GI Flashcards
(197 cards)
1
Q
what are worrying features of PR bleeding?
A
tachycardic dizziness reduced GCS abdo pain and weight loss vomiting hypotension
2
Q
initial management of PR bleeding
A
A-E assessment
abdo exam
PR exam
protoscopy
3
Q
what is included in the D part of an A-E assessment?
A
GCS, blood glucose, pupils
4
Q
what are the key bloods of PR bleeding?
A
FBC clotting U&Es LFTs group and save or cross match 2 units glucose lactate
5
Q
what other investigations except bloods are needed in PR bleeding?
A
stool sample
faecal calprotectin
scoping- colonoscopy, proctosigmoidoscopy
6
Q
differentials of PR bleeding?
A
polyps diverticular disease haemorrhoids fissures IBD Cancer
7
Q
what type of bleeding does a fissue in ano produce?
A
bright red rectal bleeding
8
Q
features of fissue in ano history?
A
Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation
9
Q
features of fissue in ano exam?
A
muco-epithelial defect usually in the midline posteriorly
10
Q
what type of bleeding do haemorrhoids produce?
A
Bright red rectal bleeding
11
Q
hx of haemorrhoids?
A
Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool.
PAINLESS bleeding
12
Q
examination of haemorrhoids?
A
Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable
13
Q
tx of fissure in ano?
A
1st line- GTN ointment or distiazem cream
2nd line- botox
3rd line- Internal sphincterotomy
14
Q
tx of haemorrhoids?
A
lifestyle advice
small haemorrhoids- injection sclerotherapy or rubber band ligation
external haemorrhoids- haemorrhoidectomy
15
Q
what are external and internal haemorrhoids?
A
external- originate below the dentate line
painful, prone to thrombosis
internal- below dentate line
no pain
16
Q
features of upper GI bleeding?
A
Haematemesis and/ or malaena
Epigastric discomfort
Sudden collapse
17
Q
differentials of upper GI bleeding?
A
oesophageal
- oesophagitis
- cancer
- Mallory Weiss tear
- varices
gastric
- gastric cancer
- gastritis
- gastric ulcer
18
Q
ABCDE of upper GI bleeding?
A
admit to hosp
A-E assessment
- B- O2, ABG, sats probe, auscultate
-C- give fluids- 500mls stat, catheter, ?ECG, IV access
E- bleeding elsewhere, abdo pain, signs of chronic liver disease?
Bloods- cross match, FBC, LFTs, U&Es, clotting
19
Q
what blood is urgently transfused in patients with ongoing bleeding and haemodynamic instability?
A
O negative blood pending cross matched blood
20
Q
mx of upper GI bleeding after A-E?
A
make nil by mouth
correct clotting abnormalities- prothrombin complex if on warfarin or platelets if platelet count <50
fresh frozen plasma to patients who have fibrinogen <1 g/litre, or a prothrombin time (international normalised ratio) or APTT >1.5 times normal
urgent endoscopy within 24 hours
21
Q
what do patients with suspected varices need prior to endoscopy?
A
terlipressin and prophylactic abx (quinolones)
22
Q
mx of Mallory Weiss tear?
A
resolves spontaneously usually
23
Q
cause of Mallory Weiss tear?
A
usually following comiting
24
Q
cause of oesophagitis?
A
usually history of GORD symptoms
25
symptoms of varices?
usually large volume of fresh blood
| swallowed blood can cause malaena
26
what is the risk assessment of acute upper GI bleeding due to varices or peptic ulcer disease?
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
Blatchford score of 0 may be considered for early discharge- urea, Hb, SBP, HR, presence of maleana, syncope, hepatic disease, Cardiac failure
27
mx of varices?
```
NBM
fluids +/- blood
terlipressin and ABx
correct clotting
urgent OGD- band ligation if oesophageal varices and N-butyl-2-cyanoacrylate for patients with gastric varices
```
continued bleeding= TIPS surgery
prevention- propranolol
prescribe LMWH
28
Ix in change of bowel habit?
```
Bloods- FBC, U&E, LFT, CRP, TFT, glucose, calcium, iron studies, haematinics
Anti-TTG, IgA, anti-endomysial
Stool sample
AXR
Scoping
```
29
what is H.Pylori associated with?
peptic ulcer disease
gastric cancer
Bcell lymphoma of MALT tissue
atrophic gastritis
30
what type of bacterial is H.Pylori?
gram negative bacteria
31
mx of H.pylori?
eradication may be achieved with a 7 day course of
a PPI + amoxicillin + clarithromycin, or
a PPI + metronidazole + clarithromycin
32
What is the definition of GORD?
symptoms of oesophagitis secondary to refluxed gastric contents
33
Mx of endoscopically proven oesophagitis?
full dose PPI for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
34
Mx of negative reflux disease?
full dose PPI for 1 month
antacids e.g Gavison
if no response then H2RA or prokinetic for one month
35
what is barrett's oesophagus?
metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium
36
what cancer is increased risk in barrett's oesophagus?
oesophageal adenocarcinoma
37
RFs for barrett's oesophagus?
GORD
male gender
smoking
central obesity
38
mx of barrett's oesophagus?
endoscopy recommended every 3-5 years for metaplasia
high dose PPI
for dysplasia- endoscopic mucosal resection
radiofrequency ablation
39
NICE guidelines for urgent referral for endoscopy?
1. all patients with dysphagia
2. all patients with upper abdo mass consistent with stomach cancer
3. patients >55 with weight loss AND ONE OF:
- upper abdo pain
- reflux
- dyspepsia
40
non urgent referral for endoscopy?
1. haematemesis
2. >55 and treatment resistant dyspepsia or upper abdo pain with low Hb or raised platelets with N&V, wt loss, reflex etc
41
test for H.pylori?
carbon-13 urea breath test or a stool antigen test
42
treating patients with dyspepsia who don't meet referral guidelines?
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a 'test and treat' approach for H. pylori
43
RFs for gastric cancer?
```
H.pylori infection
pernicious anaemia
smoking
blood group A
salty/spicy diet
```
44
histology of gastric cancer?
signet ring cells
45
features of gastric cancer?
dyspepsia
N&V
anorexia and weight loss
dysphagia
46
Ix of gastric cancer?
endoscopy with biopsy
staging: CT or endoscopic USS
PET CT
47
tx of gastric cancer?
subtotal gastrectomy if proximally sites disease >5-10cm from OG junction
total gastrectomy if tumour <5cm from OG junction
lymphadenectomy
48
Ix of oesophageal spasm?
```
upper GI endoscopy
oesophageal manometry
oesophageal pH studies
barium swallow
USS
```
49
Mx of oesophageal spasm>
```
dietary modification
trial of PPI to rule out GORD
nitrates
CCBS
anti-depressants
botox injection
surgery
```
50
red flags of IBS?
>60 years old
rectal bleeding
unexplained/unintentional weight loss
FH bowel or ovarian cancer
51
diagnosis of IBS?
6 months of:
- abdo pain and/or
- bloating and/or
- change in bowel habit
52
other features of IBS?
```
usually abdo pain is relieved by defecation
altered stool passage
worse with eating
passage of mucus
fatigue
nausea
backache
bladder symptoms
```
53
Ix of IBS in primary care?
FBC
ESR/CRP
coeliac screen (TTG antibodies)
54
mx of IB?
1st line-
pain: antispasmodic e.g. mebeverine
constipation- loperamide
diarrhoea- laxatives but avoid lactulose (use linaclotide if conventional laxatives not working)
2nd line- low dose TCA e.g. amitriptyline
psychological intervention- CBT, hypnotherapy
dietary advice- regular small meals, avoid fizzy drinks, not too much fibre
55
causes of acute diarrhoea? (<14 days)
gastroenteritis
diverticulitis
antibiotic therapy
constipation causing overflow
56
causes of chronic diarrhoea?
IBS
IBD
colorectal cancer
coeliac disease
57
common drugs causing constipation?
```
iron
NSAIDS
antimuscarinics- procyclidine, antidepressants
antiepileptic drugs
antihistamines
diuretics
opiates
```
58
mx of constipation?
bulk forming laxatives- fybogel (ispaghula husk), methylcellulose
osmotic laxatives (soften stool)- lactulose, polyethylene glycol
stimulant laxative- Bisacodyl, senna, sodium picosulfate
stop/treat the caues
59
complications of constipation?
overflow diarrhoea, acute urinary retention, haemorrhoids
60
presentation of constipation in very elderly?
nausea/loss of appetite
overflow diarrhoea
urinary retention
delirium/ confusion
61
2 week wait of colorectal cancer referral?
- Patients >40 years with unexplained weight loss AND abdo pain
- Patients >50 years with unexplained rectal bleeding
- Patients >60 with iron deficiency anaemia OR change in bowel habit
- FOBT positive
62
who is FOBT offered to?
every 2 years to men and women aged 60-74 years
may be given to younger patients with symptoms of abdo pain and weight loss or change in bowel habit or rectal bleeding
63
how does FOBT work?
uses antibodies that recognises human haemoglobin
| patients with abnormal results offered a colonoscopy
64
most common locations of colorectal cancer?
rectal (40%)
| sigmoid (30%)
65
3 types of colon cancer?
1. sporadic (95%)
2. hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
3. Familial adenomatous polyposis (FAP, <1%)
66
Amsterdam criteria for HNPCC?
- at least 3 family members with colon cancer
- the cases span at least 2 generations
- at least one case diagnosed before the age of 50 years
67
features of crohn's disease?
diarrhoea usually non-bloody
weight loss more prominent
upper GI symptoms, mouth ulcers, perianal disease
abdo mass in RIF
68
extra intestinal features of crohn's disease?
gallstones (secondary to reduced bile acid reabsorption)
arthritis
erythema nodosum
pyoderma gangrenousm
69
complications of crohns
obstruction
fistula
strictures
colorectal cancer
70
pathology of crohn's?
lesions anywhere from mouth to anus
| skip lesions may be present
71
histology of crohn's?
- inflammation in all layers from mucosa to submucosa
- increased goblet cells
- granulomas
72
endoscopy of crohn's?
deep ulcers
skin lesions
cobblestone appearance
73
radiology of crohn's?
strictures- kantors string sign
proximal bowel dilatation
rose thorn ulcers
fistulae
74
features of UC?
Bloody diarrhoea more common
abdo pain in left lower quadrant
tenesmus
75
extra intestinal features of UC?
```
primary sclerosing cholangitis
uveitis
arthritis
erythema nodosum
pyoderma gangrenosum
```
76
complications of UC?
Risk of colorectal cancer higher in UC than crohns
77
pathology of UC disease
inflammation always starts at rectum and never spreads beyond ileocaecal valve
CONTINUOUS disease
78
histology of UC disease
no inflammation beyond submucosa
crypt abscesses
depletion of goblet cells
79
endoscopy of UC?
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps
80
radiology of UC
On barium enema:
loss of haustrations
superficial ulceration, 'pseudopolyps'
long standing disease: colon is narrow and short -'drainpipe colon'
81
mx of crohn's
inducing remission-
- glucocorticoids
- budesonide
- 5-ASA drugs e.g. mesalazine are 2nd line
```
maintaining remission-
- stopping smoking
1st line- azathioprine or mercaptopurine
2nd line- methotrexate
TNF inhibitors- infliximab
```
surgery
82
mx of UC (mild and moderate)
proctitis- rectal aminosalicylate e.g. mesalazine
change to oral after 4 weeks if no improvement
oral corticosteroids
maintaining remission with topical or oral aminosalicylate
83
mx of UC (severe)
```
should be treated in hospital
IV steroids 1st line
analgesia
fluids
IV ciclosporin added if no improvement after 72 hours
surgery
```
84
what is coeliac disease and the pathology?
an autoimmune disease caused by sensitivity to gluten
| repeated exposure leads to villous atrophy which in turn causes malabsorption
85
associations with coeliac disease?
```
thyroid disease
dermatitis herpetiformis
IBS
T1DM
1st degree relative with coeliac disease
```
86
S&Ss of coeliac disease?
```
chronic or intermittent diarrhoea
failure to thrive or faltering growth
prolonged fatigue
recurrent abdo pain, crampy or distension
sudden or unexpected weight loss
unexplained iron-deficiency anaemia
```
87
immunology of coeliac disease?
TTG antibodies
Endomyseal antibody
anti-casein antibodies
88
jejunal biopsy findings of coeliac disease?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
89
tx of coeliac disease?
gluten free diet
| pneumococcal vaccine- due to association with functional hyposplenism
90
complications of coeliac disease?
```
anaemia
hyposplenism
OP, osteomalacia
lactose intolerance
gastric lymphoma e.g. MALT
subfertility
oesophageal cancer
```
91
Ix of IBD?
WCC and CRP raised
faecal calprotectin
AXR
colonoscopy
92
3 fat soluble vitamins that are reduced in malabsorption?
ADEK
A deficiency- poor vision
D- rickets, osteomalacia
K- clotting abnormalities
93
life-threatening causes of abdo pain?
```
Perforation
Bowel infarct/ischaemia
Obstruction
Acute pancreatitis
AAA
Appendicitis
Strangulated hernia
MI
Acute cholangitis
Ruptured ectopic
Ovarian torsion
```
94
key investigations for abdo pain?
```
bloods- FBC, U&E, LFT, amylase
MSU- b-HCG (need to rule out pregnancy)
ECG (?MI)
Erect CXR (?perforation)
AXR (?bowel obstruction)
CT KUB (?renal stone)
USS (hepatobiliary causes)
CT abdo
```
95
pathophysiology of acute pancreatitis?
- autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis
96
causes of pancreatitis?
```
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune e.g. polyarteritis nodosa
Scorpion venom
Hypertriglyceridaemia, calcaemia,hyperthermia
ERCP
Drugs (azathioprine, mesalazine, furosemide, steroids)
```
97
features of acute pancreatitis?
Severe epigastric pain that may radiate through to the back
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign)
98
Ix of acute pancreatitis?
```
raised amylase seen in 75%
hyperglycaemia (less insulin production)
serum lipase
neutrophilia
elevated LDH and AST
```
99
causes of false positive amylase?
pancreatic pseudocyst
perforated viscus
acute cholecystitis
DKA
100
mx of acute pancreatitis?
```
IV fluids
O2
analgesia
catheter
NBM
treat cause
```
101
cause of chronic pancreatitis?
alcohol (80%)
genetic- CF, haemochromatosis
ductal obstruction
102
feature of chronic pancreatitis?
pain is typically worse 15-30 mins following a meal
steatorrhoea
DM develops later
103
Ix of chronic pancreatitis?
AXR- pancreatic calcification
CT-pancreatic calcification
faecal elastase may assess exocrine function
104
mx of chronic pancreatitis?
pancreatin- contains protease, lipase, amylase (taken with food)
analgesia- NSAIDs and opiates
105
SE of pancreatin?
irritation of the mouth
perianal rash
N&V
abdo discomfort
106
endocrine and exocrine role of the pancreas?
endocrine- regulate blood sugar- insulin, glucagon, somatostatin
exocrine- bicarb and digestive enzymes
107
surgical causes of acute abdomen?
infective- GE, appendicitis, pyelonephritis, diverticulitis, PID
Inflammatory- pancreatitis, peptic ulcer disease
Vascular- MI, mesenteric ischaemia, ruptured AAA
Traumatic- ruptured spleen
Metabolic- renal/ureteric stones, DKA
108
what is biliary colic?
pain caused by the gallbladder contracting against a stone lodged in the cystic duct
109
what is cholithiasis vs cholecystitis vs choledocholithiasis?
Cholithiasis= gallstones in gallbladder
Cholecystitis= inflamed gallbladder due to gallstones (raised WCC and CRP), continuous pain
Choledocholithiasis=gallstones in the common bile duct
110
RFs for biliary colic?
Fat: enhanced cholesterol synthesis and secretion
Female: Oestrogen increases activity of HMG-CoA reductase
Fertile: pregnancy is a risk factor
Forty
111
cause of gallstones?
occur due to ↑ cholesterol, ↓ bile salts and biliary stasis
112
features of biliary colic?
colicky abdominal pain, worse postprandially, worse after fatty foods. The pain may radiate to the right shoulder
nausea and vomiting are common
113
Ix for gallstones?
Abdo USS
| LFTs
114
mx for biliary colic?
If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
115
features of acute cholecystitis?
Right upper quadrant pain
Fever
Murphys sign on examination
Occasionally mildly deranged LFT's (especially if Mirizzi syndrome)
116
Ix for acute cholecystitis?
1st line- USS
2nd line- cholescintigraphy (HIDA) scan
bloods- WCC, CRP, serum amylase
117
tx of acute cholecystitis?
IV antibiotics
| early laparoscopic cholecystectomy within 1 week of diagnosis
118
what is ascending cholangitis?
ascending infection of the biliary tree
| typically E.coli
119
Charcot's triad for cholangitis?
RUQ pain
jaundice
RUQ pain
hypotension and confusion are also common
120
Mx of cholangitis?
intravenous antibiotics
| endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
121
complications of cholangitis?
```
severe sepsis
liver abscesses
liver failure
AKI
septic shock
```
122
what is the common bile duct formed from?
```
cystic duct (from gall bladder)
and common hepatic duct (from liver)
```
goes into pancreas to join with pancreatic duct
enters duodenum at sphincter of Oddi
123
RFs of peptic ulcer disease?
H.Pylori
drugs- NSAIDs, SSRIs, corticosteroids, bisphosphonates
Zollinger-Ellison syndrome- gastrin secreting tumour
124
features of peptic ulcer disease?
epigastric pain
nausea
duodenal ulcers- pain relieved by eating
gastric ulcers- worsened by eating
125
Ix of peptic ulcer disease
urea breath test or stool antigen test (tests for H.pylori)
126
tx of peptic ulcer disease
if H.pylori negative -> PPI (omeprazole) given until the ulcer is healed
if H.pylori positive -> eradication therapy given
127
features of acute appendicitis?
peri-umbilical pain to RIF
vomiting once or twice
mild pyrexia
anorexia
if perforation -> generalised peritonitis
DRE may reveal boggy sensation of pelvic abscess is present
128
diagnosis of acute appendicitis?
raised inflammatory markers
neutrophils- predominantly leucocytes
urinalysis- rule out pregnancy, renal colic and UTI
USS
129
Tx of appendicitis?
appendicectomy
prophylactic IV Abx reduces wound infection
abdo lavage
130
what is diverticulosis?
multiple outpouchings of the bowel wall, most commonly in the sigmoid colon
131
what is diverticular disease?
symptomatic diverticulosis
altered bowel habits, colicky left-sided abdo pain, bleeding and bloating
treat with high fibre diet and drain any abscesses
132
what is diverticulitis?
the infection of a diverticulum
133
RFs for diverticulitis?
```
Age
Lack of dietary fibre
Obesity: especially in younger patients
Sedentary lifestyle
Smoking
NSAID use
```
134
features of diverticulitis?
Severe abdominal pain in the left lower quadrant
N&V
Change in bowel habit: constipation is more common
Urinary frequency, urgency or dysuria (10-15%): this is due to irritation of the bladder by the inflamed bowel.
PR bleeding
Symptoms such as pneumaturia or faecaluria
135
Ix of diverticulitis?
FBC: raised WCC
CRP: raised
Erect CXR: may show pneumoperitoneum in cases of perforation
AXR: may show dilated bowel loops, obstruction or abscesses
CT: this is the best modality in suspected abscesses
Colonoscopy: should be avoided initially due to increased risk of perforation in diverticulitis
136
tx of diverticulitis?
oral antibiotics, liquid diet and analgesia
if the symptoms don't settle within 72 hours, or more severe symptoms, the patient should be admitted to hospital for IV antibiotics
137
features of intestinal obstruction?
colicky abdo pain and vomiting
abdo distension and constipation
peritonism
138
RFs for obstruction?
malignancy
adhesions
strangulated hernia
volvulus
139
mx of obstruction?
Abdominal film: small bowel loops with fluid levels
laparotomy
CT if suspect malignancy
140
what are signs of peritonitis?
tenderness on palpation, guarding and rebound tenderness
| patients are usually unwell and distressed, worse on movement
141
causes of peritonitis?
```
Appendicitis
Ectopic pregnancy
Infection with TB
Obstruction-colicky pain
Ulcer- epigastric pain radiating to shoulder
intraperitoneal dialysis
```
142
what is spontaneous bacterial peritonitis?
a form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis
143
features of SBP?
ascites
abdominal pain
fever
144
Diagnosis of SBP?
paracentesis: neutrophil count > 250 cells/ul
| the most common organism found on ascitic fluid culture is E. coli
145
mx of SBP?
IV cefotaxime
146
when should Abx prophylaxis be given in patients with ascites?
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: 'Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved'
147
what is acute mesenteric ischaemia and what causes it?
embolism e.g. superior mesenteric artery
classic history of AF
abdo pain is severe, sudden onset and out of keeping with physical exam findings
148
mx of acute mesenteric ischaemia
urgent surgery is usually required
149
what is ischaemic colitis?
acute but transient compromise in the blood flow to the large bowel
leads to inflammation, ulceration and haemorrhage
it is more likely to occur in areas such as splenic flexure
150
Ix of ischaemic colitis?
AXR-thumbprinting due to mucosal oedema/haemorrhage, metabolic acidosis
151
mx of ischaemic colitis?
```
fluids
analgesia
NBM
surgery if perforation or haemorrhage
thrombolytic therapy, angioplasty
```
152
what is acute liver failure?
jaundice, coagulopathy (raised PT time), hepatic encephalopathy and hypoalbuminaemia w/o cirrhosis
153
causes of acute liver failure?
paracetamol OD
hepatitis
alcohol
acute fatty liver of pregnancy
154
things to ask in acute liver failure?
history of:
- IVDU
- foreign travel
- tattoos
- sexual history
- alcohol
155
Ix of acute liver failure?
liver screen: LFTs, FBC, U&E, CRP, clotting
hepatitis serology- HbsAg
EBV and CMV serology
serum ceruloplasmin (Wilson's disease)
A1AT levels
antimitochondrial, anti smooth muscle, ANA
Transferrin
156
mx of acute liver failure?
Child-Pugh score- assess prognosis of chronic liver disease
A-E
stop hepatotoxic drugs- NSAIDs, paracetamol, ACEi, erythromycin, statins
prophylactic Abx
IV fluids
lactulose- stops encephalopathy by binding to ammonia
escalate early
157
mx of paracetamol overdose?
if patients present <1 hour, take activated charcoal to reduce absorption of the drug
Give acetylcysteine if there is a staggered overdose or there is doubt over the time of paragetamol ingestion
158
what is included in the child pugh score?
```
bilirubin
albumin
PT time
encephalopathy
ascites
```
159
what are the investigations for non-alcoholic fatty liver disease?
ALT>AST
ELF test
Fibroscan
liver biopsy if advanced disease
160
what is primary biliary sclerosis?
a rare liver disease typically presenting in middle-aged women
fatigue and itch
jaundice develops as disease progresses
161
what is primary sclerosing cholangitis?
inflammation of intra and extra-hepatic bile ducts leading to fibrosis and stricture formation
associated with IBD and cholangiocarcinoma
bilirubin, ALP and gammaGT raised
162
what is a whipple's resection?
pancreaticoduodenectomy
163
how is a hepatocellular carcinoma diagnosed?
CT/MRI
| alpha-fetoprotein
164
Ix of gastroenteritis?
stool sample- include C.diff toxin assay and norovirus PCR
| bloods- high WCC, high CRP, high urea
165
what is pseudomonas colitis most commonly caused by?
C.diff- ciprofloxacin
| typically 3-9 days post Abx
166
Symptoms of pseudomonas colitis?
green, foul smelling stool
167
progression of pseudomonas colitis?
toxic megacolon
| perforation
168
tx of pseudomonas colitis?
metronidazole
| 2nd line- oral vancomycin
169
causes and treatment of oesophageal varices?
```
portal hypertension (due to liver cirhosis) causes dilated collateral veins
tx= beta blockers
```
170
mx of haematemesis?
OGD within 24 hours
if varices -> IV terlipressin which constricts the splanchic arteries
Balloon tamponade if doesn't work
171
what's included in the Rockall score?
risk of rebleeding score
- age
- shock
- comorbidity
- endoscopic findings- active haemorrhage
172
what to do in a severe attack of UC?
do a plain AXR to exclude toxic megacolon (diameter >5.5cm) and assess faecal distribution
173
complications of UC?
```
perforation
bleeding
malnutrition
toxic megacolon
primary sclerosing cholangitis
colon cancer
```
174
rash in coeliac disease?
dermatitis herpetiformis
175
what score is used to assess the severity of acute pancreatitis?
```
glasgow score
PANCREAS
PO2
Age >55
Neutrophils
Calcium
Renal function
Enzymes (LDH,AST)
Albumin
Sugar (BG)
```
176
what anti-emetics are obstructed in mechanical bowel obstruction?
metoclopramide as it is prokinetic
177
signs of acute mechanical intestinal obstruction?
```
distension
tenderness
visible peristalsis
hernias
rectal mass on PR examination
tinkling bowel sounds (absent in paralytic ileus)
```
178
complications of gallstones?
```
biliary colic
cholestasis
empyema
obstructive jaundice
cholangitis
gallbladder perforation and peritonitis
gallstone ileus
```
179
causes of peritonitis?
```
Appendicitis
Ectopic pregnancy
Infection with TB
Obstruction- colicky pain
Ulcer- epigastric pain radiating to shoulder
Peritoneal dialysis
```
180
RFs of jaudice?
```
IVDU
Sex workers, MSM
Alcohol
Travel history
Healthcare workers
Drugs e.g. paracetamol
```
181
blood tests to assess liver synthetic function?
Albumin (decreased)
| INR- increased due to impaired synthesis of clotting factors and Vit K malabsorption
182
blood tests to find cause of liver disease?
```
FBC
Hep B&C virus serology
A1AT
Copper studies
Iron studies- Exclude haemochromatosis
Autoantibodies- AMA (PBC), ANA, SMA
```
183
complications of liver cirrhosis?
```
renal failure
portal hypertension
coagulopathy
hepatocellular carcinoma (aFP)
hepatic encephalopathy- due to ammonia build up
Spontaneous bacterial peritonitis
```
184
what is achalasia?
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated.
185
clinical features of achalasia?
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
186
Ix of achalasia?
oesophageal manometry: excessive LOS tone which doesn't relax on swallowing - considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance
CXR: wide mediastinum, fluid level
187
tx of achalasia?
intra-sphincteric injection of botulinum toxin
Heller cardiomyotomy
pneumatic (balloon) dilation
drug therapy has a role but is limited by side-effects
188
what does diffuse oesophageal spasm produce on barium swallow?
corkscrew appearance
189
how are the causes of ascites differentiated?
```
SAAG serum-ascites albumin gradient
>11g/L: transudate
Indicates portal hypertension
Cirrhosis
Alcoholic hepatitis
Cardiac ascites
Massive liver metastases
Fulminant hepatic failure
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxoedema
Fatty liver of pregnancy
```
```
<11g/L: exudate- infection, inflammation, malignancy
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction
Biliary ascites
Postoperative lymphatic leak
Serositis in connective tissue diseases
```
190
mx of ascites?
reducing dietary sodium
fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
aldosterone antagonists: e.g. spironolactone
drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin 'cover'
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis
TIPS surgery may be considered- transjugular intrahepatic portosystemic shunt
191
features of pancreatic cancer?
classically painless jaundice
Courvoisier's law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones (
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
atypical back pain is often seen
192
mx of pancreatic cancer?
a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease
193
where are pancreatic cancers normally sites?q
head of the pancreas
194
what is haemochromatosis?
autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation
195
features of haemochromatosis?
early symptoms include fatigue, erectile dysfunction and arthralgia (often of the hands)
'bronze' skin pigmentation
diabetes mellitus
liver: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
cardiac failure (2nd to dilated cardiomyopathy)
hypogonadism (2nd to cirrhosis and pituitary dysfunction - hypogonadotrophic hypogonadism)
arthritis (especially of the hands)
196
signs of liver cirrhosis?
Jaundice – caused by raised bilirubin
Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
Splenomegaly – due to portal hypertension
Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
Palmar Erythema – caused by hyperdynamic cirulation
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising – due to abnormal clotting
Ascites
Caput Medusae – distended paraumbilical veins due to portal hypertension
Asterixis – “flapping tremor” in decompensated liver disease
197
complications of cirrhosis?
Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
