2) GI system 1 Flashcards

Question 1

Q

ACUTE UPPER GI BLEED

most common causes? 5
other causes? 3

Answer

A

= Peptic ulcer disease (35-50%)

= gastroduodenal erosions (8-15%)

= oesophagitis (5-15%)

= mallory-weiss tear (15%)

= varices (5-10%)

upper GI malignancy
vascular malformations
swallowed blood (eg from facial trauma, nose bleed or haemoptysis)

Question 2

Q

UPPER GI BLEED

risk factors? 3
classes of drugs which increase risk? 5

Answer

A

alcohol dependence (all, but especially varices)
liver disease (same as above)
lots of vomiting from eg morning sickness (mallory-weiss)

(also other risk for the relevant causes - eg RFs for PUD)

DRUGS

anti-coagulants (LMWH, warfarin, DOAC)
anti-platelets (aspirin, clopidogrel)
NSAIDs
steroids
SSRIs

Question 3

Q

UPPER GI BLEED

name of two scores used?
what is each used for?

Answer

A

BLATCHFORD SCORE
- need for admission and endoscopic intervention

(0-1 = discharge w/ OP OGD)

ROCKFALL SCORE
- predicts risk of Re-bleeding and mortality post-endoscopy

(higher the score, worse the mortality)

Question 4

Q

UPPER GI BLEED

2 presentations of blood in the vomit?
2 presentation of blood in stools?
other clinical signs? 2
clinical signs and vital signs that may indicate large amount of blood loss?

Answer

A

HAEMETEMISIS

1) bright red
2) coffee ground (brown)

BACK PASSAGE

1) Melaena – tar black stools, iron smell (indicate 50-100ml blood loss)
2) Haematochezia – fresh blood or maroon (lower GI bleed)

ALSO ABDOMINAL PAIN!!!
- may also have signs of chronic alcohol abuse (jaundice etc)

Basically signs of SHOCK!

initally

light headed
SOB
anxious

Peripherally shut down

Cold
↓CRT
↓UO (<0.5ml/kg/hr)
reduced GCS

THEN
- Dyspnoea (due to anaemia) – indicates large bleed
- Tachycardic > 100bpm (compensate for ↓BP)
↓GCS
- Hypotensive <90/60 → dizzy and syncope (nb may only be postural in young people)

Question 5

Q

LARGE UPPER GI BLEED

principle of assessment + management? 1
bloods to take? 6 (and possible findings)
other things to do / give under ABC (2 do, 3 consider)

Answer

A

A-E approach

BLOODS

FBC (low or normal Hb, takes time to drop!)
U+E (raised urea out of proportion to Creat indicates massive bleed)
LFT
Clotting
VBG/ABG
cross-match OR group & save

A+B
1) airway patent and give O2 (if low)

C
2) Get IV access (ideally two) AND give fluid challenge

3) CONSIDER giving blood (O neg is immediate, type specific 20 mins, corss match 45 mins) - major haemorrhage protocol if massive!
4) CONSIDER giving vit K +/-berliplex (if active bleed on warfarin)
5) monitor urine output and CONSIDER catheterising

Question 6

Q

LARGE UPPER GI BLEED - DISABILITY + EXPOSURE:

what to make sure to do as part of abdo exam?
are patients allowed to eat + drink?
what 2 scores to calculate?
who to refer to? 1 (+ when to call)

Answer

A

DRE

essential!!
to see if any melaena (nb be aware of iron supplements!)

patients should be NBM (at least for 24hrs if big bleed)

calculate:

BLATCHFORD SCORE
need for admission and endoscopic intervention

ROCKFALL SCORE
- predicts risk of Re-bleeding and mortality post-endoscopy

refer to GASTRO REG

depnds on the size of the bleed! - if massive + active, call before even assess - if controllable, call after A-E
ask what drugs (if any to give and whether to give blood)

nb also call anaesthetist if struggling to protect airway

Question 7

Q

LARGE UPPER GI BLEED

medication to give to ALL large upper GI bleeds? 1

medication to consider giving if variceal cause? 2 (main CI to one of these)

Answer

A

ALL
- OMEPRAZOLE (80mg stat IV, then 8mg/h for 72hrs) - nb normally start this after OGD

VARICES

TERLIPRESSIN IV (decreases portal pressure, CI = IHD)
prophylactic ANTIBIOTICS (for SBP)

(nb don’t start these drugs until spoken to gastro reg)

Question 8

Q

LARGE UPPER GI BLEED

what intervention do all need? (+time frame)
purpose of this intervention
specificmanagement options within this intervention for variceal bleeds?
2nd line management options if bleed too big?

Answer

A

need ENDOSCOPY (OGD)

within 4 hrs if suspect varices
within 12-24hrs if shocked on admission or significant co-morbidity

purpose:

1) find CAUSE of bleed
2) TREAT bleed if still active

varices = SCLEROTHERAPY (inject into varices to ‘sclerose’ them) OR banding

IF V BIG BLEED

1) balloon tamponade during OGD
2) open surgery

nb other treatment options during OGD (don’t learn off by heart):

use either mechanical (clips) w/ or w/o adrenaline; thermal coag w/ adrenaline, fibrin or thrombin w/ adrenaline, haemospray (useful for ulcers)

Question 9

Q

If no site of bleeing found on OGD fopllowing upper GI bleed, what could this mean? 4

Answer

A

A) Bleeding site MISSED on endoscopy

B) Bleeding site HEALED prior to endoscopy (eg mallory-weiss or dieulafoy’s)

C) blood had been SWALLOWED (so not GI bleed)

D) Site of bleeding is DISTAL to where endoscopy done (eg meckel’s diverticulum, colonic site)

Question 10

Q

VARICEAL BLEEDING

primary prevention options? 2
secondary prevention options?

Answer

A

PRIMARY PREVENTION

propranolol (mainstay!)
repeat endoscopic banding

don’t give propranolol acutely if bleeding as may make worse!

SECONDARY PREVENTION (ie following bleed)

endoscopic banding
TIPS (transjugular intrahepatic portosystemic shunt – joins hepatic + portal vein)

Question 11

Q

What complication should you observe for for all large GI bleeds?

what signs may this present with? 5

other possible complication of all GI bleeds?

Answer

A

RE-BLEED

continuous monitoring of vitals

signs of re-bleed

rising pulse rate
falling JVP
decreasing hourly urine output
further haematemesis (or melaena)
fall in BP (late sign) + drop in GCS

40% of patients who re-bleed will die!! - make sure monitor appropriately to catch early!

other complication = ASPIRATION pneumonia! (develops later!)

Question 12

Q

VARICEAL BLEEDING

prognosis following 1st bleed?
specific complication associated with variceal bleeds? 1

Answer

A

Following 1st variceal bleed – 60% re-bleed in 1st year

complications of variceal bleeds:
- Spontaneous bacterial peritonitis (SBP)

(also re-bleed + aspiration pneumonia - as with all GI bleeds)

Question 13

Q

TYPICAL PRESENTATION of causes of OESOPHAGEAL BLEED:

oesophagitis?
oesophageal cancer?
mallory-weiss tear?
varices?

(incl amount + appearance of blood AND associated symptoms + other features of history)

also if tend to stop spontaneously or not

Answer

A

OESOPHAGITIS
- small volume fresh red blood (often streaking vomit)
- malaena rare
- often ceases spontaneously
= usually Hx of antecedent GORD-type symptoms

OESOPHAGEAL CANCER
- usually small amounts of blood (except pre-terminal when more)
- may be recurrent until malignancy managed
= dysphagia, systemic symptoms such as weight loss

MALLORY-WEISS TEAR
- typically brisk small-moderate volume of bright red blood
- malaena rare
- usually ceases spontaneously
= Hx of repeated vomiting (treat cause of this! eg anti-emetics for morning sickness)

VARICES
- usually large volume fresh blood
- swallowed blood can -> malaena
- often associated with haemodynamic instability
- may stop spontaneously, but re-bleeds common until appropriately managed
= Hx of alcohol abuse or other liver disease

Question 14

Q

TYPICAL PRESENTATION of causes of GASTRIC BLEED:

gastric cancer?
dieulafoy lesion?
diffuse erosive gastritis?
gastric ulcer?

(incl amount + appearance of blood AND associated symptoms + other features of history)

also if tend to stop spontaneously or not

Answer

A

GASTRIC CANCER
- may be frank haematemesis or altered blood mixed with vomit
- amount of bleeding variable (erosion of major vessels may -> large haemorrhage)
= prodromal dyspepsia + systemic Ca symptoms

DIEULAFOY LESION
- may produce quite considerable bleeding
- may be difficult to detect endoscopically
= often no prodromal features prior to haematemesis + malaena

DIFFUSE EROSIVE GASTRITIS
- usually haematemesis (coffee ground or fresh) and epigastric discomfort
- large haemorrhage may occur with haemodynamic instability
= Hx of underlying cause: eg recent NSAID etc use, often have epigastric discomfort

GASTRIC ULCER
- small low volume bleeds more common -> iron-deficiency anaemia
- erosion into a significant vessel may -> significant haematemesis
= tend to present with symptoms (and RFs) of PUD and iron-deficiency anaemia

Question 15

Q

What is a DIEULAFOY LESION?

Answer

A

about 1% of all GI bleeds

condition characterized by a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds.

it is an arteriovenous malformation

It can present in any part of the gastrointestinal tract

can be hard to detect on OGD

Question 16

Q

CONSTIPATION:

definition?
what criteria used to assess? (roughly describe what this consists of)

Answer

A

= 2 or fewer bowel movements a week (or fewer than normal for person)

OR

= stools passed with:

difficulty / straining
pain
feeling of incomplete evacuation (tenesmus)

ROME CRITERIA
“making stools glamarous”
- DON’T LEARN SPECIFIC criteria, just be aware!

constipation = persence of 2 or more features

A) straining for >25% stools
B) lumpy / hard stools for >25% stools
C) tenesmus for >25% stools
D) sensation of anorectal obstruction / blockage for >25% stools
E) manual manouveres to facilitate for >25% bowel movements
F) < 3 bowel movements a week

nb these criteria are not commonly formally used as they tend to overdiagnose - go moreon affect on QOL and any concerning features!

Question 17

Q

CONSTIPATION:

lifestyle causes / contributing factors? 3
situational causes / contributing factors? 5
functional / psych causes? 4

Answer

A

LIFESTYLE

poor diet
lack of exercise
not enough water

SITUATIONAL

old age (very common!!!)
post-op pain
dehydration
hospital environ (decrease privacy, have to use bed pan)
distant, squalid or fearsome toilets

FUNCTIONAL / PSYCH

IBS
anorexia nervosa
depression
abuse as a child

Question 18

Q

ORGANIC CAUSES of CONSTPIATION:

anorectal disease? (2 common/important, 3 rare)
intestinal obstruction? (4 common/important, 1 rare) - think inter + extra luminal!
metabolic / endocrine? (2 common/important, 3 rare)
neuromuscular? (1 common/important, 3 rare)

(nb medications can also cause / exacerbate constipation - see next flashcard)

Answer

A

ANORECTAL DISEASE
(consider esp if painful!!)
= anal or colorectal Ca
= fissures, strictures (incl herpes)
- Proctalgia fugax
- rectal prolapse
- pelvic muscle dysfunction / levator ani syndrome

INTESTINAL OBSTRUCTION
= colorectal Ca
= strictures (eg crohn’s)
= pelvic mass (foetus, fibroids)
= diverticulosis (rectal bleeding more common)
- pseudo-obstruction (nb different to paralytic ileus)

METABOLIC / ENDOCRINE
= hypercalcaemia
= hypothyroidism (rarely the presenting feature though)
- hypokalaemia
- porphyria
- lead poisoning

NEUROMUSCULAR (slow transit from decreased propulsive activity)
= paralytic ileus (spinal / pelvic nerveinjury, eg surgery or trauma)
- agangliosis (hirschprungs, chagas)
- systemic sclerosis
- diabetic neuropathy

nb constipation is unlikely to be the sole symptom of a serious disease - ask re associated symptoms

Question 19

Q

Medications which can cause / exacerbate constipation? (2 very common, 3 common, 1 other)

(nb majority of these are classes of medication)

how to prevent constipation occuring? 2

Answer

A

= opiates
= anti-cholinergics (eg tricyclics)

iron
diuretics (eg furosemide)
calcium channel blockers

(- some antacids, eg w aluminium)

warn pts of this side effect - as it may affect compliance

1) dietary advice
2) co-prescribe laxatives if high risk

Question 20

Q

ASSOCIATED SYMPTOMS to ask about in CONSTIPATION which may indicate an ORGANIC cause (and thus need investigations):

GI-related? 6
systemic symptoms? 2
other specific symptoms? 2
what other demographic detail should be taken into account? 1

(say which condition each symptom may be suggestive of)

Answer

A

OTHER GI FEATURES

mucus? (Ca)
blood? (Ca)
passing wind (if not, could be obstruction!)
vomiting (obstruction)
abdo pain
Tenesmus (Ca)

nb if constipation alternating with diarrhoea + no other features - suspect IBS

also aways ask about diet AND medications!

SYSTEMIC

weight loss (Ca)
symptoms of anaemia (Ca)

OTHER

menorrhagia + other hypothyroid
symptoms suggestive of hypercalcaemia

AGE
- if NEW constipation >40 (esp with other signs) then investigate more!

Question 21

Q

POSSIBLE investigations for CONSTIPATION:

bedside? 1
bloods? 5
imaging if suspect obstruction? 1
other imaging? 2

when should you do these investigations?

Answer

A

DRE
- look for fissures etc as well as feeling for stool

BLOODS

FBC (for anaemia)
U+Es
ESR
Ca 2+
TFTs

if suspect obstruction = Abdo XR

sigmoidoscopy to biopsy abnormal tissue if appropriate

IF SUSPECT Ca
- colonoscopy / barium enema

Do if red flags for Ca or other organic causes or if functional is not resolving with lifestyle changes or laxatives

Question 22

Q

red flag symptoms for colorectal cancer? 4

Answer

A

change in bowel habit
over 40
weight loss
anaemia

Question 23

Q

symptomatic MANAGEMENT of CONSTIPATION (if organic cause ruled out)
- lifestyle advice? 4

Answer

A

reassurance
drink more water
eat more fibre (introduce slowly to avoid bloating)
exercise more

Question 24

Q

MEDICATION for symptomatic management of CONSTIPATION

when should this be used?
principles of use?

Answer

A

LAXATIVES

Use for symptomatic management of functional constipation (for a short period while changing lifestyle)

co-prescribe for drugs known to cause constipation

prescribe for organic constipation (whilst also treating underlying cause)

Question 25

Q

LAXATIVES:
- four different types?

for each type:

drug name examples (at least 2)
mechanism of action?

Answer

A

BULKING AGENT
= Bran powder
= ispaghula husk (eg fybogel)
- increase faecal mass, stimulating peristalsis

STIMULANT LAXATIVES
= senna
= docusate (stimulant + softening)
- increase intestinal motility

STOOL SOFTENERS
= arachis oil (can take as enema)
= docusate (stimulant + softening)
= liquid parafin
- soften stool

OSMOTIC LAXATIVES
= lactulose
= macrogel (eg movicol)
= phosphate enemas (pre-procedural)
- draw water into the bowel lumen
- movicol can cause bloating

Question 26

Q

BULKING AGENTS

drug name examples? 2
mechanism of action?
when to use?
how to tell pts to use?
contraindications? 3

Answer

A

BULKING AGENT
= Bran powder
= ispaghula husk (eg fybogel)

increase faecal mass, stimulating peristalsis (similar to how increased fibre works)

can use 1st line for functional constipation (alongside senna)

drink with lots of water, may take a few days to work

X CI: difficulty swallowing, GI obstruction or faecal impaction

Question 27

Q

STIMULANT LAXATIVES

drug name examples? 2
mechanism of action?
main side effect? 1
when to use?
contraindications? 3

Answer

A

STIMULANT LAXATIVES
= senna
= docusate (stimulant + softening)

increase intestinal motility (SE: abdo cramps)

short-term relief of functional constipation (often alongside bulk-forming)

X CI: intestinal obstruction, acute colitis, prolonged use (can cause colonic atony + hypokalaemia)

Question 28

Q

STOOL SOFTENERS

drug name examples? 3
mechanism of action?
when to use? 1
contraindications? 1

Answer

A

STOOL SOFTENERS
= arachis oil (can take as enema)
= docusate (stimulant + softening)
= liquid parafin

soften stool
particularly good for painful conditions (eg fissures)

X CI: don’t use liquid parafin for prolonged period

Question 29

Q

OSMOTIC LAXATIVES

drug name examples? 3
mechanism of action?
when to use? 3
main side effect? 1?

Answer

A

OSMOTIC LAXATIVES
= lactulose
= macrogel (eg movicol)
= phosphate enemas (pre-procedural)

draw water into the bowel lumen
often used for kids
can be 1st line for functional (if not use stimulant/bulk-forming)
pre-procedural as an enema
movicol can cause bloating

Question 30

Q

Who should you avoid using docusate in?

Answer

A

young people!

(only use in elderly or terminally ill)
- as long term cancer risk!

***CHECK THIS! - NOT SURE IF TRUE - THINK i’VE GOT CONFUSED WITH ANOTHER ONE

Question 31

Q

DIARRHOEA

common GI causes? 7
less common GI causes? 9
non-GI causes? 4

nb some meds also cause diarrhoea - on seperate flashcard

Answer

A

COMMON GI CAUSES

= gastroenteritis
= parasites / protazoa

= IBS

= Crohn’s
= UC
= Coeliac

= colorectal Ca

(also remember medication causes! see other flashcard)

LESS COMMON GI CAUSES

microscopic colitis
chronic pancreatitis
c. diff.
diverticular disease
lactose intolerance
laxative abuse
overflow diarrhoea
ileal / gastric rescetion
ischaemic colitis (high lactate)

NON-GI CAUSES

thyrotoxicosis
autonomic neuropathy
addison’s
carcinoid

Question 32

Q

DIARRHOEA

- broadly, what 3 things can decrease stool consistency?

Answer

A

water
fat (steatorrhoea)
inflammatory discharge

Question 33

Q

DIARHOEA

- three types of ‘watery’ diarrhoea? (and types of things that cause it)

Answer

A

OSMOTIC
- eg laxative induced

SECRETORY
- eg microscopic colitis

FUNCTIONAL
- eg IBS

Question 34

Q

STEATORRHOEA

three features?
three causes?

Answer

A

increased gas
offensive smell
floating, hard to flush stools
pancreatitis
coeliac disease
giardiasis

Question 35

Q

Inflammatory diarrhoea:

two most common causes?
two main features?

Answer

A

crohns
US
blood
frank pus
^in stools

nb just mucus in stools could be IBS, polyps or cancer so not that helpful…

Question 36

Q

Common drugs / drug classes that can cause diarrhoea? 8

nb there are many more but learn these especially

Answer

A

antibiotics
laxatives
PPIs
NSAIDs
propranolol
digoxin
cytotoxics
alcohol

Question 37

Q

ACUTE DIARRHOEA:

timeframe definition?
risk factors for gastroeneteritis to ask about? 4
systemic symptom which may point towards infective cause? 1

Answer

A

< 2 weeks = acute diarrhoea

medications (eg recent Abx or PPIs)
travel
contact with D&V
diet change (eg food intolerance or food poisoning)

systemic symptom:
- fever

Question 38

Q

Red flags for diarrhoea:

acute? 2
acute + chronic? 1
chronic? 2

Answer

A

ACUTE
- clinical dehydration
- fever
^ie systemically unwell - look for any signs of shock!

ACUTE + CHRONIC
- blood

nb if just mucus, this could be IBS

CHRONIC

weight loss (IBD or Ca)
anaemia (IBD or Ca)

Question 39

Q

What shoud you rule out in NEW IBS in post-menopausal women?

Answer

A

ovarian cancer

esp if accompanied weight loss!

Question 40

Q

DIARRHOEA

bedside test for ALL?

bedside tests for systemically unwell or chronic diarrhoea? 2 (1 for unwell, 2 for chronic)

Blood tests if systemically unwell / dehydrated with diarrhoea? (do 3, consider 1)

blood tests if chronic diarrhoea? 3

Answer

A

DRE for ALL diarrhoea (or will miss faecal impaction w overflow)

STOOL SAMPLES

culture + microscopy (for unwell or chronic)
faecal calprotectin (IBD)
faecal occult blood test (FOBT) (Ca)

IF SYSTEMICALLY UNWELL
- FBC (eosinophilia if parasites)
- U+E (low K if severe)
- VBG
(- blood cultures)

CHRONIC (w concerning features)

FBC (microcytic anaemia if coeliac or Ca, macrocytic if alcohol abuse or low B12, eg crohns or coeliac)
TFTs (hyperthyroid)
TGT (for coeliac)

nb can do CEA, but if suspect Ca should do imaging and not rely on this as only raised in some Ca’s

Question 41

Q

Aside from if someone who is systemically unwell with acute diarrhoea, what other features of the Hx may make you do a stool culture and microscopy for acute diarrhoea? 6 (although not necessarily urgent)

Answer

A

local food poisoning outbreak
raw seafood ingestion
foreign travel
recent Abx use
rectal intercourse
immunocompromised

Question 42

Q

which imaging should be considered for chronic diarrhoea if suspect:

crohn’s? 1
UC? 1
Bowel Ca? 1

Answer

A

crohns = flexible sigmoidoscopy

UC = colonoscopy / barium enema

Bowel cancer = colonoscopy / barium enema

nb don’t do colonoscopies / sigmoidoscopies if acute flare of IBD!!

Question 43

Q

Management of acute diarrhoea:

mainstay?
when should IV fluids be considered? 2
when to use abx? 2
what medications to consider? 2 (and when not to use 1)

Answer

A

ORAL rehydration FLUIDS (better than IV)

IV if:

very clinically dehydrated
bloody diarrhoea + dehydrated for >2 weeks

(nb also replace electrolytes dependent on bloods)

ABx if

systemically unwell with known infective diarrhoea
c. diff. (PO vancomycin or metronidazole)

CONSIDER:
- codeine
- loperamide 
CI: colitis (may precipitate megacolon)
^tbh rarely use for this purpose!! (rehydration salts best thing!)

Question 44

Q

DIARRHOEA

- advice to patients re going back to work? 2

Answer

A

48 hours after symptoms stop if viral gastroenteritis

no work until stool samples negative (if handle food - eg chefs)

Question 45

Q

MALNUTRITION:

- common groups of causes of malnourished patients in hospital? (also applies to out of hospital too)

Answer

A

1) INCREASED nutritional REQUIREMENTS (eg sepsis, burns, surgery, cancer)
2) INCREASED nutritional LOSSES (malabsorption, output from stoma)
3) DECREASED INTAKE (dysphagia, nausea, sedation, coma)
4) EFFECT of TREATMENT (eg nausea, diarrhoea)
5) ENFORCED STARVATION (enforced periods NBM)
6) MISSING MEALS through being whisked off (eg for investigations)
7) DIFFICULTY in FEEDING (eg lost dentures, no one to help)
8) UNAPPETISING FOOD

Question 46

Q

MALNUTRITION

- use of investigations in malnutrition?

Answer

A

General;ly not that helpful, but can see vitamin/electrolyte losses

low albumin is suggestive but not always (but raising albiumin is good sign of recovery!)

signs on physical exam like cachexia, falling BMI and look ing dehydrated artee more useful

Question 47

Q

main tools of prevention of malutrition during hospital? 3

Answer

A

1) make sure food is appetising
2) ensure that meal times are uninterrupted where possible
3) get advice from nutritionist (if someone at risk or underweight)

Question 48

Q

If increasing oral intake doesn’t work, what other main groups of methods of feeding can be used if patients are malnourished? 2

who must you consult before doing any of these?

if someone has been malnourished for a long time, what is an important thing to consider during management?

Answer

A

1) ENTERAL FEEDING
- NG feeding, gastrostomy etc

2) PARENTERAL FEEDING
- ie IV nutrition
- can use partial if can’t get all nutrints enterally (eg short bowel syndrome or active crohns) or use TPN if can’t take anything enterally

consult DIETICIAN before starting someone on enteral or parenteral feeding!

revent REFEEDING syndrome (ie refeed people slowly and routinely check electrolytes)

Question 49

Q

VITAMIN DEFICIENCY SYNDROMES:

vit A? 1
vit B1? (aka?) 2
vit B2? 2
vit B6? 1
vit B12? 3
vit C? 1
vit D? 2
vit K? 1

(describe each condition briefly)

also if there is a condition which often causes this condition then mention it too

Answer

A

VIT A
= XEROPTHALMIA
- big cause of blindness in developing world

VIT B1 (thymine)
= WERNICKE’S ENCEPHALOPATHY
- triad of: confusion, ataxia + opthalmoplegia
= BERI BERI
- heart failure w oedema (wet beri beri) or neuropathy (dry beri beri)

VIT B2
= ANGULAR STOMATIS
= CHEILITIS (aka angular stomatis)

VIT B6
= POLYNEUROPATHY

VIT B12
= MACROCYTIC ANAEMIA
= NEUROPATHY
= GLOSSITIS

VIT C
= SCURVY
- listlessness, anorexia/cachexia, gingivitis, loose teeth, halitosis, bleeding from gums, nose, hair follicles, or intro joints, bladder, gut, muscle pain/weakness, oedema

VIT D
= RICKETTS
- growth retardation, hypotonia, bow-legged or knocked knees
= OSTEOMALOACIA
- bone pain + tenderness, fractures, proximal myopathy

VIT K
= BLEEDING DISORDERS
- (basically equivalent of putting a pt on warfarin)

Question 50

Q

Which vitamins are fat-soluable? (and so often have malabsorption of if have steatorrhoea)

Answer

A

DAKE

= fat soluable vitamins

Question 51

Q

GORD

pathophysiology?
main complications it can lead to? 3

Answer

A

reflux of stomach acid + bile into oesophagus

→ if prolonged reflux →

oesophagitis
strictures
Barrett’s (can lead to Ca)

Question 52

Q

GORD:

specific causes? 3
risk factors? 4

Answer

A

CAUSES

Lower oesophageal sphincter defect + hypotension
Hiatus hernia
Loss of oesophageal peristaltic function or Slow Gastric emptying

Risk factors

Abdominal obesity
pregnancy
smoking
alcohol

Question 53

Q

GORD:

- what drug classes cause / exacerbate reflux? 2

Answer

A

anticholinergics (incl TCAs)

- nitrates

Question 54

Q

GORD:

oesophageal? 5
extra-oesophageal? 3

Answer

A

OESOPHAGEAL

HEART BURN (reflux) – (burning, retrosternal discomfort)
– Worse post-meal, lying down
– Relieved by anti-acids ( and PPI or H2 antag)
BELCHING
ACID BRASH
– acid or bile regurgitation (ask if taste acid in mouth)
WATER BRASH
– ↑↑salivation

ODYNOPHAGIA
-– painful swallowing may indicate oesophagitis or ulcers

EXTRA-OESOPHAGEAL

nocturnal asthma or CHRONIC COUGH (very common!)
LARYNGITIS
– hoarseness, throat clearing
SINUSITIS

Question 55

Q

GORD:
- red flag features? 6 (incl acronym!)

over what age is new-onset reflux also a red flag?

Answer

A

ALARMS symptoms

A = Anaemia
L = Loss of weight
A = Anorexia
R = Recent/ Refractory/progressive
M = Meleana/haematemesis
S = swallowing difficulty

NEW ONSET over 55 years = red flag

Question 56

Q

GORD:
- main three investigations? 3

when should you use each ?

Answer

A

A) ENDOSCOPY
– if over 55
- > 4wks
- ALARMS features

nb Stop PPI 2 weeks before scope

B) 24hr pH study ± Manometery
– if endoscopy normal

C) Barium swallow
– if screening for hiatus hernia

Question 57

Q

What classification system is used for GORD

Answer

A

Los Angeles Classification of GORD (1-4)

Question 58

Q

Conservative management of GORD:

dietary advice? 8
other lifestyle advice? 3

Answer

A

DIETARY

small, regular meals (avoid big)

avoid:

hot drinks
alcohol
fizzy drinks
citrus
spicey food
chocolate
eating < 3 hrs before bed

OTHER ADVICE

raise bed head
weight loss (reduce pressure on stomach)
smoking cessation

Question 59

Q

What medications to avoid if patient has GORD:

ones that damage gastric mucosa? 4
ones affecting gastric / oesophageal motility? 3

Answer

A

Avoid drugs that DAMAGE MUCOSA

– NSAIDs

steroids
K+ salts
Bisphosphonates

Avoid drugs REDUCING gastric/oesophageal MOTILITY

nitrates
calcium channel blockers
anti-cholinergics

Question 60

Q

GORD:

1st line symptomatic medical management? 2
2nd line medical management? 1 (+ alternative drug class = 1)
option if medications don’t work / very severe? 1

Answer

A

1ST LINE (if no alarms)

Antacids (Magnesium trisilicate mixture)
Alginates (Gaviscon)

2ND LINE

1) PPI (start high dose + taper down)
2) H2 antagonist (if PPI not working + ruled out alarms)

if neither working after couple of months, consider DDx (eg h.pylori)

SURGICAL OPTIONS

nissen fundoplication
stretta radiofrequency ablation of GOJ

^ consider surgeries if no other cause DDx found and refractory to drugs

(don’t both learning names of surgical options - just know they exist as last line!)

Question 61

Q

Possible complications of GORD? 5

Answer

A

Oesophagitis
strictures
ulcers
anaemia
Barrett’s oesophagus (leading to oesophageal cancer)

Question 62

Q

GORD differentials? (5 common/serious, 2 rare)

Answer

A

= H. pylori gastritis
= drug-induced gastritis
= Peptic ulcer disease

= gastric cancer
= oesophageal cancer

achalasia
eosinophilic oesophagitis

Question 63

Q

Describe pathophysiology of barret’s oesophagus?

what main risk>?

Answer

A

distal oesophagus epithelium undergoes metaplasia (squamous → columnar) → Dysplasia → oesophageal Ca (50-100 fold risk)

Question 64

Q

OESOPHAGEAL CANCER

- two types? (location + cell type)

Answer

A

ADENOCARCINOMA

lower 1/3rd
associated with Barrett’s
more common in western world

SQUAMOUS CELL CARCINOMA

upper 2/3rds
same risk factors as for head + neck cancers
less common in developed world

Answer 65

A

Male > F

obesity
↓in vit.A/C
alcohol
smoking
achalasia
nitrosamine exposure
reflux oesophagitis
Barrett’s

(also increasing age)

Answer 66

A

OESOPHAGEAL

= Dysphagia + Dyspepsia PROGRESSIVE! (First solids → soft food → liquids)

= Odynophagia

Regurgitation + Vomiting → Haematemesis or Melaena (small volumes)

= Retrosternal chest pain (reflux)

OTHER LOCAL

Hiccups
Lymphadenopathy
Hoarseness – pressure on recurrent laryngeal or larynx
Cough – may be paroxysmal if aspiration pneumonia

SYSTEMIC (these are LATE signs!)

↓Weight
↓Appetite
Fatigue

Answer 67

A

Referral for ENDOSCOPY 1st line

Urgent (2 wks) – if:

= dysphagia 
OR
= age ≥ 55 AND wt loss and any of: 
- upper abdo pain
- reflux
- dyspepsia

(don’t worry about learning exact referral criteria!)

Upper GI endoscopy w/ BRUSHINGS + BIOPSY

Answer 68

A

TNM staging

Endoscopic US or CT/MRI

Answer 69

A

cure = RADICAL OESOPHAGECTOMY

if T1/2
Neo-adjuvant Chemotherapy may be considered

Chemo-radiotherapy if surgery not suitable

Palliative chemo-radiotherapy to restore swallowing

Answer 70

A

POOR – with or without treatment

5yr survival is 20-25% for all stages

Answer 71

A

Herniation of stomach through oesophageal aperture of diaphragm

POSSIBLE CAUSATIVE MECHANISMS:

1) Widening diaphragmatic hiatus
2) Oesophageal shortening pulls up the stomach
3) ↑Intra-abdominal pressure Pushes stomach up

Obesity
Pregnancy
Ascites
↑Age
Trauma chest/abdo
skeletal deformities (scoliosis, kyphosis, pectus excarvatum)

Answer 72

A

‘SLIDING’ (80%)
= GOJ slides into thorax

↑↑↑Reflux (common as LOS becomes less competent)
Dysphagia

‘ROLLING’ (para-oesophageal 20%)
= GOJ remains in abdo, but part of the stomach (cardia) herniates into thorax

Dysphagia
Chest pain
Epigastric pain or fullness
Nausea

(Reflux less common)

Answer 73

A

BARIUM SWALLOW
= best diagnostic test ∆

UPPER GI ENDOSCOPY
- in any patient > 55 with new dysphagia, must exclude oesophageal cancer!!

(Stop PPI 2 weeks before scope)

CXR (may be picked up incidentally)

Soft tissue opacity w or w/o air fluid level
Retro-cardiac air-fluid level = Rolling (para-oesophageal)

Answer 74

A

SYMPTOMATIC MANAGEMENT:
- Same as GORD

SURGICAL OPTIONS

1) Laparoscopic fundoplication (if refractory symptoms and risk of strangulation)
2) Gastropexy (suturing of stomach to abdominal wall)

Answer 75

A

H. PYLORI = BIGGEST
- 95% DU, 80% GU)

smoking
NSAIDs
alcohol

Answer 76

A

Epigastric PAIN related to: food, hunger, time of day
TENDER epigastrium
HEART BURN (retrosternal chest pain + reflux)
BLOATING + Early SATIETY

DUODENAL ULCERS (80%)

50% asymptomatic
PAIN is BEFORE meals or at NIGHT (wakes from sleep)
RELIEVED by EATING or milk

GASTRIC ULCERS (20%)

PAIN at MEALS
RELIEVED by ANTACID
also get weight LOSS

Answer 77

A

ALARMS symptoms

A = Anaemia
L = Loss of weight
A = Anorexia
R = Recent/ Refractory/progressive
M = Meleana/haematemesis
S = swallowing difficulty

NEW ONSET over 55 years = red flag

Answer 78

A

1) Non-invasive H.Pylori test – use CARBON-13 UREA BREATH TEST

do FBC to look for LOW Hb (alarms feature -> refer)

ENDOSCOPY

exclude malignancy + determine extent of oesophagitis
only if alarms symptoms present

nb during endoscopy:

Multiple Biopsies (histology, H.Pylori CLO)
Brushings (cytology)

nb Ensure repeat endoscopy post-treatment for gastric ulcers, due to risk of malignant conversion

Answer 79

A

Stop PPI 2 wks before endoscopy

Answer 80

A

H. Pylori = TRIPLE THERAPY

full dose PPI
TWO Abx for a week (norm amox + clarithro)

(or can replace amox with metranidozole)

NSAID-induced

1) stop NSAIDs
2) PPI (ulcers should heal in 8wks)

high risk of relapse in both!!

Answer 81

A

HAEMATEMESIS / MALAENA
- associated with erosion of large blood vessels

PERFORATION
- can cause acute abdomen w epigastric pain -> generalised rigidity (air under diaphragm on CXR)

PYLORIC STENOSIS

due to scarring of duodenum
weight loss + projectile vomiting

(projectile vomiting presents in same way as kids!)

GASTRIC CANCER
- think alarms features

Answer 82

A

H. Pylori (2 fold risk)
pernicious anaemia
gastritis
diet low in fruit + veg
smoking
M > F
increased age (95% in pts >55 years)

nb gastric cancer is 5th most common cancer in UK (after the big 4)

Answer 83

A

Typical:

Dysphagia + DYSPEPSIA – progressive

Nausea + Vomiting → Haematemesis ± Melaena

Reflux

Upper abdo mass

Epigastric pain/discomfort

Weight loss, LoA, Fatigue (due to anaemia)

ALARMS symptoms

Anaemia
Loss of weight 
Anorexia – LoA 
Recent onset, refractory or progressive symptoms 
Melaena (or haematemesis)
Swallowing difficulty (dysphagia)

Answer 84

A

ENDOSCOPY (w biopsies + brushings)

2 wk rapid referral if: 
= Dysphagia 
OR
= Age > 55 with weight loss and 1 of: 
- upper abdo pain
- reflux
- dyspepsia

Histology (biopsy) = may show SIGNET RING CELLS (large vacuole of mucin which displaces nucleus to one side – high number of cells indicates poor prog)

(stop PPI 2 weeks before scope)

CT or EUS – stage tumour

Answer 85

A

GASTRECTOMY

if localised disease
plus local lymph nodes

chemo-radiotherapy

neo-adjuvant
adjuvant
palliative

15% 10 year survival

Answer 86

A

epigastric mass
TROISIER’s sign (enlarged left supraclavicular node – VIRCHOW’s node)
hepatomegaly
jaundice
ascites
acanthosis nigricans

Answer 87

A

majority of tumours are EXOCRINE

ADENOCARCINOMA (95%, poor prog)
– 60% head, 25% body, 15% tail

nb other types = Ampulla of Vater or Pancreatic islet cells – insulinoma, gastrinoma, glucagonoma (good prog)

Answer 88

A

chronic pancreatitis
DM (both types)
smoking
alcohol
abdominal obesity
fat / processed meat diet
M > F
over 60 = greatest risk

NB >95% have KRAS2 mutation

Answer 89

A

Epigastric DISCOMFORT - radiating as dull backache

Worse supine
relieved sitting forward

Tumour compressing gall bladder → gastric outlet obstruction or delayed emptying → NAUSEA + VOMITING

STEATORRHOEA – secondary malabsorption (loss of exocrine func)

ANOREXIA

WEIGHT LOSS

HEAD OF PANCREAS

Dark urine
Pale stools
Yellow, jaundiced skin
Pruritis

COURVOISIER’s sign
= PALPABLE gall bladder in presence of PAINLESS, obstructive JAUNDICE
– highly indicative of pancreatic cancer 25%)

DM (common complication)

nb symptoms if in tail / body = Non-specific pain, Weight loss

Answer 90

A

↑CA19-9 = specific to Pancreatic Ca

FBC – normochromic anaemia or thrombocytosis (↑Plt)

LFTs – ↑Bilirubin, ↑↑ALP, ↑↑GGT (if alcohol) > ↑ALT (mild)

↑Glucose serum

Answer 91

A

ENDOSCOPIC ULTRASOUND SCAN (EUS)

scan liver, bile duct, pancreas
Pancreatic mass ± dilated biliary tree ± hepatic mets

Abdominal high resolution CT or MRI
– if EUS inconclusive and high suspicion (overlying bowel gas or fat may hide the pancreas)
- gold standard test

Answer 92

A

RADICAL (resectable - rare)

Pancreato-duodenectomy (WHIPPLE’s) – if fit, no mets
Laparoscopic excision – tail lesions
Post-op chemo

PALLIATIVE (unresectable – common)

ERCP with stenting (may help obstructive jaundice + anorexia in palliative patients (frequently used))
Analgesia or Radiotherapy for pain

POOR prognosis – late presentation, early metastasis, poor survival

<1/5th of pts present with localised, potentially curable tumours

5 year survival is < 5%

Answer 93

A

Duodenal obstruction (15-20%)

DVT or PE

secondary diabetes mellitus

Answer 94

A

Immune mediated intolerance to gluten (gliadin) → causes cytotoxic T-cell inflam response in s.bowel (duodenum + jejunum) → villous atrophy + enteropathy → ↓Absorption, ↑Excretion of H2O, Ulcers, Strictures

PMHx of other autoimmune conditions
FHx of coeliac or other autoimmune conditions

bimodal distribution
- early childhood
- age 40-60
though can be diagnosed at any age!

Answer 95

A

INITALLY:

1) Diarrhoea + FATTY STOOLS – pale, floating + foul
2) FTT + weight loss
3) ABDO DISCOMFORT, cramping or distension - ie IBS-like symptoms (in response to gluten rich food)

derm = DERMATITIS HERPETIFORMIS

classic skin (75%)
Chronic, polymorphic, pruritic, blistering skin disease
Elbows, knees and buttocks

LATE

Muscle WASTING (buttocks) + ARTHRALGIA
IRON (duodenum) or FOLATE (jejunum) deficiency → FATIGUE
DELAYED PUBERTY
MOUTH ULCERS

Answer 96

A

BLOODS

Total IgA tissue transglutaminase (tTG)
FBC (low Hb, microcytic anaemia)
low folate (sometimes low B12 too0

ENDOSCOPIC BIOPSY of s.bowel for CONFRIMATION ∆

(continue eating gluten, until biopsy is undertaken)

Jejunum (mainly – “VIC”) + Duodenum

diffuse Villous atrophy
↑IE lymphocytes in LP
Crypt hyperplasia

Answer 97

A

GLUTEN-FRE DIET
- Avoid wheat, rye, oats, barley.

Markers of compliance: Sx improve, histology + IgA Ab levels return to normal, -ve serology

Annual review

if presented as an infant, can do gluten challenge aged 2 to see if still have

Answer 98

A

COELIAC CRISIS

incredibly rare
life threatening DEHYDRATION due to diarrhoea + malabsorption

T-CELL LYMPHOMA
- ↑risk if poor adherence to diet

Answer 99

A

Cows milk protein intolerance – not improved w/ gluten diet
Giardiasis

(also any other cause of FTT - eg heart problems)

Answer 100

A

INDIRECT

go through deep AND superficial ring due to patent processus vaginalis
INFANTS
“Infants get Indirect”

DIRECT

goes directly through superficial inguinal ring
ADULTS (wth below risk factors)

MALES (8:1)
- remember, although less common, women do still get them!!

RISK FACTORS

obesity
chronic cough
constipation
urinary obstruction
heavy lifting
previous abdo surgery

nb more common on Right side

Answer 101

A

Intermittent swelling in groin or scrotum

Firm + tender

Mass especially during coughing (↑IA pressure)

Sudden pain – unlikely to be severe

(also Vomiting + Irritability in infant)

Answer 102

A

do abdo AND genital exam

examine and then ask patient to cough to see if lump appears / gets larger

check if hernia is reducible (if not reducible check not a scrotal lump)

also check if you can palpate above it (more likely to be scrotal lump) or not

try to transilluminate, to locate a hydrocele

can do ULTRASOUND scan if any doubt

Answer 103

A

loose weight
manage exacerbating factors (eg chronic cough / constipation)

definitive = SURGERY
- mesh repair commonest type

conservative if DIRECT and SMALL + NO complications

ALWAYS operate on if any complications or all INDIRECT (ie in infants)

nb don’t wait for indirect - do quickly! - undescended testes is the paeds urology surgery that you wait a few months before doing

Answer 104

A

Irreducible / incarcerated hernia – occurs chronically over time as hernia enlarges + fibrous adhesions form → STRANGULATION (compromises vasc supply) → SMALL BOWEL OBSTRUCTION (common complication of hernias)

irreducible hernia
very painful to touch / increasing pain
any signs of obstruction (vomiting, abdo distension etc)

for INDIRECT, can get HYDROCELE secondary to the patent processus vaginalis

get painless scrotal swelling increasing, transuillum,inates
norm self-limiting but surgery if still present 18-24mo

Answer 105

A

Femoral hernia

swelling at top of inner thigh, under inguinal ligament

Answer 106

A

lying prostrate
lying still
shocked
rigid abdomen (board-like)
guarding
percussion tenderness

nb don’t test rebound tenderness as this is cruel! - percussion tenderness is just as accurate and hurt as much

no bowel sounds

COUGH TEST
- ask pt to cough and watch face - if they wince or clutch abdomen as they do so, then positive

nb may also have symptoms like fresh blood per rectum and fever - depending on the cause of the peritonitis

nb. often confused with ‘colic’ (biliary, renal, bowel) - but pts are often restless with this and can’t sit down! - also pain waxes and wanes

Answer 107

A

peptic ulcer disease (perforation)
gall bladder (perforation)
appendix (perforation)
diverticulitis (perforation)
ischaemic bowel perforation
spontaneous bacterial peritonitis (SBP, secondary to ascites)

so if you see true peritonitis - think perforation of somnething!!

PANCREATITIS can present exactly like peritonitis but does not require surgery - always exclude with blood tests!

Answer 108

A

blood glucose
urine dip
ECG (eg pre-op)

^nb norm don’t do the top 2 if truely peritonitic

BLOODS

VBG
FBC
U+Es
LFTs
amylase

(- consider CRP)

GROUP + SAVE

(- consider clotting)

ERECT CXR = 1st line

CT abdo pelvis if this not clear (and pt stable)

Answer 109

A

‘drip + suck’

IV fluids
NBM
analgesia (norm IV paracetamol + morphine)

need LAPAROTOMY!
- talk to surgeons about urgency (make as well enough as possible with fluids etc before surgey if time!)

Answer 110

A

guarding at a certain area - but not all over the abdomen

cholecystitis
simple appendicitis
diverticulitis
salpingitis

nb if abscess formation is suspected (swelling, swinging fever, and raised WCC) then may need drainage (through skin or through surgery)

Answer 111

A

spleen
aorta
ectopic pregnancy

main feature is SHOCK!

peritonism may be mild in these conditions!

Answer 112

A

main RF = female

HERNIATED MASS

– points DOWN leg
- in UPPER MEDIAL thigh

Appears or swells on coughing/straining
Disappears or reduces when relaxed/supine

Neck of hernia felt infero-lateral to pubic tubercle

Femoral canal boundaries: inguinal lig (anterior), lacunar lig (medially), femoral vein (lateral), pectineus/Pectineal lig (posterior)

Answer 113

A

none needed, is a clinical diagnosis
- assume can use USS if unsure though…

often misdiagnosed as an inguinal hernia
- these point TOWARDS GROIN and can be felt supero-medial to pubic tubercle

google images to see difference in location!

Answer 114

A

surgically repair ALL!! (as high risk of complication if left!)

Answer 115

A

Strangulation (HIGH RISK 22%) → Incarceration

Mass 
– red
- tender
- tense
- irreducible

Colicky abdominal pain

Abdo distension

Vomiting

Answer 116

A

Breakdown of muscle closure following abdo SURGERY

10-20% of laparotomies (much less common if laprascopic surgery)

abdominal obesity increases risk (and also makes management more difficult)

Answer 117

A

MESH REPAIR
- decreases recurrence, but can increase infection rates!

Like all hernias: can strangulate and cause bowel obstruction! - but rare!!

do always ask about prev abdo surgery if pt presents with bowel obstruction (or any abdo problem tbh) and examine scar sites for hernias!

Answer 118

A

10-30% of all hernias

mass at, above or below umbilicus

INFANTS
- prematurity increases risk

ADULT

pregnancy
obesity
ascites

Answer 119

A

INFANT

normally spontaneously resolves by age 4
operate if >1.5cm or child >4 years

ADULT

less likely to spontaneously resolve
more likely to need operation

so watch and wait OR operate

operation called MAYO REPAIR and repairs the rectus sheath

Answer 120

A

change in bile (cholesterol + bile pigment, phospholipids) concentration → formation of stones in biliary tract

fair
fat
female
fertile
fourty

70% asymptomatic

Answer 121

A

Stones made in GB → symptomatic w/ cystic duct obstruction, or if passed into CBD

Sudden RUQ pain

collicky (gets better + worse)
Radiating to R.Shoulder
A/w nausea + vomiting
often following food
Better with analgesia

RED FLAGS

fever
jaundice

(red flags also dark urine or pale stools too - ie obstructive jaundice)

nb if vomiting makes pain better - then more likely to be colic - if little effect then more likely to be complication

Answer 122

A

CHOLECYSTITIS

pain similar to biliary colic but more severe
MURPHY’s sign positive
may have local peritonism
fever

CHOLANGITIS

gall stone stuck in common bile duct -> obstruction
fever
jaundice
CHARCOT’S TRIAD = fever, jaundice, RUQ pain / tenderness

^both of thses can perforate -> full peritonism!! surgical emergency!

nb can also get chronic cholecystitis (chronic inflammation + colic that doesn’t respond to ABx, - treat surgically!)

nb can also get Acalculous cholecystitis

More common in T2 DM or UL disease
RUQ pain w/ Fever but no evidence of gall stones on US (likely due to biliary stasis or ischaemia)
Often presents with sepsis

Answer 123

A

FBC (no raised WCC)
LFTs (not raised)

Abdo USS
- visualise stones in gallbladder

Answer 124

A

analgesia
rehydrate
NBM

Elective laparoscopic cholecystectomy

Answer 125

A

increase in the blood pressure in the portal vein, which carries the blood from the bowel and spleen to the liver

PRE-HEPATIC
- thrombus (portal or splewnic vein)

INTRAHEPATIC

= CIRRHOSIS (80% in UK)

schistosomiasis (commonest worldwide)
sarcoidosis
myeloproliferative diseases
congenital hepatic fibrosis

POST-HEPATIC

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

Answer 126

A

ascites
caput’s medusa (if severe)
ankle oedema
splenomegaly

(can also have anorectal varices)

often presents as: ACUTE GI BLEED (norm from varices - but can be PUD too)

also get symptoms of liver disease - eg jaundice, deranged clotting etc

Answer 127

A

oesophageal variceal bleed
spontaneous bacterial peritonitis (SBP)
hepatic encephalopathy (

Answer 128

A

diffuse hepatic inflammation characterised by fibrosis and conversion of normal liver architecture into structurally abnormal nodules → cirrhosis often final stage of liver disease (80-90% liver parenchyma destroyed) and non-reversible (end-stage liver damage)

Fibrosis → distortion of hepatic vasculature → ↑intrahepatic resistance + portal HTN → Porto-systemic shunt

Portal HTN → oesophageal varices + hypo-perfusion of kidneys + water/salt retention (→ascites, transudative pleural effusion, splenomegaly) + ↑CO

Damage to hepatocytes → impaired liver function → ↓clotting factors + Alb (↑PT/↓Alb) and ↓ability to detoxify substances

Answer 129

A

= Alcohol abuse

= Non-alcoholic fatty liver disease (NAFLD)

= HCV (20% develop)
= HBV

Less common:

PBC (primary biliary cirrhosis IgM = AMA)
PSC (primary sclerosing cholangitis ANCA IgG)
Auotimmune hepatitis
haemochromatosis
methotrexate
biliary obstruction (CF, atresia)
Budd-Chiari syndrome (→venous outflow obstruction)
chronic heart failure

Answer 130

A

Often asymptomatic (compensated) until obvious complications of liver disease (decompensated)

Fatigue / Malaise
Anorexia
Nausea
Weight loss

SIGNS
(variable depending on extent of disease)

Jaundice + hair loss
Leukonychia (↓Alb)
Clubbing
Dupuytren’s contracture, - Palmar erythema
Xanthelasma
Kayser-Fleischer ring (brown-green copper deposit – Wilson’s)
Hepatomegaly
Spider naevi (blanch and fill from centre outwards)
Gynaecomastia
Hypogonadism e.g. testicular atrophy or amenorrhoea

PORTAL HYPERTENSION

Ascites (can be detected clinically ≥ 1.5 litres)
Caput medusae
Splenomegaly
Oesophageal varices → upper GI bleed

Answer 131

A

aka hepatic failure!

Triggered by

infection
GI bleed
constipation
opiates
alcohol
AKI
electrolyte disturbance

^basically can be triggered by anything that puts additional strain on body!

Oedema + Ascites
Jaundice
Easy bruising due to coagulopathy (↓factor II, VII, IX, X → ↑INR)
Oesophageal variceal rupture
Spontaneous bacterial peritonitis (SBP – ascetic neut > 250)
Hepatic encephalopathy

Answer 132

A

Liver flap
Confusion
Drowsy / ↓GCS

Answer 133

A

CHILD-PUGH SCORE
- determines severity of cirrhosis

based on:
- Albumin
- Prothrombin Time (PT)
- Bilirubin
- Ascites
- Encephalopathy 
^don't worry about knowing parameters - just know it measures severity

Nb LFTs are a poor determinant of liver failure progression, albumin and coagulation are much more sensitive

Initially: LFTs – ↑Bil ↑↑AST >↑ALT ↑ALP ↑yGT

Then, after loss of liver function - ↓Albumin ↑PT/INR

↓WCC ↓Platelets (indicate hypersplenism)

↓Clotting factors

↓Hb (may indicate occult bleeding)

Blood film – non-megaloblastic macrocytic anaemia suggests alcohol abuse

Answer 134

A

work out extent AND cause of liver damage

1) LIVER USS + DUPLEX
- Look at GB/biliary tree stones,
Liver echo texture, Vasculature = portal + hepatic veinm (to detect retrograde flow and thrombus)

2) VIRAL SEROLOGY
- Hepatitis B – HBsAg, HBcAg, HBeAg, IgG/IgM
- Hepatitis C – Anti-HCV Ab, HCV RNA PCR, IgG/IgM

3) AUTOIMMUNE ANTIBODIES
- IgA = Alcohol
- IgM = AMA for primary biliary cirrhosis (PBC)
- IgG = ANA and ASA/SMA for AI Hepatitis or
- ANCA for primary sclerosing cholangitis (PSC)

4) GENETIC TESTS
- Wilson’s – ↓Serum caeruloplasmin, ↓Serum Cu, ↑24hr urinary Cu (speech + behaviour problems, Kayser Fleischer)
- Hereditary haemochromatosis - ↑Serum Ferritin > 1mg/L; Fasting Transferrin saturation > 45%; HFE gene (C282Y)
- Å1-antritrypsin – check for emphysema, liver cirrhosis or HCC; test serum a1-antritruypsin (↓a1AT < 11 umol/L)

DON’T NEED TO KNOW THIS MUCH DETAIL! - just know roughly the groups of causes and thus what looking for

Answer 135

A

GOLD STANDARD = liver biopsy

test for spontaneous bacterial peritonitis = Ascetic Tap for MC&S

Answer 136

A

stop alcohol
loose weight
exercise more

also consider stopping aggravating meds: eg NSAIDs, opiates etc

consider:

general nutrition
thiamine (esp if alcohol-related)
zinc?

also treat underlying cause if possible - eg anti-virals for Hep C

liver transplant is only definitive treatment

Answer 137

A

Colestestyramine

Answer 138

A

fluid restrict (<1.5 L/day)
low salt diet

1st) SPIRONOLACTONE
- monitor with daily weights

2nd) FUROSEMIDE
- monitor U+Es

may require:

therapeutic paracentesis
HAS

Answer 139

A

1) HEPATIC ENCEPHALOPATHY
- large amounts of ammonia cross BBB → presents with Asterix (liver flap) w/ gentle hyper-extension of wrist → coma

2) OESOPHAGEAL VARICES
- portal hypertension -> engorged oesophageal veins -> rupture and large GI bleeds

3) HEPATOCELLULAR CARCINOMA
- painless jaundice with weight loss

4) SPONTANEOUS BACTERIAL PERITONITIS
- consider in any pt. who suddenly deteriorates; commonly E.coli, Klebsiella or Strep

5) RENAL FAILURE
- ↓Hepatic clearance of immune complex leads to accumulation in kidney → IgA nephropathy and hepatic glomerulosclerosis

Answer 140

A

lactulose - look this up!!!**

Answer 141

A

Hepato-renal syndrome = Cirrhosis + Ascites + Renal failure

nb this has something like an 80% mortality rate…

Answer 142

A

HEP A
- faecal-oral route
= Acute

HEP B
- Blood and Babies (vertical)
= acute or chronic (if vertical, more likely chronic - 10% chronic)

HEP C
- blood
= acute -> Chronic (90%)

“A for Acute
B for Blood and Babies
C for Chronic”

Answer 143

A

HEP A

Africa
south America
travellers
children
IVDU
MSM

HEP B

+ve mothers
IVDU
sexual intercourse

HEP C

blood transfusion
IVDU
acupuncture
perinatal transmission

don’t worry if don’t get all - understand general pattern

Answer 144

A

INITIAL of BOTH

fever (mild)
malaise
arthralgia
nausea
anorexia

LATER of HEP A

jaundice (rare in child)
tender hepatomegaly
lymphadenopathy
diarrhoea (if child)

nb can also have obstructive picture (dark urine -> pale stools)

OTHER of HEP B

urticaria (COMMON!)
jaundice
dark urine -> pale stools

Answer 145

A

FULMINANT HEPATITIS
= liver failure within 8 wks

DECOMPENSATED LIVER DISEASE

ascites
encephalopathy
GI haemorrhage

CHRONIC HEP B

fatigue
anorexia
nausea
abdo pain RUQ

Answer 146

A

Early infection often mild/asymptomatic (85%)

May have similar mild systemic Sx to HBV:

Jaundice (20%)
fatigue
arthralgia

Answer 147

A

CIRRHOSIS
- 25% after 20 years

HEPATOCELLULAR CANCER
- highest risk of all Hep viruses

of those who get cirrhosis, 4% will get cancer

nb can also get other complications, eg:

glomerulonephritis
cryoglobinaemia
thyroiditis
autoimmune hep[atitis
PAN
polymyositis

Answer 148

A

NEEDS HBV for assembly

so HBV vaccine prevents HBD

presents similarly to Hep B! (as present simulataneously or after)

always do check ANTI-HDV ANTIBODIES (blood test) if Hep B positive

Answer 149

A

faecal-oral

?pigs in eastern europe?

almost always acute

Answer 150

A

Significant mortality in PREGNANCY

Similar presentation to Hep A

“think of as Hep A but affects pregnancy more and different geographical distribution”

Answer 151

A

ALT and AST both raised in all three

conjugated and unconjugated bilirubin can both be raised as well

Answer 152

A

↑IgM +ve (from day 25 = acute/recent inf.)

↑IgG +ve detectable for life and indicates recovery or vaccination

Answer 153

A

HBsAg 
= surface antigen
- vaccine = neg
- past inf = neg
- acute inf = POS
- chronic inf = POS

Anti-HBs 
= antibody against surface antigen
- vaccine = POS
- past inf = POS
- acute inf = POS
- chronic inf = POS

Anti-HBc 
= antibody against core antigen
- vaccine = neg
- past inf = POS
- acute inf = POS (IgM)
- chronic inf = POS (IgG)

“so if just had a vaccination then just touched the SURFACE of the condition - only get to the CORE if have/had disease”

“only detect ANTIGENS in active disease - antibodies if don’t currently have disease”

“if acute infection then IgM, if chronic IgG”

nb all of these are -ve if someone has not come into contact with virus or been vacinated!

nb there’s also an E antigen which is high in acute infection (but don’t bother remembering!)

Answer 154

A

Hep B virus DNA serology (to confirm if any doubt)

liver biopsy (if complications / decompensated liver disease)

if positive, always check for anti Hep D antibodies

Answer 155

A

confirms exposure
= anti-HCV antibodies

confirms ongoing infection / chronicity
= HCV-PCR

investigation to asssess liver damage
= liver biopsy

nb can also do hcv genotype

Answer 156

A

male
older
use of alcohol
Hep b
HIV
higher HCV viral load

Answer 157

A

reduce alcohol (zero is best!)

if an acute virus, eg Hep A, stop alcohol until LFTs normalised!

Answer 158

A

IV fluids

anti-emetics (Metoclopramide)

Chlorphenamine (pruritis)

Answer 159

A

Inferferon-A (an antiviral)

nb only use in Hep A and E if fulminant hepatitis occurs (rare)

basically need additional antivirals (2 or 3 in combo - don’t bother learning names!)

Answer 160

A

need follow up:

Hep B
Hep C
Hep D

liver transplant

(Hep C is leading indication for liver transplant in UK)

Answer 161

A

1)LIVER DISEASE (75%)

2) CANCER (15%)
- mainly GI tract (gastric, colonic, pancreatic, liver Ca), also Meigs syndrome (rare complication of ovarian cancer) or secondary liver mets

heart failure
kidney disease
TB
pancreatitis
hypothyroidism
protein-losing enteropathy
nephrotic syndrome

Answer 162

A

EARLY

Abdominal DISTENSION (increases with time)
Abdominal DISCOMFORT (often mild. If severe, may be related to underlying malignancy)
WEIGHT GAIN (due to ↑fluid retention)

LATER

NAUSEA and ANOREXIA – due to pressure on stomach + s.bowel

DYSPNOEA – due to ↓venous return from lower limb from pressure on IVC and ↓expansion of lungs due to pressure on diaphragm

do SHIFTING DULLNESS to look for ascites

Answer 163

A

Abdo USS (often 1st line)

CXR – may demonstrate pleural effusion or pleural metastases or HF

Diagnostic ascetic tap or paracentesis – determines aetiology, detects cancerous cells, differentiates transudate vs. exudate, perform MC&S

Answer 164

A

HYPONATRAEMIA – diuretic effect of spironolactone or loops

HEPATORENAL SYNDROME – renal failure following liver failure (see cirrhosis notes)

Answer 165

A

Adhesions (60%)

Hernias (20%)

Volvulus (5%)

Gall stones (rare)

Answer 166

A

constipation
faecal impaction
stricture (eg dt diverticular / IBD)
volvulus (sigmoid – bowel twists upon mesentery)
colon Ca/malignancy,
hernia
Intussusception (infants)

Answer 167

A

Nausea + VOMITING

CONSTIPATION

ANOREXIA and DEHYDRATION
- (lack of colonic absorption)

Abdominal DISTENSION - ↑as obstruction progresses

Colicky ABDO PAIN
- Diffuse, central (typical)

Answer 168

A

FAECULENT
- fermentation of intestinal contents in established obstruction

FAECAL
- colonic fistula within the proximal gut causes retrograde peristalsis

BILIOUS

bright green
indicative of small bowel

Answer 169

A

Complete (faeces + flatus) = high obstruction

Partial (faeces)

Answer 170

A

LARGE BOWEL

distension more
vomiting is later
pain lower in abdomen and constant

SMALL BOWEL

vomiting is bilious + early
distension less
pain higher in abdomen

Answer 171

A

abdominal distension
- ↑Resonance on percussion

tender abdomen (diffuse)

Tinkling bowel sounds (LOUD)

examine

all hernial orrifices
do PR exam (ALWAYS!)

Answer 172

A

1) ABDO X-RAY

SMALL BOWEL

central gas shadow
Valvulae Conniventes ladder like series (completely crosses lumen)
no gas in large bowel

LARGE BOWEL

peripheral gas proximal to blockage but not in rectum
haustra (do not fully cross lumen)

SMALL
- should be < 3cm
CAECUM
- should be < 6cm
LARGE 
- should be < 9cm

(if larger than this then suggests obstruction (or toxic megacolon etc)

COFFEE BEAN SIGN = sigmoid volvulus

Answer 173

A

CXR erect – determine if perforation (pneumoperitoneum)

Contrast enema CT – use to determine exact location of obstruction

Answer 174

A

Simple – one obstructing point, no vasc compromise

Closed loop – two points of obstruction, forms loop of grossly distended bowel (→ perforation typically at caecum (bowel is thin + wide))

Strangulated – blood supply compromised, patient toxic with peritonism the cardinal sign

Answer 175

A

“DRIP and SUCK”

IV fluids (and NBM)
NGT (ryles + food)

Also do a fluid chart

Also avoid any pro-kinetic drugs e.g. metoclopramide

EMERGENCY surgery (laparotomy) – if closed loop or strangulated or >12cm dilatation

Endoscopic stenting – useful in palliative + elderly pts.

Sigmoidoscopy + flatus tube – sigmoid volvulus

Right hemicolectomy – caecal volvulus (Rare)

DON’T LEARN specific names of surgery - just know broad different types: eg emergency laparotomy, stenting for palliative etc

Answer 176

A

STRANGULATED

sharp constant pain
local peritonism
fever
↑WCC

PERFORATION

Fever
severe pain
toxic patient

Answer 177

A

PSEUDO OBSTRUCTION (Ogilvie’s syndrome) – massive dilatation of colon ± s.intestine → mechanical like GI obstruction, no cause 
- basically mechanical obstruction but with no cause found

ILEUS

non-mechanical obstruction (ileus)
commonly paralytic i.e. absence of peristalsis → adynamic bowel

Answer 178

A

ILEUS = non-mechanical or functional obstruction, commonly paralytic i.e. absence of peristalsis → adynamic bowel
- ‘normal’ obstruction is actually mechanical obstruction (ie there’s something physically in the bowel!)

IATROGENIC

post-abdo surgery
Tricyclic anti-depressants
opioids

(nb other drugs too, but these most common)

OTHER

pancreatitis
peritonitis
uraemia
electrolyte disturbances (norm HYPOkalaemia, also ↓Mg+/↓Ca2+)

Answer 179

A

Painless distension!

Bowel sounds absent entirely!!

No bowel movement or flatus

Large amounts of gas in rectum

Answer 180

A

“DRIP and SUCK”

IV fluids (and NBM)
NGT (ryles + food)

Also do a fluid chart

only do NG tube if vomiting etc - may be okay just with fluids and NBM

DEFINITIVE = treat underlying cause

eg just wait post-surgical, stop meds, correct electrolytes, treat pancreatitis and peritonitis

Answer 181

A

Abdo symptoms with no identifiable organic cause due to abnormal intestinal motility or ↑visceral perception

FEMALE>M (2:1)

≤ 40yo

nb also commonly have PMHx of mental health conditions

Answer 182

A

Criteria for diagnosis:

ABDO PAIN relieved by defecation OR a/w altered stool form

AND > 2 of:

Altered stool passage (urgency, straining, incomplete evacuation)
Abdo bloating, distension or tension
Mucous PR
Worsening symptoms after food

Answer 183

A

Lethargy
Nausea

Bladder symptoms - ↑freq, nocturia etc.

Back ache

Examination often normal
- Abdominal tenderness (general) is common

Answer 184

A

Exacerbation with stress, menstruation or post-infective

Answer 185

A

crohns
ulcerative colitis
coeliac disease
lactose intolerance
diverticular disease
gastroenteritis (eg giardiasis)
colon cancer
endometriosis
ovarian tumours
hypo/hyperthyroid

medications, eg opioids, TCAs, calcium channel blockers

Answer 186

A

FHx:

colon cancer
ovarian cancer
IBD

if >50 at presentation (GI or ovarian malignancy)

waking at night with pain / diarrhoea
timing cyclical with period (endometriosis)
mouth ulcers (crohn’s)
anorexia
weight loss
blood in stools (or on PR)

nb mucus is often present in IBS

red flags if any abnormality on bloods or other investigations

Answer 187

A

Bloods – if Hx is classic IBS then:

FBC
LFT
ESR
CRP
TTG (Coeliac screen)

Serum CA-125 = exclude ovarian Ca (ESSENTIAL if >50yo woman, if high → urgent USS)

always do FAECAL CALPROTECTIN
- if raised, consider IBD

consider stool culture if diarrhoea prominent

Referral Colonoscopy – if > 50yo or any marker or organic disease (Blood PR, ↓Weight)

Answer 188

A

Regular meals, avoid missing meal or long gaps
8 cups fluid/d, restrict tea + coffee to 3/d, ↓fizzy drink/alc
↓high fibre food; starch; fruit (↓3/d)

encourage ↑exercise

CONSTIPATION
= Bisacodyl (stimulant) + Sodium Picosulfate (stool softener)
- (must avoid lactulose - osmotic)

DIARRHOEA
= Loperamide (take after each loose stool)

BLOATING / COLIC
= antispasmodics (eg Mebeverine, Alverine citrate)

2nd LINE

amitryptiline (or SSRIs)
CBT (if no response in 12mo)

Answer 189

A

weak anal sphincter PLUS prolonged straining or chronic neuro/psych disorder → mucosa (partial/type 1), or all layers (complete/type 2 – more common) of rectum protrude through anus

nb can be Internal or External

Answer 190

A

biggest:

ELDERLY
FEMALE
MULTIPAROUS

CAUSES OF ↑INTRA-ABDOMINAL PRESSURE

constipation
diarrhoea
BPH
preg
obesity
chronic cough (eg COPD, CF, Whooping cough)

OTHER RARER

pelvic floor dysfunction
parasitic infection
neuro disease (lumbar disc disease, cauda equine synd)

Answer 191

A

Mass protruding through anus:

1) Initially after bowel movement, retracts spontaneously
2) Then protrudes often, with straining + valsalva manoeuvres e.g. cough, sneeze
3) Late protrudes w/ normal ADL, manually replace

Pain
Constipation
Faecal incontinence (75% - common in external)
discharge of mucous
rectal bleeding
Ulceration if external

Answer 192

A

DRE – protruding mass (w/ concentric rings of mucosa), rectal ulcers, ↓anal tone

Barium enema /Colonoscopy – evaluate colon prior to surgery to exclude other lesion

Stool microscopy/cultures – GI infection

Answer 193

A

Child

Use water-soluble lubricant
High fibre diet
Mild laxative

Elderly

Manually reduce prolapse – covering w/ sugar ↓swelling
Subcutaneous circumanal rubber ring

Answer 194

A

RECTO-SIGMOID-ECTOMY
- if prolapse is strangulated

HAEMORRHOIDECTMY
- if simply mucosal prolapse

ABDOMINAL PROCEDURES

preferred and include either
– Marlex rectopexy (Ripstein’s), suture rectopexy, resection rectopexy (Frykman-Goldberg)

PERINEAL PROCEDURES
- ↑recurrence rate
- ↓morbidity
eg Anal encirclement (Thiersch;s wiring), Derlome’s mucosal sleeve resection (common), Altemeir’s perianal rectosigmoidoscopy

don’t learn details: just know conservative options and broadly different types of surgery

Answer 195

A

straining, effects of gravity (erect posture) and ↑anal tone → disrupted and dilated anal cushions → piles
– vulnerable to trauma + bleeds readily

different types:

EXTERNAL (below dentate line)
– more prone to thrombosis

INTERNAL (above dentate line) grading:

1st degree = remains in rectum
2nd degree = prolapse through anus on defecation, spontaneously resolves
3rd degree = requires digital reduction
4th degree = remain persistently prolapsed, cannot be reduced

nb haemorrhoids is the Greek word for running blood

Answer 196

A

Constipation
pelvic tumour
preg
CCF
portal HTN

Basically any type of congestion downstream in the blood vessels

Answer 197

A

1) PAINLESS Rectal BLEED – bright red (most common)
- Often coats stools, on tissue or dripping in toilet post-defecation

Pruritis ani (irritation of anal region)
Mucous discharge
Rectal fullness or discomfort
Anaemia/fatigue due to bleed

Answer 198

A

piles are not painful (unless THROMBOSED when gripped by anal sphincter – blocking venous return)

Answer 199

A

Weight loss
tenesmus
change in bowel habit

Answer 200

A

Abdominal + PR exam – (1st line) palpate 3 cushions, prolapsing piles are obvious, internal haemorrhoids are not palpable

OTHER INVESTIGATIONS TO CONSIDER

FBC - if think also anaemic

Proctoscopy – visualise internal haemorrhoids + other causes for bleeding

Sigmoidoscopy – visualise high rectal pathology

Answer 201

A

LIFESTYLE

↑Fluid intake
↑Fibre

MEDICAL – eg for 1st degree haemorrhoids:

analgesia (Topical/PO analgesics + steroids)
Stool softener

avoid codeine (↑constipation), NSAIDs (worsens bleeds)

NON-OPERATIVE – for 2nd/3rd degree

RUBBER BAND LIGATION (1st line) – low recurrence rate, band is applied to base of haemorrhoid causing strangulated haemorrhoid to become necrotic and slough off

others:
- Sclerotherapy (high recurrence)
- Infra-red coag
- Cryotherapy – high complication rate
^don’t bother learning these 3 methods

SURGICAL

1) EXCISIONAL HAEMORRHOIDECTOMY – most effective Tx involves excision of piles ± ligation of vasc pedicles
2) STAPLED HAEMORRHOIDECTOMY – circular stapling gun excises haemorrhoid

Answer 202

A

Strangulation a “vicious cycle” – vascular cushions protrude through tight anus → ↑congestion + hypertrophy of cushions → ↑frequency of protrusion → ↑risk of strangulation → pain!!

Answer 203

A

Perianal haematoma
anal fissure/abscess,
Proctalgia fugax (aka functional recurrent anorectal pain - diagnosis of exclusion)
rectal cancer

Answer 204

A

= Abscess (collection of pus) located in anal or rectal region

E. Coli
Staph Aureus

also:

STI
blocked anal glands

PERI-ANAL (45%)

Can also be Ischiorectal (<30%) or Intersphincteric (>20%)

Answer 205

A

Crohn’s disease
diverticulitis
anal / colorectal cancer
diabetes mellitus
immunocompromised
anal sex

Answer 206

A

Painful (throbbing, worse when sat down) +

Hardened tissue in peri-anal area – erythematous, swollen, tender

Lump or nodule at anus

Discharge of pus from rectum
Fever
Constipation
Pain a/w bowel movement

Answer 207

A

DRE – usually sufficient for diagnosis

Procto-sigmoidoscopy – may be performed to exclude associated diseases / risk factros (see prev flashcard)

Answer 208

A

1) Surgical incision + drainage
2) Analgesia
3) Abx – not usually necessary unless a/w DM or immunosuppression

Answer 209

A

Fistula-in-ano – 40% of abscess pts.

Answer 210

A

inflammatory bowel disease

anal / colorectal cancer

Answer 211

A

aka Fissure-in-ano

nb don’t confuse with FISTULA-in-ano

Painful tear in squamous mucosa of lower anal canal (often chronic w/ sentinel pile or mucosal tag externally)

common – 11% lifetime incidence

Answer 212

A

constipation / hard faeces
spasms (→constricts rectal artery →ischaemia → ↓healing ability)
trauma
syphilis
herpes
crohn’s
anal cancer

Answer 213

A

Common between 20-40yo

M=F

Acute < 6 wks

Chronic ≥ 6 wks

Answer 214

A

1) ANAL PAIN
- Exacerbated by defecation
- Feels like passing shards of glass
- Persists several hours post-defecation

2) BLEEDING during defecation
– FRESH, bright red

Answer 215

A

Fissure visualised on EXTERNAL exam of anus
– linear split of mucosa

Part the buttocks gently to view

Majority are posterior in midline

Acute
= clear edges, liner
Chronic
= deep, a/w external skin tag

Secondary
= tend to be multiple
Primary
= tend to be single

Do not attempt DRE – VERY PAINFUL!!!!

Answer 216

A

1) ANALGESIA
– Paracetamol or Iburpofen
- Do not prescribe opioids (will exacerbate)

2) Bulk forming LAXATIVE – 1st line

TOPICAL

1) TOP ANAESTHETIC
– Lidocaine 5% ointment (severe pain)

2) PR GTN ointment
– if primary anal fissure with symptoms > 1 week w/o improvement

2ND LINE
- TOP Diltiazem
- TOP Botulinum toxin
(don’t bother learning this)

Answer 217

A

Good anal hygiene,

Avoid stool holding,

Soak in shallow warm bath

Answer 218

A

Haemorrhoids,
Abscess,

Proctitis,
Perianal sepsis

Answer 219

A

chronic constipation → colon becomes distended with gas → twists on mesenteric pedicle → CLOSED LOOP OBSTRUCTION

if not treated quickly can → venous INFARCTION → PERFORATION → faecal peritonitis

Answer 220

A

elderly
Male
chronic constipation or laxative use
crohn’s disease
prev abdo surgery

Answer 221

A

Acute abdominal PAIN
– Colicky

GROSS Abdominal DISTENSION

CONSTIPATION
– Failure to pass stool OR FLATUS

Vomiting (late typically, at this point distension is severe)

how to distinguish from other causes of large bowel obstruction:

increased speed of onset (over a few hours)
increased degree of abdo distension

NB: it may present insidiously with chronic abdo distension, constipation, vague colicky pain, vomiting

Answer 222

A

GROSS abdo DISTENSION

INCREASED resonance to precussion
palpable mass (maybe)

DRE
– test for passage or presence of flatus or stool
- Often find EMPTY RECTAL AMPULLA

Answer 223

A

bowel wall ischaemia
perforation (norm follows ischaemia)
blood-stained stool
peritonitis
shock
increased temp

need EMERGENCY surgery!! (norm laparotomy - if fit enough!)

Answer 224

A

AXR
– Single grossly dilated sigmoid loop > 9cm (COFFEE BEAN)
– commonly reaches xiphisternum

Erect CXR
– exclude perforation (air under diaphragm)

CT abdo – allows visualisation of volvulus and assessment of bowel wall ischaemia

Answer 225

A

1) URGENT DECOMPRESSION
- Pt. lies left lateral, insert Sigmoidoscope into rectum as far as possible and pass Flatus tube alongside
- Manoeuvre into obstructed loop through twisted bowel
- Rush of liquid faeces and flatus → relieves obstruction
- Leave tube in situ for 24hrs – maintains decompression, prevents recurrence, promotes bowel’s vascular supply recovery

2) SURGICAL
- After conservative Tx, recurrences occurs therefore elective surgery is frequently required
- Resection of redundant sigmoid colon – usually a double barrel colostomy (Paul-Mikulicz)

Answer 226

A

other causes of LARGE BOWEL obstruction (eg cancer, faecal impaction, strictures, hernias etc)

also consider pseudo obstruction, ileus etc

also could be a giant sigmoid diverticulum