(1) Flashcards
History:
Lower GI symptoms - 4 domains
Upper GI symptoms - 5 domains
Systemic symptoms - 5
Systemic symptom for cholestasis
Systemic symptom for encephalopathy
Stool - D/C, Melaena, Steathorrhoea
PR bleeding
Abdo pain
Bloating/abdominal distention
Jaundice (Could also have itch) Ulcers N&V - VCC - Haematemesis Reflux Dysphagia/Odynophagia
Anorexia Weight loss (malignancy/malabsorption) Nausea Fatigue Fever
Pruritus
Confusion
History:
Abdominal pain locations:
What do the following pain locations suggest the differential is:
RIF - 3 LIF - 2 Epi - 2 RUQ - 2 Flank pain - 2 Suprapubic
RIF pain (appendicitis, Crohn’s disease, ectopic pregnancy)
LIF (diverticulitis, ectopic pregnancy)
Epigastric (oesophagitis and gastritis)
RUQ pain (cholecystitis and hepatitis)
Flank pain (renal colic and pyelonephritis)
Suprapubic pain (urinary tract infection)
History:
Travel history:
What to ask about? - 4
Area of travel: note areas with a high prevalence of specific diseases (e.g. malaria, campylobacter, shigella, giardia).
Diet: ask the patient if they recently ate any high-risk food in these areas (e.g. salmonella).
Insect bites: ask if the patient noticed any insect bites (e.g. mosquito bites preceding malarial symptoms).
Contact with contaminated water: ask the patient if they ingested water which may have been contaminated (e.g. swimming in contaminated water).
History:
PMH - What should you not forget to ask about?
DHx - GI side effects of the following meds:
- Aspirin
- Nsaids
- St john’s wart
- Opiates - 2
- Penicillin
- Ondansetron
SHx:
- Risk of smoking - 2
- Risk of alcohol - 2
- Risk of IVDU
- ASK ABOUT DIET!!!!!!!!!!!!!!!!!
Procedures such as endoscopy and colonoscopy
A - worsen GI bleeding
N - gastric/duodenal ulcer
JW - can alter clearance of prescribed meds
O - constipation, nausea
P - hepatitis
O - constipation
GI malignancy (oesophageal and oral cancers) + Crohn’s Disease
GI malignancy (oesophageal and oral cancers) + hepatitis/cirrhosis
Hep B
Examination:
What do the following indicate (also what are they called):
- Clubbing - 3
- White area on nails
- Spoon shaped nails
Signs of CLD from hands? - 2
Flapping tremor? - 2
Spider naevi?
Eyes:
- 2 main things to look for?
- Hyperlipidaemia - 2
- Wilsons - 1
Mouth:
- Low iron - 1
- Low B12
DONT FORGET LYMPH NODES
ALD - raised oestrogen - SPECIFICALLY ALCOHOL (>3)
IBD
Cirrhosis
Coeliac
Leukonychia - low albumin
Koilonychia - iron
Palmar erythema
Dupuytren’s contracture
Hepatic encephalopathy
Hypercapnia
Jaundice + anaemia
Xanthelasma + Corneal arcus
Angular stomatitis
Atrophic glossitis
Examination:
Caput medusae?
Palpation:
- Hepatomegaly - 3
- Splenomegaly - 2
- Tender kidneys - 2
- Palpable kidneys - 1
- How would you know it is a AAA?
Percussion:
- Why percuss?
Auscultation - where do you listen for the following:
- AAA
- Renal arteries
What do they following suggest?
- No BS - 2
- Tinkling/high pitched BS
What 4(men)/5(women) exams do you say you will order or do after the examination?
Pulsatile, EXPANSILE mass
Dilation of epigastric vein
Portal HTN
Liver disease
Congestive HF (Right sided)
Cancer
Cirrhosis and other liver diseases
Infection
UTI/stones
Hydronephrosis - retention?
Organomegaly + ascites (shifting dullness)
3cm above umbilicus
3cm either side of a point 3 cm above umbilicus
So 3x3 basically
Paralytic ileus/peritonitis
Obstruction ======= Hernial orifices PR/DRE External genitalia Urine dipstick
Pregnancy
DR Exam:
What 3 things may be seen?
What do you test for before advancing finger?
Once finger in, what do you get them to do?
If mass found, what 2 things should be recorded?
How would you know its stool?
What is felt with:
- BPH
- Cancer
What to do when you take finger out?
Lesions
External piles
Fistula
Sensation
Squeeze finger - weakness
Distance from anus + % of circumference
Stool moves and tends to be soft
Firm, nodular enlargement
Ill defined ——
Blood!!!!
BMI and Mouth Ulcers:
Underweight?
Overweight?
Obese?
Leukoplakia - what is it? Candidiasis - associated with? Aphthous ulcers: - 2 GI diseases that cause - CON RX - 2 - MED Rx - 2
Gingivitis:
- Vit deficiency?
O > 30
UW - <18.5
OW >25
Oral mucosal white patch (pre-malignant)
Coeliac and Crohn’s = PAINFUL ULCERS
Soft toothbrush
Avoid acidic food
Antimicrobial mouthwash
Topical steroids and analgesia
=======
Vit C deficiency
GI Imaging:
Endoscopy:
- What can be done to look at the jejunum?
- How many wks to stop PPI?
- How long should they fast?
- Anaesthesia? - 2
2 types of lower GI endoscopy?
- What 3 therapeutic procedures can be done?
- What can be done for blood in stool?
- What has been done in the end?
- When should it not be done? - 2
- What given for a clear view?
- What drug is used for sedation? - M
Stops anticoags/platelets for procedures with high bleeding risk!
2 indications for a AXR?
Topical anaesthesia/IV sedation
Enteroscopy
2 wks
6 hrs - same for LOWER a
Sigmoidoscopy (splenic flexure)
Colonoscopy (terminal ileum)
Polypectomy
Stenting - for blockage
Decompression - twisting of bowel
Perforation
Diverticuitis - increases risk of perforation
Enema - clears bowel
Midazolam
Bowel obstruction - also do erect CXR for pneumoperitoneum
Foreign body
Dysphagia:
Within lumen:
- Infectious causes - 4
- Other causes?
- Pre-cancerous
Within muscle:
- Caused by GORD?
- 2 type of oesophageal strictures?
- LOS closure?
- Also oesophageal spasm
Extramural:
- Type of hernia
- Congenital
- Compressive process
Neurological causes - 5
Polyp
Candidiasis
Pharyngtiis
Retropharyngeal abscess
Oesophagitis***
Foreign body
Benign strictures
Oesophageal web (linked to iron deficiency anaemia) Oesophageal ring
Rolling hiatus hernia
Pharyngeal pouch
Malignancy
Stroke MG MS MND PD
Dysphagia:
What do the following features suggest:
OATES:
O:
- Both solid and liquids from start
- Solids then liquids
- Difficulty initiating movement
A:
- Bulge or gurgle in neck
- Cough on lying down - 2
- Heart burn
- Odynophagia - 3
T:
- Intermittent
- Constant/worsening
- Both
E:
S ……
You may wish to do a neurological exam if indicated
Neuro - bulbar palsy
Spasm
Malignancy
Achalasia
Pharyngeal pouch
Achalasia + PP
Motility issue - MG, pharyngeal issue
Stricture - benign or malignant
GORD ====== Ulcer Oesophageal spasm Oesophagitis
Dysphagia:
Inv:
Bloods - 2
Imaging:
- Gold standard?
- For pharyngeal pouch
- Gold standard for dysmotility?
Oesophageal spasm:
- 2 main symptoms?
How to Rx oesophageal stricture?****
Oesophageal manometry
FBC + U&E (anaemia and dehydration)
Upper GI endoscopy +/- biopsy
Barium /contrast swallow
Intermittent dysphagia
Chest pain
ENDOSCOPIC BALLOON DILATATION
N&V:
Appearance:
- Coffee grounds
- Recognisable food
- Faeculent
Timing:
- Morning - 2
- Post-prandial
- Vomiting relieving pain
- Preceded by loud gurgling
Other causes:
- Infection
- Acute upper GI - 2
- Occurs more distally
- Malignancy
- Ulcer
Non-GI causes - look at main cuecards
Thicker and foul-smelling - distal bowel obstruction
Upper GI bleeding
Gastric stasis
Pregnancy
Raised ICP
Gastric stasis/gastroparesis - happens in DM and pyloric sphincter closure
Peptic ulcer
GE
Acute cholecystitis or pancreatitis
Gastric cancer
PUD
N&V:
Inv:
- What is seen on ABG?
- Imaging and why?
- What is persistent vomiting/blood?
1 Rx?
Endoscopy
Metabolic alkalosis
AXR - bowel obstruction
Anti-emetics
Monitor electrolytes and fluid balance
Anti-emetics:
(1) Anti-histamines:
- 2 examples
- Type of side-effects it has
(2) Anti-dopaminergic (METACLOPAMIDE):
- Side effects - 3
(DOMPERIDONE)
- What type of patient is this safe to use in?
(3) Anti-serotonergics:
- 1 example
- Main GI side effect
SE for all anti-emetics
Sniffing isopropyl alcohol swabs for rapid relief!
Constipation
Cyclazine
Promethazine
Anti-cholinergic effects
Confusion Dyskinesia + Parkinsonism** ======== Parkinson Disease ==== Ondansetron - also used in reflux - H1 receptor blocker
Sedation
Dyspepsia:
3 symptoms it comes alongside?
You can get functional dyspepsia!
Causes:
Most common cause
Oesophageal - 3
Gastric - 2
Fullness
Belching
Nausea
=====
PUD
GORD
Oesophagitis
Oesophageal cancer
Gastritis
Gastric cancer
PUD:
DUO>GAS
Main cause of DU?
Main cause of GU? - 2
Other causes:
- Lifestyle -2
- Med?
S+S:
- Burning, epigastric pain/tenderness
- Timing?
- Which type if relieved by food?
- 2 signs of a bleeding ulcer?
Inv:
Bed:
2 test for H. Pylori?
Instructions to patient?
Bloods - 1 and why?
Imaging - Endoscopy with biopsy - what further test can be done after biopsy?
Steroids
H. Pylori - gastric acid hypersecretion
H. Pylori - damage of epithelial tight junctions
NSAID’s
Smoking + Alcohol
GU (1-3 hrs after food)
DU (4-5 hrs after - so more likely to wake you up in the night
DU - as food buffers acid - REMEMBER - acid hypersecretion is the cause of this
Haematemesis Melena ======= 13C urea breath test ******* Stool antigen test ********
Stop PPI 2 wks before
FBC - anaemia
Rapid urease test - biopsy place into medium with urea - changes colour if positive
PUD:
Prevention for long term steroids
Alternative to NSAID’s
Management of dyspepsia:
- Review meds and lifestyle changes - CON
- How do you know it is more PUD > GORD?
MED:
H. pylori - Triple therapy given? **
What if they are negative?
SURG:
- For severe disease
2 complications of PUD?
Mneumonic - CAMP to remember all the drugs used
Prophylactic PPIs
COX2 inhibitors - celecoxib
Epigastric pain greater in PUD ==== 7 days of PPI - can keep for months \+ 1 wk of Amoxicillin \+ 1 wk of Clarithromycin or Metronidazole
1-2 months PPI (lansoprazole)
Bleed
Perforation or penetration (fistula)
PUD:
Perforated ulcer:
- 3 features?
- Imaging and why?
Management:
- Initial management
- SURG - how is it repaired?
Gastritis very similar to PUD but without an actual ulcer - it is a precursor so a useful differential
Epigastric pain
Shock
Peritonitis
Erect CXR - pneumoperitoneum
CT can also be used!
Drip and suck (IV and empty stomach)
Peritoneal washout
Surgical repair with patch of omentum
GORD Causes:
Medical:
- Hiatus hernia - 2 types and which one is more common?
- Infection?
- Oesophageal dysmotility?
- DM
Lifestyle - 3?
Meds:
- 2 BP tablets
- Also anticholinergics + COCP
- Pain meds?
Heartburn pain:
- Character
- Pain better/worse after food
- What makes it worse?
- Relieving meds?
Other symptoms in GORD - 5
NSAIDs
SLIDING - cardia of stomach moves up *******
Rolling - funds moves up
H. pylori - gastric acid hypersecretion
Systemic sclerosis
Delayed gastric emptying ====== Obesity + overeating Alc Smoking - Nicotine products can weaken your LES, increasing your symptoms. ====== BB + CCB - slows motility
Burning pain
Worse after eating
Bending forward makes it worse
Antacids ===== Cough Hoarseness - due to acid affecting vocal cords Nocturnal asthma Belching Acid brash (acid regurg)
GORD:
What can be done to diagnose it clinically?
INV:
Endoscopy:*******
- Indicated if ALARM signs - what are they?
- 3 things seen?
- PPI?
- What can be done if endoscopy not diagnostic?
Management:
CON - USUALLY DONE FIRST:
- Lifestyle - 2
- Eating habits - 4
MED:
- 1st line med with 2 examples?
- What should be done if still symptomatic after meds?
- Alternative to PPI
Complications of GORD - 4
24 hr pH monitoring in oesophagus (<4 diagnostic)
Clinical - after trial with PPI
Anaemia - bleeding Loss of weight Anorexia Recent onset/progressive sym Melaena/haematemesis
Swallowing difficulty - Dysphagia
Oesophagitis
Barret’s
Oesophageal cancer
Lose weight + exercise
Reduce Alc and S
Reduce spicy and fatty foods
Small regular meals
No food < 3 hrs before bed
Raise the bed head
PPI 1-2 months - Lansoprazole /Omeprazole
Test for H. pylori ===== H2 blockers - famotidine/ranitidine ===== Oesophagatiis Oesophageal ulcers Benign oesophageal strictures (peptic stricture) Barrett's oesophagus
Upper GI bleed:
Causes:
- Common causes?
- Inflammation - 3
- Vomiting
- UPPER GI CANCER **
Other causes:
Varices: - Cause Rx: - MED - 1 - reduce BP - SURG - 1
Portal HTN:
- Pre-hepatic cause?
- Hepatic —?
- Post-hepatic —? - 2
S+S:
- 2 sites of pain
- Vomit
- Stool
- If severe?
Mallory-Weiss tear
PUD - alcohol can also be a cause for an ulcer
Oesophagitis
Gastritis
Duodenitis
CLD
BB
Endoscopic banding/sclerotherapy (Sclerotherapy is a form of treatment where a doctor injects medicine into blood vessels or lymph vessels that causes them to shrink).
Thrombosis
Cirrhosis
Epigastric
Diffuse abdo pain
Red if ACTIVE
Coffee-ground if SETTLED
Melaena - black and foul smelling - also caused by Fe and cancer
SHOCK**
Upper GI Bleed:
INV: Bed - OBS Bloods - 5 and why? Imaging - 2? What is the GOLD standarrd imaging for diagnosis?
RISK ASSESSMENT:
- Score to stratify upper GI bleeding patients who are “low-risk” and candidates for outpatient management.
- Score to assess severity?
MEDICALRx:
- ABCDE if unstable - what may need to be given if needed - 3
- Instructions for patient?
Oesophageal variceal bleed:
- Main drug given until haemostasis reached?
- What can be added if it is due to portal HTN?
- What should you not forget?
Gastric variceal bleed
4. N-Butyl cyanoacrylate - why?
Non-variceal bleed - 1 drug that is used in this?
SURGICAL Rx:
Oesophageal variceal bleed:
- 1st line
- 2nd line if 1st line unsuccessful
Gastric variceal bleed:
- 1st line
Non-variceal bleed:
- Endoscopy - what do they do? - 3
You can only continue aspirin after an acute bleed which has been resolved!
Endoscopy (if not acute, then within 24 hrs)
FBC - rule out anaemia LFT's Coag U&E - raised urea Group and save + crossmatch - surgery
Erect CXR + AXR
CT abdo-chest
Blatchford score - Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.
Rockall score (used pre-endoscopy)
Complete rockall score (post-endoscopy to determine severity)
======
O2 + fluids + transfusion (FFP, PCC for those on warfarin)
NIL BY MOUTH
Terlipressin - vasoconstrictor - stop after haemostasis
Somatostatin - diminishes flow to portal system
Prophylactic AB - due to risk of infection
Gastric varices - basically a glue
========
PPI IV - decrease the rate of further bleeding and need for surgery in such patients.
========
Band ligation
TIPS - connects portal vein and hepatic vein
========
Clipping
Thermal coag + adrenaline
Fibrin or thrombin + adrenaline
Achalasia:
Get fluid regurg but what else may it cause?
INV:
- Gold standard imaging + sign seen?
- How to measure of LOS?
MED Rx:
- 1st line - Cardiac drug for given for relaxation?
- 2nd line
SURG Rx:
- 1st line to dilate LOS?
- 2nd line?
Oesophageal manometry
Aspiration pneumonia
Upper GI endoscopy
Bird peak sign**
CCB - nifedipine
1st - Endoscopic dilatation of LOS
2nd - Cardiomyotomy
Pharyngeal Pouch:
2 symptoms?
Why nocturnal cough?
SURG Rx:
- 2?
Regurg of food
Dysphagia
Regurg
Excision of pouch
Stapling
Hiatus hernia:
Define sliding and rolling?
Main symptom?
Other signs:
- Vomiting
- Weight loss
- Bleeding (due to ulceration)
- Hiccups/palpitations
One sign on examination?
GOLD standard INV?
CON Rx
- Lifestyle - 2?
- Eating habits - 2?
MED Rx - 1
SURG Rx - 2 types?
Sliding - junction into thorax (80%)
Rolling - funds of stomach moves into thorax
GORD - worse lying flat
Bowel sounds in left chest ====== Endoscopy ====== Weight loss Stop smoking
Avoid large meals before bed Raised head of bed ======= PPI ======= Insertion of mesh
Fundoplication - fundos wrapped around LOS to strengthen it and prevent herniation
Oesophageal perforation:
Iatrogenic cause?
2 other causes?
Mackler’s triad?
GI symptoms - 2
INV:
- Initial imaging?
- GOLD STANDARD?
Management:
- How to feed?
- If perf, what should not be forgotten?
- SURG Rx? - don’t need to know - refer to cardiothoracic and get surgeon
CT***** - not endoscopy as it is introducing more foreign pathogens into the mediastinum
Endoscopy
Trauma + swallowed sharp foreign body
Neck, chest or epigastric pain - EXCRUCIATING
Vomiting
Subcutaneous emphysema
Upper GI bleed
Dysphagia
======
CXR
NG suck of contents
NasoJEJUNAL feeding
Prophylactic ABs
Debridement of mediastinum and T-tube for oesophagocutaneous drainage
Diarrhoea (> 3 stools per day)
Bristol stool chart - score?
When is it chronic?
Cause of Acute D?
Bloody diarrhoea - 2 causes?
Pussy diarrhoea - 2 causes?
Explosive diarrhoea - causasive pathegen - 3
Steatorrhoea - 4 signs? - 2 causes?
GI:
- Endocrine causes? - 2
3 signs of dehydration?
INV BEDSIDE - Stool - 4
- 2 things you look for/do for stool samples?
- What specific pathogen can be looked for?
- What is used to look for chronic pancreatitis?
- For IBD and IBS?
- Test for H. pylori causing D?
- For lactose intolerance?
INV - BLOODs - 5:
(1) FBC - what do the following suggest?
- Low mcv
- High mcv
- low B12
(2) U&E:
- What electrolyte is expected to fall with D?
* *******
(3) ESR/CRP - 3 causes of rise
(4) TFT’s - why?
(5) EXTRA for bloods - Coeliac serology?
INV (Initial):
- When is 2WW done?
GE
5-7
> 4 wks
IBD - especially UC
Colorectal cancer
Diverticultiis + fistula/abscess ==== Cholera Rotavirus Noravirus ==== Increased gas Offensive smell Floating Hard to flush
Pancreatic insufficiency
Biliary obstruction
========
Thyrotoxicosis + Addison’s
Dry mucosa Reduced skin turgor Raised CRT ======== MC+S Ova cysts and parasites C. diff
Faecal elastase
Faecal calprotectin - done to rule out
Stool antigen test - H. pylori can cause D
Iron deficiency - Coeliac or CC
Alcohol abuse
Coeliac and Crohn’s Disease
Potassium - so hypokalaemia***
Infection, IBD and cancer
Thyrotoxicosis
Anti-TTG
=====
New onset change in bowel habit >55 yrs old + ALARM
Diarrhoea - Management:
Most self-resolve.
Rx - 2 therapeutic interventions?
What 2 meds can help?
What is done for AB diarrhoea?
Oral rehydration/IV
Electrolyte replacement
Loperamide - reduces smooth muscle tone stopping D
Codeine
Probiotics
Constipation (<3 a wk):
What does alternating with D suggest?
Causes - BOWEL:
- 2 anal causes
- Rectum - 1
- Neoplasm
- How can Crohn’s cause it?
- Extraluminal - 2
- BOWEL OBSTRUCTION IS AN OBVIOUS CAUSE!
Causes - DIETARY - 2?
Causes - FUNCTIONAL - 1
Causes - METABOLIC:
- 2 electrolyte imbalances and why?
Causes - ENDOCRINE - 1
Causes - NEUROLOGICAL - 2
Causes - PSYCH - 1
Causes - DRUGS - 3
Why post-operatively? - 2
Why hospital? - 2
Fetus and fibroids
IBS
Anal fissure and stricture
Rectal prolapse
CC
Crohn’s stricture
Dehydration and low fibre
Hypercalcaemia Constipation is worse due to dehydration associated with hypercalcemia.
Hypokalaemia - poor nervous control leading to slowing of movement of food
Hypothyroidism ====== PD Spinal cord lesion ====== Depression ====== Opiates Iron Diuretics - dehydration ====== Pain meds and muscle relaxants
Reduced privacy + having to use a bedpan
Constipation:
INV - BEDSIDE - 1
INV - BLOODS - 4 and why?
INV - IMAGING - 1 - not usually done
CON Rx - 2
MED Rx:
- 4 types of laxatives
- What is the main type?
- Which one is the fastest?
AXR
PR exam
FBC - iron for anaemia
ESR/CRP - inflam
U&E’S = K+Ca
TFT’s
Increased fibre and fluid
BULKING AGENTS****
Stimulant laxatives - fastest
Osmotic Laxatives
Stool softener
Constipation:
Bulking agents:
- MOA
- Onset?
Stimulant L:
- Examples? - 2
- MOA?
- SE - 1?
Osmotic L:
- MOA
- Main example?
Stool softeners:
- 3 examples?
- Softens stool to allow easier passage. When may it then be indicated?
Few days
https: //www.youtube.com/watch?v=EEBjuiqEp4w
https: //www.youtube.com/watch?v=4bkAH_Z8tmc - better video
Soluble fibre - creates gel making stool bulkier but easier to pass - NEEDS TO BE TAKEN WITH PLENTY OF WATER
SENNA **
Stimulate bowel movements
Salts and sugar which can’t be absorbed = causes water to move into bowel
LACTULOSE - hepatic encephalopathy Magnesium sulfate - FASTEST ======= DOCUSATE ****** Enema (basically an oil) Liquid paraffin
Anal tissues or painful anal pathology
Jaundice:
Say/draw out bilirubin cycle!!!
Over what level leads to jaundice?
PRE-HEPATIC:
- Causes? - 1
- Gilbert’s syndrome - what is it?
- What is raised in bloods and urine?
- Stool and urine normal
HEPATIC (liver dysfunction):
- Stool?
- Urine?
- What is raised in bloods?
OBSTRUCTIVE:
Cause:
- Luminal - 1
- Mural - 2
- Extra-mural - 2
- Mirizzi’s syndrome?
- Autoimmune - 2
- Pregnancy - 1
Features:
- Stool?
- Urine?
- Why do they itch?
- Bloods?
- Urine - what is high and what is low?
INV for obstructive:
- 1st line imaging?
- GOLD STANDARD imaging?
Management for obstructive:
MED Rx:
- Done according to needs to patient - e.g. IV fluids
SURG Rx:
- GOLD STANDARD Rx
Complication:
- Why is IV Vit K given?
History:
- What would you ask about for Hep B? - 4
- What recent Rx would you ask about? - 1
Obstetric cholestasis
> 35 μmol/L
Haemolytic anaemia
Impaired conjugation
High unconjugated B
High levels of urobilinogen - This unconjugated bilirubin isn’t water-soluble so can’t be excreted in the urine. INTERSTINAL BACTERIA convert some of the extra bilirubin into urobilinogen, some of which is re-absorbed and IS excreted by the kidneys – hence urinary urobilinogen is increased.
======
Normal stool - some conjugation
Dark urine - raised unconjugated bilirubin - less urobilinogen
High UNconjugated bilirubin
======
L - gallstones
M - Cholangiocarcinoma Biliary strictures (PBC, PSC)
E - Pan Cancer + Enlarged lymph nodes
GS in cystic duct - compresses hepatic duct
PBC and PSC
PALE stool + DARK urine
Due to build up of BILE SALTS - not bilirubin
High CONJUGATED bilirubin
USS
ERCP - stenting, clearance, or sphincterotomy ****
======= They are at risk of coagulopathy due to impaired absorption of Vit K - it is a fat soluble vitamin (ADEK) ======== IVDU Piercings Tattoos Sexual activity
Blood transfusions
UC:
Transmural or mucous only?
2 features if severe?
S+S - INTESTINAL:
- 2 main symptoms?
- 2 rectal symptoms?
UC attacks - Trigger?
Same as Crohn’s:
S+S - NON-INTESTINAL:
- Eyes - 3
- Mouth - 1
- Hands - 1
- Shin’s - 1
- Leg - 1
What is the most common non-GI sign?
What autoimmune disease of liver can it cause?
Why are they at an increased risk of VTE?
Risk factors - linked gene?
INV - BEDSIDE - STOOL - 3
- To rule out infection?
- Marker for inflammation?
- Pathogen that cause D?
INV - BLOODS - 4 and why?
- What does inflam do to platelets and albumin?
- Autoantibody?
INV - IMAGING - ENDOSCOPY:
- What is done if acute and if chronic?
- What is seen on endoscopy?
AXR - why? - 3
HLA-B27
Colonic mucosa and submucosa only
Inflammation and ulceration ===== Diarrhoea - usually bloody (and mucousy ******) \+ Cramps
Urgency (and Tenesmus (feeling need to pass stool with pain, cramping and strain BUT VERY LITTLE STOOL COMES OUT *****)
Infection ===== Uveitis Episcleritis Conjunctivitis
Aphthous ulcers
Clubbing
Erythema nodosum
Pyoderma Gangrenosum
ARTHRITIS ======= PSC ======= Chronic inflammation leads to thrombocytosis
MC+S
Faecal calprotectin
FBC - Hb and haematinics (iron, folate and B12) - patients usually have anaemia
Thrombocytosis as well
CRP/ESR - inflam
U&E’s - Hydration, electrolytes
LFT’s - hepatobilioary disease - PSC
RAISED platelets and LOW alb
A - limited flexible sigmoidoscopy with biopsy ** GOLD STANDARD
C - full colonoscopy with biopsy****
Crypt architecture ========= Perforation Gross dilatation Toxic megacolon (>6 cm)
UC - Management:
Score used to assess severity?
CON Rx - Patient education
MED Rx - Mild to moderate:
- 1st line is 5-aminosalicylic acid (5-ASA) for distal disease - give 2 examples? - M, S
- Whats added if more proximal?
MED Rx - Severe:
- What is severe?
- 1st line med?
- 2nd line to induce remission - 2nd line for refractory disease
MED Rx - Remission:
- After how many attacks are immunosuppressors (azathioprine) needed?
SURG Rx:
- Type done in acute cases?
- MAIN SURGICAL Rx?
- What is a J pouch?
Can also add PR steroid foams
Truelove and Witt’s severity index
Mild to moderate:
MESALAZINE***** - maintains remission and reduces flare ups as it reduces inflammation
SULPHASALAZINE
Prednisolone
Severe - >6 stools, systemically unwell
IV Corticosteroids
Ciclosporoin - immunosuppressor
> # 2 use of steroids in a yr or severe attack
Subtotal colectomy - remove everything but rectum and end ileostomy made
Panproctocolectomy with ileostomy (removal of whole large bowel)
Ileo-anal pouch anastomosis made after resection of bowel - harder to do though so not preferred
Crohn’s:
Main place affected?
This is transmural - granulomatous inflammation
Younger or older?
S+S:
- 2 main
- Other features are weight loss, fever and fatigue.
- Is it more chronic/acute than UC?
- Perianal signs? - 3
- What may be found on examination?
Same as UC: S+S - Non-GI: - Mouth - 1 - Eyes - 3 - same as UC - Nail - 1 - Shin's - 1 - Leg - 1
What is the most common non-GI sign?
INV - BEDSIDE - same as UC
INV - BLOODS - same as UC
- Antibody associated with Crohn’s?
INV - IMAGING:
- AXR - 2 features you could find?
- Barium enema - what will it show?
- What imaging for more detailed look at disease extent?
FOR DIAGNOSIS - INV - COLONOSCOPY - 2 KEY signs?*******
What will biopsy show?
Younger - tend to be smokers as well
Terminal ileum
Diarrhoea
Abdo pain
Usually more ACUTE
Abscess
Fistula
Tags
Aphthous ulcers
Uveitis
Episcleritis
Conjunctivitis
Clubbing
Erythema nodosum
Pyoderma Gangrenosum
ARTHRITIS ======== Anti-saccharomyces cerevisiae antibodies (ASCA) ======== Dilatation - toxic megacolon Abscess
Strictures
Skip lesions
Cobblestone appearance
Transmural disease with granulomas
Crohns - Management:
CON Rx - 1
MED Rx to induce remission - 1 drug - REMEMBER - Crohn’s tends to be more acute
2 Drugs that can be added for refractory disease?
MED Rx for maintaining remission:
- 1st line
- 2nd line
MED Rx for symptomatic relief:
- For diarrhoea?
- For cramping?
SURG Rx - Small bowel:
- Can get short gut syndrome - 4 effects?
SURG Rx - Large bowel:
- MAIN SURGICAL Rx?
Complication of surgery:
- 2 effects of (disease or) removal of terminal ileum and how to solve them?
Immunosuppressors - methotrexate or biologics
Cut out smoking
Methylprednisolone IV 3 days
THEN
Prednisolone PO for 2 wks after
Azathioprine
Biologics
=====
5-ASA - Azathoiprine
Loperamide
Antispasmodic - Buscopan ===== Diarrhoea Steatorrhoea Electrolyte abnormalities Malnutrition - vitamin deficiencies, weight loss and fatigue ALL due to lack of absorption ====== Panproctocolectomy with ileostomy ======= B12 deficiency - Replace - loss of terminal ileum Loss of bile acids - replace - Ursodeoxycholic acid
Crohns vs UC:
Where does it tend to affect?
Main symptom
Thickness of inflammation
Complications - 2
Also go through stomas deck!
Rectum - UC
Terminal ileum - C
Bloody diarrhoea - UC
Crampy abdo pain - C
Submucosa or mucosa - UC
Transmural - C
Haemorrhage and toxic megacolon - UC
Fistulas, abscesses, obstruction - C
GI Malabsorption:
3 causes?
3 causes of low bile?
2 causes of pancreatic insufficiency?
What deficiencies would cause:
- Anaemia
- Bleeding disorder
- Oedema
- Metabolic bone disease
- Neurological feature
Coeliac Disease
Chronic pancreatitis
Crohn’s Disease
Primary biliary cholangitis
Ileal resection
Biliary obstruction
Pancreatic cancer
Cystic fibrosis
Low iron, B12 and folate
Low Vit K
Low protein
Low Vit D
Neuropathy
Coeliac Disease:
Define?
4 GI symptoms? Stool? Mouth? - 2 Due to malabsorption? - 3 Skin?
ASK ABOUT AUTOIMMUNE DISEASES
INV - BLOODS - 3 and why?
- Why LFT’s?
- Autoantibody?
- What must the patient do to make sure bloods are accurate?
INV for osteoporosis?
What is done for diagnosis?**
Rx - 2
Stay ON gluten
Autommune response to gluten
Cause intestinal damage
Diarrhoea (may be bloody)
Abdominal pain
Bloating
Weight loss
Steatorrhoea - fat malabsorption
Ulcers
Angular stomatiis - seen in Fe
Anaemia - Fe, B12 + folate
Osteoporosis - lack of Ca and + Vit D
Oedema - protein
Dermatitis Herpatiformis =========== FBC - anaemia (iron, B12) U&E - Ca Albumin - oedema
Causes raised ALT
Anti-tTG IgA
DEXA
====
Upper Endoscopy + biopsy **** ===== Life long gluten free diet Remove wheat (bread and pasta), rye and barley)
Replace micronutrients
IBS:
What is the main difference in the stool between IBS and IBD
List a few symptoms?
INV - BEDSIDE - 2
INV - Bloods - 3 and why?
- What test can be used to differentiate between IBS and IBD?
- To rule out coeliac
- How can you make sure there is no blood?
CON Rx - Dietary - list a few
Low FODMAP diet also used if severe!
MED RX for symptomatic relief:
- For bloating
- For diarrhoea
- For constipation
- For cramps
What is another cause of iBS that shouldn’t be forgotten about?
It is never bloody
Tenesmus Worse after food Bloating Urgency MUCUS PR**** ========= Hydrogen breath test - H. pylori
FBC - anaemia
ESR/CRP - rules out IBD
TFT’s - hyperthyroidism
Coeliac antibodies - Anti-TTG to rule out
Faecal calprotectin - normal in IBS
FOB - shows blood thats not seen - rules out IBD ========= - Regular meals - Good hydration (8 cups per day) - Reduce alc - Max 3 fruit portion per day - AVOID too much fibre especially if insoluble Encourage soluble fibre ========= Antimuscuranic - MEBEVERINE
Loparmide
Laxative
Anti-spasmodic - Hyoscyamine
PSYCH - DEPRESSION!!!
Nutritional Disorders:
Scurvy:
- Cause?
S+S:
- Gum?
- Muscle?
- Also get anorexia, cachexia and halitosis
- Rx? - A
Vit A def - causes?
Vit B12 deficiency - 3 signs
Vit D def - 2
Iodine def leading to?
Vit C deficiency
- Gingivitis - loose teeth and bleeding
- Muscle pain and weakness
Ascorbic acid
Night blinds
=====
Macrocytic anaemia
Neuropathy
Glossitis - inflame of the tongue
Rickets in children
Osteoporosis
Goitre
Obesity:
BMI for overweight and obese
2 endocrine causes?
Health risk:
- CVD
- Metabolic syndrome - 3
- Resp
- GI
- Bone
Management:
1, 2, 3 and 4th line?
Osteoarthritis
> 25
>35 ===== Hypothyroidism Cushing's Syndrome ===== HTN, stroke etc.
T2DM + NAFLD + HTN
Obstructive sleep apnoea
Gallstones
Weight loss diet
Regular exercise
Orilistat
Bariatric surgery
Gastroenteritis:
Viral - name?
Bacterial - name?
2 symptoms?
Campylobacter - how do you usually catch it?
Salmonella - how do you usually catch it?
Profuse water D - cause?
INV - Bedside - 1
INV - BLOODS - 4 and why?
D+V can be a feature of sepsis and many other infections - CNS, urinary, appendicitis
CON Rx - 1
MED Rx - inpatient - 2
Complications:
- Joint
- Neuro
Acute D and/or VOMITING
Norovirus
Adenovirus
Rotavirus
Salmonella
C. diff
Shigella
E. coli
Eating infected poultry
Infected poultry, eggs and milk
Stool - MC+S
FBC (RAISED WBC) U&E (Dehydration) CRP (Inflammatory marker) LFT (Helps with differentials) ===== Oral fluids
Anti-emetics
Anti-diarrhoeal - loparemide
Reactive arthritis
Gillian-Barre syndrome - CAMPYLOBACTER
C.diff:
Iatrogenic cause?
S+S:
- Diarrhoea?
- 2 more?
INV - BEDSIDE - what can be done to confirm from a stool sample? *****
INV - BLOODS - 2
Rx with specific AB’s
ABs
Profuse watery d
Abdo pain and tenderness
Fever
PCR +/- toxin immunoassay****
FBC - raised WBC
U&E - AKI due to dehydration
Acute abdomen and surgical emergencies:
Types of pain in obstruction?
Peritonitis:
- What makes pain worse?
- 3 other features?
What do rigors suggest? - 3
INV - BEDSIDE - 2 and why?
INV - BLOODS - 6 and why?
For women?
INV - IMAGING - 4?
When should an exploratory laparotomy be considered?
Colicky pain
Pain worse on movement
Guarding - VOLuntary contraction of abdo muscles when palpated
Rigidity - Involuntary contraction of abdo muscles when palpated
{Guarding, in contrast, is a voluntary contraction of the abdominal wall musculature to avoid pain. Thus, guarding tends to be generalized over the entire abdomen, whereas rigidity involves only the inflamed area. Guarding can often be overcome by having the patient purposely relax the muscles; rigidity cannot be.}
Rebound tenderness
====
Cholangitis
Pyelonephritis
Intra-abdominal abscess
======
Urine dip - UTI
ABG - acid/alk
- FBC - WBC for infection
- U&E - dehydration
- Coagulation - surgery
Group and save (crossmatch) - if surgery is needed - LFT - function
- ESR/CRP - inflammation
- Lactate - sepsis
Beta hCG - ectopic
USS
Erect CXR
AXR
CT abdo
Due to radiation risk to foetus
Acute abdomen and surgical emergencies:
Lower GI bleed:
INV - BLOODS - 6 and why?
INV - IMAGING - 1
INV - Special test - COLONOSCOPY:
- How may haemostasis be achieved? ***
CT abdo-pelvis
- FBC - WBC for infection
- U&E - dehydration, raised urea
- Coagulation - surgery
Group and save (crossmatch) - if surgery is needed - LFT - function
- ESR/CRP - inflammation
- Lactate - sepsis
Adrenaline, thermal coag or clipping
Nasogastric the placement:
How to determine length?
Confirmation:
- 1st line
- CXR - 3 signs
Nose to ear to the xiphoid
pH (should be <5.5) - aspirate some contents
CXR:
- Crosses carina
- Crosses diaphragm
- Tip visible beneath D
Appendicitis:
Pain:
- Character
- Radiation
What indicates peritonitis? - 3
What indicates abscess?
4 signs on examination and define?
3 complication if untreated?
Colicky visceral pain - umbilical to RIF
Pain on movement
Guarding
Rebound tenderness
Fever
McBurney’s sign - 1/3 of the way between right ASIS and umbilicus is extremely tender **
Rovsing’s sign - RIF pain on pressing the LIF *****
Psoas sign - Pain on extending the hip (if retrocaecal appendix)
Obturator sign - Pain on flexion and internal rotation of the right hip
https://www.youtube.com/watch?v=SkiekzdEtu4
Perforation
Peritonitis
Abscess formation
Appendicitis:
INV - BEDSIDE - OBS
INV - BLOOD - 6 and why?
INV - IMAGING - 2
MED Rx - 1
SURG - Rx - 1
Management of complications:
- Abscess
Appendectomy
- FBC - WBC for infection
- U&E - dehydration
- Coagulation - surgery
Group and save (crossmatch) - if surgery is needed - LFT - function
- ESR/CRP - inflammation
- Lactate - sepsis
USS
CT Abdo-pelvis **
=====
Antibiotics IV
IV antibiotics and CT-guided drainage
Diverticular Disease:
Difference between diverticulosis and diverticular disease
What is it?
Cause?
Non-specific symptoms of diverticular disease - 4
Diverticulitis:
- LIF pain - what else may be seen?
- Stool? - 2
- Anorexia and N&V as well
- Signs of perf?
Complications:
- 2 types of fistula?
- Cause of bowel obstruction
- 2 complications of perf?
Can get PR bleeding but not common
Diverticula present
Plus symptoms
Small outpouchings of the colonic mucosa and submucosa through the muscular layer
Due to high intramural pressures due to LACK OF FIBRE IN DIET ==== Pain Bloating*** Constipation Diarrhoea
Guarding
PR mucus and blood + diarrhoea
Colovaginal and colovesical
Strictures
Abscess (may be hypochondriac or in splenic flexure
Perintotis
Diverticular disease:
INV - BLOODS - 6 and why?
INV - IMAGING - 2 and why?
Management:
CON Rx - 1 - uncomplicated
MED Rx - 3 - uncomplicated at home
SURG Rx:
- Over how many cm’s is an abscess drained?
- How is it drained?
- What procedure is done for severe disease?
- What classification is used to classify colonic perforation due to diverticular disease and therefore guides management?
- FBC - WBC for infection
- U&E - dehydration
- Coagulation - surgery
Group and save (crossmatch) - if surgery is needed - LFT - function
- ESR/CRP - inflammation
- Lactate - sepsis
Erect CXR - for perforation
CT abdo - to diagnose ****
========
High fibre diet
ABs and oral fluids at home
Pain relief
> 3cm
CT-guided aspiration
Hartmann’s procedure - temporary
Hinchey’s classification
