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Sharon's phase 3b/4 > GI/hepatobiliary > Flashcards

GI/hepatobiliary Flashcards

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1
Q

Pancreatitis

A

Inflammation of the pancreatitis
- Acute: rapid onset, function returns after
- Chronic - longer-term inflammation and symptoms, progressive, permenant deterioration in function

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2
Q

Causes of pancreatitis

A

Key causes:
- Gallstones
- Alcohol
- Post-ERCP (endoscopic retrograde cholangiopancreatography)

I GET SMASHED mnemonic: Idiopathic, Gallstones, Ethanol, Trauma, Steriods, Mumps, Autoimmune, Scorpion sting, Hyperlipidaemia, ERCP, Drugs (furosemide, thiazide diuretics and azathioprine)

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3
Q

Presentation of pancreatitis

A

Acute: clinical dx with presentation + amylase levels

  • Severe epigastric pain
  • Radiating through to the back
  • Associated vomiting
  • Abdominal tenderness
  • Systemically unwell (e.g., low-grade fever and tachycardia)

Chronic = similar symptoms but longer period of onset

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4
Q

Investigations for acute pancreatitis

A

Ix for acute abdomen: FBC (WCC), U+Es (urea), LFTs (transaminases and albumin), Calcium, ABG (PaO2 and BM)

  • Amylase = raised x3
  • Lipase = more senesitive + specific
  • CRP
  • USS if gallstones suspected
  • CT abdo if complications suspected+

+ Necrosis, abscesses, fluid collection

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5
Q

Glasgow Score for severity of pancreatitis

A

PANCREAS mnemonic:

  • P – Pa02 < 8 KPa
  • A – Age > 55
  • N – Neutrophils (WBC > 15)
  • C – Calcium < 2
  • R – uRea >16
  • E – Enzymes (LDH > 600 or AST/ALT >200)
  • A – Albumin < 32
  • S – Sugar (Glucose >10)

0/1 = mild
2 = moderate
3 or more = severe

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6
Q

Management of acute pancreatitis

A
  • Admit for supportive mx, moderate/severe = HDU/ICU
  • ABCDE + aggressive fluid resus
  • IV fluids
  • Analgesia
  • Oral/parenteral nutrition
  • Careful monitoring
  • Gallstone tx (ERCP/cholecystectomy)
  • Abx if infection
  • Complications tx

Should improve in a week

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7
Q

Chronic pancreatitis

A

Alcohol is common cause, fibrosis adn reduced function

Key complications:
- Chronic epigastric pain
- Loss of exocrine (pancreatic enzymes) and endocrine (insulin) function
- Damage + strictures = obstruction of pancreatic juice and bile
- Pseudocysts and abscesses

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8
Q

Management of chronic pancreatitis

A
  • Stop alcohol and smoking
  • Analgesia
  • Creon (replacement pancreatic enzymes)
  • SC insulin reigme if diabetes
  • ERCP with stenting if strictures and obstruction
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9
Q

Bowel cancer (colorectal)

A

4th most common cancer in UK (after breast, prostate and lung)

Risk factors
- FHx
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC) i.e. Lynch syndrome
- IBD
- Increased age
- Diet high in processed meat and low in fibre
- Obesity and sedentary lifestyle
- Smoking
- Alcohol

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10
Q

Presentation of bowel cancer

A

Red flags:
- Change in bowel habit
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdo pain
- Iron-deficency anaemia (IDA)
- Abdo/rectal mass

2WW criteria
- > 40 with abdo pain + unexplained weight loss
- > 50 with rectal bleeding
- > 60 with change in bowel habit or IDA

Unexplained IDA is indication for 2WW referral for colonscopy/gastroscopy for GI malignancy

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11
Q

Screening and investigation for bowel cancer

A
  • Faecal immunochemical test (FIT)- looks for human haemoglobin in stool
  • Screening for 60 - 74 y/o every 2 years
  • Colonscopy is gold standard Ix, suspicious lesions are biopsied
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12
Q

TNM classification of bowel cancer

Tumour, Node, Metastasis

A

Tumour:
- Tx - unable to assess size
- T1 - submucosa
- T2: spread to muscularis propria (muscle)
- T3: Subserosa and serosa (outer later)
- T4: Serosa (4a), other tissues/organs (4b)

NX - unable to assess nodes
N0 - no nodal spread
N1: 1 - 3 nodes
N2: > 3 nodes

M0 - no metastasis
M1 - metastasis

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13
Q

Management of bowel cancer

A
  • MDT: surgeons, oncologists, radiologists, histopathologists, specialist nurses
  • Surgical resection
  • Chemo
  • Radioherapy
  • Palliative care

Follow-up for a period of time e.g. 3 years:

  • Serum carcinoembryonic antigen (CEA)
  • CT thorax, abdomen and pelvis
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14
Q

Alcoholic-related liver disease

A

Stages
1. Alcoholic fatty liver (hepatitic steatosis) - buildup of fat, reversible with abstinence
2. Alcoholic hepatitis - long-term alcohol use = liver cell inflammation, mild is reversible with abstinence
3. Cirrhosis - scar tissue replaces functional liver tissue, irreversible

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15
Q

Complications of alcohol

A
  • Alcohol-related liver disease
  • Cirrhosis and its complications (e.g., hepatocellular carcinoma)
  • Alcohol dependence and withdrawal
  • ↑ CVD risk
  • Wernicke-Korsakoff syndrome (WKS)
  • Pancreatitis
  • Alcoholic cardiomyopathy
  • Alcoholic myopathy, with proximal muscle wasting and weakness
  • ↑ cancer risk, particularly breast, mouth and throat cancer
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16
Q

Investigations for alcohol-related liver disease

A
  • ↑MCV
  • ↑ALT and AST
  • AST:ALT ratio above 1.5
  • ↑ GGT
  • ↑ ALP late stage
  • ↑ bilirubin in cirrhosis
  • ↑ prothrombin time
  • ↓albumin
  • Liver USS = fatty changes “increased echogenicity”, cirrhotic changes
  • Fibroscan for fibrosis degree
  • Endoscopy to assess and treat oesophageal varice if portal HTN
  • Diagnostic = liver bopsy
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17
Q

Management of alcohol-related liver disease

A
  • Stop drinking
  • Detox reigme
  • Referal to drugs and alcohol services
  • Psychological interventions (motivational interviewing, CBT)
  • Thiamine and high-protein diet
  • Corticosteroids short-term for inflammation
  • Tx complications of cirrhosis - portal HTN, vrices, ascites and hepatocellular carcinoma
  • Liver transplant (at least 6m abstinence)
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18
Q

Anal fissure

A

Longitudinal/elliptical tears of the squamous lining of the distal anal canal

RFs: constipation, IBD, STI e.g. HIV/syphilis

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19
Q

Clinical features of anal fissures

A
  • Painful, bright red, rectal bleeding
  • 90% on posterior midline
  • If other locations, consider alternative dx e.g. Crohn’s
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20
Q

Management of anal fissure

A

Acute (1w)
- Soften stool - fibre,fluid, bulk-forming laxatives (e.g. ispaghula husk) 1st line
- Lubricants e.g. petroleum jelly
- Topical anaesthetics
- Analgesia

Chronic
- As above
- 1st line - topical glyceryl trinitrate

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21
Q

Appendicitis

A

Inflammation of appendix, a long thin tube arising from caecum, pathogens can get trapped > infection + inflammation > gangrene and rupture

Peak 10 to 20 years old

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22
Q

Clinical features of appendicitis

A

CLassic:
- Central abdo pain than moves and localises to RIF
- Tenderness on palpation at McBurney’s point
- Anorexia
- N+V
- Fever
- Rovsing’s sign (palpation of LIF = pain in RIF)
- Guarding on abdo palpation
- Rebound tenderness in RIF (↑pain on releasing deep palpation) + Percussion tenderness = peritonitis = rupture

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23
Q

Diagnosis of appendicitis

A
  • Clinical presentation and raised inflammatory markers
  • Diagnostic = CT
  • Key ddx: ectopic pregnancy (hCG), ovarian cysts (pelvic and iliac fossa pain if rupture or torsion)

If woman of child-bearing age, assume pregnant until proven otherwise with test

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24
Q

Management of appendicitis

A
  • Emergency admission under sugical team
  • Laparoscopic/open appendicetomy
  • Complication: bleeding, infection, damage to bowel, bladder, other organs, removal of normal appendix, VTE
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25
Ascites
Abnormal accumulation of fluid in abdomen Causes either serum-ascites ablumin gradient (SAAG) <11g/L or >11g/L SAAG = Serum album conc - ascitic fluid album conc
26
Management of ascites
- Reduce sodium intake - Fluid restriction - Aldosterone antagonist e.g. spirolactone - Drainage (abdo paracentesis) - Prohylactic abx - oral ciprofloxacin if ascitic protein 15g/L or less - Transjungular intrahepatic portosystemic shunt (TIPS) in some pts
27
Acute cholangitis
Infection + inflammation in the bile ducts Surgical emergency and high mortality (sepsis and septicaemia) Causes: obstruction (gallstones in common bile duct), infection from ERCP E.coli, Klebsiella species, Enterococcus species
28
Presentation of acute cholangitis
Charcot's Triad - RUQ - Fever - Jaundice (raised bilirubin)
29
Management of acute cholangitis
- Emergency admission Sepsis and acute abdomen mx: - Nil by mouth - IV fluids - Blood cultures - IV abx (local guideline) - Seniors, HDU, ICU Diagnostic for common bile duct stones and cholangitis (least to most sensitive): - Abdo USS - CT - MRCP - Endoscopic USS
30
Tx acute cholangitis
Endoscopic retrograde cholangio-pancreatography - removes stones blocking bile duct
31
Acute cholecystitis
Blockage of cystic duct, no bile drainage > inflammation of gallbladder Gallstones in gallbladder neck or cystic duct
32
Presentation of acute cholecystitis
- RUQ pain +/- radiation to right shoulder - Other: fever, N+V, tachycardia, tachypnoea, RUQ tendernesss, Murphy's sign, raised inflammatory markers and WCC ## Footnote Murphy's sign - hand on RUQ, deep breath, stop inspiration due to pain = positive
33
Investigations + management for acute cholecystitis
1st line: abdo USS gallstone - thickened wall, stones/sludge, fluid around Mx: emergency admission, NBM, IV fluids, abx (local guidelines), NG tube if vomit ERCP = remove stones in common bile duct Cholecystectomy
34
Complications of acute cholecystitis
- Sepsis - Gangrene - Perforation - Gallbaldder empyema (infection and pus in gallbladder), mx: IV abx and cholecystectomy OR cholecystostomy (drain infected content from gallbaldder)
35
Liver Cirrhosis
Chronic inflammation and damage to liver cells Functional liver cells > fibrosis (scar tissue) as nodules > increased resistance in vessels leading to liver (portal hypertension)
36
Causes of liver cirrhosis
- Alcohol-related liver disease - NAFLD/MASLD - Hep B/C
37
Liver cirrhosis examination findings
- Cachexia - Jaundice - Hepatomegaly - Small nodular liver (late) - Splenomegaly (portal hypertension) - Spider naevi - Palmar erythema - Gynaecomastia and testicular atrophy (endocrine dysfunction) Bruising - Excoriations - Ascites - Caput medusae Leukonychia (white fingernails) associated with hypoalbuminaemia Asterixis (“flapping tremor”) in decompensated liver disease
38
Investigations for liver cirrhosis
- Bloods: LFTs, maybe normal in cirrhosis, deranged in decompensated cirrhosis: - ↑ bilirubin, ↑ALT, ↑AST, ↑ALP - Low albumin - Increased PTT - Thrombocytopenia (advanced) - Urea + creatinine deranged in hepatorenal syndrome - AFP marker in hepatorenal syndrome - Enhanced liver fibrosis (ELF) blood test = 1st line in NAFLD ( ≥ 10.51 = advanced) - Transient elastography (fibroscan) = stiffness of liver
39
What investigation is used to diagnose NAFLD?
Ultrasound (exclude other causes), fatty changes = increased echogenicity Also screens for hepatocellular carcinoma (with AFP blood test)
40
Management of liver cirrhosis
- Stop alcohol, lifestlye for NAFLD, antivirals hep C - Malnurtition - dietician, regular meals, high protein + calories, reduced sodium, avoid alcohol - Monitor complications: MELD score (6-monthly), USS + AFP (6-monthly), endoscopy oesophageal varices (3-yearly) - Liver transplant (AHOY) ## Footnote AHOY - Ascites, Hepatic encephalopathy, Oesophageal varice bleeding, Yellow
41
Liver cirrhosis: ascites
Fluid in peritoneal cavity from increased portal pressure = leaky cappillaries and abdo organs into peritoneal cavity Fluid loss = reduced BP, kidneys activate renin-angiostensin-aldosterone system > fluid and sodium rentention Management: low sodium, aldosterone anatogonists (spironolactone), paracentesis, prophylactic abx (ciprofloxacin) < 15g/L protein
42
Liver cirrhosis: spontaneous bacterial perionitis (SBP)
- Complication of ascites - 10-20% - Idiopathic infection of ascitic fluid + peritoneal lining - E.coli or Klebsiella pneumoniae - Asymptomatic or fever, abdo pain, raised WBC/CRP, ileus, hypotension - Mx: diagnostic ascitic tap, IV abx e.g. piperacillin with tazobactam
43
Liver cirrhosis: hepatic encephalopathy
Build-up of neurotoxins affecting brain Ammonia produced by intestinal bacteria as protein waste product, liver impirment and collateral vessels between portal and systemic circulation = ammonia build-up in blood Acute = reuced conciousness + confusion Chronic: personality, memory and mood changes Mx: lactulose + rifaximin (reduced intestinal bacteria, poor GI absorption)
44
Coeliac Disease
Autoimmune diease triggered by gluten. Autoantibodies to gluten, target small intestine epithelial cells > inflammation - Anti-tissue transglutaminase (anti-TTG) - Anti-endomysial antibodies (anti-EMA) New T1DM and autoimmune thyroid = screen for coeliac disease
45
Clinical features of coeliac disease
Often asymptomatic and under-diagnosed - Failure to thrive - Diarrhoea - Bloating - Fatigue - Weight loss - Mouth ulcers - Dermatitis herpetiformis (itchy, blistering rash) - Anaemia (iron, B12, folate) - Neuro: peripheral neuropathy, cerebellar ataxia, epilepsy
46
Diagnosis + management of coeliac disease
Continue gluten 1st line bloods: total immunoglobulin A and anti-TTG 2nd line: anti-EMA IgG if IgA deficiency Diagnostic: endoscopy + jejunal biopsy Mx: life-long gluten-free diet
47
Complications of coeliac disease
If gluten eaten: - Anaemia - Osteoporosis - Hyposplenism - Ulcerative jejunitis - Emteropathy-associated T-cell lymphoma (EATL) - Non-Hodgkin lymphoma - Small bowel adenocarcinoma
48
Diverticular diease
Diverticulum = pouch/pocket in bowel wall Diverticulosis = presence of diverticula Diverticulitis = inflammation + infection of diverticula
49
Diagnosis + management of diverticulosis
- Sigmoid colon most common - RFs: age, low fibre, obseity, NSAIDs (↑ haemorrhage) - Incidental on colonscopy/CT scans - Mx: increase fibre, bulk-forming laxatives (ispaghula husk), avoid stimulant laxatives (senna)
50
Acute diverticulitis
Inflammation in diverticula - Pain and tenderness in LIF - Fever - Diarrhoea - N+V - Rectal bleeding - Raised CRP + WCC
51
Management of acute diverticulitis
Uncomplicated = primary with oral co-amoxiclav (5d), analgesia, only clear liquids, FU in 2d Severe/complications = hospital - NBM, IV abx, fluids, analgesia, urgent CT, urgent surgery if complications Complications: perforation, peritonitis, sepsis, large haemorrhage, ileus/obstruction | Avoid NSAIDs and opiates
52
Gallstones and biliary colic
Small stones in gallbladder, mostly cholesterol from concentrated bile Biliary colic: intermittent RUQ/epigastric pain, gallstones irriatate bile ducts 4RFs: Fat, Fair, Female, Forty
53
Clinical features of cholelithiasis (gallstones)
Biliary colic - stones temporarily obstructing drainage by blocking gallbladder neck or cystic duct Fat = cholecytokinin (CCK) secretion from duodenum > gallbladder contraction > biliary colic 30 mins - 8hrs Or complication: - Acutte cholecystitis/cholangitis - Obstructive jaundice - Pancreatitis
54
Investigations for cholethialisis (gallstones)
LFTs suggestive of biliary obstruction - ↑ bilirubin, obstructive picture (dark urine, pale stool) - ↑ ALP (non-specific marker) + RUQ pain +/- jaundice - Slight ↑ALT + AST 1st line imaging: ultrasound if symptomatic gallstones suspected ## Footnote CT not useful, more for ddx pancretic head CA, complications e.g. perforation/abscesses
55
Management of gallstones
- Asymptomatic = conservative - Symptomatic/complications = cholecytectomy, usually laparoscopic
56
Gastric cancer
- 2% in developed countries, >75yo, male (2x) - MC Adenocarcinoma, glandular epithelium of stomach lining Risk factors - H.pylori (mucosal inflammation > metaplasia > dysplasia) - Pernicious anaemia - Salt + preserved foods - Japanese/Chinese - Smoking
57
Clinical features of gastric cancer
- Epigastric pain, unexplained dyspepia - Weight loss + anorexia - N+V - Dysphagia if proximal - Lymphatic spread: left supraclavicular lymphodenopathy (Virchow's node)
58
Investigations for gastric cancer
- Diagnostic: OGD + biopsy - Signet ring cells - CT TAP for met. disease
59
Management of gastric cancer
Surgery depends on extent and location - Endoscopic mucosal resection - Partial gastrectomy - Total gastrectomy - Chemotherapy
60
GI perforation
Hole in GI tract (stomach, small/large bowel or rectum) > leak into abdominal cavity > peritonitis Caused by appendicitis, diverticulitis, peptic ulcers, Crohn's Feaurres: severe abdo pain, sepsis, acute abdo (pain requring emergency dx + tx) Ix: CXR or CT = free air under diaphragm Mx: surgery + broad-spectrum abx
61

Sharon's phase 3b/4 (15 decks)

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