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GI Flashcards

1
Q

where in the oesophagus are oesophageal varices most likely

A

lower oesophagus and gastric cardia

also found in the stomach, around the umbilicus (caput medusae) and rectum.

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2
Q

name pre-hepatic causes of oesophageal varices

A

portal or hepatic vein thrombosis

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3
Q

name intra-hepatic causes of oesophageal varices

A

cirrhosis

schistosomiasis (developing countries)

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4
Q

name post-hepatic causes of oesophageal varices

A

right heart failure
budd-chiari syndrome
veno-occlusive disease
constrictive pericarditis

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5
Q

risk factors for variceal bleeds

A

high portal pressure
variceal size
endoscopic features of variceal bleed (e.g. haematocystic spots)
child-pugh score ≥8

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6
Q

prophylaxis of variceal bleeds

A

propranolol
endoscopic band ligation

secondary cause
- transjugular intrahepatic portal-systemic shunt (TIPSS)

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7
Q

acute variceal bleed management

A

call senior
resus until harm-dynamically stable
correct clotting abnormalities - vitamin K, FFP, platelets.

IVI TERLIPRESSIN

endoscopic band ligation or sclerotherapy 2nd line

Sengstaken-Blakemore tube - if bleeding ongoing

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8
Q

liver failure causes

A

Infections

  • hepatitis B + C
  • EBV
  • CMV

Hereditary

  • Wilsons disease
  • Hereditary haemachromatosis
  • Alpha 1 antitrypsin deficiency

Budd-chiari syndrome

NAFLD

alcohol fatty liver disease

Primary biliary cirrhosis
primary sclerosis cholangitis

autoimmune hepatitis

drugs

  • paracetamol overdose
  • isoniazid

HELLP syndrome
malignancy (HCC, cholangiocarcinoma)

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9
Q

signs of liver failure

A

jaundice
hepatic encephalopathy
fetor hepaticus (smells like pear drops)
asterixis/flap

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10
Q

Bloods for liver failure

A

FBC, U+E, LFT, Clotting, GLUCOSE

paracetamol level
hepatitis serology
cmv + ebv serology

ferritin
alpha-1-antitrypsin level
caeruloplasmin autoantibodies

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11
Q

imaging for liver failure

A

abdominal USS

DOPPLER-FLOW STUDIES TO ASSESS FOR PORTAL VEIN THROMBOSIS

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12
Q

management of liver failure

A
  • Nurse with a 20° head-up tilt in ITU. Protect the airway with intubation and insert an NG tube to avoid aspiration and remove any blood from stomach.
  • Insert urinary and central venous catheters to help assess fluid status.
  • Monitor T°, respirations, pulse, BP, pupils, UO hourly. Daily weights.
  • Check FBC, U&E, LFT and INR daily
  • 10% glucose IV, 1L/12h to avoid hypoglycaemia. Do glucose every 1-4h.
  • Treat the cause, if known (e.g. GI bleeds, sepsis, paracetamol poisoning)
  • If malnourished, get dietary help: good nutrition can decrease mortality (e.g. carbohydrate-rich foods). Give thiamine and folate supplements.
  • Treat seizures with lorazepam!
  • Haemofiltration or haemodialysis if renal failure develops
  • Try to avoid sedatives and other drugs with hepatic metabolism
  • Consider PPI as prophylaxis against stress ulceration, e.g. omeprazole
  • Liaise early with nearest transplant centre.
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13
Q

complications of liver failure

A
  • Bleeding
  • Ascites
  • Infection - sbp
  • hypoglycaemia
  • encephalopathy
  • cerebral oedema
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14
Q

factors that indicate worse prognosis in liver failure

A
  • Grade III-IV encephalopathy
  • Age >40y
  • Albumin <30g/l
  • High INR
  • Drug-induced liver failure
  • Late-onset hepatic failure worse than fulminant failure
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15
Q

name some hepatotoxic drugs

A 
o	Paracetamol
o	Methotrexate
o	Isoniazid
o	Azathioprine
o	Phenothiazines
o	Oestrogen 
o	6-mercaptopurine
o	Salicylates 
o	Tetracycline
o	Mitomycin
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16
Q

which drugs should be avoided in patients with liver failure

A

opiates - cause constipation (increase risk of encephalopathy)

sedatives

oral hypoglycaemics

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17
Q

underlying cause of hepatic encephalopathy

A

liver failure causes ammonia build up in the circulation and passes to the brain.

astrocytes clear it (by processes involving the conversion of glutamate to glutamine.

excess glutamine causes an osmotic imbalance and a shift of fluid into these cells - hence cerebral oedema in liver disease.

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18
Q

grading of hepatic encephalopthy

A

o I – altered mood/behaviour; sleep disturbance (e.g. reversed sleep pattern); dysparaxia (please copy this 5 pointed star); poor arithmetic. No liver flap.
o II – increasing drowsiness, confusion, slurred speech ± liver flap, inappropriate behaviour/personality change (ask family)
o III – incoherent; restless; liver flap; stupor
o IV – coma

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19
Q

management of hepatic encephalopathy

A

lactulose ± enemas

rifaximin

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20
Q

triad of hepatorenal syndrome

A

cirrhosis + ascites + renal failure

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21
Q

types of hepatorenal syndrome

A

HRS1 - rapidly progressive deterioration in circulatory and renal function (median survival 2 weeks)

HRS2 - steady deterioration (survival about 6 months)

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22
Q

King’s college criteria for liver transplantation - paracetamol-induced liver failure

A

Paracetamol-induced liver failure
- Arterial ph <7.3 24hours after ingestion

OR ALL OF THE FOLLOWING
o PT >100sec
o Creatinine >300umol/l
o Grade III or IV encephalopathy

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23
Q

King’s college criteria for liver transplantation - non-paracetamol liver failure

A

Non-paracetamol liver failure
- PT >100sec

OR 3 OUT OF 5 THE FOLLOWING:
o	Drug-induced liver failure
o	Age <10 or >40y
o	>1week from 1st jaundice to encephalopathy 
o	PT >50sec
o	Bilirubin ≥300umol/l
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24
Q

cirrhosis causes

A
  • Chronic alcohol abuse
  • HBV or HCV infection
  • Genetic disorders: haemochromatosis, alpha1-antitrypsin deficiency, Wilson’s disease
  • Hepatic vein events (budd-Chiari)
  • Non-alcoholic steatohepatitis
  • Autoimmunity: primary biliary cirrhosis; primary sclerosing cholangitis; autoimmune hepatitis
  • Drugs: amiodarone, methyldopa, methotrexate
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25
chronic liver disease signs
leukonychia - white nails with lunula demarcated, from hypoalbuminaemia. terry's nails - while proximally but distal 1/3 reddened by telangiectasia. ``` clubbing palmar erythema hyper dynamic circulation dupuytren's contracture spider naevi xanthelasma gynaecomastia atrophic testes loss of body hair parotid enlargement hepatomegaly small liver in late disease ```
26
complications of portal hypertension
ascites splenomegaly oesophageal varices (± life threatening upper GI bleed) caput medusae - enlarged superficial periumbilical veins
27
complications of cirrhosis
``` coagulopathy encephalopathy hypoalbuminaemia sepsis spontaneous bacterial peritonitis hypoglycaemia hepatocellular carcinoma ```
28
management of cirrhosis | - general
``` o Good nutrition is vital o Alcohol abstinence o Avoid NSAIDs, sedatives and opiates o Colestyramine helps pruiritis o Consider USS and alpha-fetoprotein every 3-6m to screen for HCC ```
29
management of cirrhosis | - specific
o High-dose ursodeoxycholic acid in PBC may normalize LFT, but may have no effect on disease progression. o Penicillamine for Wilson’s disease
30
management of ascites
o Bed rest, fluid restriction (<1.5l/d), low salt diet (40-100mmol/d) o Give spironolactone o Chart daily weight and aim for weight loss of ≤0.5kg/d o If response is poor, add furosemide ≤120mg/24h PO; do U&E (watch Na) o Therapeutic paracentesis with concomitant albumin infusion (6-8g/l fluid removed) may be tried.
31
management of spontaneous bacterial peritonitis
o MUST BE CONSIDERED IN ANY PATIENT WITH ASCITES WHO DETERIORATES SUDDENLY (MAY BE ASYMPTOMATIC) o Common organisms – E.coli, Klebsiella and streps o Rx  CEFOTAXIME 2g/6h or TAZOCIN 4.5g/8h for 5d or until sensitivities known (+ METRONIDAZOLE 500mg/8h IV if recent instrumentation to ascites) o Give prophylaxis for high-risk patients (low albumin, high PT/INR, low ascitic albumin) or those with a previous episode  NORFLOXACIN 400MG PO daily continued until death, transplant or ascites resolves.
32
definitive treatment for cirrhosis
LIVER TRANSPLANT
33
scoring system used to assess severity of cirrhosis
Child-Pugh score MELD - Assesses bilirubin, albumin, PT (seconds > normal), ascites, encephalopathy
34
what is hereditary haemachromastosis
Autosomal recessive disorder - Inherited disorder of iron metabolism in which high intestinal iron absorption leads to iron deposition in joints, liver, heart, pancreas, pituitary, adrenals and skin. - MALES > FEMALES (menstrual blood flow is protective in women - so usually presents later in females)
35
major mutations in hereditary haemachromatosis
C282Y H63D on HFE gene (chromosome 6)
36
clinical presentation of hereditary haemochromatosis
TIREDNESS ARTHRALIGIA ERECTILE DYSFUNCTION (hypogonadism) - amenorrhoea in females SKIN HYPERPIGMENTATION (BRONZE SKIN) later - SLATE-GREY SKIN PIGMENTATION - signs of chronic liver disease - hepatomegaly - cirrhosis - dilated cardiomyopathy - osteoporosis - DIABETES
37
Tests for hereditary haemochromatosis
bloods - high iron - high ferritin - high transferrin saturation - low TIBC LFT - deranged imaging - x-ray - chondrocalcinosis - liver MRI - iron overload - liver biopsy - Perl's stain quantifies iron loading and assesses disease seventy. - ecg/echo - monitor cardiomyopathy
38
treatment of haemachromatosis
VENESECTION - 1unit/1-3 weeks, until ferritin ≤50 consider desferrioxamine if intolerant to this. monitor LFT/GLUCOSE/HBA1C diet - well balanced low iron diet tea, coffee and red wine lowers iron absorption screening - serum ferritin and genotype
39
causes of secondary haemachromatosis
- high number of transfusions - red meats, liver, seafood, enriched breakfast cereals and pulses and spices (e.g. paprika) are iron-rich iron absorption occurs mainly in the duodenum and jejunum
40
where does iron absorption occur
iron absorption occurs mainly in the duodenum and jejunum
41
what is alpha-1-antitrypsin deficiency
commonly affects lung and liver causes emphysema and cirrhosis of the liver and hcc AUTOSOMAL RECESSIVE - chromosome 14
42
what is A1AD associated with
``` HCC asthma pancreatitis gallstones wegener's ```
43
tests for A1AD
serum alpha-1-antitrypsin levels - low
44
management of A1AD
- MDT with GP, lung and liver specialists and geneticists - Supportive treatment for emphysema and liver disease may be sufficient - Quit smoking - Give IV A1AT pooled from human plasma is expensive and useless according to some, but COPD exacerbations may be prevented. - Liver transplantation – decompensated cirrhosis - Inhaled A1AT has been tried in lung disease
45
which transaminase is high in alcoholic liver disease
AST > ALT high GGT and macrocytosis high IgA
46
risk factors for NAFLD
OBESITY DM HIGH LIPIDS
47
what is ischaemic hepatiits
seen in conditions where circulatory overload is low (MI, hypotension and haemorrhage)
48
drug-induced hepatitis - which transaminase is high
ALT > AST (in 1000s)
49
commonest drug causes of drug-induced hepatitis
``` co-amoxiclav disulfiram flucloxacillin NSAIDs carbamazepine phenytoin ```
50
test for PBC
anti-mitochondrial antibodies high IgM
51
test for PSC
p-ANCA positive
52
test for autoimmune hepatitis
anti-smooth muscle antibodies | high IgG
53
what is PBC
interlobular bile ducts damaged by chronic autoimmune granulomatous inflammation causing cholestasis --> fibrosis, cirrhosis, portal hypertension
54
who is affected PBC the most
female patients in their 50s
55
presenting signs of PBC
``` itching jaundice XANTHELASMA/XANTHOMATA hepatosplenomegaly tiredness skin pigmentation ```
56
complications of PBC
cirrhosis osteoporosis malabsorption of ADEK due to cholestasis and low bilirubin in the gut lumen results in osteomalacia and coagulopathy. vitamin A - vision, reproduction, immune system, skin vitamin D - strengthens bones, calcium absorption, immune system vitamin E - immune system, flushes toxins vitamin K - blood clotting
57
tests for PBC
high alkaline phosphate high GGT mildly elevated AST and ALT 98% - AMA M2 positive IgM high Ultrasound liver
58
treatment of PBC
ursodeoxycholic acid pruritus - colestyramine diarrhoea - codeine osteoporosis - calcium, vit d, bisphosphonates ADEK supplements liver transplant - end stage
59
monitor in PBC
for HCC - ultrasound and AFP levels every 6 months | regular LFTs
60
what is PSC
progressive cholestasis with bile duct inflammation and strictures of the intrahepatic and extra hepatic bile ducts.
61
presentation of PSC
pruritus fatigue jaundice
62
what is PSC associated with
IBD cancers - cholangiocarcinoma - HCC - colorectal cancer
63
tests for PSC
high Alk Phos high bilirubin ANCA positive ERCP biopsy of liver - fibrotic
64
treatment of psc
ursodeoxycholic acid colestyramine for pruritis antibiotics if ascending cholangitis suspected liver transplant
65
what is autoimmune hepatitis
autoimmune disease of the liver causing damage to the hepatocytes. affects young or middle-aged women (10-30y or >40y)
66
what are the different types of autoimmune hepatitis
I – seen in 80%. Typical patient – F <40y. - Anti-smooth muscle antibodies (ASMA) +ve in 80%. - Antinuclear antibody (ANA) +ve in 10%. - IgG high in 97% - Good response to immunosuppression in 80% - 25% have cirrhosis at presentation II – commoner in Europe than USA. MORE OFTEN SEEN IN CHILDREN - MORE COMMONLY PROGRESSES TO CIRRHOSIS AND LESS TREATABLE - ANTILIVER/KIDNEY MICROSOMAL TYPE 1 (LKM1) antibodies +ve - ASMA and ANA -ve III – like type I but ASMA and ANA NEGATIVE - Antibodies against soluble liver antigen (SLA) or liver-pancreas antigen
67
tests for autoimmune hepatitis
serum bilirubin, AST, ALT, and alk phos all high high IgG Anti-smooth muscle antibody, ANA + LKM1 positive anaemia, low WCC, low Plt - hypersplenism liver biopsy - mononuclear infiltrate of portal and periportal areas and piecemeal necrosis ± fibrosis
68
management of autoimmune hepatitis
prednisolone - for 1 month azathioprine - maintains remission liver transplant
69
association of autoimmune hepatitis
``` pernicious anaemia UC autoimmune thyroiditis autoimmune haemolysis DM PSC glomerulonephritis ```
70
what is NAFLD
fatty liver entails high fat in hepatocytes (steatosis) ± inflammation (steatohepatitis).
71
typical patient for NAFLD
OBESE FEMALE - middle aged
72
risk factors for NAFLD
- DM - Obesity - dyslipidaemia - parenteral feeding - Wilsons disease
73
investigation for NAFLD
liver USS | ± biopsy
74
management of NAFLD
control risk factors - lifestyle advice no drug proven to benefit
75
what is Wilson's disease
Wilsons disease is a rare INHERITED DISORDER OF BILIARY COPPER EXCRETION WITH TOO MUCH COPPER IN LIVER AND CNS (basal ganglia e.g. globus pallidus hypodensity ± putamen cavitation). autosomal recessive - on chromosome 13 - ATP7B
76
pathophysiology of wilsons disease
In Wilsons disease, intestinal copper absorption and transport into the liver are intact, while copper incorporation into caeruloplasmin in liver and its excretion into bile are impaired. Therefore, copper accumulates in liver and later in other organs.
77
signs of wilsons disease
Liver disease - hepatitis, cirrhosis, fulminant liver failure. CNS signs - tremor, dysarthria, dysphagia, dyskinesia, dystonia, hand clapping, dementia, parkinsonism, micrographia, ataxia/clumsiness. mood - depression/mania, labile emotions, high/low libido, personality change. cognition - low memory, quick to anger, low IQ KAYSER-FLEISCHER RINGS -- COPPER IN IRIS other - haemolysis - blue nails - arthritis - hypermobile joints - grey skin
78
difference between haemachromatosis and wilsons disease
NO CNS SIGNS WITH HAEMOCHROMATOSIS. in wilsons disease, copper deposits in the basal ganglia causing dystonia, tremor, dyskinesia, parkinsonism.
79
investigation for wilsons disease
serum copper - low serum caeruloplasmin - low urinary copper - high LFT - deranged slit lamp exam - keiser-fleisher rings on iris/descemet's membrane liver biopsy - high hepatic copper, hepatitis, cirrhosis MRI - degeneration in basal ganglia
80
management of wilsons disease
diet - avoid high copper content foods e.g. liver, chocolate, nuts, mushroom, legumes and shellfish LIFELONG PENCILLINAMINE (can cause a pancytopenia) alternative - Trientine dihydrochloride
81
most liver tumours are secondary - where do they originate from
breast lung GI tract - colon, stomach
82
benign tumours of the liver
```  Cysts  Haemangioma – commonest benign tumour, F:M = 5:1  Adenoma  Focal nodular hyperplasia  Fibroma  Benign GIST = leiomyoma ```
83
malignant tumours of the liver
```  HCC  Cholangiocarcinoma  Angiosarcoma  Hepatoblastoma  Fibrosarcoma and hepatic GI stromal tumour (GIST, formerly leiomyosarcoma) ```
84
symptoms and signs of liver cancer
``` fever malaise anorexia weight loss ruq pain ``` hepatomegaly chronic liver disease signs evidence of decompensation feel for an abdominal mass
85
investigations for liver cancer
``` FBC clotting LFT hepatitis serology AFP HIGH ``` imaging - CT + ultrasound to identify lesions and guide biopsy. - ERCP if cholangiocarcinoma suspected - biopsy
86
causes of HCC
``` HBV HCV Autoimmune hepatitis cirrhosis (alcohol, haemachromatosis, PBC) NAFLD ```
87
causes of cholangiocarcinoma
PSC (screen with CA19-9) HBV HCV DM
88
presentation of cholangiocarcinoma
``` fever abdo pain ± ascites malaise high bilirubin very high alk phos ```
89
management of cholangiocarcinoma
70% are unsuited to surgery surgery - major hepatectomy + extrahepatic bile duct excision + caudate lobe resection. or to improve QOL - stenting of an obstructed extrahepatic biliary tree, percutaneously or via ERCP
90
what is UC
relapsing and remitting inflammatory disorder of the colonic mucosa
91
what are the subtypes of UC
proctitis (rectum) left sided colitis pancolitis (entire colon)
92
Pathology of UC
hyperaemic/haemorrhagic granular colonic mucosa ± pseudo polyps formed by inflammation punctate ulcers may extend deep into the lamina propriety - inflammation is normally not transmural
93
histology findings in UC
``` inflammatory infiltrate goblet cell DEPLETION glandular distortion mucosal ulcers CRYPT ABSCESSES ```
94
is smoking protective of uc
yes
95
symptoms of UC
episodic or chronic diarrhoea (± blood and mucus) crampy abdo discomfort bowel frequency relates to severity. urgency/tenesmus = rectal uc systemic symptoms in attacks - fever, malaise, anorexia, weight loss
96
signs of UC
acute, severe UC - fever tachycardia tender, distended abdomen
97
extra-intestinal signs of uc
``` erythema nodosum episcleritis, scleritis arthralgia pyoderma gangrenosum aphthous oral ulcers PSC ``` sacroilitis ankylosing spondylitis amyloidosis
98
investigations for uc
BLOODS - FBC, U+E, ESR/CRP, LFT, Blood culture stool mc&S - rule out infective cause erect CXR - perforation COLONOSCOPY + BIOPSY - DIAGNOSTIC
99
which scoring method used to assess UC severity
Truelove and Witt's severity index
100
what parameters are found in truelove and witt's index to diagnose uc
``` number of motions in a day rectal bleeding temperature resting HR haemoglobin ESR ```
101
complications of uc
``` PERFORATION HAEMORRHAGE toxic megacolon venous thrombosis colorectal cancer ```
102
first line recommended treatment for UC (proctitis + left sided colitis)
topical aminosalicylate (sulfasalazine)
103
second line rx for UC (proctitis) if no improvement after 4 weeks
add an oral aminosalicylate (mesalazine)
104
3rd line rx for UC (proctitis) if still no improvement
add a topical or oral corticosteroid for 4-8 weeks
105
second line rx for UC (left sided colitis) if no improvement after 4 weeks
add a high dose oral aminosalicylate or switch to a oral aminosalicylate + topical corticosteroid (4-8 weeks)
106
3rd line rx for UC (left sided colitis) if still no improvement
STOP TOPICAL TREATMENT offer - oral aminosalicylate + oral corticosteroid (4-8 weeks)
107
first line rx for PANCOLITIS (UC)
topical aminosalicylate + oral aminosalicylate
108
2nd line rx for pancolitis after 4 weeks
STOP TOPICAL TREATMENT offer - oral aminosalicylate + oral corticosteroid (4-8 weeks)
109
rx for patients unsuitable for aminosalicylates in UC
give topical or an oral corticosteroid for 4-8 weeks | give oral corticosteroid in pancolitis
110
treatment of acute severe UC
NBM and IV fluids IV HYDROCORTISONE or methylprednisolone 2nd line - IV ciclosporin consider surgery in patients who do not improve with iv steroids within 72h.
111
maintenance of remission in UC
proctitis - rectal aminosalicylate or in combination with an oral aminosalicylate. left sided colitis/pancolitis - low dose oral aminosalicylate severe relapse or ≥2 exacerbations requiring steroids - oral azathioprine or oral mercaptopurine
112
what surgery required in UC
proctocolectomy + terminal ileostomy
113
what is crohn's disease
- Chronic inflammatory GI disease characterized by TRANSMURAL GRANULOMATOUS INFLAMMATION AFFECTING ANY PART OF THE GUT FROM MOUTH TO ANUS (esp terminal ileum in 70%) and proximal colon) - SKIP LESIONS PRESENT
114
does smoking increase risk of crohn's disease
yes - x3-4
115
symptoms of crohn's disease
diarrhoea/urgency abdo pain weight loss fever, malaise, anorexia
116
signs of crohn's disease
aphthous oral ulcers abdo tenderness perianal abscess/fistulae/skin tags anal strictures
117
complications of crohn's disease
``` small bowel obstruction toxic megacolon abscess fistulae perforation haemorrhage small intestine cancer ```
118
investigation for crohn's disease
bloods - FBC, U+E, ESR/CRP, LFT, B12, FOLATE, IRON PROFILE, CLOTTING stool mc&s - exclude infection COLONOSCOPY + BIOPSY
119
histology for crohns disease
transmural inflammation non-caseating granulomas goblet cells
120
non-pharmacological management of crohns disease
smoking cessation | optimise nutrition - elemental diet containing amino acids
121
rx - first presentation of crohns disease (Acute)
ORAL PREDNISOLONE or IV hydrocortisone (BUDESONIDE if distal ileal, ileocaecal or right-sided colonic disease and if steroids are C/I) add on therapy (only if there are ≥2 inflammatory exacerbations in 1 year or the corticosteroid dose cannot be reduced): - add azathioprine or mercaptopurine (if both c/i --> add methotrexate instead) if inadequate response to above --> add the TNF-alpha inhibitors (adalimumab or infliximab)
122
maintenance therapy for crohns disease
azathioprine or mercaptopurine 2nd line - methotrexate (DO NOT OFFER CORTICOSTEROIDS OR BUDOSENIDE)
123
maintenance of remission following surgery in crohns
azathioprine + metronidazole for 3 months
124
poor prognosis factors in crohns
onset at age <30y steroids needed at first presentation. perianal disease diffuse small bowel disease
125
what is irritable bowel syndrome
- IBS denotes a mixed group of abdominal symptoms for which no organic cause can be found. - Most are probably due to disorders of intestinal motility or enhanced visceral perception - Age at onset - ≤40 years - Female:male - ≥2:1
126
diagnosis of IBS
abdominal pain (or discomfort) is either relieved defecation or associated with altered stool form or bowel frequency (constipation and diarrhoea may alternate) ``` AND THERE ARE ≥2 OF: o URGENCY o INCOMPLETE EVACUATION o ABDO BLOATING/DISTENSION o MUCOUS PR o WORSENING OF SYMPTOMS AFTER FOOD ```
127
what criteria is required to diagnose IBS
``` chronic symptoms (≥6 months) exacerbated by stress, menstruation or gastroenteritis (post-infection IBS) ```
128
investigations for IBS
bloods - FBC, ESR, CRP, LFT, COELIAC SEROLOGY if ≥50y or any marker or organic disease (high temp, blood PR, weight loss) = colonoscopy. exclude ovarian cancer - CA125, ultrasound o If diarrhoea is prominent do: LFT, stool culture, B12/folate, anti-endomysial antibody (coeliac), TSH
129
treatment for IBS
- Explanation and reassurance are vital as is interdisciplinary teamwork - Ensure healthy diet; fibre; lactose; fructose; wheat; starch; caffeine; sorbitol alcohol and fizzy drinks may worsen symptoms. constipation - bisacodyl. increase fibre. diarrhoea - loperamide after each loose stool. colic/bloating - antispasmodics - mebeverine consider CBT, hypnosis
130
what are risk factors for developing pancreatic cancer
``` SMOKING ALCOHOL carcinogens Diabetes chronic pancreatitis increased waist circumference ```
131
what type of carcinoma is pancreatic cancer
DUCTAL ADENOCARCINOMA
132
where is a common place for pancreatic cancer to arise
head of the pancreas other - body - tail - ampulla of vater - pancreatic islet cells (insulinoma, gastrinoma)
133
which gene affected in pancreatic cancer
KRAS2 gene
134
typical presentation of pancreatic cancer
PAINLESS OBSTRUCTIVE JAUNDICE other - anorexia - weight loss - diabetes - acute pancreatitis
135
signs of pancreatic cancer
JAUNDICE + PALPABLE GALLBLADDER (courvoisier's law) epigastric mass hepatosplenomegaly lymphadenopathy ascites
136
investigations for pancreatic cancer
cholestatic jaundice - high GGT, high alk phos CA19-9 level imaging - USS or CT abdomen scan + biopsy - shows a pancreatic mass ± dilated biliary tree ± hepatic metastases endoscopic sonography (EUS) - most accurate for diagnosis and staging. ERCP - shows biliary tree anatomy and may localise site of obstruction.
137
treatment of pancreatic cancer
pancreato-duodenectomy (whipple's procedure) post-op chemo palliation of jaundice - endoscopic or percutaneous stent insertion may help jaundice and anorexia. pain - analgesia
138
which vitamin lacking in scurvy
vitamin C
139
signs of scurvy
``` anorexia, cachexia gingivitis, loose teeth, foul breath bleeding from gums, nose, hair follicles or into joints, bladder, gut muscle pain and weakness oedema ```
140
treatment of scurvy
ascorbic acid
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what is beriberi
lack of vitamin B1 (thiamine). wernickes causes this.
142
what is wet beriberi
heart failure with general oedema
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what is dry beriberi
peripheral neuropathy
144
what is pallegra
lack of nicotinic acid. classic triad - diarrhoea, dementia and dermatitis - ± neuropathy, depression, insomnia, tremor, rigidity, ataxia, fits
145
treatment of Allegra
o Education o Electrolyte replacement o Nicotinamide 100mg/4h PO
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what is xerophthalmia
vitamin A deficiency syndrome big cause of BLINDNESS IN THE TROPICS
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what are carcinoid tumours
tumours of enterochromaffin cells (neural crest) origin, by definition capable of producing 5HT. 80% of tumours >2cm across will metastasize (i.e. consider all as malignant).
148
common site for carcinoid tumour
appendix ileum rectum
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what is carcinoid syndrome
occurs in 5% and implies hepatic involvement.
150
symptoms and signs of carcinoid syndrome
bronchoconstriction paroxysmal flushing diarrhoea CCF
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investigation for carcinoid syndrome
24-hour urine 5-hydroxyindoleacetic acid (5-HIAA) HIGH - CXR + Chest/Pelvis MRI/CT help locate primary tumours - ECHO and BNP – used to investigate carcinoid heart disease
152
treatment of carcinoid syndrome
octreotide (somatostatin analogue) tumour resection - only cure for carcinoid tumours.
153
what is a carcinoid crisis
- When a tumour outgrows its blood supply or is handled too much during surgery, mediators flow out. - Life-threatening vasodilation, hypotension, tachycardia, bronchoconstriction, and hyperglycaemia. - TREATED WITH HIGH DOSE OCTREOTIDE, SUPPORTIVE MEASURES AND CAREFUL MANAGEMENT OF FLUID BALANCE (i.e. a central line is needed)
154
what are symptoms of malabsorption
``` diarrhoea weight loss lethargy steatorrhoea bloating ```
155
tests for malabsorption
bloods - fbc: low or high MCV - low calcium - low iron - low b12/folate - high INR - lipid profile coeliac serology stool mc&s, elastase endoscopy + small bowel biopsy ERCP - biliary obstruction
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commonest causes of malabsorption in the UK
coeliac disease, chronic pancreatitis, crohn's disease
157
what is coeliac disease
T-cell mediated AUTOIMMUNE DISEASE OF THE SMALL BOWEL. Gliadin intolerance causes villous atrophy and malabsorption.
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when is coeliac disease suspected
in those with diarrhoea + weight loss or ANAEMIA
159
associations of coeliac disease
HLA-DQ2 (92%) HLA-DQ8 autoimmune disease DERMATITIS HERPETIFORMIS
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presentation of coeliac disease
``` steatorrhoea/smelly stools diarrhoea abdo pain bloating nausea and vomiting ``` weight loss fatigue weakness 1/3 asymptomatic
161
signs of coeliac disease
aphthous oral ulcers angular stomatitis osteomalacia failure to thrive in children
162
investigations for coeliac disease
low Hb low iron low B12 antibodies - anti-transglutaminase antibodies - anti-endomysial antibodies - an IgA antibody (95% specific unless IgA deficient) - so if low IgA, can't interpret accurately. - alpha-gliadin antibodies DIAGNOSTIC - ENDOSCOPY + BIOPSY OF DUODENUM - --- intraepithelial WBCs high - ---villous atrophy - --- crypt hyperplasia exclude coeliac in all labelled as IBS
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treatment for coeliac disease
lifelong gluten free diet rice maize soya potatoes oats and sugar are ok.
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complications of coeliac disease
``` ANAEMIA 2° lactose intolerance GI T-cell lymphoma (rare) INCREASED RISK OF MALIGNANCY (gastric, oesophageal, bladder, breast, brain) myopathies neuropathies hyposplenism osteoporosis ```
165
symptoms of chronic pancreatitis
epigastric pain radiates to back relieved by sitting forward bloating steatorrhoea weight loss brittle diabetes
166
causes of chronic pancreatitis
``` ALCOHOL CF haemochromatosis pancreatic duct obstruction high PTH congenital ```
167
investigations for chronic pancreatitis
ultrasound ± CT (pancreatic calcification) AXR - speckled calcification
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treatment of chronic pancreatitis
analgesia lipase fat-soluble vitamins insulin - variable surgery for unremitting pain, narcotic abuse, weight loss- pancreatectomy or pancreaticojejunostomy
169
complications of chronic pancreatitis
``` pseudocyst diabetes biliary obstruction local arterial aneurysm splenic vein thrombosis gastric varices pancreatic carcinoma ```
170
tools used to assess alcohol dependence
CAGE questionnaire | AUDIT
171
Alcoholic hepatitis - what are the raised parameters on bloods
``` AST:ALT >2 high GGT high MCV high INR high urea high WCC ``` low platelets - hypersplenism or toxicity
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signs of severe alcoholic hepatitis
jaundice encephalopathy coagulopathy
173
treatment of alcoholic hepatitis
stop alcohol consumption (if withdrawal - chlordiazepoxide PO or lorazepam IM) IV pabrinex high protein diet - prevent encephalopathy, sepsis daily weight, LFT, U+E, INR prednisolone 40mg/d for 5d tapered over 3 weeks if Maddrey score >31 and encephalopathy.
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what is found on histology for cirrhosis (biopsy findings)
mallory bodies | neutrophil infiltrate
175
CNS signs of alcohol excess
wernicke's encephalopathy korsakoff's - confabulation ``` cortical atrophy retrobulbar neuropathy seizures falls wide-based gait neuropathy ```
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GI signs of alcohol excess
``` obesity d+v gastric erosions peptic ulcers varices pancreatitis cancer - oesophagus, stomach, pancreatic, mouth, liver oesophageal rupture (Boerhaave's syndrome - shock and surgical emphysema) ```
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alcohol excess findings on bloods
high MCV, anaemia - megaloblastic anaemia due to bone marrow depression, GI bleeding, alcoholism-related folate deficiency, haemolysis, sideroblastic anaemia.
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heart problems in alcoholics
arrhythmia high BP cardiomyopathy sudden death
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symptoms of alcohol withdrawal and time frame
starts 10-72h after last drink - tachycardia - hypotension - tremor - confusion - seizures - delirium tremens - hallucinations (animals crawling over skin)
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pregnancy complication of alcohol excess
fetal alcohol syndrome - low iq, short palpebral fissure, absent philtrum, small eyes
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management of alcohol withdrawal
admit, do BP chlordiazepoxide (wean over 7-10d). alternative - diazepam
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long term treatment of alcohol withdrawal to prevent relapse
disulfiram acamprosate group therapy - AA
183
5 causes of abdominal distention
``` flatus - obstruction faeces - stool impaction fetus - pregnancy fluid - ascites fat - obesity ```
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if ascites suspected, how to investigate
aspirate ascitic fluid (paracentesis) - cytology, culture and protein level (≥30g/l) ultrasound abdomen
185
causes of ascites
``` malignancy infection - tb low albumin CCF pancreatitis myxedema ```
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causes of ascites with portal hypertension
cirrhosis budd-chiari syndrome ivc or portal vein thrombosis portal nodes
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causes of splenomegaly with fever
infection - malaria, SBE/IE, hepatitis, EBV, CMV, TB, HIV sarcoid malignancy
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splenomegaly with arthritis causes
``` sjogrens syndrome RA SLE infection - lyme disease vasculitis/behcets ```
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splenomegaly with anaemia
``` sickle cell disease thalassaemia leishmaniasis leukaemia pernicious anaemia ```
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splenomegaly with lymphadenoapthy
glandular fever leukaemia lymphoma sjogrens
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splenomegaly with ascites
carcinoma | portal hypertension
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splenomegaly with weight loss + CNS signs
cancer lymphoma TB
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splenomegaly with purpura
septicaemia DIC meningococcaemia
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splenomegaly with murmur
SBE/IE | rheumatic fever
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massive splenomegaly causes
``` malaria myelofibrosis CML gaucher's syndrome leishmaniasis ```
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acute abdomen - clinical syndromes requiring laparotomy
rupture of organ - spleen, aorta, ectopic pregnancy shock is the leading sign abdo swelling hx of trauma: blunt trauma = spleen, penetrating trauma -= liver PERITONITIS
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what is peritonitis
perforation of peptic ulcer/duodenal ulcer, diverticulum, appendix, bowel or gallbladder
198
signs of peritonitis
``` shock lying still tenderness rebound tenderness board-like abdominal rigidity guarding no bowel sounds ```
199
investigation for peritonitis
ERECT CXR - pneumoperitoneum
200
signs of abscess
swelling swinging fever high WCC
201
what is colic
regular waxing and waning pain caused by muscular spasm in a hollow viscus - gut, ureter, sapling, uterus, bile duct or gallbladder restlessness
202
investigation for peritonitis
bloods - abc, u&e, AMYLASE, LFT, CRP, ABG (?mesenteric ischaemia), urinalysis
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imaging for peritonitis
erect CXR AXR - may show Rigler's sign USS - may identify perforation or free fluid immediately
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treatment of peritonitis
``` NBM treat shock crossmatch/ group and save blood cultures antibiotics - cefuroxime + metronidazole ``` analgesia iv fluids ECG if >50y ?AAA
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causes of a medical acute abdomen
``` IBS MI mesenteric ischaemia acute pancreatitis leaking AAA gastroenteritis lower lobe pneumonia thyroid storm TB sickle cell crisis phaeochromocytoma ```
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symptoms of acute appendicitis
periumbilical pain that moves to the RIF pain precedes vomiting in surgical abodmen
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general signs of acute appedicitis
``` tachycardia fever (low grade) 37.5-38.5 furred tongue lying still foetor ± flushing shallow breaths coughing hurts ```
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signs of acute appendicitis
guarding rebound + percussion tenderness anorexia rovsig's sign - pain in RIF when LIF pressed. psoas sign - RIF pain on extending hip cope sign - pain on flexion and internal rotation of right hip
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investigation for acute appendicitis
bloods - neutrophil leukocytosis, elevated CRP if female - DO A PREGNANCY TEST ABDO USS CT abdo pelvis more accurate but can cause fatal delay
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treatment of acute appendicitis
prompt appendicectomy antibiotics - cefuroxime + metronidazole laparoscopy - done in women and obese
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complications of acute appendicitis
perforation appendix mass appendix abscess
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division points of the foregut
proximal to 2nd part of duodenum supplied by coeliac trunk
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midgut division points
2nd part of duodenum to 2/3 along transverse colon supplied by SMA
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hindgut division points
1/3 along transverse colon to anus supplied by IMA
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pathology of pain in acute appendicitis
early inflammation irritates the structures and walls of the appendix - colicky pain referred to mid-abdomen as inflammation progresses and irritates the parietal peritoneum, the somatic, lateralised pain settles at mcburney's point (2/3 along from the umbilicus to the right ASIS)
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differential diagnosis of RIF pain
``` ectopic pregnancy UTI mesenteric adenitis cholecystitis diverticulitis PID crohns disease perforated ulcer PID ```
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bowel obstruction features
nausea and vomiting colicky abdominal pain constipation (absolute - no flatus passed) abdominal distention fever tachy faeculent vomiting - late sign (colonic fistula with proximal gut)
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causes of obstruction (mechanical)
Adhesions - commonest cause in SBO colorectal cancer intussusception - common in children (ileocaecal valve) hernia volvulus- caecum and volvulus
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causes of obstruction (pseudo-obstruction)
paralytic ileus - post-op likely, pancreatitis, spinal injury, low K, low Na, uraemia, peritoneal sepsis and drugs neuropathy hirschsprung disease
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AXR findings in SBO
central gas shadows with valvulae conniventes spanning across the lumen
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AXR in LBO
peripheral gas shadows proximal to the blockage (caecum) large bowel haustra do not cross the lumen's width
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common causes of SBO
adhesions | hernia
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common causes of LBO
malignancy diverticular disease volvulus
224
complications of bowel obstruction
bowel ischaemia perforation sepsis
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management of bowel obstruction
drip and suck - give iv fluids and insert NGT NBM ``` analgesia bloods - FBC, U+E, amylase AXR erect CXR catheterise to monitor fluids ``` if imaging inconclusive - consider early CT WITH CONTRAST
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characteristic sign of sigmoid volvulus on AXR
'coffee bean' sign | inverted 'u' loop of bowel
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management of sigmoid volvulus
sigmoidoscopy + insertion of a FLATUS TUBE
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classic triad of stomach volvulus causing obstruction
vomiting pain failed attempts to pass NG tube
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complications of gastric volvulus
incarceration | strangulation
230
risk factors for gastric volvulus
congenital - paraoesophageal hernia - congenital bands - bowel malformations - pyloric stenosis acquired - gastric/oesophageal surgery
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investigations for gastric volvulus
erect CXR - gastric dilatation and double fluid level
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treatment of gastric volvulus
acutely unwell - prompt resus and laparotomy
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definition of a hernia
protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position.
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what is a irreducible hernia
Said to be irreducible if they cannot be pushed back into the right place.
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what is a incarcerated hernia
contents of the hernial sac stuck inside by adhesions
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what is an obstructed hernia
gastrointestinal hernias are obstructed if bowel contents cannot pass through them - the classical features of intestinal obstruction occur.
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what is a strangulated hernia
if ischaemia occurs, the patient becomes toxic and requires urgent surgery.
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femoral hernia - what is it
bowel enters the femoral canal, presenting as a mass in the upper medial thigh or above the inguinal ligament where it points down the leg, unlike an inguinal hernia which points to the groin.
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who does a femoral hernia commonly affect
middle aged women and the elderly
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anatomical location of femoral hernias
inferior and lateral to the pubic tubercle
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treatment of femoral hernia
surgical repair herniotomy - ligation and excision of sac herniorrhaphy - repair of the hernial sac
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what is gastroschisis
protrusion of the abdominal contents through a defect in the anterior abdominal wall to the RIGHT OF THE UMBILICUS. protruding wall is covered by a thin 'peel' prompt surgical repair is performed after cautious resuscitation
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what is an exomphalos (omphalocele)
abdominal contents are found outside the abdomen, covered in a 3-layer membrane consisting of a peritoneum, Wharton's jelly and amnion. surgical repair is less urgent than in gastroschisis as the bowel is protected by the membranes. associated with congenital abnormalities, such as anencephaly, cardiac defects, hydrocephalus, spina bifida.
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what is a direct inguinal hernia
push their way directly forward through the posterior wall of the inguinal canal, into the defect in the abdominal wall. hesselbach's triangle; medial to the inferior epigastric vessels
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what is indirect inguinal hernia
push through the deep internal ring, and if large, out through the external ring. lateral to the inferior epigastric vessels
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which conditions predispose to umbilical hernia
``` MALES > FEMALES chronic cough constipation urinary obstruction heavy lifting ascites past abdominal surgery (e.g. damage to the iliohypogastric nerve during appendicectomy) ```
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where is the deep ring found
mid-point of the inguinal ligament
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where is the superficial ring found
split in the external oblique aponeurosis just superior and medial to the pubic tubercle (the body prominence forming the medial attachment of the inguinal ligament)
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relations of the inguinal canal
- Floor: inguinal ligament and lacunar ligament medially - Roof: fibres of transversalis, internal oblique - Anterior – external oblique aponeurosis + internal oblique for the lateral 1/3 - Posterior – laterally, transversalis fascia; medially, conjoint tendon
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examination of a lump in the groin
- Look for previous scars - Feel the other side (more common on the right) - Examine the external genitalia - Then ask o Is the lump visible?  If so, ask the patient to reduce it – if he cannot, make sure it is not a scrotal lump o Ask him to cough  Appears above and medial to pubic tubercle o If no lump is visible, ask for a cough impulse o Repeat examination with patient standing
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how to distinguish between direct and indirect hernias
reduce the hernia and occlude the deep ring with 2 fingers. ask the patient to cough or stand. if the hernia can be controlled after being reduced --> INDIRECT if the hernia still protrudes --> DIRECT gold standard for determining type is at surgery - direct hernia: arise media to the inferior epigastric vessels - indirect hernia: arise lateral to the inferior epigastric vessels
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treatment of inguinal hernias
weight loss smoking cessation laparoscopic repairs - transabdominal pre-peritoneal (TAPP) - totally extraperitoneal (TEP)
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when is return to work advised for patients with inguinal hernias
advise 4 weeks rest and convalescence over 10 weeks
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what are the contents of the inguinal canal in a male
- Spermatic cord o Vas deferens, obliterated processus vaginalis, and lymphatics o Arteries to the vas, cremaster and testis o Pampiniform plexus and the venous equivalent of the above o Genital branch of the genitofemoral nerve and sympathetic nerves - Ilioinguinal nerve, which enters the inguinal canal via the anterior wall and runs anteriorly to the cord
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what are the contents of the inguinal canal in a female
the round ligament of the uterus
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what type of cancer is a colorectal cancer
adenocarcinoma affects >60 year olds
257
predisposing factors to colorectal cancer
``` neoplastic polyps IBD genetic - FAP + HNPCC diet - low fibre, increased red and processed meats excessive alcohol smoking previous cancer ```
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how to prevent colorectal cancer
aspirin - thought to inhibit polyp growth
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presenting features of colorectal cancer- left-sided
bleeding/mucus PR altered bowel habit or obstruction tenesmus mass PR weight loss fever, night sweats perforation haemorrhage fistula
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presenting features of colorectal cancer- right-sided
weight loss low Hb abdominal pain obstruction less likely
261
investigations for colorectal cancer
FBC - microcytic anaemia faecal immunochemical test (FIT) COLONOSCOPY + BIOPSY CT/MRI CEA - used to monitor disease and effectiveness of treatment
262
dukes staging for colorectal cancer
A – limited to muscularis mucosae – 95% 5y survival B – extension through muscularis mucosae – 77% C – involvement of regional lymph nodes – 48% D – distant metastases – 6.6%
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treatment of colorectal cancer
surgery - removal depends on where the lesion is: - RIGHT HEMICOLECTOMY o Caecal, ascending or proximal transverse colon tumours - LEFT HEMICOLECTOMY o Tumours in distal transverse or descending colon - SIGMOID COLECTOMY o For sigmoid tumours - ANTERIOR RESECTION for low sigmoid or high rectal tumours - ABDOMINO-PERINEAL (AP) RESECTION o Tumours low in the rectum (≤8cm from anus): permanent colostomy and removal of rectum and anus. - HARTMANN’S PROCEDURE o Emergency bowel obstruction, perforation or palliation adjuvant chemotherapy used. radiotherapy used in palliation of colon cancer.
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is there screening available to detect colorectal cancer
all 60-74 year olds are sent a faecal immunochemical test (FIT) home-kit every 2 years automatically. if it is positive - further imaging with colonoscopy is offered.
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what are different types of polyps found in the bowel
1. INFLAMMATORY o UC, crohns, lymphoid hyperplasia 2. HAMARTOMATOUS o Juvenile polyps o Peutz-Jeghers 3. NEOPLASTIC o Tubular or villous adenomas o Malignant potential esp. if >2cm - Polyps should be biopsied and removed if they show malignant change - Most can be reached by flexible colonoscope
266
what type of cancer is a stomach cancer
adenocarcinomas
267
presentation of stomach cancer
non-specific ``` dyspepsia weight loss vomiting dysphagia anaemia ```
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signs of stomach cancer
large left supraclavicular (Virchow's node) = Troisier's sign acanthosis nigricans epigastric mass hepatomegaly jaundice ascites
269
investigation for stomach cancer
Gastroscopy + multiple ulcer edge biopsies - AIM TO BIOPSY ALL GASTRIC ULCERS AS EVEN MALIGNANT ULCERS MAY APPEAR TO HEAL ON DRUG TREATMENT. - Endoscopic ultrasound – evaluate depth of invasion - CT/MRI – staging
270
treatment for stomach cancer
partial gastrectomy - may suffice for distal tumours total gastrectomy - more proximal tumours adjuvant chemotherapy
271
risk factors for developing oesophagus cancer
``` ALCOHOL excess smoking diet achalasia plummer-vinson syndrome obesity reflux oesophagitis ± barrett's oesophagus ```
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which type of cancer affects the distal oesophagus
ADENOCARCINOMA
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which type of cancer affects the proximal oesophagus
SQUAMOUS CELL CARCINOMA
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presentation of oesophagus cancer
dysphagia dysphonia (hoarse voice) dyspnoea (airway obstruction) weight loss retrosternal chest pain
275
investigation for oesophagus cancer
OGD with biopsy
276
staging for oesophagus cancer
- Spread of eosophageal cancer is direct, by submucosal infiltration and local spread -or to nodes, or later, via blood. - Tis – carcinoma in situ o T1 – invading lamina propria/submucosa o T2 – invading muscularis propria o T3 – invading adventitia o T4 – invasion of adjacent structures - Nx – nodes cannot be assessed o N0 – no nodes spread o N1 – regional node metastases - M0 – no distant spread o M1 – distant metastases
277
management of oesophagus cancer
if localised T1/T2 - radical curative oesophagectomy
278
cause of oesophageal rupture
iatrogenic - endoscopy/biopsy/dilatation (85-90%) trauma - penetrating injury/ingestion of foreign body carcinoma boerhaave syndrome - rupture due to violent vomiting corrosive ingestion
279
clinical features of oesophageal rupture
odynophagia tachypnoea dyspnoea fever shock surgical emphysema - crackling sensation felt on palpating skin over the chest or neck caused by air tracking from the lungs.
280
treatment of oesophageal rupture
iatrogenic perforations are less prone to mediastinitis and sepsis and may be managed conservatively with NGT, PPI and Abx others require resuscitation, PPI, Abx, antifungals, and surgery.
281
what is a major risk factor for a cholangiocarcinoma
PSC
282
management of cholangiocarcinoma
surgical resection if palliative - biliary stenting and chemotherapy
283
what must you consider in a patient presenting with abdominal pain who has AF
mesenteric ischaemia
284
what is acute mesenteric ischaemia
Almost always involves the SMALL BOWEL and may follow SMA THROMBOSIS OR EMBOLISM, MESENTERIC VEIN THROMBOSIS, OR NON-OCCLUSIVE DISEASE.
285
what is the cause of acute mesenteric ischaemia
Arterial thrombus or an embolic event would cause it
286
presenting symptoms of acute mesenteric ischaemia
acute severe abdominal pain no abdominal signs rapid hypovolaemia --> shock
287
investigations for acute mesenteric ischaemia
``` high lactate high WCC persistent metabolic acidosis high Hb modestly raised plasma amylase ```
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imaging for acute mesenteric ischaemia
CT/MRI angiography arteriography ECG
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treatment of acute mesenteric ischaemia
``` ABCDE resuscitation with - IV fluids - IV Abx (gentamicin + metronidazole) - LMWH ``` surgery - remove necrotic bowel (laparotomy) ITU
290
what is chronic mesenteric ischaemia
'Intestinal angina'
291
triad of chronic mesenteric ischaemia
severe, colicky post-prandial abdominal pain ('gut claudication') weight loss upper abdominal bruit +PR bleeding, malabsorption, n+v
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cause of chronic mesenteric ischaemia
vascular disease (95% due to diffuse atherosclerotic disease in all 3 mesenteric arteries)
293
investigations for chronic mesenteric ischaemia
CT angiography and contrast enhanced MR angiography doppler USS
294
treatment for chronic mesenteric ischaemia
surgery considered - risk of ongoing risk of acute infarction.
295
what is ischaemic colitis
low flow in the inferior mesenteric artery territory ranges from mild ischaemia to gangrenous colitis
296
presentation of ischaemic colitis
lower left-sided abdo pain | bloody diarrhoea
297
investigation for ischaemic colitis
colonoscopy + biopsy - gold standard barium enema - shows characteristic 'thumb' printing of submucosal swelling
298
treatment for ischaemic colitis
conservative - fluids and abx gangrenous ischaemic colitis (presents with peritonitis and hypovolaemic shock) requires prompt resuscitation followed by resection of the affected bowel and stoma formation.
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what are the physical complications of gastrectomy and peptic ulcer surgery
recurrent ulceration abdominal fullness- feeling of early satiety (±discomfort + detention) improving with time. advise small, frequent meals. afferent loop syndrome - post-gastrectomy. afferent loop may fill with bile after a meal, causing upper abdo pain and billous vomiting. diarrhoea gastric tumour - as reduced acid production high amylase
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metabolic complications of gastric surgery
dumping syndrome - fainting and sweating after eating due to food of high osmotic potential being dumped in the jejunum, causing hypovolaemia from rapid fluid shifts. weight loss - poor calorie intake bacterial overgrowth ± malabsorption may occur anaemia - lack of iron osteomalacia
301
complications of peptic ulcer disease
perforation haemorrhage - controlled endoscopically by adrenaline injection, diathermy, laser coagulation or heat probe. pyloric stenosis - late complication of duodenal ulcers due to scarring. tx - endoscopic balloon dilatation followed by maximal acid suppression. (hypokalaemic, hypocholaraemic metabolic alkalosis)
302
what is severe obesity associated with
``` T2DM hypertension IHD sleep apnoea osteoarthritis depression ```
303
indications for bariatric surgery
BMI ≥40 or ≥35 with significant comorbidities that could improve with weight loss. failure of non-surgical management to achieve and maintain clinically beneficial weight loss for 6months fitness for surgery and anaesthesia as part of an integrated programme that provides guidance on diet, physical activity and psychological concerns, as well as lifelong medical monitoring. patient must be well informed and motivated. if BMI ≥50, surgery is first line treatment.
304
what are the 2 main mechanisms by which bariatric surgery help reduce weight
- restriction of calorie intake by reducing stomach capacity. - malabsorption of nutrients by reducing the length of functioning small bowel
305
2 main procedures in bariatric surgery
laparoscopic adjustable gastric banding (LAGB) - restrictive technique creates a pre-stomach pouch by placing a silicone band around top of stomach - serves as a new smaller stomach. Roux-en-Y gastric bypass - portion of the jejunum is attached to a small pouch to allow food to bypass the distal stomach, duodenum, and proximal jejunum.
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presentation of pyloric stenosis in child
first 3-8 weeks projectile vomiting M:F 4:1 baby is malnourished and always hungry
307
investigation for pyloric stenosis
ultrasound abdomen - hypertrophied pylorus muscle
308
examination findings of pyloric stenosis
palpate the olive-shaped pyloric mass in the RUQ during feed. visible gastric peristalsis starts in the LUQ
309
cardinal electrolyte + ABG finding in pyloric stenosis
hypocholaraemic, hypokalaemic metabolic alkalosis
310
treatment for pyloric stensosi
ramstedt's pyloromyotomy
311
presentation of intussusception in paediatrics
typical age - 5-12months episodic intermittent inconsolable crying. drawing up of legs (colic) billous vomiting REDCURRANT STOOLS (blood PR)
312
diagnosis of intussusception
sausage shaped mass on palpation may become shocked USS abdomen - target sign
313
management of intussusception
resuscitation first - iv fluids, crossmatch and pass NGT USS with reduction by air enema or pneumatic reduction under radiographic control. surgery - if above doesn't work
314
presentation of midgut rotation in paediatrics
dark green bilious vomiting distention rectal bleeding
315
imaging for malrotation in children
upper GI contrast study - barium swallow
316
treatment of malrotation in children
resuscitation surgery - broadening mesentery and untwisting bowel
317
what are diverticula
a GI diverticulum is an out pouching of the gut wall, usually at sites of entry of perforating arteries.
318
what are the 3 types of diverticular disease
Diverticulosis – diverticula are present Diverticular disease – implies that the diverticula are symptomatic Diverticulitis – inflammation of a diverticulum
319
where is the most common site for diverticulae
sigmoid colon
320
underlying pathology of diverticular disease
lack of dietary fibre is thought to lead to high intraluminal pressures which force the mucosa to herniate through the muscle layers of the gut at weak points adjacent to penetrating vessels.
321
presenting features of diverticular disease
altered bowel habit ± left-sided colic relieved by defecation. nausea flatulence
322
features of diverticulitis
altered bowel habit nausea flatulence ``` pyrexia high WCC high CRP/ESR tender colon ± localised or generalised peritoneum ```
323
diagnosis of diverticular disease
CT ABDOMEN - gold standard to confirm acute diverticulitis. ERECT CXR - ?perforation DONT DO COLONOSCOPY ACUTELY - RISK PERFORATION
324
treatment of diverticulitis
``` analgesia NBM IV fluids antibiotics CT-guided percutaneous drainage if abscess ```
325
complications of diverticulitis
``` perforation haemorrhage fistulae - enterocoelic, colovaginal, colovesicle abscess post-infective strictures ```
326
management of haemorrhage - diverticulitis
ABCDE bloods - FBC, U+E, LFT, clotting, amylase, CRP, Group and save. imaging - erect CXR, AXR insert 2 wide bore cannulae give crystalloid as replacement and maintainance iv blood transfusion is rare. insert urinary catheter antibiotics - if sepsis/perforation - cefuroxime + metronidazole IV consider omeprazole iv keep bedbound - large bleed can occur resulting in collapse on walking. start stool chart - mc&s diet - clear fluids surgery indication - unremitting, massive bleeding bleeding usually stops with bed rest. if not, embolisation or colonic resection may be necessary after locating bleeding points by angiography or colonoscopy
327
what is angiodysplasia
submucosal arteriovenous malformations typically present as FRESH PR BLEEDING IN ELDERLY.
328
pathology of angiodysplasia
70-90% lesions occur in right colon, though angiodysplasia can affect anywhere in GI tract.
329
diagnosis of angiodysplasia
PR examination + colonoscopy - to exclude other diagnoses. mesenteric angiography - useful in diagnosing angiodysplasia (shows early filling at the lesion site, then extravasation). CT angiography is an alternative
330
treatment of angiodysplasia
embolisation endoscopic laser electrocoagulation resection
331
causes of rectal bleeding
``` diverticulitis colorectal cancer haemorrhoids IBD perianal disease angiodysplasia ischaemic colitis ```
332
perianal disease - pruritus ani causes
itch occurs if the anus is moist/soiled; fissures, incompetence, poor hygiene, tight pants, threadworm, fistula, dermatoses, lichen sclerosis, anxiety, contact dermatitis.
333
treatment of pruritus ani
``` careful hygiene anaesthetic cream moist-wipe post defecation no spicy food no steroid/antibiotic cream capsaicin may help ```
334
what are the causes of fissure-in-ano
most are due to hard faeces/constipation. usually a painful tear in the squamous lining of the lower anal canal - often, if chronic, with a 'sentinel pile' or mucosal tag at the external aspect.
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rare causes of fissures
``` syphilis herpes trauma crohns anal cancer psoriasis ```
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treatment of fissures
5% lidocaine ointment + GTN ointment or topical diltiazem (CCB) increased dietary fibre, fluids ± stool softener and hygiene advice. botulinum toxin injection (2nd line) and topical diltiazem. surgery - lateral partial internal sphincterotomy
337
what is a fistula-in-ano
track communicates between the skin and anal canal/rectum
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pathophysiology of fistula-in-ano
blockage of deep intramuscular gland ducts is thought to predispose to the formation of abscesses which discharge to form the fistulae
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causes of fistula-in-ano
``` perianal sepsis abscesses crohn's disease TB diverticular disease rectal carcinoma immunocompromise ```
340
investigation for fistula-in-ano
MRI | endoanal US scan
341
treatment of fistula-in-ano
fistulotomy + excision
342
where are anorectal abscesses most likely and rx
perianal (45%) ischiorectal (30%) intersphincteric (20%) supralevator (5%) rx - incise and drain under GA
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causes of anorectal abscesses
DM crohn's malignancy fistulae
344
what is a pilonidal sinus
obstruction of natal cleft hair follicles approx 6cm above the anus INGROWING OF HAIR EXCITES A FOREIGN BODY REACTION AND MAY cause secondary tracks to open laterally ± abscesses, with foul-smelling discharge.
345
who is a pilonidal sinus more common in
males obese caucasians asia, middle east and mediterranean at high risk
346
treatment of a pilonidal sinus
excision of sinus tract ± primary closure. offer hygiene and hair removal advice
347
causes of rectal prolapse
lax sphincter prolonged straining related to chronic neurological and psychological disorders.
348
treatment of rectal prolapse
fix rectum to sacrum (rectopexy) ± mesh insertion ± rectosigmoidectomy
349
treatment of perianal warts (condylomata acuminata)
podophyllotoxin or imiquimod OR cryotherapy/surgical excision
350
what is proctalgia fugax and treatment
idiopathic, intense, brief, stabbing/crampy rectal pain. worse at night. rx - reassurance. inhaled salbutamol or topical GTN or topical diltiazem may help
351
what type of cancer is an anal cancer
squamous cell (85%) anal margin tumours - well differentiated, keratinising lesions with a good prognosis. anal canal tumours - arise above the dentate line, poorly differentiated, non-keratinising with a poorer prognosis.
352
risk factors for anal cancer
HPV 16, 6, 11, 18, 31, 33 syphilis anoreceptive homosexuals
353
presentation of anal cancer
``` bleeding pain bowel habit change pruritus ani masses stricture ```
354
treatment of anal cancer
chemo-irradiation (inc radiotherapy)
355
what are haemorrhoids
disrupted, dilated anal cushions. - The effects of gravity (our erect posture), increased anal tone (?stress) and the effects of straining at stool may make the anal cushions (spongy vascular tissue) both bulky and loose and so to protrude to form piles. o Vulnerable to trauma (e.g. from hard stools) and bleed readily from the capillaries of the underlying lamina propria ----> haemorrhoids.
356
why do internal haemorrhoids not cause pain
As there are no sensory fibres above the dentate line (squamomucosal junction), piles are not painful unless they thrombose when they protrude and are gripped by anal sphincter, blocking venous return
357
causes of haemorrhoids
constipation with prolonged straining. congestion from a pelvic tumour pregnancy CCF portal hypertension
358
classification of haemorrhoids
o 1st degree – remain in the rectum o 2nd degree – prolapse through the anus on defecation but spontaneously reduce. o 3rd degree – as for 2nd degree but require digital reduction o 4th degree – remain persistently prolapsed
359
symptoms of haemorrhoids
bright red rectal bleeding mucuous discharge pruritus ani severe anaemia may occur no pain usually unless thrombosed.
360
investigation for haemorrhoids
PR EXAM abdominal examination proctoscopy - internal haemorrhoids
361
treatment for haemorrhoids
first line managment - increased fluid intake and fibre is key - topical analgesia and stool softener non-operative management if medical management failed - rubber band ligation - sclerosants - infra-red coagulation - cryotherapy - not recommended but last resort. surgery (4th degree) - excisional haemorrhoidectomy (most effective) - stapled haemorrhoidoplexy
362
management of prolapsed, thrombosed piles
treat with analgesia, ice packs, and stool softeners.
363
what is bile composed of
cholesterol bile pigments phospholipids
364
what is a pigmented gallstone
small, friable and irregular | cause is haemolysis
365
what is a cholesterol gallstone
``` large, often solitary causes - male - age - obesity ```
366
what is a mixed gallstone
calcium stones, pigment and cholesterol
367
what is acute cholecystitis
inflammation of the gallbladder - may cause continuous epigastric or RUQ pain (referred to right shoulder), vomiting, fever, local peritonism, or a gallbladder mass.
368
common sign in acute cholecystitis
MURPHY’S SIGN – lay 2 fingers over the RUQ; ask patient to breath in. This causes pain and arrest of inspiration as an inflamed GB impinges on your finger. - Only positive if the same test in the LUQ does not cause pain
369
tests for acute cholecystitis
- High WCC - ULTRASOUND o Thick-walled, shrunken GB, pericholecystic fluid, stones, CBD (dilated if >6mm)
370
treatment for acute cholecystitis
NBM analgesia IV fluids antibiotics e.g. cefuroxime <1 week - laparoscopic cholecystectomy
371
complications of gallstones
``` - In the gallbladder and cystic duct o Biliary colic o Acute and chronic cholecystitis o Mucocele o Empyema o Carcinoma o Mirizzi’s syndrome - In the bile ducts o Obstructive jaundice o Cholangitis o Pancreatitis - In the gut o Gallstone ileus ```
372
what is acute pancreatitis
Self-perpetuating pancreatic inflammation by enzyme-mediated autodigestion. - Oedema and fluid shifts cause hypovolaemia, as extracellular fluid is trapped in the gut, peritoneum, and retroperitoneum (worsened by vomiting). - Progression may be rapid – from mild oedema to necrotising pancreatitis
373
causes of acute pancreatitis
- Gallstones - Ethanol (alcohol) - Trauma - Steroids - Mumps - Autoimmune (PAN) - Scorpion venom - Hyperlipidaemia, hypothermia, hypercalcaemia - ERCP and emboli - Drugs
374
symptoms of acute pancreatitis
- Gradual or sudden severe epigastric or central abdominal pain (radiates to back, sitting forward may relieve) - VOMITING
375
signs of acute pancreatitis
- May be mild in severe disease - Tachycardia - Fever - Jaundice - Shock - Ileus - Rigid abdomen - ± local/general tenderness ``` Periumbilical bruising (Cullen’s sign) & Flank bruising (Grey Turner’s sign) from blood vessel autodigestion and retroperitoneal haemorrhage. ```
376
tests for acute pancreatitis
serum amylase serum lipase ABG erect CXR USS - screening for gallstones CT abdomen - standard choice of imaging
377
score used to assess severity of acute pancreatitis
Glasgow criteria ```  ≥3 positive factors detected within 48h of onset suggest severe pancreatitis and should prompt transfer to ITU/HDU. (mneomonic – PANCREAS) • PaO2 - <8kPa • Age - >55y • Neutrophilia – WBC >15 • Calcium - <2mmol/l • Renal function – urea >16 • Enzymes – LDH >600; AST >200 • Albumin - <32g/L (serum) • Sugar – glucose >10mmol/l ```
378
treatment of acute pancreatitis
``` NBM IV fluids to counter 3rd space losses of fluid. insert urinary catheter analgesia - pethidine IM or morphine nutrition ``` - Hourly pulse, BP and UO; daily FBC, U&E, Calcium, glucose, amylase, ABG - If worsening: ITU, oxygen if low PaO2. - In suspected abscess formation or pancreatic necrosis (on CT), consider PARENTERAL NUTRITION ± LAPAROTOMY & DEBRIDEMENT - Antibiotics may help in specific severe disease e.g. imipenem if >30% necrosis - ERCP + gallstone removal – for progressive jaundice - Repeat imaging (CT) performed in order to monitor progress
379
early complications of acute pancreatitis
``` shock ARDS renal failure DIC sepsis low calcium high glucose ```
380
late complications of acute pancreatitis
``` pancreatic necrosis pseudocyst abscess bleeding thrombosis fistulae recurrent oedematous pancreatitis ```

Finals (4 decks)

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