Direct Coombs test: positive = AI, negative = do a blood film = membrane abnormalities, G6PD etc
379
What causes elevation in ALT?
Acute hepatitis - A, B, C, E, EBV/CMV/toxoplasmosis, drugs, immunoglobulins, AI
Chronic hepatitis - B, C, diabetes, thyroid, lipids, immunoglobulins, a1-antitrypsin
380
What causes elevation in ALP?
Acute cholestatic illness: stones, tumours, pancreas,drugs
| Chronic cholestatic illness: PBC, PSC, NASH, HIV, sarcoidosis, amyloidosis, a1-antitrypsin
381
What drugs can cause acute cholestatic disease?
OCP, azathioprine, isoniazid, allopurinol
382
What score assess alcoholic hepatitis?
Glasgow Acute Alcoholic Hepatitis score
383
7 causes of acute liver failure
```
Drugs (paracetamol, halothane, ecstasy)
AI hepatitis
Viral hepatitis
Ischaemic hepatitis
Budd-Chiari syndrome
Wilson’s disease
Acute fatty liver of pregnancy
```
384
Treat acute liver failure - 9
```
N-Ac
Abx
Central access
Ventilate
Monitor coagulopathy, hypoglycaemia, renal function and acidosis
Nutrition
```
385
6 signs of chronic liver failure
```
Asterexis
Oedema
Splenomegaly
Gynaecomastia
Testicular atrophy
Relative hypotension
```
386
What is the mechanism of ascites and what is its incidence in liver failure?
50% of chronic liver failure patients in 10y, 50% die in 2y
Dilated peripheral arteries, reduced blood pressure, RAAS/SNS/ADH activation, increased water and sodium, dilutional hyponatraemia/reduced urinary sodium
387
Treat ascites - 3
Salt and water restriction
Diuretics - spironolactone, furosemide
Paracentesis - diagnostic and therapeutic
388
2 products contributing to encephalopathy
Protein = ammonia
| Urea
389
How is protein linked to encephalopathy?
From intake, GI bleed and constipation - increased ammonia and nitrogen production and absorption
390
How is urea linked to encephalopathy from liver failure?
Renal failure increases urea
391
What 2 physical mechanisms cause encephalopathy?
Reduced hepatocellular function from disease, anaemia, sepsis, hypotension
Portocaval shunting
392
What causes portocaval shunting? (4)
Surgical
Spontaneous
TIPS
Portal vein thrombosis
393
What drugs cause encephalopathy? (4)
Psychoactive - benzodiazepines, antiemetics, antihistamines, ethanol
394
Treat encephalopathy - 4
Decrease disease effects: prevent sepsis, bleeding, stop drug
Avoid sedatives, hypnotics and opiates
Laculose BD
Metronidazole/neomycin
395
5 causes of encephalopathy
```
Increased protein = ammonia from intake/GI bleed/constipation
Urea from renal failure
Portocaval shunting
Hepatocellular dysfunction
Psychoactive drugs
```
396
2 ADRs of terlipressin for variceal haemorrhage
Ischaemia
| Arrhythmia
397
2 treatments for hyponatraemia
Fluid restriction
| NaCl - hypertonic saline
398
When to admit someone with hyponatriaemia -4
Severe or acute onset
Symptomatic
Hypovolaemia
?Addison’s?
399
What kinds of things causes SIADH? (4)
Pulmonary disease
CNS disease
Drugs
Neoplasm
400
What is the mechanism of SIADH?
```
Continued AVP (arginine vasopressin) despite normal or increased plasma volume
Causes hyponatraemia, hypoosmolarity and sodium renal excretion
```
401
3 ADRs of interferons for hepatitis B
Lethargy
Neuropsychiatric
Neutropoenia
402
Ribavirin 3 ADRs for hepatitis C
Thrombocytopoenia, haemolytic anaemia
| Anxiety
403
Risk factors for HCV? (3)
PWID
Haemodialysis
Birth - vertical
404
Results from HCV treatment?
20% cleared
80% chronic - of these, 1/3 will have no sx, 2/3 will have sx/cirrhosis
Eventual: 4% liver failure, 1.5% cancer
405
How does terlipressin work in hepatorenal syndrome?
Stops splachnic dilatation so stops hypovolaemia - prevents renal bv constriction and lowering of GFR
406
Outcome of hepatorenal syndrome and treatment?
80-95% 2w mortality
| Decrease with transplant, vasopressin analogues and TIPS
407
How does TIPS work in hepatorenal syndrome and what are 2 ADRs?
Lowers blood pressure, prevents vasodilation
| Encephalopathy and haemolysis
408
Risk factors for hepatorenal syndrome in hepatic failure - 2
Advanced diuretic resistant ascites
| Large volume paracentesis
409
Types of hepatorenal syndrome?
Type 1 = acute with 2w survival: creatinine rises or 24h CrCl decreases
Type 2 = chronic with 6m survival: refractory ascites
410
Microscopic changes in non alcoholic fatty liver disease (4)
Mallory bodies
Lobular neutrophil inflammation
Perisinusoidal fibrosis
Ballooning degeneration
411
Treat NASH?
Treat diabetes and hyperlipidaemia - statins, fibrates
412
What 2 things contribute to NASH?
Insulin resistance and oxidative stress
413
What 4 things cause oxidative stress?
Endotoxins
Cytokines
ROS
Toxins
414
What 3 cellular things cause NASH?
Stellate cell activation
Cytokines
Peroxidation of hepatocyte membrane
415
4 complications of non alcoholic fatty liver disease
Advanced liver fibrosis
Diabetes 2
Hypertension
CKD
416
4 complications of non alcoholic fatty liver disease and diabetes 2?
AF
MI
Stroke
CVD
417
5 drugs that cause non alcoholic fatty liver disease?
```
MC-fAT
Methotrexate
Corticosteroids
tamoxiFen
Amiodarone
Tetracycline
```
418
Diagnose NAFLD? -3
LFT
USS
Biopsy
419
3 symptoms of NAFLD
Fatigue
Malaise
Abdo discomfort
420
4 treatments of NAFLD?
Diet
Exercise
Antiglycaemics
Bariatric surgery
421
What complicates diagnosis of cirrhosis?
Don’t diagnose if have diabetes or obese, unless NAFLD or ALF
422
Diagnose cirrhosis
Transient elastography
| Biopsy
423
Management of cirrhosis and its complications - 8
```
Varicael band ligation
IV abx if upper GI bleed
TIPS if refractory ascites
PO ciprofloxacin if refractory ascites
Albumin, vit K, blood products
Anticoagulation - prothrombotic, even if increased INR
```
424
Liver transplant for hepatitis c?
50% recurrence
| Follow with corticosteroid then calcineurin inhibitor ie tacrolimus
425
When to refer for liver transplant? (3)
Irreversible progressive impairment (synthetic function) or portal hypertension problems
Significantly impaired QoL
Curable HCC
426
Contraindications to liver transplant? (3)
Extrahepatic infection
Advanced malignancy
Poor cardiorespiratory status
427
3 assessments of alcohol intake
CAGE
AlcoholUseDisorderID questionnaire
Severity of AlcoholDependenceQuestionnaire (psych, phys and cognitive)
428
Sx of chronic alcoholism - 6
```
Dupeytron’s contracture
Gynaecomastia
Spider angiomata
Enlarged spleen
Large/small liver
Testicular atrophy
```
429
Sx of alcohol withdrawal - 8
```
NV
Headache
Anxiety
Agitation
Diapheresis
Tremor
Seizures
Hallucinations
```
430
How much is one unit and what is a binge?
250ml beer, 125ml wine
| 8 units for men, 6 units for women
431
4 parts of brief alcohol intervention
Advice on dangers
Avoid triggers
Set objectives
Info on local organisations
432
When inpatient for withdrawal alcohol?
Suicide risk, lack of social support of hx of withdrawal reactions
433
Community management of alcohol withdrawal - 4
Daily supervision for vomiting/mental deterioration
Multivitamins for encephalopathy
BZD for symptoms
Support
434
Acute management of alcohol withdrawal - 4
Diazepam for tremor/agitation (diazepam)
Lorazepam for seizures
+- b blockers
Vit B complex, thiamine, multivitamins
435
3 drugs for alcohol abstinence and what for?
Acamprosate - maintain stabilisation
Naltrexone for binges
Nalmefene if no withdrawal Sx - give with psych support
436
How does acamprosate work? - 2 mechanisms, 2 results
Inhibits NMDA receptors which are unregulated by alcohol, preventing delirium tremens
Positive allosteric modulator at GABA receptors which have been down regulated by alcohol (also a positive allosteric modulator), preventing physical withdrawal symptoms
- neuroprotective, reduces cravings
437
How does naltrexone work?
Blocks competitive opioid receptor. Take 1h before alcohol, reduces positive effects of alcohol
438
When should naltrexone not be used (3)?
Liver failure, acute hepatitis or recent opioid use
439
5 causes of dysphagia
Inflammatory candidiasis/epiglottitis/retropharyngeal abscess
Obstructive - malignancy, structure, posterior cricoid web
Pharyngeal pouch
CT disorder
CNS disorder - MS, myasthenia gravies, bulbar palsy, CVA
440
Signs of acute abdo (3)
Vomiting
Guarding
Reduced bowel sounds
441
Vomiting and rectal bleeding?
GI inflammation
| Malignancy
442
Epigastric pain radiating to back (2)
Acute pancreatitis
| Ruptured AAA
443
Chronic epigastric pain (3)
IBS
GORD
CVS
444
Epigastric pain relieved leaning forward
Pancreatitis
445
Epigastric pain relieved by eating
DU
446
Epigastric pain relieved with defecation
IBS
447
Signs of pancreatitis (3)
Rigid abdo
Epigastric pain relieved leaning forward
Flank discolouration
448
Rigid abdo and epigastric pain (2)
Pancreatitis
| Peritonitis
449
2 faeces tests for diarrhoea
```
Calprotectin = IBD
Elastase = pancreatic disease
```
450
5 causes of diarrhoea with blood
```
Haemorrhoids
Anal fissure
Gastroenteritis
Diverticular disease
IBD
```
451
6 GI red flag symptoms
```
Dyspepsia
Dysphagia
Vomiting
Epigastric pain
Diarrhoea
Constipation
```
452
Leading causes of c dif (2)
2nd and 3rd gen cephalosporins
| Clindamycin
453
First and second line treatments for c dif
PO metronidazole for 10-14d
| Then PO vancomycin and IV metronidazole if very unwell, or just PO vancomycin if relatively well
454
What is Charcot's triad?
For ascending cholangitis: fever/rigors, jaundice, RUQ pain
455
What is Reynold's pentad?
Severe ascending cholangitis = Charcot's triad plus hypotension and confusion
456
What is cyclic vomiting syndrome?
Episodes of vomiting precipitated by nausea and sweating, last hours to days
No symptoms in between
Associated with migraines
457
Most common kind of oesophageal cancer
Adenocarcinoma
458
1st line investigation for oesophageal cancer
Upper GI endoscopy
459
What is Troussea’s sign and what cancer is it most commonly seen in?
Migratory thrombophlebitis in pancreatic cancer
460
Microscopy of Crohn’s disease (3)
All layers inflamed
Granulomas
Goblet cells increased
461
Microscopy of UC (3)
Not beyond submucosa
Crypt abscesses
Depletion of goblet cells
462
2 complications/conditions from Crohn’s
Gall stones - reduced bile acid absorption
| Renal stones - oxalate as reduced calcium absorption due to reduced bile acid absorption
463
5 sx of pharyngeal pouch
```
Dysphagia
Regurgitation
Aspiration
Halitosis
Neck swelling which gurgles on palpation
```
464
Management of ascending cholangitis
IV abx
| ERCP to relieve obstruction 24-48h after
465
Management of Barrett’s oesophagus metaplasia (2)
Endoscopic surveillance and biopsy (/3-5y)
| PPI
466
Management of oesophageal dysplasia (2)
Endoscopic mucosal resection
| Radiofrequency ablation
467
First and second line treatment of mild/moderate UC
Mesalazine
| + PO prednisolone if not improving in 4w
468
When to do surgery in sigmoid volvulus?
Suspected peritonitis or perforation
Necrotic bowel on endoscopy
Repeated failed decompressions
469
2 treatments initially for hepatic encephalopathy
PO/PR lactulose
| PO rifaximin
470
Why do coeliacs need vaccinations and which do they need?
Pneumococcal and yearly influenza
| Due to functional hyposplenism
471
4 features of Peutz-Jegher’s and key complication
```
Hamartamous GI (small bowel) polyps
Pigmented lesions mouth, feet, palms
Intestinal obstruction ie intussusseption
GI bleed
50% die of colorectal cancer by 60y
```
472
Causes of peritonitis - 5
Primary = rare, strep from bloodstream
Secondary =
- perforation of appendix/diverticuli/upper gi/tumour/ischaemic bowel
- acute pancreatitis - inflammatory
- peritoneal dialysis - atypical or cutaneous organisms
- post-op - anastomotic leak or enteric injury
473
Symptoms of peritonitis - 3
Severe generalised abdo pain radiating to back and shoulders, worse with cough and movement
Anorexia
Fever
474
Signs of peritonitis - 4
Fever, tachycardia
Generalised abdo pain with guarding and rigidity, may be maximal on source
Mass on gentle palpation
475
Initial management and tests for peritonitis
Resuscitation with large bore cannula
Catheter and fluid balance chart
FBC, UE, CRP, G&S
Amylase for peritonitis
ABG for ischemic bowel, pancreatitis, shock
Abdo CT for source of pathology
Antibiotics - metronidazole and cefuroxime
476
Appendicitis management
Open/laparoscopic resection
| IV antibiotics
477
Upper GI causing peritonitis management
Omental patch - prepyloric or DU
Excision - GU
Gastrectomy
478
Diverticular disease causing peritonitis management
IV antibiotics
| Resection
479
Management for peritonitis from peritoneal dialysis
Lavage
| Antibiotics - fluid culture
480
2 causes of small bowel and large bowel obstruction
Small bowel - adhesions and hernias
| Large bowel - malignancy, volvulus, diverticular disease
481
Extramural, mural and intramural GI obstructions
Extramural - hernias, adhesions, volvulus, peritoneal masses
Mural - carcinoma, Meckel’s diverticum, inflammatory strictures, intususception, lymphoma
Intramural - foreign body, faecal impaction, gallstone ileus
482
Pathology of GI obstruction causing perforation
1. Dilatation of proximal limb
2. Increase in peristalsis
3. Secretion of large volume of electrolyte-rich fluid (third spacing)
4. Ischaemia and perforation
483
What is a closed loop obstruction?
When there is a proximal secondary obstruction such as volvulus or competent valve
484
Symptoms of GI obstruction - 4
Pain
Vomit
Distension
Absolute constipation
485
Signs of GI obstruction - 2
Tinkling bowel sounds
| Focal tenderness/guarding/rebound = ischaemia
486
Inv finding on GI obstruction
Low K, high urea
Lactate = ischaemia
Metabolic disturbance from dehydration/vomiting
487
Differentials for GI obstruction - 3
Paralytic ileus
Pseudoobstruction
Toxic megacolon
488
AXR findings for GI obstruction
SI >3cm, valvulae conniventes, central
| LI >6cm, >9cm at caecum, peripheral, haustra
489
CT findings for GI obstruction
True or pseudo
Location and cause
Mets
490
Imaging for GI obstruction
AXR
CT - more sensitive than AXR
Contrast fluoroscopy for SI
491
Initial management GI obstruction
```
NBM
NGT decompression
IV fluids and electrolyte correction
Catheter and fluid balance
Analgesia
```
492
When to operate on GI obstruction - 4
Ischaemia
Small intestine obstruction without previous surgery
Tumour or strangulation
Failure to improve >48h
493
Manage adhesions in SI
Conservative unless ischaemia/strangulation
494
Complications of GI obstruction - 3
Ischaemia
Perforation causing faecal peritonitis
Dehydration and renal impairment
495
2 complications of gastric outlet obstruction
Intermittent - vomiting - weightloss, dehydration and electolyte disturbance
Gastric dilatation - reduced contractility - undigested food accumulates - aspiration pneumonia
496
Benign causes of gastric outlet obstruction - 6
```
Gastric polyps
Pyloric stenosis
Congenital duodenal web
Gall stones
Pancreatic pseudocyst
Bezoar
```
497
How does PUD cause gastric outlet obstruction?
Acute inflammation - oedema - fibrosis and scarring
498
Manage PUD
H2 antagonist, PPI
| H pylori eradication
499
Tumours causing gastric outlet obstruction - 5
```
Gastric
Duodenal
Pancreatic
Ampullary
Cholangiocarcinoma
```
500
Symptoms of gastric outlet obstruction
```
N&V - undigested food within 1h
DU or incomplete obsturction causes
- early satiety, weight loss
- epigastric fullness
- indigestion
- pain
- metabolic insufficiency, malnourished
```
501
Exam findings for gastric outlet obstruction
Chronic dehydration/malnutrition
Tympanic mass
Succession splash
502
Investigations for gastric outlet obstructiotn - 4
Electrolyte abnormalities - urea, nitrogen, creatinine high
= Hypokalaemic hypochloraemic metabolic acidosis (low K and Cl)
NaCl test - 750ml through NGT, >400ml after 30 mins = GOO
Imaging - CT, endoscopy for intraluminal obstruction
503
Manage gastric outlet obstruction
```
Treat cause
Pneumatic balloon dilatation
NG decompression
Vagotomy
Pyloroplasty
```
504
Consideration before surgery for gastric outlet obstruction
Pre-op nutrition important, and electrolyte corrections
505
Complications of treatment for gastric outlet obstruction - 3
Perforation
Stent migration
Anastamotic leak
