PBL week 2

Question 1

when do gallstone symptoms occur?

Answer 1

don’t usually cause symptoms but of they block one of the bile ducts it causes sudden severe abdominal pain = biliary colic

Question 2

biliary colic

Answer 2

severe sudden abdominal pain that lasts for 1-5 hours
pain felt in centre of abdomen just under ribs on right and spreads to side and shoulder blade
referred pain to C4 dermatome
pain is constant and not relieved by urination, defecation, vomiting or passing wind
pain can be triggered by eating fatty foods
can occur at any time of day and may cause waking during night
pain is infrequent

Question 3

other symptoms of gallstones

Answer 3

sweating 
vomiting
can cause more severe problems if block bile flow for long periods of time or move to other organs 
- pyrexia 
- more persistent pain
- tachycardia 
- jaundice
- itchy skin
- diarrhoea 
- chills/ shivering attacks 
- confusion
- loss of appetite

Question 4

causes of gallstones

Answer 4

imbalance in chemical make up of bile in gallbladder
high cholesterol in gallbladder is most common cause
bilirubin in gallbladder
these substances build-up and crystallise

Question 5

risk factors for gallstones

Answer 5

female 
overweight/ obese
>40
conditions that affect bile flow
crohn's disease 
IBS
family history
recent weight loss - dieting or surgery 
taking ceftriaxone antibiotic

Question 6

female risk factors

Answer 6

having had children
taking combined contraceptive pill
undergoing high-dose oestrogen therapy

Question 7

what conditions affect bile flow?

Answer 7

cirrhosis
primary sclerosing cholangitis
obstetric cholestasis

Question 8

diagnosis of gallstones

Answer 8

often diagnosed when looking for other conditions 
murphy's sign test 
blood tests
liver function tests
ultrasound 
MRI
cholangiography 
CT scan - looks for complications

Question 9

Murphy’s sign test

Answer 9

hands/ fingers on upper right quadrant and ask patient to breathe in
if this is painful = inflammation

Question 10

cholangiography

Answer 10

x-ray with dye in bloodstream or administered via endoscope

Question 11

when to treat gallstones?

Answer 11

depends on symptoms and if they affect quality of life
active monitoring required if asymptomatic
need treatment if patient has a condition increasing risk of developing complications - cirrhosis, portal hypertension or diabetes
needed if there are high levels of calcium in gallbladder as can cause cancer

Question 12

how to treat gallstones?

Answer 12

analgesics
healthy diet
cholecystectomy - removal of gallbladder
endoscopic retrograde cholangio-pancreatography
medication to dissolve gallstones

Question 13

cholecystectomy

Answer 13

can be laparoscopic
single incision
keyhole surgery
open surgery

Question 14

endoscopic retrograde cholangio-pancreatography

Answer 14

removal of gallstones from bile duct

Question 15

medications to dissolve gallstones

Answer 15

ursodeoxycholic acid tablets

not that effective and need to be taken for a long time

Question 16

what are the possible complications of gallstones?

Answer 16

acute pancreatitis 
acute cholecystitis 
jaundice
acute cholangitis 
gallbladder cancer 
gallstone ileus

Question 17

acute pancreatitis

Answer 17

inflammation of pancreas

Question 18

acute cholecystitis

Answer 18

inflammation of gallbladder

if bile duct becomes blocked causing a build-up of bile inside

Question 19

acute cholangitis

Answer 19

bile duct infection

Question 20

gallstone ileus

Answer 20

bowel obstruction caused by gallstones caused by fistula

Question 21

heartburn

Answer 21

burning feeling in chest caused by stomach acid travelling up to throat
when it occurs repetitively = gastro-oesophageal reflux disease
common - often no obvious reason for it

Question 22

causes/ risk factors of acid reflux

Answer 22

certain foods and drinks 
overweight
smoking
pregnancy
stress/ anxiety
some medicines - NSAIDs
hiatus hernia 
eating close to bedtime

Question 23

what foods/ drinks increase risk of acid reflux?

Answer 23

coffee
alcohol
chocolate
fatty foods
spicy foods

Question 24

hiatus hernia

Answer 24

part of stomach moves up into chest

Question 25

example of PPI

Answer 25

omeprazole

Question 26

how do PPIs work?

Answer 26

reduces stomach acid production irreversible covalently binds to H+/K+ ATPase pump blocking gastric proton pump of parietal cells proton pump is the final stage of gastric acid secretion as it secretes H+ ions into the gastric lumen given in an inactive form so can cross cell membranes into acidic environments protonated intracellularly to give active form

Question 27

Ranitidine

Answer 27

currently unavailable due to possible risk with ingredients | H2 blocker - antagonist

Question 28

how does Ranitidine work?

Answer 28

competitive, reversible inhibitor of histamine 2 receptors, preventing histamine binding at gastric parietal cells reduces H+/K+ pump action histamine normally stimulates gastric secretion decreased gastric acid secretion

Question 29

symptoms of acid reflux

Answer 29

``` heartburn unpleasant sour taste in mouth - caused by stomach acid cough recurring hiccups bad breath bloating nausea dysphagia weight loss ```

Question 30

what makes acid reflux symptoms worse?

Answer 30

after eating lying down bending over

Question 31

diagnosis of acid reflux

Answer 31

``` history generally diagnosed by symptoms and assessment of risk factors elimination of other more serious diagnoses barium swallow - oesophagram oesophageal manometry pH monitoring endoscopy biopsy x-ray with contrast gastroscopy ```

Question 32

oesophageal manometry

Answer 32

measures rhythmic muscle contractions of oesophagus during swallowing

Question 33

treatments for acid reflux

Answer 33

``` antacids PPIs H2 antagonists metoclopramide surgery to repair lower oesophageal sphincter ```

Question 34

antacids

Answer 34

``` aluminium hydroxide magnesium carbonate magnesium trisilicate magnesium hydroxide calcium carbonate sodium bicarbonate can be bought OTC ```

Question 35

PPIs

Answer 35

omeprazole | lansoprazole

Question 36

H2 antagonists

Answer 36

Ranitidine

Question 37

metoclopramide

Answer 37

empty stomach quicker

Question 38

uses/ pros of endoscopy

Answer 38

``` evaluate stomach pai evaluate ulcers, gastritis or difficulty swallowing investigate GI bleeding investigate changes in bowel habits diagnose polyps or growths in colon biopsy - prevents surgery safer minimally invasive can be used for treatments allows for descriptive and photographic description of lesions ```

Question 39

cons/ limitations of endoscopy

Answer 39

``` cannot detect functional disease cannot estimate luminal diameter invasive sedation required cannot detect disease in most small intestine cannot detect disease in deep submucosa, muscularis or serosa not appropriate for bowel perforation cannot assess or biopsy lymph nodes some risks ```

Question 40

risks of endoscopy

Answer 40

GI perforation laceration of major blood vessels or organs decreased venous return/ hypoxia if stomach overinflated bradycardia due to vasovagal reflex from over distension mucosal bleeding bacteraemia

Question 41

indigestions

Answer 41

used to describe a wide range of digestive issues | discomfort in upper abdomen

Question 42

what does indigestion cause?

Answer 42

``` heartburn feeling full or bloated nausea belching flatus bringing up food or bitter tasting fluids in mouth symptoms occur after eating or drinking ```

Question 43

causes of indigestion

Answer 43

``` overeating eating too quickly fatty/ greasy/ spicy foods smoking too much caffeine too much chocolate too many carbonated beverages anxiety certain antibiotics certain analgesics certain iron supplements ```

Question 44

what conditions cause indigestion?

Answer 44

``` gastritis peptic ulcers celiac disease gallstones constipation pancreatitis stomach cancer intestinal blockage intestinal ischaemia ```