GI Flashcards
1
Q
GORD: What are 2 natural defence mechanisms against acid reflux?
A
- Saliva
- primary and secondary peristaltic waves
2
Q
Define oesophagitis
A
Local inflammation (edema and erosion) of the oesophagus
3
Q
What are 6 risk factors for GORD?
A
Obesity, fat-rich diet, caffeine, alcohol, smoking, medications (anti histamines, CCB, benzos, glucocorticoids)
4
Q
What are three medical conditions that increase risk of GORD?
A
Hiatul hernia, scleroderma, zollinger ellison syndrome
5
Q
What are 5 symptoms of GORD/it’s complications and when are they at their worst?
A
Heartburn, regurgitation, dysphagia (if stenosis), hoarseness, coughing. Worse lying down.
6
Q
How is GORD diagnosed?
A
Clinical symptoms, give PPI trial and see if stops or 24 hr pH monitoring
7
Q
What investigation is useful to identify complications of GORD?
A
X-ray with barium contrast
8
Q
What investigation is used do diagnose baretts and evaluate the risk of cancer?
A
endoscopy/biopsy
9
Q
What are the four treatment groups for GORD?
A
Advice, medical, endoscopy, surgery
10
Q
How is barrett’s metaplasia treated?
A
Non dysplastic - endoscopy every 3 years. Dysplasia - surgery, endoscopic resection or laser treatment.
11
Q
Define GORD
A
decreased tone in LOS causes excess stomach acid in oesophag
12
Q
What are 2 broad categories of causes of GORD?
A
- Disruption of mechanisms that prevent reflux - (e.g LOS)
- Prolonged oesophageal clearance
13
Q
What percentage of adults experience GORD?
A
5-10%
14
Q
What could you find on examination of GORD pt?
A
Normally nothing. Epigastric tenderness, wheeze on auscultation, dysphonia.
15
Q
State the different treatmenrs for GORD within the 4 categories
A
Advice - weight loss, elevating head, stop smoking, low fat. Medical - antacids, alginates, H2 antagonists, PPIs. Endoscopy - to look for barrett’s. Surgery - Nissen fundoplication.
16
Q
What are 6 complications of GORD? (4 in oesophagus, 1 in resp, 1 general)
A
- Oesophageal ulceration
- Peptic stricture
- Anaemia
- Barrett’s Oesophagus
- Oesophageal adenocarcinoma
- Chronic asthma and laryngitis
17
Q
What percentage of patients respond to lifestyle measures for GORD?
A
50%
18
Q
What is the prognosis for patients on drug therapy for GORD?
A
withdrawal is associated with relapse
19
Q
What percentage of GORD pt’s undergoing endoscopy have Barrett’s oesophagus?
A
20%
20
Q
Define peptic ulcer disease
A
Ulceration of GI tract caused by exposure to gastric acid and pepsin - most commonly gastric and duodenal.
21
Q
Define gastritis
A
Inflammation of the lining of the stomach
22
Q
State the underlying problem with peptic ulcer disease/gastritis. State 3 things that can cause this
A
An imbalance between damaging action of acid and pepsin and the mucosal protective mechanisms.
- H pylori
- NSAIDS
- Zollinger-Ellison syndrome
23
Q
Epidemiology of PUD and gastritis:
- How common is it?
- What is the annual incidence /1000?
- More common in M or F?
- Mean age for duodenal ulcer? stomach ulcer?
A
- Common
- 1-4/1000
- Males
- Duodenal ulcer - 30’s, Stomach ulcer - 50’s
24
Q
What are 4 symptoms you could get with peptic ulcers?
A
- Epigastric pain (gastric - worse eating/weight loss, duodenal - worse after eating/weight gain)
- Bloating
- Belching
- Vomiting
May present with complcations - haematemesis, malaena
25
What, if any, signs may present with PUD?
may be none. epigastric tenderness. or signs of complications - anaemia.
26
What investigations would you do for peptic ulcer disease?
1. H pylori breath test/stool antigen test
2. Upper GI endoscopy
3. FBC - check for microcytic anaemia
27
How would you manage a pt with an active bleeding ulcer?
1. Endoscopy +- blood transfusion + PPI
| 2. Surgery
28
How would you manage a pt with no active bleeding and h pylori negative?
1. Treat underlying cause + PPI
| 2. H2 antagonist
29
How would you manage a pt no active bleeding and H-pylori positive?
1. H-pylori eradication therapy (triple therapy - 2 antibiotics and a PPI)
30
What is the rate of complication of PUD and gastritis?
| What are 3 major complications?
1% per year
| -Haemorrhage, perforation, obstruction/pyloric stenosis.
31
What is general prognosis of PUD?
Generally food because ulcers from H. pylori can be cured.
32
What 2 things characterise achalasia?
Oesophageal motility disorder - loss of peristalsis and failure of relaxation of LOS
33
What is the pathophysiology of achalasia?
Degeneration of ganglion cells in myenteric plexus. (Infection in south America causes chagas' disease)
34
How many people /100,000 get it? What age range does it usually present?
1/100,000. 25-60 years.
35
What are 6 symptoms of achalasia?
-Intermittent dysphagia, difficulty belching, regurgitation, heartburn, chest pain (retrosternal, cramping), weight loss.
36
What 3 signs may you get with achalasia?
Signs of complications:
| Aspiration pneumonia, malnutrition, weight loss
37
What are 4 investigations to do for achalasia?
1. Upper GI endoscopy (frothy saliva retained)
2. Barium swallow (beaked appearance)
3. Oesophageal manometry - raised pressure
4. CXR - unusual oesophagus shape, absence of gastric bubble
38
What is Barrett's oesophagus?
Prolonged exposure of normal squamous epithelium of the oesophagus to reflux = mucosal inflammation and erosion = replacement with metaplastic columnar epithelium
39
What can cause barrett's oesophagus?
LOS not properly working or hiatus hernia.
40
What percentage of GORD pt's get Barrett's?
3-5%
41
What are 6 symptoms of Barrett's oesophagus? What are the signs?
Heartburn, Nausea, water brash, bloating, belching, burning pain when swallowing. Signs - look for symptoms.
42
What are 2 investigations you could do for barrett's?
1. Upper GI endoscopy w biopsy
| 2. Barium oesophagogram - identifies hiatal hernia + reflux
43
How would you treat non-dysplastic Barrett's oesophagus?
PPI inhibitor and surveillance w endoscopy every 2 yrs
44
How would you treat low-grade dysplasia?
Radiofrequency ablation w or wo endoscopic mucosal resection
45
How would you treat HIGH grade dysplasia?
radiofrequency ablation w or wo endoscopic mucosal resection + PPI inhibitor.
46
What is the complication of Barrett's?
oesophageal adenocarcinoma
47
What is the prognosis of Barrett's?
30-60x higher risk of cancer than gen pop. but most Barrett's don't develop cancer. 5-10% of Barrett's get adenocarcinoma over 10-20 yrs.
48
What is a mallory weiss tear?
Tearing in lining of oesophagus around the junction with stomach due to violent vomiting/retching.
49
What is MW tear caused by and what are some rf's?
Prolonged violent vomiting. RF: chronic alcohol abuse, bulimia, trauma, intense cough, gastritis.
50
How common are these tears?
Rare
51
What are 6 presenting symptoms of MW tears? (same as signs)
MOST cases do not cause symptoms.
1. Abdo pain
2. Severe vomiting
3. Haematemesis
4. involuntary retching
5. Black tarry stools
6. Symptoms of hypovolaemia if severe.
52
What investigations are used for MWT?
1. FBC
| 2. OGD
53
What is used to treat MWT?
1. 80-90% of the time they self-heal
| 2. If bleeding does not stop surgery - Injection sclerotherapy, coag therapy, arteriography.
54
What is a complication of MWT?
Boerhaave's perforation
55
What's the overall prognosis of a MWT?
GOOD.
56
What is oesophageal cancer? What are the two types?
Malignant tumour of oesophageal mucosa. SCC and adenocarcinoma.
57
What are the rfs for both of these types?
Smoking, age >60yrs, achalasia
58
What are 3 specific rfs for SCC?
Alcohol, hot fluids, caustic strictures (+ others - plummer vinson syndrome, scleroderma)
59
What are 3 specific rfs for adenocarcinoma?
GORD, obesity, male
60
How common is oesophageal cancer?
8th most common in world, 3x more in males. SCC - developing, adenocarcinoma - western.
61
What are up to 8 symptoms of oesophageal cancer?
Often asymptomatic
1. Progressive dysphagia
2. Regurgitation
3. Cough
4. Choking after food
5. Hoarseness of voice
6. Odynophagia
7. Weight loss
8. Fatigue
62
What signs might a oesophageal cancer pt present with?
may be no signs.
| supraclavicular lymphadenopathy, hepatomegaly, hoarseness, sighns of bronchopulmonary involvement.
63
What investigations can be used for oesophageal cancer?
1. OGD w biopsy
2. Metabolic profile (advanced cases: hypokalaemia, elevated creatinine and serum urea/nitrogen)
3. CT thorax/abdo
4. Barium swallow
5. PET scan
64
What is appendicitis? How common is it? When does it occur?
Inflammation of the appendix, most common surgical emergency and mostly 10-20yrs
65
What causes appendicitis?
Lumen obstruction = gut organisms accumulate in appendix = oedema/necrosis/perforation
66
What can cause the obstruction?
Lymphoid hyperplasia, feacolith, filarial worms
67
What does appendicitis present with?
Periumbilical pain that radiates to right iliac fossa. Anorexia. Fever. vomiting/constipation/diarrhoea
68
What signs does appendicitis present with?
tachycardia, fever, furred tongue, coughing hurts, shallow breaths, GURADING, rebound tenderness. Rovsing's sign, Psoas sign
69
What investigations would you do for appendicitis?
FBC, Abdo/Pelvic CT
70
How would you treat appendicitis?
Appendicectomy + antibiotics (cefuroxime, metronidazole) + drainage if there's an abcess
71
What are the complications of appendicitis?
Perforation, abcess, appendix mass - inflamed appendix covered in omentum
72
What is the prognosis for appendicitis?
Uncomplicated - majority recover no issue. ruptured - greater risk of complications/death
73
What is peritonitis?
Inflammation of the peritoneal lining of abdo cavity. Can be localised part of peritoneum or generalised
74
What are the causes of localised peritonitis?
- Appendicitis
- Cholecystitis
- Diverticulitis
- Salpingitis
75
What is primary generalised peritonitis?
Bacterial infection of peritoneal cavity without an obvious source (RF: Ascites, nephrotic syndrome)
76
What is secondary generalised peritonitis?
Bacterial translocation from a localised focus. Could be non-bacterial due to spillage of bowel contents, bile and blood.
77
How common is localised, primary generalised and secondary generalised peritonitis?
Localised and secondary generalised - common in surgical patients. Primary - rare (usually adolescent females)
78
What are the symptoms of peritonitis?
continual, sharp, localised pain exacerbated by movement and coughing. Symptoms may be VAGUE in liver disease due to encephalopathy
79
What signs might peritonitis present with?
Tenderness, guarding, rebound tenderness, unwell, signs of sepsis, shallow breathing, reduced bowel sounds, DRE may show anterior tenderness
80
What investigations could you do for peritonitis?
Bloods: FBC - Leukocytosis, anaemia. ^creatinine, ascitic tap: hazy fluid, ^neutrophil, gram stain and culture bacteria. Erext CXR: Air under diaphragm
81
How would you treat localised peritonitis?
- Depends on cause (e.g. appendectomy)
| - Antibiotics
82
How would you treat generalised peritonitis?
death from sepsis/shock. Give them IV fluids, IV antibiotics, Urinary catheter, NG tube. Laparotomy - to remove infected or necrotic tissue. Peritoneal lavage. Use antibiotics
83
What is Spontaneous bacterial peritonitis treated with?
Quinolone antibiotics or Cefuroxime/metronidazole
84
What are some complications of peritonitis?
Septic shock, respiratory failure, multiorgan failure, paralytic ileus, wound infection, abscesses, incisional hernia, adhesions.
85
What is the prognosis of localised, generalised peritonitis and SBP?
Localised peritonitis usually resolves with treatment of cause. Generalised peritonitis has mortality of 30-50%. Primary peritonitis has good prognosis w antibiotics. SBP >30% mortality w delayed treatment.
86
What is a GI perforation?
Perforation of the wall of the GI tract with spillage of bowel contents.
87
What are 3 common causes of large bowel perforation?
Diverticulitis, colorectal cancer, appendicitis (others include: volvulus, UC)
88
What are 2 causes of gastroduodenal perforation?
Perforated duodenal or gastric ulcer. Gastric cancer
89
What are 3 causes of small bowel perforation?
RARE. Trauma, infection (e.g. TB), Crohn's disease
90
What causes oesophagus perforation?
Boerhaave's perforation
91
How common are these perforations?
Incidence depends on cause
92
What are the presenting symptoms of large bowel perforation?
Peritonitic abdo pain - MAKE SURE YOU RULE OUT AAA
93
What are symptoms of gastroduodenal perforation?
Sudden onset severe epigastric - worse on movement. Pain becomes generalised. If it was gastric malignancy - likely accompanying weight loss + N+V
94
What are symptoms of oesophageal perforation?
Severe pain following vomiting
95
What are signs of GI perforation?
Unwell, septic shock, pyrexia, pallor, dehydration, peritonitis signs, loss of liver dullness (due to overlying gas)
96
What investigations would you do?
FBC, U+E, LFTs
Amylase (raised but not astronomical)
Erect CXR - Air under diaphragm. AXR - abnormal gas shadowing. Gastrograffin swallow - suspected oesophageal perforations
97
How would you manage a GI perforation?
1) Resuscitation - fluid, electrolytes, IV antibiotics
2) Surgical -
Large bowel - identify site of perforation, peritoneal lavage, resection of perforated part (hartmann's procedure).
Gastroduodenal - laparotomy, peritoneal lavage, perforation covered with omental. Ulcers biopsied, H-pylori eradication if +ve.
Oesophageal - pleural lavage, repair of oesophagus
98
What is a complication of large and small bowel perforation?
Peritonitis
99
What are some complications of oesophageal perforation?
Mediastinitis, shock, sepsis, death
100
What is the prognosis of a gastroduodenal perforation?
Morbidity +mortality of gastric ulcers > duodenal ulcers. Poor prognosis for perforated gastric cancer
101
What is the prognosis of large bowel perforation?
High risk of faecal peritonitis if left untreated - septicaemia -> multiorgan failure -> death
102
What is a hiatus hernia?
The prolapse of the upper stomach through the diaphragmatic oesophageal hiatus (opening)
103
What can cause a hiatus hernia?
Congenital, traumatic, non-traumatic.
104
What are the 2 types of hiatus hernias?
1) Sliding - hernia moves in and out of the chest
| 2) Para oesophageal - hernia goes through a hole in the diaphragm
105
What are some risk factors for this hernia?
Obesity, low-fibre diet, chronic oesophagitis, ascites, pregnancy
106
Where are these hernias common? In which age group are they common?
Common in the west. Increased frequency w age, 70% are >70 years old.
107
What are the presenting symptoms of a hiatus hernia?
Mostly asymptomatic. Sliding hernias - more likely to cause symptoms.
Symptoms of GORD - heart burn, waterbrash
108
What are the signs of hiatus hernia?
Usually none.
109
What investigations would you do for hiatus hernia?
CXR - retrocardiac air bubble or normal.
Upper GI series - stomach partially or completely intrathoracic
OGD - inflammation of oesophagus and proximal migration of the gastro-oesophageal junction
CT/MRI scan
110
How would you medically treat a hiatus hernia?
Modify lifestyle factors, inhibit acid production (PPI inhibitors), enhance GI motility
111
How would you surgically treat hiatus hernia?
Minority of patients. Nissen fundoplication. Belsey mark IV fundoplication. Hill repair - gastric cardia anchored to posterior abdo wall.
112
What are some oesophageal complications of a hiatus hernia?
intermittent bleeding, oesophagitis, erosions, barrett's, oesophageal strictures
113
What are some non-oesophageal complcations?
Incarceration of hiatus hernia (paraoesophageal hernias only) - can lead to strangulation and perforation
114
What's the prognosis of a hiatus hernia pt?
Generally good. sliding > rolling prognosis
115
What are hernias? (Specifically inguinal and femoral)
Abnormal portrusion of peritoneal sac through weakness of abdo wall. Direct - appears through Hesselbach's triangle. Indirect - through deep inguinal ring. Femoral - inferior to inguinal ligament.
116
What causes congenital and acquired hernias?
Congenital: patent processus vaginalis. Acquired: increased intra-abdo pressure
117
What are risk factors for hernias?
Male, prematurity, age, obesity, chronic cough, constipation, bladder outflow obstruction, intraperitoneal fluid.
118
How common are they and at what age do they peak? What gender is more likely to get it?
Common. Peak between 55-85yrs. Males 9x more likely.
119
What are some presenting symptoms of a hernia?
asymptomatic, discomfort/pain, irreducible, increased in size.
120
What are some signs of a hernia?
lump that extends to scrotum or labia. May be bowel sounds over hernia. Tenderness if strangulated.
121
What investigations would you do for a hernia?
Usually detected clinically. US of groin.
122
How would you treat a hernia?
Acute (surgical repair), ongoing (watchful waiting)
123
What are 3 complications of a hernia?
incarcerated hernia, strangulation, bowel obstruction
124
What is the prognosis of a hernia?
Slowly enlarge if left alone. Surgical mesh repair has good outcome.
125
What is a pilonidal sinus?
Abnormal epithelium-lined tract filled with hair that opens onto the surface. Most commonly in the natal cleft.
126
What is a pilonidal sinus caused by?
Shed or sheared hairs penetrating the skin + inciting an inflammatory reaction and sinus development
127
What are 3 risk factors for pilonidal sinus?
Hirsutism, spending a lot of time sitting down and occupational (hairdresses may develop interdigital pilonidal sinus)
128
How common is this sinus?
Common - 0.7% of adults
129
What are the presenting symptoms of this sinus?
Painful natal cleft
discharging swelling
these are often recurrent.
130
What are some signs of a pilonidal sinus on examination?
- Midline openings/pits between the buttocks
- Hairs may protrude from the swelling
- Tender (if infected or abscess)
- Fluctuant feeling and may discharge pus/blood-stained fluid on compression
131
What investigations might you do?
1. Clinical, no diagnostic test required.
| 2. Bloods - to check for infection
132
What would you do for a acute and chronic pilonidal sinus and how would you prevent them occuring?
Acute pilonidal abscess - Incision + drainage
Chronic sinus - excision under anaesthesia w exploration
Prevention - good hygiene and shaving
133
What are 4 possible complications of this sinus?
Pain, infection, abscess and recurrence.
134
What is the prognosis of this sinus like?
Good w draining, shaving will cure, usually resolves by 40.
135
What is acute pancreatitis?
Acute inflammation of pancreas with variable involvement of other regional tissues or remote organ systems.
136
What is the underlying pathophysiology of acute pancreatitis?
Insult = activation of pancreatic proenzymes in duct/acini = tissue damage/inflammation
137
What are the causes of acute inflammation?
```
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridaemia/hypercalcaemia
ERCP
Drugs
```
138
How common is acute pancreatitis? What is the incidence /10,000? What is the peak age? What is the common cause in males and females?
```
Common.
10/10,000 anually
60 yrs is peak
males - alcohol
females - gallstones
```
139
What kind of pain does pancreatitis present with?
Severe epigastric pain/abdo pain - radiating to back - relieved sitting forward, aggravated moving.
140
What other symptoms of acute pancreatitis are there?
Anorexia, N+V
141
What signs may you find on examination of acute pancreatitis?
epigastric tenderness, fever, shock, tachycardia, tachypnoea. If severe and haemorrhagic - Turner's sign and Cullen's sign
142
What investigations would you do for acute pancreatitis?
1. Serum lipase/amylase
2. FBC - Leukocytosis
3. CRP - C-reactive protein
4. LFTs - deranged depending on cause
5. U+E's - low calcium
143
What 2 scores assess the severity of pancreatitis?
1. Modified glasgow + CRP
| 2. APACHE-11 score
144
What medical treatment would you give acute pancreatitis ?
Fluid + electrolyte resus. analgesia/blood sugar control. NG tube feeding + urinary catheter
145
What can you use if it's gallstone pancreatitis?
ERCP + sphincterotomy
146
What can you do if symptoms persist?
Image guided fine needed aspiration for culture
147
When would you use surgical intervention?
Pt with necrotizing pancreatitis
148
What are some local, systemic and long term complications of acute pancreatitis?
Local - Pancreatic necrosis, pseudocyst, abscess, ascites, pseudoaneurysm, venous thrombosis.
Systemic - Multiorgan dysfunction, sepsis, ARDS, DIC, hypocalcaemia, diabetes
Long term - chronic pancreatitis
149
What is the prognosis of acute pancreatitis?
20% - severe fulminating course with high mortality
150
What is chronic pancreatitis?
Inflammatory disease of pancreas with irreversible parenchymal atrphy + fibrosis -> impaired pancreatic function
151
What is the main cause of chronic pancreatitis?
alcohol (70%) Idiopathic (10%)
152
What's the annual incidence of chronic PT? What age group does it affect?
annual incidence - 1/100,000. age 40-50 in alcohol disease
153
What are some presenting symptoms of chronic pt?
recurrent severe epigastric pain (same as acute), weight loss, bloating, steatorrhoea
154
What are the examination findings?
epigastric tenderness, weight loss, malnutrition
155
What investigations would you do for chronic pancreatitis?
1) Blood glucose - elevated
2) CT - pancreatic calcifications
3) ERCP/MRCP - May show dilation of ducts/chain of lakes appearance
156
How would you manage chronic pancreatitis?
1) Lifestyle modifications - stop drinking and smoking
2) Endoscopic therapy - sphincterotomy, stone extraction, dilatation/stenting of strictures, lithotripsy.
3) Surgery if medical management fails
157
What are 5 potential local complications of chronic pancreatitis?
Pseudocysts, biliary duct stricture, duodenal obstruction, pancreatic ascites, pancreatic carcinoma.
158
What are systemic complications of pancreatitis?
Diabetes, steatorrhoea
159
What is the prognosis for chronic pancreatitis?
pain may better, worsen or stabilise. surgery improves symptoms in 60-70%.
160
What is pancreatic cancer?
Malignancy of exocrine or endocrine tissue of pancreas
161
What causes pancreatic cancer?
Genetic mutations.
162
What are some none- modifiable risk factors for pancreatic cancer?
Non-modifiable:
- Male
- Afro-american
- Over 65 yrs
163
What are some modifiable risk factors for pancreatic cancer?
- Smoking
- Obesity
- Diet high in red meat
164
What other disease increase risk of pancreatic cancer?
Diabetes, chronic pancreatitis, liver cirrhosis (these are all associated with alcohol abuse)
165
What genes are associated with pancreatic cancer?
BRCA2, PALB2
166
What is the incidence of pancreatic cancer /100,000?
Males or females?
What age does it peak at?
8-12/100,000. Worldwide 8th cause of cancer death.
2x more common in males
Peak age 60-80 yrs
167
What symptoms does pancreatic cancer present with?
Initial symptoms are quite non-specific. Anorexia, malaise, weight loss, nausea - jaundice/epigastric pain
168
What are some modifiable risk factors for pancreatic cancer?
- Smoking
- Obesity
- Diet high in red meat
169
What other disease increase risk of pancreatic cancer?
Diabetes, chronic pancreatitis, liver cirrhosis (these are all associated with alcohol abuse)
170
Define intestinal obstruction
Obstruction of the normal movement of bowel contents
171
What is the incidence of pancreatic cancer /100,000?
Males or females?
What age does it peak at?
8-12/100,000. Worldwide 8th cause of cancer death.
2x more common in males
Peak age 60-80 yrs
172
What symptoms does pancreatic cancer present with?
Initial symptoms are quite non-specific. Anorexia, malaise, weight loss, nausea - jaundice/epigastric pain/courvoisier sign (palpable non-tender gallbladder)
173
What are some signs of pancreatic cancer on examination?
Weight loss, epigastric tenderness. Jaundice/palpable gallbladder. Hepatomegaly is metastatic spread. Trousseau's sign - superficial thromboplebitis
174
What investigations can be done for pancreatic cancer?
1. Abdo ultrasound - pancreatic mass, dilated bile ducts, liver mets
2. CT - mass in pancreas/spread of cancer
3. LFTs - ^Bilirubin, ALP, GGT
4. Bloods - CA19-9 elevated
175
How can bowel obstruction be classified?
Small or large, partial or complete, simple or stangulated
176
What are three causes of mechanical obstruction in both the small and large bowel?
- IBD (can cause strictures/adhesions)
- Foreign body
- Intussusception
177
What are 2 causes of small bowel mechanical obstruction?
Postoperative adhesions. Hernias.
178
What can cause a large bowel mechanical obstruction?
Volvulus
179
What is the pathophysiology functional obstruction?
Decreased smooth muscle contractility
180
What 4 things can cause decreased smooth muscle contractility?
- Postoperative ileus - trauma during durgery causes transient paralysis of smooth muscle
- Infection/inflammation (appendicitis/peritonitis)
- Hypothyroidism
- Electrolyte abnormalities - hypokalaemia, hypercalcaemia
181
How common is intestinal obstruction?
Common. more common in elderly due to increased risk of adhesions, hernias, malignancy
182
State 4 symptoms of intestinal obstruction
1. Cramping + abdo pain
2. Constipation
3. Vomiting
4. Abdo distension
183
What are some signs of intestinal obstruction?
Auscultation - high pitch tinkling sounds (mechanical), absence of normal bowel sounds (functional).
Abdo distension, generalised tenderness, hernias, abdo scars from previous surgery.
184
Describe presenting symptoms of complete obstruction
Sudden, obstipation.
185
What are some features of symptoms of small bowel obstruction?
Vomiting is more common. Pain is periumbilical - cramping+intermittent. bouts lasting a few mins
186
What are features of symptoms of large bowel obstruction?
Vomiting is less common. Pain in lower abdo, less frequent pain but bouts are longer
187
What investigations would you do for bowel obstruction?
1) Upright abdo X-ray - dilated loops of bowel w/ multiple air-fluid levels (mechanical), Uniform distension of large+small bowel. air under diaphragm (functional)
2) Bloods - elevated WBC, variable electrolytes, elevated amylase/lipase
188
Define intestinal ischaemia
Obstruction of a mesenteric blood vessel leading to bowel ischaemia and necrosis
189
What are 5 complications of bowel obstruction?
Dehydration, bowel perforation, peritonitis, toxaemia, gangrene of bowel wall
190
What's the prognosis of intestinal obstruction like?
Varies depending on pt state and complications
191
What are some occlusive causes intestinal ischaemia?
- Thrombus
- Embolism
- Tumour
- Hernia
- Volvulus
- Intussusception
192
What are some non-occlusive cusses of bowel ischaemia?
Related to decreases in systemic blood flow
1. Hypovolaemia
2. Low cardiac output
193
What are some signs of intestinal ischaemia on examination?
- Abdo tenderness
- Abdo distended
- tender palpable mas - ischaemic bowel
- bowel sounds may be absent
- cardiovascular collapse potentially
- Signs of sepsis if perforation
194
What are some symptoms of intestinal ischaemia?
- Severe abdo pain - may be soft/easy to press
- Vomiting
- bloody diarrhoea
- Distended abdo
195
What investigations would you do for intestinal ischaemia?
1. AXR - thickening of small bowel folds + signs of obstruction
2. FBC - Leukocytosis, anaemia, ABG - lactic acidosis
3. Mesenteric angiography is stable
196
What is gastric cancer?
Gastric malignancy - mostly Adenocarcinoma
197
What causes gastric malignancy? What are some risk factors for it?
Mainly environmental factors in genetically predisposed individuals. RF: H. pylori infection, atrophic gastritis, high smoked/processed food/nitrosamines diet, smoking, alcohol
198
How common is gastric cancer? Where in the world and where in the stomach does it occur? What gender?
common cause of cancer death, particularly in asia. 2:1 male., >50yrs. Cancer of carida/gastro-oesophageal junction^.
199
What are some symptoms of gastric cancer?
Early: asymptomatic. Early satiety, EG discomfort. Weight loss, anorexia, n+v. Haematemesis, melaena, symptoms of anemia. Dysphagia. Symptoms of metastases, abdo swelling/jaundice - liver involvement.
200
What are some signs of gastric cancer?
may be normal. Epigastric mass, abdo tenderness, ascites. Anaemia signs. Virchow's node, sister mary jospeh node, Krukenberg's tumour.
201
What investigations would you do for gastric cancer?
Upper GI endoscopy with biopsy - ulcer, mass or mucosal changes. Endoscopic ultrasound - determines TNM. FBC - anaemia, LFTs. CT/MRI - staging/planning of surgery
202
What is diverticular disease?
Diverticulosis: the presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel. Diverticular disease: Diverticulosis assosciated with complications e/g haemorrhage, infection, fistulae. Diverticulitis: acute infection and inflammation of diverticula (classified using Hinchey classification)
203
What can cause diverticular disease?
low fibre diet (loss of stool bulk) = high pressures needed to propel stool = herniation of mucosa and submucosa. Occurs at sites of nutrient artery penetration, obstruction of them by faeces = bacterial overgrowth, toxin production and muscosal injury = diverticulitis, perforation, phlegmon, abscess, ulcers, fistulae or strictures.
204
In what population is this common? What age does it tend to occur in?
60% of people in industriliazed areas, rare <40yrs. Right sided more common in asia
205
What are some symptoms of diverticular disease?
Asymptomatic (80-90%). Bloating, constipation, PR bleeding, left iliac fossa/lower abdo pain, fever. Diverticular fistulae into bladder: penuomaturia, faecaluria and recurrent UTI
206
What are some signs of diverticular disease?
Diverticulitis: Tender abdo, signs of peritonitis
207
What can you use to investigate diverticular disease?
Bloods: FBC (polymorphonuclear leukocytosis). Abdo x-ray (pneumoperitoneum, ileus, soft tissue densities, free air in bowel). CT scan. CXR (air under diaphragm). Contrast enema (after acute symptoms resolved to confirm diagnosis)
208
What investigation should you avoid in diverticulitis?
DON'T DO colonoscopy in acute diverticulitis - could lead to perforation
209
How would you treat asymptomatic diverticular disease?
Asymptomatic: soluble high-fibre diet. GI bleed: IV rehydration, antibiotics and blood transfusion (if necessary) Angiography+embolisation/surgery if severe.
210
How would you treat diverticulitis?
Diverticulitis: IV antibiotics, IV fluid rehydration, abscesses drained radiologicaly.
Surgery: in pts with recurrent attacks/complications. Open surgery: proctosigmoidectomy leaving a stoma OR one stage resection/anastomosis
211
What is the prognosis of patients with diverticular disease?
10-25% have one or more episodes of diverticulitis.
212
What is the prognosis of patients with diverticular disease?
10-25% have one or more episodes of diverticulitis.
213
What is a colorectal carinoma?
Malignant adenocarcinoma of large bowel.
214
What can causes colorectal carcinoma?
Genetic changes in oncogenes and tumour surpressor genes = epithelial dysplasia ->adenoma -> carcinoma.
215
What are some non-modifiable risk factors for colorectal carcinoma?
Non-modifiable RF: Male, Old, IBD.
216
What are some modifiable risk factors for colorectal carcinoma?
Modifiable: Smoking, red meat, no fibre, obese
217
What are some familial disorders that are RF's for colorectal carcinoma?
FAP and hereditary nonpolyposis cancer
218
How common is this cancer and what age does it typically arise?
2nd most common cancer death in the west. Avg age 60-65 years old.
219
What are some symptoms of colorectal cancer? Split into left and right colon
Depends on size and location. Left sided colon and rectum: change in bowel habit, rectal bleeding, tenesmus. Right sided colon: presents later (doesn't obstruct bowel till later), anaemia symptoms, weight loss, Non-specific malaise, lower abdo pain
220
What are some signs a pt with colorectal cancer might present with?
Anaemia, Abdo mass, Hepatomegaly, Ascites, mass on DRE (low lying rectal tumours)
221
What investigations could you do for colorectal cancer?
Bloods: FBC (Anaemia), LFTs, CEA (Tumour marker). Stools: FOBT - used as screening. Imaging/biopsy - Colonoscopy. Double-contrast barium enema - 'apple core' strictures. Contrast CT - Duke's Staging
222
What is a volvulus?
Rotation of a loop of bowel around itself and its surrounding mesentry
223
Where do volvulus usually occur?
Sigmoid colon, caecum and midgut (in neonates usually)
224
What are the risk factors for developing a sigmoid volvulus?
- Middle aged/elderly - constipation
- Pregnancy - fetus can cause displacement
- Abdo adhesions
- Stool
225
What are risk factors for a caecal volvulus?
Mobile caecum
226
What causes midgut volvulus?
Neonatal malrotation of the midgut
227
How common are these volvulus? /100.000. What age do they typically occur?
2-3/100,000. 30-70yrs.
228
What are some symptoms of a volvulus?
Severe colicky pain and swelling, constipation, vomiting, bloating, bloody stool
229
What signs may a volvulus present with?
Signs of bowel obstruction w abdo distension, tenderness, absent/tinkling bowel sounds, fever, tachycardia, dehydration
230
How would you investigate a potential volvulus?
1. AXR - looks like coffee bean. Barium enema - shows bird's beak shape
2. Erect CXR - if peforation suspected
231
What are haemorrhoids?
Anal vascular cushions become enlarged and engorged - they portrude, bleed or prolapse in the anal canal. Internal - above dentate line, external - below dentate line. 4 degrees of haemorrhoids
232
What causes haemorrhoids? What are some risk factors?
disorganisation of fibromuscular stroma of anal cushions. RFs: Constipation, prolonged straining, deranged internal anal sphincter, pregnancy, portal HTN.
233
How common are haemorrhoids?
common - peak age 45-65 yrs
234
What symptoms does haemorrhoids present with?
Asymptomatic. Bleeding (bright red, not mixed w stool). No red flag symptoms (weight loss, anaemia, change in BH etc). Itching, anal lumps, prolapsing tissue. Thrombosed can be painful.
235
What signs are you looking for in haemorrhoids?
1+2nd degree not visible on external inspection. Internal not palpable unless thrombosed. Usually visual on protoscopy.
236
What is used to investigate haemorrhoids?
DRE, protoscopy, Anoscopic exam, sigmoidoscopy - to rule out other sources of bleeding.
237
How are haemorrhoids managed?
Conservative - high fibre, increased fluid intake, bulk laxatives, creams for anaesthetic. Injection sclerotherapy - fibroses of dilated veins. Banding 0 causes them to fall off. Surgery - for 3rd and 4th degree.
238
What are some possible complications of haemorrhoids?
bleeding, prolapse, thrombosis, gangrene. Complications of injection scleropathy and haemorrhoidectomy.
239
What is the prognosis for haemorrhoids?
often chronic. high rate of recurrence. Surgery can provide long term relief.
240
What is rectal prolapse?
Abnormal protrusion of the full thickness/mucosal layer of rectum through the anus
241
What can cause rectal prolapse?
- Straining
| - Abnormal rectal anatomy/physiology (e.g weak pelvic floor)
242
What are risk factors for rectal prolapse?
- Constipation
- Cause of increased straining
- Cystic fibrosis
- Previous trauma to anus/perineum
- Neuro conditions (cauda equina/MS)
243
How common is rectal prolapse? What ages does it affect?
Relatively common. mostly children <3yrs and elderly
244
What signs may a rectal prolapse present with?
-Seen on straining, may be ulcerated or necrotic if vascular supply is compromised, reduced anal sphincter tone.
245
What investigations would you do for rectal prolapse?
1) Imaging - proctosigmoidoscopy or defecating proctogram or barium enema
2) Anal sphincter manometry
3) Pudendal nerve studies
4) Sweat chloride test - for kids to test for cystic fibrosis
246
What are perianal abscesses and fistulae?
Abscess - a pus collection in the perianal region
| Fistula - abnormal chronically infected tract between perianal skin and either anal canal/rectal
247
What can cause these abscesses/fistulae to form?
Bacterial infection. fistulae develop as a complication of abscess. fistulae can also occur from crohn's disease. (pepper pot perineum)
248
What are some risk factors for perianal abscess/fistula?
IBD, DM, malignancy
249
How common are these abscesses/fistulae?
COMMON.
250
How do anal abscesses/fistulae present?
Constant throbbing pain in the perinuem. Intermittent discharge near anal region. personal/fh of IBD
251
What signs do anal abscesses/fistulae present with?
Localised tender mass. Small skin lesion near anus (opening of fistula)
252
What can you feel on a DRE?
Thickened area over abscess/fistula may be felt. DRE's not always feasible due to pain/anal sphincter spasm
253
What law can help you determine the location of the internal fistula?
Goodsall's Law
254
What would you do to investigate anal abscess/fistula?
1. Clinical examination or examination under anaesthetic
2. MRI
3. Ultrasound
255
How would you treat an anal abscess/fistula?
- Requires SURGICAL TREATMENT
- Open drainage of abscess
Low fistula - fistulotomy - don't damage anal sphincter
High fistula - Fistulotomy would cause INCONTINENCE. Use Seton (suture which allows drainage too)
Antibiotics
256
What are some complications for anal abscesses//fistula?
Recurrence, damage to internal anal sphincter, incontinence, persisting pain
257
What is the prognosis for anal abscesses/ fistulae?
High recurrence rate without complete excision
258
What is an anal fissure?
A break/tear in the skin of the anal canal. Painful tear in the squamous lining of the lower anal canal
259
What causes anal fissures?
Most: hard faeces, pregnancy. Rarer: syphilis, herpes, trauma, crohn's, cancer, psoriasis.
260
What causes delayed healing of an anal fissure?
Anal sphinter spasm -> constriction of inferior rectal artery -> ischaemia + impaired healing process
261
What is the lifetime risk of getting an anal fissure? What age does it occur at?
1/10 overlifetime. 10-30yrs.
262
What symptoms does an anal fissure present with?
Tearing pain when passing stool, little blood in faeces or stool, anal spasm, anal itching (pruritus ani)
263
What signs will you see in an anal fissure?
Tears in squamous lining of anus
264
What investigations would you do?
Clinical examination of the anus
265
What treatment would you give for an anal fissure? Split into advice, medical, surgical
Conservative: High fibre, laxatives, good hydration. Medical: Lidocaine, GTN ointment or diltiazem (relaxes sphincter/promotes healing), Botulinum toxin injection. Surgical: Lateral sphincterotomy
266
What complications may a anal fissure present with?
chronic anal fissure, incontinence after surgey, recurrence
267
What's the prognosis of an anal fissure?
Usually heals in about a week. Treatment is based on easing pain (keeping stools soft) and relaxing anal sphincter to promote healing
268
What is amyloidosis?
Heterogenous group of diseases characterised by extracellular deposition of amyloid fibrils
269
What is the underlying pathophysiology of amyloidosis?
Polymers of amyloid fibrils fold in the B-pleated sheet incorrectly and deposit and disrupt the function of normal tissue. Classified according to the fibril subunit proteins.
270
How common are the different types of amyloidosis?
AA: 1-5% of pts with chronic inflammatory disease. AL: 300-600 cases in UK. Hereditary amyloidosis: ~5% w/systemic amyloidosis.
271
What are the symptoms of amyloidosis? Split them into renal, heart, intestinal, tongue, nerves, cns
Renal: swelling in face and legs. Heart: Palps+SOB, Intestinal: weight loss, Tongue: interferes with speech and swallowing, noisy breathing at night. Nerves: Numbness/pain in fingers + toes. Diarrhoea+constipation. Orthostatic hypotension. CNS: Alzheimers (memory loss, difficulty in learning new skills)
272
What signs can amyloidosis present with?
Renal: Proteinuria, hypoalbuminaemia, edema, hyperlipidaemia (Nephrotic syndrome). Cardiac: Restrictive cardiomyopathy, HF, arrhythmia, angina. GI: Macroglossia, hepatosplenomegaly, gut dysmotility, malabsorption, bleeding. Neuro: Sensory + motor neuropathy, autonomic neuropathy, carpal tunnel syndrome. Skin: waxy skin/easy bruising, purpura around the eyes, plaques and nodules. Joints: Painful assymetrical large joints, enlargement of anterior shoulder. Haem: bleeding tendency.
273
What investigations would you do for amyloidosis?
1. Tissue biopsy (diagnostic) ; 2. Urine - Proteinuria, free immunoglobulin light chains; 3. Bloods - CRP/ESR, Rheumatoid factor, Immunoglobulin levels, serum electrolytes, LFTs, U+Es
274
What is gastroenteritis/infectious colitis?
Acute inflammation of GI tract.
275
What causes gastroenteritis/IC?
Viruses, bacteri,a prozoa, toxins in food/water.
276
Give some examples of pathogens that cause gastroenteritis/IC
Rapid med
277
How common is gastroenteritis/IC?
Common and underreported
278
What symptoms can gastroenteritis/IC present with?
sudden N+V, anorexia. Diarrhoea. Abdo pain/discomfort.
279
What signs does gastroeneteritis/IC present with?
Diffuse abdo tenderness, abdo distension, bowel sounds increased. If severe - pyrexia, dehydration, hypotension, peripheral shutdown.
280
What investigations would you do for gastroenteritis/IC?
1. FBC
2. Urea/electrolytes
3. creatinine
281
How would you treat gastroenteritis/IC?
Bed rest, fluid, electrolyte replacement, antibiotics only if severe or infective agent identified.
282
What complications may arise with gastroenteritis/IC?
Dehydration, electrolyte imbalance, prerenal failure.. Sepsis and shock.
283
How is the prognosis for gastroenteritis/IC?
generally good as most cases are self-limiting
284
What is vitamin B12 deficiency?
Having insufficient vitamin B12 to meet demands
285
What causes B12 deficiency?
Pernicious anaemia - autoimmune condition - leads to lack of intrinsic factor (needed for b12 absorption) -> leads to megaloblastic anaemia
286
What are some other causes of B12 deficiency?
Gastric - gastrectomy, atrophic gastritis
Inadequate intake
Intestinal - malabsorption, ileal resection, crohn's, tropical sprue
Drugs - colchicine, metformin
287
What's the peak age for vitamin b12 deficiency?
Peak age = 60 years. Vegans have a higher risk
288
What are presenting symptoms of B12 defiency?
Anaemia symptoms:
Fatigue, lethargy, dyspnoea, faintness, palps, headache. Neuro symptoms: parasthesia, numbness, cognitive changes, visual disturbances
289
What are the signs of b12 deficiency on examination?
Pallor, heart failure, glossitis, angular stomatitis, neuropsychiatric: irritability, dementia, depression. Neuro - degeneration of spinal cord, peripheral neuropathy
290
What is the investigation for b12 deficiency?
FBC/Blood film: - Hypersegmented neutrophils, oval macrocytes, circulating megaloblasts. Pernicious anaemia tests - anti-intrinsic factor antibodies, anti-parietal cell antibodies. schilling test
291
What is ulcerative colitis?
chronic relapsing and remitting IBD. Colonic.
292
What is the cause of UC?
Genetic . Immune response to bacteria/autoimmune response. Altered neutrophil function. Family history. Increased PANCA.
293
How common is UC? in which population does it usually occur in?
1/1500. caucasions and jews. Peaks 20-40yrs.
294
What symptoms does UC present with?
blood/mucous diarrhoea. Tenesmus, urgency. Crampy abdo pain. Weight loss, fever.
295
What signs does UC present with?
signs of anaemia , dehydration, clubbing, abdo tenderness, tachycardia. Blood, mucus, tenderness on DRE.
296
What tests would you do for UC and what would the results be?
neg culture and c difficile. Raised faecal calprotectin. FBC: anaemia, leukocytocis, thrombocytocis. LFTs for primary scelorisng cholangitis. ESR/CRP. Sigmoidoscopy/colonoscopy w biopsy. Barium enema.
297
How would you manage UC?
Corticosteroids, anti-inflamatories, infliximab, colectomy.
298
What are some potential complications of UC?
Haemorrhage, toxic megacolon, perforation, colonic carcinoma, gallstones, PSC. Extra GI: Uveitis, renal calculi, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, osteoporosis, amyloidosis.
299
What's the general prognosis for UC?
normal life expectancy. Relapsing and remitting. Poor progonosis: ABCDEF - albumin low, blood pr, CRP raised, dilated loops of bowel, eight or more bowel movements a day, fever.
300
Define crohn's disease
Chronic granulomatous inflammatiory disease of GI tract. Crohns+UC = IBD
301
What causes crohn's disease?
Exaggerated immune response. Interplay between environment and genetics. 40% affects terminal ileum
302
How common is crohn's disease?
UK incidence 5-8/100,000. prevalence: 50-80/100,000. peaks in teens, 20's and 40's.
303
What symptoms does crohn's disease present with?
Crampy abdo pain (from inflammation, fibrosis, bowel obstruction). Diarrhoea. Fever/malaise/weight loss. Iliac fossa pain.
304
What signs does crohn's disease present with?
Weight loss, clubbing, signs of anaemia, ulcers in mouth, perianal fistulae and abscesses. Uveitis, erythema nodosum, pyoderma gangrenosum.
305
How would you investigate crohn's disease?
FBC: Low Hb, high platelets, high WCC. High ESR (chronic inflammation) Iron studies - may show iron deficiency. Serum B12 - normal/low. Stool microscopy: exclude infective colitis. AXR: toxic megacolon, Erect CXR: shows any perforation. Colonoscopy/Biopsy: Differentiate between UC/Crohns. If other investigations are contra-indicated: Radionucide-labelled neutrophil scan to localise infammation
306
How would you manage crohn's disease?
Acute: Fluid resus, corticosteroids, 5-ASA analogue (anti-inflammtory, aspirin is not effective hence need for analogues)
307
What are some GI complications of crohn's disease?
Haemorrhage, strictures, perforation, fistulae, perianal fistulae + abscesses, GI cancer, malabsorption
308
What are some extraintestinal complications of crohns?
Uveitis, episcleritis, gallstones, kidney stones, arthropathy, sacroiliitis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, amyloidosis.
309
What is the prognosis of crohn's?
Chronic relapsing condition
310
What is coeliac disease?
Inflammatory disease from gluten intolerance -> chronic bowel malabsorption
311
What causes coeliac disease?
Hypersensitivity to Glaidin - glaidin is not destroyed as usual, is taken into intestinal cells and presented on MHCs, triggering an immune response. RF: Genetic susceptibility
312
How common is coeliac disease?
1/2000 in UK. More common in Ireland
313
What are the presenting symptoms of coeliac disease?
Asymptomatic. Abdo discomfort/pain/distension. Steatorrhoea, Diarrhoea. Normal diet but abnormal absorption = tiredness, malaise, weight loss. Children = failure to thrive. Amenorrhoea in young adulrs.
314
What are signs of coeiliac disease on examination?
Signs of anaemia - pallor. Signs of malnutrition - short, abdo distension, wasted buttocks in children. Signs of vitamin/mineral deficiencies (E.g osteomalacia, easy bruising). Intense itchy blisters on elbows/knees/buttocks (dermatitis herpetiformis) - Autoimmune blistering related to coeliac
315
What investigations could you do for coeliac disease?
1) FBC/Blood smear - Iron deficiency is common presentation (Low Hb and microcytic). 2) IgA-tTG (higher than normal) 3) Endomysial antibody, EMA (elevated). 4) Skin biopsy
316
How would you manage coeliac disease?
Advice: Withdrawal of Gluten from diet. Dietary advice is essential. Medical: Vitamin and Mineral supplements. Oral corticosteroids if disease persists.
317
What are complications of coeliac disease?
Iron, folate, Vot B12 deficiency, osteomalacia, ulcerative jejunoileitis, GI lymphoma, bacterial overgrowth. Rarely cases cerebella ataxia.
318
What is the general prognosis of coeliac disease?
Strict adherence to diet = likely to make full recovery. But needs to be followed for life.
319
What is IBS?
functional bowel disorder with recurrent episodes of abdo pain/discomfort for >6 months of the previous year. Associated with two of: Altered stool passage, bloating, worse after eating, passage of mucous
320
What causes IBS?
Unknown cause. Visceral sensory hypersensitivity, gut mobility abnormalities, psychosocial factors (stress), food intolerance (e.g lactose)
321
How common is IBS?
10-20% of adults, more common in females.
322
What symptoms does IBS present with?
>6 month history of abdo pain (Colicky in lower abdo, relieved by defecation/flatus). Altered bowel frequency with >3 bowel motions daily or <3 motions weekly. Bloating, change in stool consistency. Urgency, straining, tenesmus. Red flag symptoms: weight loss, anaemia, PR bleeding, >60yrs
323
What signs does IBS present with?
Nothing. Perhaps mild abdo distension or mildly tender
324
What investigations would you do for IBS?
FBC - normal. anaemia = non IBS disease. Stool: normal. Wbcs/parasites = non-IBS. Anti-endomysial antibodies: Negative, positive in coeliac disease. US: exclude gallstone disease. Hydrogen breath test: exclude dyspepsia from H pylori infection. Endoscopy: if other pathologies suspected.
325
How would you manage IBS?
Advice: Dietary modification (reduce insoluble fibre) - help with constipation. Medical (symptomatic treatment) - antispasmodics, Prokinetic agents, anti-diarrhoeals, laxatives. Psychological: CBT, relxation and psychotherapy.
326
What are some complications of IBS?
Physical and psychological co-morbidity. Increase risk of colonic diverticulosis.
327
What is the prognosis of IBS?
chronic relapsing and remitting course, often exacerbated by stress.
328
What is alcoholic hepatitis?
Inflammatory liver injury from chronic alcoholism
329
What causes alcoholic hepatitis?
in the middle of the spectrum of disease caused by alcoholism. Histopathological features are many: centrilobular ballooning, necrosis of hepatocytes, steatosis, cholestasis, giant mitochondria
330
How common is alcoholic hep in heavy drinkers?
10-35% of heavy drinkers
331
What symptoms does alcoholic hep present with?
asymptomatic, nausea, malaise, pain, jaundice, ascites, swollen ankles
332
What signs does alcoholic hep present with?
signs of alcohol excess: malnourished, palmar erythema, D's contracture, spider naevi, parotid enlargement, easy bruising. Signs of severe alcoholic hep: febrile, tachycardia, jaundice, bruising, encephalopathy, ascites, hepatomegaly, splenomegaly
333
What investigations would you do for alcoholic hep?
Bloods: LFTs (high ast, alt, alp, bilirubin, ggt. Low albumin and protein). FBC (Low platelets, Low Hb, leukocytosis, High MCV)
334
How would you manage alcoholic hep?
Acute: thiamine, Multivitamins (esp vit c), monitor electrolytes, manage hepatorenal syndrome (ensure adequate urine output), dieuretics for ascites. Nutritional: vits and supplements. Steroid: reduce short term mortality for severe AH.
335
What are some complications of alcoholic hep?
Acute liver decompensation, hepatorenal syndrome, cirrhosis
336
What's the mortality rate for alcoholic hep?
10% mortality in first month, 40% in first year. Most progress to cirrhosis in 1-3 yrs.
337
What is cirrhosis?
End-stage of chronic liver disease. Normal tissue replaced by diffuse fibrosis and nodules of regenerating hepatocytes.
338
What causes cirrhosis?
Alcohol misuse, viral hepatitis, autoimmune hepatitis, drugs, inherited conditions, vascular causes, chronic biliary diseases, cryptogenic, NASH
339
How common is cirrhosis?
In top ten deaths in the world
340
What symptoms can cirrhosis present with?
Early non-specific symptoms - anorexia, nausea, fatigue, weakness, weight loss. Decreased liver synthetic function - easy bruising, swelling, ankle oedema. Decreased detox function - Jaundice, encephalopathy, altered sleep pattern, amenorrhoea/galactorrhea. Portal htn: abdo swelling, haematemesis, PR bleed or malaena
341
What signs can cirrhosis present with?
Asterixis, ascites, ankle oedema, atrophy of testicles bruises, clubbing, colour change in nails, dupuytren's contracture, caput medusae palmar erythema, encephalopathy, gynaecomastia, hepatomegaly, increased parotid size, jaundice. Others: Spider naevia, scratch marks, splenomegaly
342
What investigations would you do for cirrhosis?
LFTs: High AST, ALT. Usually alt>ast, but this may reverse in progression of liver disease. Increased bilirubin. Low albumin, low platelets. Antibodies to hep c virus. Hep B surface antigen. Other investigations (to determine cause): viral serology, a1-antitrypsin, caeruoplasmin etc. Ascitic tap: Microscopy, culture and sensitivity. Liver biopsy. Imaging: Ultrasound, CT, MRI. Endoscopy to look for varices.
343
How would you manage cirrhosis?
GENERAL: Treat the cause. Avoid: alcohol, sedatives, opiates, NSAIDs, drugs that affect the liver. Nutrition is important. NG feeding maybe. TREATING COMPLICATIONS: Encephalopathy - treat infections, exclude GI bleed, avoid sedation, use lactulose - reduces the absorption of ammonia from the gut. Ascites - Diuretics, dietary sodium restriction, therpautic paracentesis
344
What are some complications of cirrhosis?
Portal hypertension w ascites, hepatic encephalopathy, variceal haemorrhage, SBP, HCC, renal failure, pulmonary HTN
345
What is the prognosis of cirrhosis?
Child-pugh grading is used to determine prognosis. (based on albumin, bilirubin, PT, ascites, encephalopathy)
Depends on complications. generally poor prognosis. overall 5 yr survival - 50%. Ascites - 2yr survival - 50%
346
What is liver failure?
Severe liver dysfunction. Leads to jaundice, encephalopathy and coagulopathy
347
What are the different stages of liver failure?
1) Hyperacute - jaundice w enceph of <7days
2) Acute J + Enc after 1-4 weeks
3) subacute J + enc after 4-12 weeks
4) Acute on chronic - acute deterioration in pts with chronic liver disease
348
What are some causes of liver failure?
Viral - hep ABDE
Drugs - Paracetamol overdose, other drug reactions
Less common causes: Autoimmune hep, Budd-Chiari, pregnancy, malignancy, haemochromatosis, wilson's disease
349
What causes each of these: Jaundice, encephalopathy, coagulopathy?
Jaundice - decreased conjugated bilirubin
Encephalopathy - Increased ammonia
Coagulopathy - decreasde synthesis of coag factors
350
What is the most common cause of liver failure?
50% due to paracetamol overdose of acute LF
351
What symptoms does liver failure?
- Fever
- Nausea
- Possibly jaundice
352
What signs may a liver failure patient present with?
Jaundice, encephalopathy, liver asterixis, fetor hepaticus. Ascites/splenomegaly. Bruising. Look for secondary causes - bronze skin, copper rings
353
How would you investigate liver failure?
1) Idetify the cause - viral serology, paracetamol levels, autoantibodies, ferritin, caeruloplasmin.
2) Blood - FBC, WCC, U+E (hepatorenal failure), LFTs
3) Ultrasound liver/CT scan
4) Ascitic tap - microscopy/culture
3) Doppler of veins - Budd chiari
4) EEG
354
How would you manage liver failure?
1) Resuscitation
| 2) Treat the cause - N-acetylcysteine for paracetamol OD
355
What are some complication of liver failure?
Infection, coagulopathy, hypoglycaemia, electrolyte disturbances, renal failure, resp failure, cerebral oedema, effects on CVS
356
What's the prognosis of liver failure?
Depends on severity/aetiology
357
What is portal hypertension?
Increased pressure in hepatic portal venous system
358
What is the most common cause of portal HTN?
Cirrhosis
359
What are 3 causes of pre-hepatic portal HTN?
Blockage of portal vein before liver:
- Portal vein thrombosis
- Splenic vein thrombosis
- Extrinsic compression
360
What are 3 hepatic causes of portal HTN?
Cirrhosis, chronic hep, schistosomiasis
361
What are 3 post-hepatic causes of portal HTN?
Budd-Chiari syndrome, constrictive pericarditis, right heart failure
362
How common is portal HTN?
Common consqeunce of cirrhosis
363
What are some presenting symptoms of portal HTN?
Features of liver disease: Jaundice, history of alc abuse, FH.
-Hameatemeis, malaena, abdo distension, pain + fever (SBP), lethary/irritability/sleep change (encephalopathy)
364
What are signs of portal hypertension?
Caput medusae, splenomegaly, ascites. Signs of liver failure.
365
What investigations would you do for portal HTN?
Bloods - hypersplenism = low Hb and platelets. LFTs = ALP, GGT.
Determine the cause of liver disease.
Imaging - Abdo US - assess portal blood flow. Doppler US - check direction of slow.
Endoscopy - oesophageal varices.
HVPG - Heptic venous pressure gradient
366
How would you treat portal HTN?
- Treat underlying cause
- Salt restriction, diuretics
- Non-selective beta-blockers reduces portal pressure
- TIPS: Transjugular intrahepatic portosystemic shunt
- Liver transplant
367
What are some complications of portal HTN?
Oesophageal varices, ascites (SBP), hepatorenal syndrome, Pulmonary complications, liver failure, hepatic encephalopathy
368
What is the prognosis for portal htn?
depends on cause. variceal haemorrhages have 1 yr mortality of 40%
369
What is NASH?
Build up of fat in liver due to causes other than excess alcohol
370
What can increase chances of NASH?
Fat persisting can cause inflammation/fibrosis (steatohepatitis)
- Obesity
- T2DM
- HTN
- Hypercholesterolaemia
- Age >50yrs
- Smoking
371
How common is NASH?
Most common liver disorder in developed countries. 1/3 of people in UK have early stages
372
What symptoms does NASH present with?
No symptoms in early stages.
- Dull/aching RUQ pain
- Fatigue
- Unexplained weight loss
- Weakness
373
What are some signs of NASH?
RUQ pain/tenderness
| Signs of cirrhosis in late stages
374
What investigations would you do for NASH?
1. Bloods - LFTs (raised AST/ALT/Bilirubin)
2. Liver US - may show steatosis
3. Liver biopsy
375
How would you manage NASH?
Conservative - controlling risk factor
376
What are some complications of NASH?
Cirrhosis, ascites, varices, encephalopathy, hep carcinoma, liver failure
377
What % of NASH pt's get cirrhosis?
20%
378
What is viral hep (A+E)?
Hep followed by an infection with RNA viruses A and E- Acute with no progression to chronic
379
How are Hep A and E viruses transmit?
Faecal-oral route
380
How do these viruses act?
Replicate in hepatocytes and secreted into bile. Liver inflammation/necrosis caused by the IMMUNE RESPONSE (Targeted by CD8+ T cells/NK cells)
381
Where does HAV and HEV occur in the world?
HAV - developing world
| HEV - Asia, africa, central america
382
What are the symptoms of HAV and HEV?
```
Incubation period - 3-6 weeks.
Prodromal period (time between symptoms starting and max symptoms) - malaise, anorexia, fever, N+v.
```
383
What are symptoms of hepatitis?
Dark urine, pale stools, jaundice of around 3 weeks.
384
What are some signs of viral hepatitis?
Pyrexia, Jaundice, Tender hepatomegaly, spleen may be palpable. NO CHRONIC LIVER DISEASE SIGNS.
385
What investigations would you do for viral hep? (A+E)
Bloods - LFTs - High AST, ALT, ALP and Bilirubin.
Viral serology - anti-HAV IgM (acute illness, disappears 3-5 months). Anti-HAV IgG (recovery phase and lifelong).
Anti-HEV IgM (raised 1-4 weeks after onset), Anti-HEV IgG
Urinalysis - Raised urobilinogen, +ve for bilirubin
386
How would you manage viral hep?
Bed rest+symptomatic treatment.
Best management is prevention. - safer water, sanitation, food hygiene
Vaccine available for HAV
387
What are the potential complications of viral hep?
Fulminant hepatic failure. Cholestatic hepatitis. Post-hep syndrome.
388
What is the prognosis for HAV/HEV?
Usually recover in 3-6 weeks. may relapse in recovery. Fulminant hep failure mortality - 80%
389
What is viral hepatitis (B+D)?
Hep caused by infection of HBV (can be acute or chronic (>6 months)). HDV is defective virus (may only co-infect with HBV or infect carriers of HBV)
390
How are these viruses transmitted?
Blood, sexual contact, vertical transmission (mom to baby)
391
What are some viral proteins produced by HBV/HDV?
Core antigen (HBcAg), Surface antigen (HBsAg), e antigen (HBeAg)
392
What are risk factors of HBV/HDV?
IV drug use, unscreened blood/blood products, infants with HBeAg +ve mums, Sexual contact with carriers, Youngers more likely to be chronic carriers.
393
How common is Hep B? Where is it found?
Common. 1-2 million deaths annually. In southeast asia, africa, mediterranean.
394
What are the presenting symptoms of viral hep?
Incubation - 3-6 months. 1-2 months prodrome - malaise, headache, anorexia, N+V, diarrhoea, RUQ pain, serum sickness, jaundice.
395
How long until recovery of hep b/d?
4-8 weeks. but 1% develop fulminant liver failure.
396
How can we tell if someone is a chronic carrier?
- Routine LFT testing
- Cirrhosis
- they develop decompensation
397
What signs does viral hep present with acutely?
Jaundice, pyrexia, tender hep, splenomegaly, cervical lymphadenopathy
398
What signs can viral hep have chronically?
May have none or may have signs of chronic liver disease
399
What investigations would you do for viral hepatitis?
Viral serology (see laz for list). LFTs, clotting, liver biopsy.
400
How would you treat viral hep?
Prevention. Vaccine. Symptomatic treatment. Chronic HBV - nucleoside/nucleotide analogues.
401
What are some complications of viral hep?
```
1% get fulminant liver failure.
Chronic HBV infection
Cirrhosis
HCC
Extrahepatic immune complex disorders
HBV + HDV may cause deterioration
```
402
What is the prognosis of viral hep b/d infection?
10% -infections become chronic
| of these, 20-30% get cirrhosis.
403
What is viral c hep?
Hep caused by infection with hep C often after a chronic course
404
How is Hep c transmitted?
Parenteral, sexual, vertical
405
Which patients are at risk of HCV infection?
Recipients of blood products, IVd rug users, non-sterile acupuncture, tattooing, haemodialysis, health care workers
406
How common is HCV?
Common. different genotypes have different geographical prevalence.
407
What are the symptoms of hep c?
90% of acute are ASYMPTOMATIC. 10% may be jaundiced w mild flu-like illness
408
What are the signs of viral hep?
May be no signs or signs of chronic liver disease, skin rash or renal dysfunction
409
What investigations would you do for viral hep?
HCV serology - anti hcv antibodies. LFTS. Liver biopsy.
410
How would you manage viral hep c?
prevention (but no vaccine available),
| Medical - acute - mainly supportive. Chronic - Pegylated interferon-a, ribavirin.
411
What are some complications of viral hep C?
fulminant hep failure, chronic HCV, Hep carcinoma. and some less common ones on Laz's notes.
412
What's the prognosis of HCV?
80% get chronic carriage. of those 20-30% develop cirrhosis.
413
What is hepatocellular carcinoma?
Primary malignancy of liver parenchyma
414
What can cause hepatocellular carcinoma?
Chronic liver damage (alcoholism, hep c+b, autoimmune disease), metabolic disease (haemochromatosis), aflatoxins (fungi contaminated cereals)
415
How common is hepatocellular carcinoma?
Common. 1-2% of malignancies. High incidence where hep b and c are endemic.
416
What symptoms does hepatocellular present with?
Malaise, weight loss, loss of appetite, abdo distension, jaundice.
417
What signs does hepatocellular carcinoma present with?
cachexia, lymphadenopathy, hepatomegaly, jaundice, ascites
418
What investigations would you do for hepatic carcinoma?
FBC - microcytic anaemia/thrombocytopenia. Hyponatraemia, high urea. LFTs - ^ALP, bilirubin and aminotransferase. Low albumin. Normal or raised PT/INR time. AFP.
419
Define liver abscesses and cysts
abscess: liver infection resulting in a walled off collection of pus
Cyst: liver infection resulting in walled off collection of cyst fluid.
420
What are some causes of these abscesses/cysts?
- Pyogenic: list of organisms of laz's notes. 60% caused by biliary tract disease.
- Amoebic abscess - entamoeba histolytica.
- Hyatid cyst - tapeworm
421
What's the commonest type of liver abscess?
Pyogenic in industrialised world. Amoebic most common worldwide
422
What are some presenting symptoms of abscesses/cysts?
Fever, malaise, nausea, anorexia, night sweats, weight loss, RUQ/epigastric pain - may be referred to shoulder, jaundice, diarrhoea, ask about foreign travel.
423
What are signs abscesses and cysts?
Fever (continuing/spiking), Jaundice, tender hepatomegaly, right lung base - dull to percuss, reduced breath sounds - reactive pleural effusion)
424
How would you investigate a liver abscess?
Bloods: FBC (Mild anaemia, leukocytosis, High eosinophils if hyatid), LFTs (High ALP, bilirubin, ESR, CRP) Stool MC+S.
Liver US or CT/MRI
425
What is autoimmune hepatitis?
Inflammation of liver caused by autoimmunity
426
What causes autoimmune hepatitis?
Environmental triggers in a genetically predisposed person -> hepatocyte expression of HLA antigens -> T-cell attack on hepatocytes. Two types: ANA, ASMA antibodies. Type 2- antibodies to liver/kidney microsomes, antibodies to liver cytosol
427
who do the two types autoimmune hep affect?
Type 1: mainly young women. Type 2: Occurs in girls and young women.
428
What are presenting symptoms of autoimmune hep?
Asymptomatic. Insidous: Malaise, fatigue, anorexia, weight loss, nausea, jaundice, epistaxis. Acute: fever, anorexia, jaundice, n+v+d, RUQ pain
429
What are signs of autoimmune hepatitis?
Stigmata of of chronic liver disease. Ascites, oedema and hepatic encephalopathy are late signs. Cushingoid features.
430
How would you investigate autoimmune hepatitis?
LFTs: high ast, alt, bilirubin, ggt, alp, low albumin, high PT. FBC: low Hb, platelets and wcc (hyposplenism if portal HTN). Hypergammaglobulinaemia: presence of antibodies. Biopsy: diagnose and to check if hep or cirrhosis. Some other investigations to rule out liver disease (Laz)
431
What is primary biliary cirrhosis?
Chronic inflammatory liver disease with progressive destruction of intrahepatic bile ducts -> cholestasis -> cirrhosis
432
What causes PBC?
Autoimmune - genetic and environmental factors
433
Who does it affect?
Middle aged women 9:1 ratio of women to male
434
What symptoms does PBC present with?
Insidious onset - fatigue, weight loss, pruritis. Discomfort in RUQ. May present with symptoms of liver decompensation.
435
What conditions are associated with PBC?
Sjogren;s syndrome, arthritis, raynaud's phenomenon
436
What signs of PBC can be seen on examination?
Early - may be none. Late - Jaundice, skin pigmentation, scratch marks, Xanthomas, hepatomegaly, ascites, signs of chronic liver disease.
437
What investigations would you do for PBC?
Bloods, LFTS.
For PBC: Anti-mitochondrial antibodies (AMAs).
Ultrasound - exclude extrahepatic biliary obstruction
Liver biopsy.
438
What is Primary sclerosing cholangitis?
Chronic cholestatic liver disease - progressive inflammatory fibrosis + obliteration of intrahepatic and extrahepatic bile ducts.
439
What are some pathological features of PSC?
- Periductal inflammation with periductal concentric fibrosis.
- Portal oedema.
- Bile duct proliferation
- Expansion of portal tracts
- Progressive fibrosis
- Development of biliary cirrhosis
440
What causes PSC?
Genetic predisposition w environmental triggers - associated with UC. 70% of PSC patients have UC.
441
What age does it usually affect?
25-40 years
442
What symptoms does PSC present with?
Intermittent jaundice, pruritis, RUQ pain, weight loss, fatigue
443
What signs does PSC present with?
May have none. Jaundice, hepatosplenomegaly, spider naevi, palmar erythema, ascites
444
What investigations would you do for PSC?
Bloods - LFTs. Serology - ASMA, ANA in 30%. pANCA present in 70%.
ERCP- Stricturing and interspersed dilation.
MRCP - non-inasive imaging
Liver biopsy - confirm diagnosis/staging
445
What is alcohol withdrawal defined as?
symptoms after suddenly stopping alcohol after chronic use or alcohol dependence
446
What is pathophysiology of alcohol withdrawal?
alcoholism surpresses glutamate, body compensates by increasing sensitivity to it. Alcohol stops = lack of inhibition of glutamate + increased sensitivity to it = excitatory symptoms
447
How common is alcohol withdrawal?
untreated 6% = symptoms of withdrawal, 10% of them = delirium tremens.
448
What symptoms does alcohol withdrawal present with?
tremor, anxiety, agitation, n+v, headache, palps, sweating, depression, craving, anorexia, hallucations, withdrawal seizures, delirieum tremens
449
What signs can alcohol withdrawal present with?
Signs of chronic alcoholism - dupuytren's contracture, palmar erythema, spider naevi, telangiectasia
450
What investigations could you use for alcohol withdrawal?
Raised urea and creatinine from dehydration, Deranged LFTs suggestive of alcoholic hep, Bloods: lactic acidosis and hypokalaemia
451
How would you manage alcohol withdrawal?
Chlordiazepoxide (reduces AW symptoms), barbiturates (if refractory to chlordiazepoxide), thiamine (prevents progression to Wernicke-Korsakoff)
452
What are some potential complications of alcohol withdrawal?
Seizures and death if untreated, delirium tremens, over sedation from treatment
453
What is the prognosis of alcohol withdrwal?
Delirium T has mortality of 35% if untreated. Mortality otherwise is <2%
454
What is haemochromatosis?
Iron overload which may lead to organ damage - liver, joints, pancreas, pituitary, heart.
455
What is the underlying cause of haemochromatosis?
Primary - hereditary (HFE gene - autosomal recessive), secondary - frequent transfusions
456
How common is Haemochromatosis?
Rare. Females have later onset.
457
What signs and symptoms does haemochromatosis present with?
Asymptomatic till later stages. Early: fatigue, weakness, arthropathy, erectile dysfunction, heart problems. Late: diabetes, bronze skin, hepatomegaly, impotence, amenorrhoea, hypogonadism, cirrhosis, arrhythmias/cardiomyopathy.
458
What investigations can you do for haemochromatosis?
1) Serum transferring saturation >45%.
| 2) Serum ferritin - raised.
459
What is Wilson's disease?
Autosomal recessive disease with reduced biliary excretion of copper -> copper accumulation in the liver and brain (basal ganglia).
460
What causes Wilson's disease?
Mutation of copper transporting ATPase -> Can't be transferred/incorporated into caeruloplasmin (normally excreted in bile). ^copper=mitochondria damage.
461
When does Wilson's disease present?
-Liver disease presents in children, Neurological disease usually in young adults
462
What are the presenting symptoms of Wilson's disease?
-Hepatitis, liver failure, cirrhosis - jaundice, easy bruising, variceal bleeds, encephalopathy.
Neuro - Dyskinesia, Rigidity, tremor, dystonia, dysarthria, dementia, ataxia.
Psychiatric - conduct disorder/personality change
463
What signs might Wilson's disease present with?
Liver - hepatosplenomegaly, Jaundice, ascites, Gynaecomastia.
Eyes - Kayser-fleischer rings
464
What investigations would you conduct for Wilson's disease?
Bloods:
LFTs - High AST, ALT, ALP. Low serum caeruloplasmin.
24hr urinary copper:
Increased
Liver biopsy: increased copper
465
What is acute cholangitis?
Infection of the bile duct as a result of obstruction
466
What causes acute cholangitis?
gall stones, ERCP, tumours (pancreas or cholangiocarcinoma), bile duct stricture or stenosis, parasitic infection
467
How common is acute cholangitis in patients with gallstones?
9% of pt's with gallstones will get it. 50-60yrs. Caucasion.
468
What are the symptoms of acute cholangitis?
Charcot's triad (RUQ pain, jaundice, fever w/ rigors). Reynold's pentad (3 + confusion and septic shock)
469
What are the signs of acute cholangitis?
fever, RUQ tenderness, mild hepatomegaly, jaundice, mental status change, hypotension, tachycardia,
470
What investigations might you do for acute cholangitis?
FBC (hi WCC and CRP), ERCP - first line and diagnostic
471
How would you treat acute cholangitis?
Manage symptoms (rehydration, antibiotics), remove obstruction (ERCP or shockwave lithotripsy), stent to widen (stricture) or cholecystectomy
472
What are some potential complications of acute cholangitis?
liver abscesses, liver faiure, sepsis, shock, organ dysfunction
473
What's the prognosis of acute cholangitis?
Mortality: 17-40%
474
What is cholangiocarcinoma?
Bile duct cancer from intra and extra hepatic bile duct. Mainly adenocarcinomas.
475
What causes cholangiocarcinoma?
Unknown aetiology. RF: existing liver/gallbladder disease, PSC, congenital abnormalities of biliary tree, genetic disorders, obesity, liver fluke infection, age, male
476
How common is cholangiocarcinoma?
very rare, more common in developing world bc of prevalence of parasitic infections
477
What are some symptoms of cholangiocarcinoma?
Obstructive jaundice: yellow sclera, pale stools/dark urine, pruritus. Abdo pain/fullness. Weight loss, malaise, anorexia.
478
What are some signs of cholangiocarcinoma?
jaundice, palpable gallbladder (in the presence of jaundice, a palpable non-tender gall bladder is unlikely to be gallstones - like cancer of pancreas/biliary tree)
479
What investigations can you do for cholangiocarcinoma?
Bloods: FBC, Bilirubin, ALP, GGT, Tumour marker - CA19-9; Imaging- US; Special-Endoscopy
480
What is cholecystitis?
Inflammation of the gallbladder
481
What can cause cholecystitis?
Causes: mixed stones (80%), pure cholesterol (10%), pigment stones - high bilirubin (10%). Risk factors: fat, female, forty, DM, drugs, caucasion. Haemolytic disorders are a rf for pigment stones
482
How common is cholecystitis?
very common. 10% prevalent in uk. 3x more common in females.
483
What are presenting symptoms of cholecystitis?
fever, prolonged ruq abdo pain - radiates to right shoulder.
484
What are some signs of cholecysitits?
Tachycardia, pyrexia, RUQ pain/epigastric tenderness, abdo guarding and rebound tenderness if peritonitis,
485
What investigations could you do for cholecystitis?
FBC - high wcc, high crp, high alp, ggt and bilirubin (ascending cholangitis), amylase to exclude pancreatitis. RUQ ultrasound scan, ercp to exclude other diagnoses
486
How would you manage cholecystitis?
conservative: follow low fat diet. Medical: NBM, IV fluids, analgesia, Anti-emetics, antibiotics (if antibiotics fail, could have an abscess/empyema. Use ERCP for urgent biliary drainage in the case of obstruction. Surgical: Laparoscopic cholecystectomy
487
What are some complications of cholecystitis?
Stones in gallbladder: Biliary colic, cholecystitis, gallbladder empyema, gallbladder cancer. Stones outside gallbladder: Obstructive jaundice, pancreatitis, ascending cholangitis, cholecystoduodenal fistula, gallstone illeus, bouveret syndrome, mirizzi syndrome. Complications of cholecystectomy: Bleeding, infection, bile leak, port-site hernia, post-cholecystectomy syndrome.
488
What's the prognosis of cholecystitis?
Gall stones don't usually cause symptoms. Surgery is a good chance of cure if they do have symptoms.
489
What are gall stones?
Gall stones: stones in the gallbladder
490
What are the different types of gallstones?
Gallstones: 1) Mixed - cholesterol AND calcium bilirubinate (fat, female, 40, fertile) 2) Pure cholesterol - similar aetiology. 3) Pigment stones - black stones from calcium bilirubinate. (haemolytic disorders, cirrhosis = ^bilirubin OR liver fluke in asia)
491
How common are gallstones?
v common, ~10% in UK, 3x more common in younger females
492
What are the presenting symptoms of gallstones?
90% asymptomatic. Biliary colic - sudden severe RUQ/EG pain (radiate to right scapula/after fatty meal/AS - N+V). Acute cholecystitis - fever, prolonged upper abdo pain w/ right shoulder radiation. Ascending cholangitis: Charcot's triad (RUQ pain, Jaundice and rigors
493
What are the presenting signs of gallstones?
Biliary colic - RUQ/EG tenderness. Acute cholecystitis - tachycardia, pyrexia, RUQ/EG tenderness, Murphy's sign. Ascending cholangitis: Pyrexia, RUQ, Jaundice
494
How can you investigate gallstones?
1) FBC - normal in biliary cholic, raised WBCs = acute cholecystitis/cholangitis. 2) LFTs - Raised ALP and Bilirubin 3) Amylase and lipase - raised in pancreatitis. 4) Ultrasound - best single diagnostic test
495
How could you manage gallstones?
Mild: conservative/avoid fat. Severe colic: IV fluids, analgeisa, antiemetics, antibiotics if potential infection. If symptoms worsen/don't improve - possibly empyema so drain it. Surgical: Laparoscopic cholecystectomy
496
What complications of gallstones are there?
"Stones within GB: colic, cholecysitis, mucocoele/gallbladder empyema, porcelain gallbladder, potentially predisposes to cancer. Stones outside gallbladder: Obstructive jaundice, pancreatitis, ascending cholangitis,
perforation and pericholecystic abscess or bile peritonitis, cholecystenteric fistula, gallstone ileus, Mirizzi syndrome (common hepatic duct obstruction by an extrinsic compression from an impacted stone in the cystic duct), Bouverets syndrome (gallstones
causing gastric outlet obstruction). "
497
What is the prognosis of gallstones?
Mostly benign w no problems. 2% develop symptoms. Surgery usually effective
498
What is biliary colic?
Pain from obstruction of gallbladder/common bile duct
499
What can cause biliary colic?
due to contractions of biliary tree against obstruction. Fair, fat, female, forty and fertile
500
How common is biliary colic?
10-15% of western world will get gallstones, of this biliary colic is most common presentation
501
What is the presenting symptoms of biliary colic?
Crampy RUQ pain, N+V, may radiate to right scapula, pain persists (does not fluctuate). Could be after fatty meal
502
What signs point towards biliary colic?
RUQ pain and epigastric tenderness
503
What tests can you do to investigate biliary colic?
1) Urinalysis, CXR, ECG - exclude other causes. 2) US - dilation of CBD, gallbladder may be thickened. 3) LFTs - raised ALP and bilirubin. 4) ERCP - useful diagnostically
504
How can you manage biliary colic?
Analegsia, IV fluids, NBM, Surgical laparoscopic cholecystectomy
505
What are some complications of biliary colic?
Of surgery - injury to bile duct, fat intolerance, post cholecystectomay syndrome - presence of abdo symptoms (dyspepsia, n+v, ruq pain)
506
What's the prognosis of biliary colic?
Of surgery - injury to bile duct, fat intolerance, post cholecystectomay syndrome - presence of abdo symptoms (dyspepsia, n+v, ruq pain)
