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A2 ME3031 ALIMENTARY > W4: Upper GI Sx; Hepatobiliary Sx; Pancreatic Sx; CRC Sx; Pancreatic Disease; Liver Diseases; IBD; > Flashcards

W4: Upper GI Sx; Hepatobiliary Sx; Pancreatic Sx; CRC Sx; Pancreatic Disease; Liver Diseases; IBD; Flashcards

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1
Q

Management of upper GI disorders

A

OESOPH. CA.
endoscopy > biopsy > staging via CT

=> Ivor-Lewis Esophagectomy = gastro-oesoph anastamosis.

  • ICU post-op, wound catheter
  • Jejunostomy - tube to allow feeding during recovery
  • oesophagectomy + ChemoT / RadioT (long recovery)

GASTRIC CA.: ALARMS; late dx
endoscopy; CT staging; Laparoscopy

=> CT shrink tumour then sx intervention

  • endoscopic resection (early)
  • partial/total gastrectomy (severity based)

GORD
endoscopy; pH studies and manometry
Laparoscopic hernia repair
SFX: dysphagia, difficult in belching + vomit

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2
Q

acute/chronic pancreatitis: principles and mgmt

A
  1. ACUTE PANCREATITIS: stone (↑intraductal pressure) alcohol (ox. dmg),
    viral: CMV, Mumps
    * CT: ?necrosis and complications. monitoring
    * serum amylase

• abdo pain, collapse, nausea, pyrexic, dehydrated

=> ERCP + endoscopic sphincterotomy (w/ jaundice and cholangitis)
=> Tx of underlying acute cause

  1. CHRONIC PANCREATITIS: irreversible glandular destruction (OATIGER!)
    * alcohol+smoking (dose-related)
    * CF-CFTR mutation / SPINX1 mutation
    * Coeliac disease higher risk to chronic pancr.

• abdo pain, exocrine insufficiency (BMI, Vit D., faecal/serum elastase), endocrine insuff. (DM)
MRI; CT, EUSS

=> ENDOSCOPIC THERAPY (ERCP): panc. duct dilatation (balloon)/stend/stone removal/papillary widening

=> lateral pancreaticojejunostomy (PUESTOW): ductal stone removal & anastamoses of pancr. + jejunum allowing direct flow of juice.

=> Sx drain: panc duct sphincteroplasty

=> Whipple’s

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3
Q

pancreatic cysts: principles and mgmt

A
  • incidental CT MRI*
    rf: jaundice, dilatedmain panc. duct
  1. EPITH. NEOPLASTIC - most common
    * intraductal papillary mucinous neoplasm - main duct ca risk. 50yo+
    - abdo pain, wt loss, N&V, jaundice
    * mucinous cystic neoplasm: body & tail
    -women
    - pre-malign pot.
    * serous cystic neoplasm: anywhere
    - women
    - non-cancerous
  2. NON-EPITH. NEOPLASTIC
    * pseudocyst

=> MDt referral

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4
Q

Pancreatic cancer: principles & mgmt

A

EUSS + biopsy. ↑Bilirubin,

=> EUS guided coeliac plexus block + NEUROLYSIS (supportive for unresectable)

=> ERCP + Metal stent

=> Radio Ablation: improves stent potency and increases survival

=> Palliative bypass / duodenal stent (duodenal obstruction)

*CA19-9 tum marker much better for tx response

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5
Q

Peritonitis: principles & mgmt

A

SYSTEMIC

FNA: culture and cell count etc.

=> Vancomycin (+ve)
=> Ciprofloxacin / Gentamicin (-ve)

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6
Q

Sx complications of chron. pancreatitis

A 
p duct stenosis
cyst
bil. tract obstr.
splenic vein thrombosis / gastric varices
portal vein compression
duodenal stenosis
colonic stricture
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7
Q

Describe the common surgical management of Gall bladder disease gallstones

A

Non-Sx:
=> dissolution via oxycolic acid
=> Lithotripsy via high energy shock waves

Sx
=> Laparoscopic cholecystectomy
=> Open cholecystectomy | CI: infection risk
=> Mini cholecystectomy
=> single port
=> cholecystectomy: perforated (or risk) GB

Sx for common bile duct stone causing jaundice
=> * Lap. trans-cystic cbd exploration *
=> Lap. exploration of CBD (removal of stone + GB)
=> ERCP: retrieval

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8
Q

Describe the common surgical management of benign biliary tract disease

A
  1. 1º SCLEROSING CHOLANGITIS (inflamm of CBD + strictures. auIm)
    => Biothinning | Oxycolic Acid
  2. Biliary Atresia
    => reconstruction + transplant
  3. Choledochal Cysts
    => dilatation of bile duct
  4. Biliary-Enteric Fistula (septic + biliary obstruction)
    Gallstone ileus => Sx
    Cholecystal duodenal fistula =>
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9
Q

Describe the common surgical management of jaundice due to malignant tumours

A 
1. Cholangiocarcinoma
=> Mainly palliative d/t 10% being surgically resectable
Sx bypass
Stenting: ERCP or PTC
RT
ChemoT
Photodynamic Tx
Liver transplant
  1. GB Ca.
    => Radical Cholecystectomy
  2. Ampullary Tumours
    => Pancreatico-duodenectomy
    => Endoscopic excision / Trans-duod. excision
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10
Q

Choledocholithiasis

A

Gallstones in common bile duct (vs cholelithiasis); incidental
1º - de novo; 2º jumped

  • ascending cholangitis: jaundice, pyrexia pain++, rigors
  • acute pancreatitis. obstructive jaundice
  • post cholecystectomy
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11
Q

Gallstones: RF, presentation, dx

A

RF: F>M; cholesterol!; haemolytic anemias + bile infection

asymptomatic
vs
• dyspepsia (flatulence); colic
• acute cholecystisis (GB inflamm d/t cystic duct block)
- neutrophillia, temp, ↑CRP, LFT (ALT+AST)
• mirizzi syndrome

dx: LFT: ASP; ALT; ALP

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12
Q

Define the types of jaundice, differential diagnosis of intra and extra hepatic jaundice

A
  1. PREHEPATIC: unconjugated bil in urine
    haemolytic nature | anemia; alcoholic jaundice
  2. HEPATIC: conjugated, coloured urine
    decompensation d/t cholestatic nature | spider naevi gynaecomastia ascites
    IVDU, drugs

1º biliary cholangitis > cirrhosis: ↑ALP, AuIm: bile ducts aetiology

  1. POST-HEPATIC: conjugated. pale poo.
    downstream blockage: cholelithiasis, CBD, extrahep bd obstruction: strictures, tumours
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13
Q

Interpret liver function tests

A

BILIRUBIN: bound to albumin and becomes soluble and conjugated.

AMINOTRANSFERASE: ALT:AST
=> ALD. Hepatocellular injury

GAMMA GT:
=>ALP + GGT = Liver source
=> Alcohol + NSAIDS

ALKALINE PHOSPHATASE (ALP): (bone; placenta; intestine)
=> bile duct obstructions

ALBUMIN: marker of synth. function
↓[ ] = chronic liver disease

PROTHOMRBIN TIME: scoring and transplant suitability

CREATININE: kidney funct. + transplant suitability

PLATELET: indirect marker of portal HT
thrombopoeitin
=> cirrhosis = splenomegaly

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14
Q

Chronic Liver Disease

A

↑lumen blood resistance w/ lymphocyte infiltration, ECM proteins, apoptotic hepatocyte.
activated kupffer cells + hepatic stellate

d/t: alcohol, AuImm., Haemochromatosis - Fe overload, Viral

Compensated CLD: routinely dilatated on screening + abn LFT

Decompensated CLD: Ascites; variceal bleeding; hepatic enceph (toxin/ammonia build-up

Hepatocellular Carcinoma: ↑risk w/ CLD

Ascites: complication of compensated.

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15
Q

Chronic Liver Disease Tx

A

=> Diuretics

=> Large volume paracentesis

=> TIPS: shunt ↓portal pressure

=> Aquaretics

=> Liver trnasplant

=> Laxatives, Neomycin (Hepatic Encephalopathy

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16
Q

Variceal Haemorrhage

A

Portal HT; blockages therefore porto-systemic anastamoses medical emergency

=> transfusion
=> endoscopic band ligation
+terapressin
+ TIPPS

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17
Q

Hepatocellular Carcinoma (Dx and Mgmt)

A

AFp tumour marker
USS, CT, MRI

=> resection
=> transplant lobule
=> ChemoT: Sorafenib TK inhibitor; Tamoxifen
=> Local. Ablative Tx: Alcohol injection / RadioT

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18
Q

Spontaneous Bacterial Peritonitis: What is it? And Mgmt

A

infection of ascitic fluid / endstage liver failure / sx cause

=> Ascitic Tap: [neutrophil] > [protein]
=> IV abx + IV albumin infusion

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19
Q

Alcoholic Hepatitis Mgmt

A

=> fluid resus, infection prophylaxis
=> BENZODIAZIPINE (alcohol withdrawal)
=> PPI (GI bleeds risk)

SEVERE (Glasgow Alcoholic Hep. Score >9)
=> PREDNISOLONE
=> Oral Steroids
=> Nutrition: *THIAMINE* B12 def.
?NG tube
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20
Q

Non-Alcohol Fatty Liver Disease

A

Steatosis => Steatohepatitis d/t obesity, DM, hypercholesterol., Alcohol

  • FIB-4 score
  • ↑↑AAT

=>Lifestyle mods
=> Metformin
=> Glucagon-like Peptide analogues
=> Vit E.

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21
Q

Viral Hepatitis

A

IgM: Active; IgG: Past; ALT

Hep A = Enteric; self-limiting acute

  • Children
  • ALT
  • Faeco-oral, sexual, blood

Hep B = Parenteral. Acute self-resolve, Chronic complication

Hep C = Chronic complications only presentation
HIV + alcohol factors

=> PEGYLATED INTERFERON
=> ORAL ANTIVIRALS: TENOFIVIR

Hep D = resistant

Hep E = Fulimant Hep failure in pregnancy. Self-limiting.

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22
Q

Autoimmune Hepatitis

A

1) AuImm Hep: women. normal LFTs
Abn ANA; SMA | LIVER BIOPSY
=> steroids and long-term azathioprine

2) 1º biliary Cholangitis: female. ↑IgM and antimitochondria Ab
* pruritus + fatigue

=> UCDA

3) 1º Sclerosing Cholangitis: Male. pANCA Ab.
MRCP/MRI
=> Liver transplant + Biliary stents

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23
Q

Liver transplantation Scoring

A

Childs scoring
MELD
UKELD

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24
Q

Contraindications for liver transplantation

A 
extrahepatic mets.
vascular involvement
substance/alcohol abuse
psychological
brain death
active extra hepatic infection
cardiopulm. comorbidities
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25
State the common disorders affecting the small intestine with particular reference to malabsorption and the principles of their investigation and management
Nutritional DEFICIENCIES INFECTION: Tropical sprue = folate def.; HIV Giardia parasite = villous atrophy => metronidazole INFLAMM = MALABS. * Coeliac: IgA, distal duodenal biopsy inflamm d/t tissue transglutaminase, lymphocytic, ANTI-GLIADIN in children + Dermatitis herpenformis; AuImm Thyroid/Hepatitis/Gastritis, DM, PBC., Sjorgens, Downs
26
SIBO - Bacterial overgrowth: diagnosis + mgmt
Malabsorption = GI symptoms, osteomalacia * H2 breath test, imaging of duodenal diverticulum * *culture of s. bowel aspirate** ``` => Abx rotation 2w each: - metronidazole - teracycline -amox. + vitamin and nutritional suppl. ```
27
Describe the signs of specific vitamin deficiencies
Vitamin C: scuvy Ca2+, Mg2+, D: osteomalacia, tetany B12: memory, dementia, niacin: dermatitis Vitamin K: increased PT Vitamin A: night blindness
28
Define functional bowel disorders
nil detectable pathology; abdn gut function diagnosed via history+examination. often good prognosis but significant effect on QoL: e.g. abdo pain, altered habit, abdo bloating, constipation (IBS) * WHOLE TRACT * PSYCHOOGICAL FACTORS
29
IBS (what?, investigations & mgmt options)
changes is normal function * SIGMOIDOSCOPY* * COLONOSCOPY* - FIT testing: Hb in stool - Stool culture - Calprotectin: inflamm marker and IBD (raised) ``` => education => dietetic review => FODMAP => anti-spasmodics (pain) => probiotics, linaeloride (bloating) => laxatives => antimotility (diarrhoea) ```
30
IBS critetia
ROME: abdo pain 3d+/3mos => improved w/ poop NICE: "" +abdo bloat, exacerbate w/ eating
31
Non-ulcer Dyspepsia
multi-association, dyspeptic pain H pylori Vs Uknown => eradication tx Vs Symptomatic treatment
32
IBD presentation and pathogen.
chronic relapsing/remitting inflamm * dysbiosius * genetic susceptibility (SNP=NOD2); environment; smoking
33
ULVERATIVE COLITIS
young,rectum to proximal colon +extracolonic: erythema nodosum, uveitis, pyoderma gangrenosum * ↓goblet * crypt abscess + limited to mucosal inflamm * faec.calp. significantly raised in UC * ENDOSCOPY*; pseudopolyps ``` proctitis proctosigmoiditis l-sided colitis extensive colitis pancolitis ``` >bleeding, bowel perforation, toxic megacolon, malnutrition, DVT, CRC (∴ surveillance in LT UC)
34
ACUTE SEVERE COLITIS
4 stool cultures, cessation of NSAIDS, opiates, antidiarrhoeals, anticholinergics => IV glucocorticosteroids => IV hydration K/Mg => LMWH (thromboembolism risk in mucosal inflammatory diseases)
35
CROHN'S DISEASE
mouth ulcers, dysphagia, abdo pain, malaena !smoking RF * ENDOSCOPY* + CT/MRI complications * GRANULOMA; transmural inflamm * SKIP LESIONS > LT: strictures, penetrating disease >colonic carcinoma risk
36
MICROSCOPIC COLITIS
-collagenous colitis - lymphocytic colitis => AuIm: RA, CD, Thyroid => STEROIDS: budesonide
37
Truelove + Witts Criteria
GRADING OF UC Mild: Moderate: CRP+ Severe: ESR++ + CRP ++ +temp; tachyl anemia Fulminant: cont. bleeding; abdo tend/distension; colonic dilatation
38
uc mgmt
(1) AMNOSALICYLCATES: induction and maintenance of remission +CORTICOSTEROIDS: induction of remission in relapse (!sfx) OR THIOPURINES: maintenance, but monitoring (lymphoma risk) (2) BIOLOGICS - !demyelination; (3) subtotal colectomy: rectal preservation; stoma (ileostomy)
39
cd mgmt
(1) STEROIDS induce remission + THIOPRINE maintenance (azathiprine or methotrexate) (2) Sx for distal ileum scenario or for complications: strictures and fistulas - drain and seton stitch - perianal CD + abx
40
Describe the Aetiology and presentation of colon cancer
RF: sporadic in male, low fibre, high meat, sedentary; underlying IBD, HNPCC FAP,*POLYPS* * rectal bleed * bowel habit * anaemia * mass * chronic obstruction * systemic symptoms
41
Describe the role of screening as applied to colon cancer
50-70y/o: FOBT every 2yr; +ve = colonoscopy =>FIT test * sigmoidoscopy * detection pre-malignant adenomas
42
Describe the staging, treatment and prognosis of colorectal cancer
STAGING via CT, MRI, PET, rectal endo USS ``` DUKES STAGING: A - mucosa B - muscularis invasion C - muscularis + lymph node invasion D - distant mets ``` ``` => Sx resection => endoscopic resection => Adjuvant - Dukes C+B => RT and ChemoT => Laparoscopic ```
43
Describe the management of colorectal cancer
PRE-OPT: surgical excision + chemo to shrink; MRI vis. *Faecal diversion = STOMA ileostomy vs colostomy * Faecal mesorectal excision; often IMA affected = C2,C3,C4 parasymp = CONTINENCE POST-OP: vascular invasion, perineural invasion
44
Describe the presentation of colorectal cancer
rectal bleeding, !!6weeks symptomatic | = colonscopy + biopsy
45
Describe the aetiology, presentation and management of intestinal obstruction
Abdo pain +/-vomit, absolute constipation, abdo distension >FLUID RESUS > otherwise conservative, based on aetiology > Sx for CLOSED LOOP OBSTRUCTION
46
Give an account of common anorectal conditions and their management.
chronic constipation faecal incontinence HAEMORRHOIDS: bleed on straining; tissue hyperplasia =>rubber band ligation => HALO (ligation+USS) => Haemorroidectomy FISSURES: pain++ d/t conspitation/hard faeces; !anal cancer *flexible sigmoidoscopy => GTN ointment - diltiazem: HypoT headache => Botox; Spincterotomy PERIANAL ABSCESS: RF-DM, BMI, imm suppr. trauma; pain+++ ?sepsis =>abx =>incision+drain >ANOFISTULA ABSCESS: abn comm.; pus discharge =>seton drain =>sphincter preservation; incontinence risk
47
ANORECTAL CANCER
Fit +ve
48
Describe how colorectal imaging can be used in the diagnosis of common anorectal conditions
COLONIC TRANSIT STUDIES: constpiation ANORECTAL MANOMETRY: sphincter function; pressure; length
49
recognise symptoms of a flare of IBD
bowel movements+++ presence of blood increasing nil pyrexia until SEVERE + tachy + anemic + ESR 30+
50
IBD :complete appropriate assessment and investigations
=>steroids: induce remission +Vit D/calcium blood tests: CRP + stool cultures (infective risk – c difficile) abdo xr
51
inflammatory markers sig. in IBD
``` Inflammatory markers in a flare of IBD often reveal a high CRP high platelets high WCC low albumin and anaemia ```
52
complete appropriate investigations and mgmt of IBD flareup
blood tests: CRP + stool cultures (infective risk – c difficile) abdo xr =>steroids: induce remission +Vit D/calcium
53
consider appropriate therapy as per severity of clinical presentation for IBD exacerbation + assessment of severity of exacerbation
TRUELOVE-WITTS SEVERE EXCABERATION: admit, (1) => IV steroids + LWMH (2) => Infliximab +colectomy TOXIC MEGACOLON: axr, descending if distended 5cm+, systemically unwell => colectomy + ileostomy formation
54
recognise complications of IBD flareup
toxic megacolon perforation abscess infection
55
Traveller's diarrhoea
Enterotoxigenic E.coli most commonly causes Traveller's diarrhoea
56
Which antibiotics have a high risk for causing C. diff infection?
CCCC ciprofloxacin ceftriaxone clarithromycin co-amoxiclav ∴ => oral metronidazole or vancomycin
57
the viruses that commonly cause diarrhoea and outline their epidemiology
ROTAVIRUS: children <5 *PCR GIARDIA LAMBLIA: contamianted water supplies *microscopy NOROVIRUS: hospital and carehomes *PCR ENTAMOEBA HISTOLYTICA: foreign travel poor hygiene * dysentry; amoebic liver cysts * microscopy
58
Mgmt of diarrhoeal illness
=> rehydration => abx in dystentry, c diff., and imm suppr only
59
Pathogen most associated with chicken
Campylobacter spp. = diarrhoea with severe abdominal cramps. *Stool cultures => rehydration
60
Diarrhoea associated with rural/agri exposure
E. coli O157 > haemolyric uraemic syndrome => abx+IV fluids

A2 ME3031 ALIMENTARY (7 decks)

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