General GI Clinical Flashcards
What are the 9 regions of the abdomen?
(Hypochondriac is more commonly known as Upper quadrants, and hypogastric is more commonly known as suprapubic)
What is the difference between visceral and somatic pain?
Somatic pain is more localised, and much more sore when you press on it. Visceral pain is more generalised and is constant
What is the differential for epigastric pain?
Cardio: MI, AAA rupture, dissected aorta
Oesophagus: GORD, oesophagitis, barrett’s
Stomach (ant.): gastritis, gastric ulcer, gastroenteritis
Gallbladder radiation: Acute cholecystitis Pancreatitis and duodenal ulcer (felt in back)
What is the differential for LUQ pain?
Lung: basal pneumonia, pleural effusion, PE
Cardiac: AAA Spleen: ruptured/infarct/injury
Kidney: pyelonenephritis
What is the differential for RUQ pain?
Lung: basal pneumonia, pleaural effusion, PE
Gallbladder: Biliary colic, cholecystitis
Liver: hepatitis, hepatic abscess, congestive hepatomegaly
Bowel: perforated duodenal ulcer
Kidney: pyelonephritis
Appendicitis (rare)
What is the differential for LLQ pain?
Appendicitis
Bowel: Meckel’s, Crohn’s, IBS, colitis, ruptured caecum. large bowel obstruction
Gyn: Ectopic pregnancy, salpingitis, ovarian/teste cyst/torsion, pelvic inflammatory disease
Hernia
What is the differential for RLQ pain?
Bowel: Diverticulitis, colitis, UC, large bowel obstruction
Gyn: Ectopic pregnancy, salpingitis, ovarian/teste cyst/torsion, pelvic inflammatory disease
Hernia
What is the differential for umbilical pain?
Cardio: AAA Early appendicitis
Gastric: gastroenteritis, gastric ulcer,
Bowel: Small bowel obstruction, bowel ischaemia, umbilical hernia, crohn’s
Pancreas: abscess, pancreatitis
What could shoulder pain with abdominal pain indicate?
Diaphragmatic irritation
If the patient is lying completely still, what does this indicate?
Inflammatory condition (worse on movement)
If the abdomen is moving with breathing what is it not?
General peritonitis
If the patient is moving around a lot and can’t stay still, what does this indicate?
Colic
Asking your patient to puff, suck in tummy or give various coughs can show the presence of what?
Peritonitis (as this is asking them to bring the area causing issues in contact with peritoneum)
Where is McBurney’s point?
Diagonal line from right anterior superior iliac spine to umbilicus, and go a third forward from the anterior superior iliac spin
True or False: Biliary colic is relieved on eating
False, it is worse on eating
True or False: diverticulitis is relieved on eating
True
What are the 3 life-threatening conditions that must always be excluded with abdominal pain?
1) Ischaemic bowel 2) Ruptured AAA 3) Acute pancreatitis
What is Murphy’s sign an indicator of?
Cholecystitis
How is Murphy’s sign tested?
It is performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner’s fingers) and winces with a ‘catch’ in breath, the test is considered positive.
What is McBurneys sign?
Tenderness over McBurney’s point is an indicator of appendicitis
What is the definition of an abdominal mass?
Any mass (swelling) which is: • Inside the abdominal cavity • In the wall Or • Bulging through the wall
Which regions does the stomach lie in?
Epigastrium and umbilical
Which regions does the liver lie in?
left hypochondrium, epigastrium and left lumbar
Which regions does the pancreas lie in?
Umbilical
For an abdominal exam, what is the appropriate exposure?
• From nipples to mid thigh in male • Below breasts to the pubic bone in females
During respiration, how will organs with a mesentery move?
Only obliquely, in ONE direction i.e., perpendicular to the line of FIXATION of the mesentery.
How would you test for a fluid thrill?
Put your hands in the middle then move it from one side to another and you will feel a thrill
What are the 4 barium contrast studies possible, and which organs would you be investigating for each?
- Barium Swallow for Oesophagus
- Barium Meal for Stomach & Duodenum (Shown)
- Barium Meal & Follow Through for Small Intestine
- Barium enema for the colon
What are some of the general postoperative complications that occur with any surgery?
- Bleeding during surgery (inevitable - Infection of incision site - Incisional hernia
What is reactionary haemorrhage?
Occurs immediately post-operatively - may occur if havent tied off a vessel properly etc (most common)
What is secondary haemorrhage?
Caused by infection (5-10days later)
How would you prevent post-operative DVT( & PE)?
- Compression stockings - Low dose subcutaneous heparin - Early mobilisation
Why can atelectasis/pneumonia occur following surgery?
Anaesthesia increases secretions in the lung and inhibits cilia. Post-op pain inhibits coughing and also stomach contents can be aspirated into lung during surgery.
What are the causes of paralytic ileus?
• Handling of bowel during surgery • Peritonitis • Retroperitoneal injury • Immobilisation • Hypokalaemia • Drugs
What can cause post-op adhesions to form?
Inflammatory responses or ischaemia
How can you prevent adhesions forming?
• No powder on gloves • Avoidance of infection • Laparoscopic surgery • Sodium hyaluronidate – substance that slightly reduces risk of adhesions
What are the causes of post-op confusion?
• Hypoxia • Oversedation • Sepsis • Electrolyte imbalance (dehydrated?) • Stroke • Hyper or hypoglycaemia • Alcohol or tranquilliser withdrawal
What is the ERAS and what are the main objectives?
Enhanced Recovery After Surgery - multimodal programme to minimise post-op complications. Objectives are to promote pain control, GI function and mobility
Which endoscope would you use to look at the oesophagus/stomach or duodenum?
Oesophago-gastro duodenoscopy or a gastroscopy for stomach alone
Which endoscope would you use to look at the small bowel?
Enteroscope
What is endoscopy the main therapeutic intervention for?
GI bleeding
What does maelena indicate for a upper GI bleed?
>400ml of bleeding
Which endoscope techniques can be used for varieal bleeding?
- Injection sclerotherapy (ethanolamine) - Banding - Histocryl glue
Which endoscope techniques can be used for arterial bleeding?
- Inhection therapy (adrenaline) - Heater probe (coagulation) - Clips ‘ligate’
What are the 3 techniques used with gallstone removal?
- Sphincterotomy • Lateral internal sphincterotomy involves stretching or cutting the internal sphincter
- Balloon and trawl • The trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile.
- Lithotripsy • Treatment, typically using ultrasound shock waves, by which a kidney stone or other calculus is broken into small particles that can be passed out by the body.
What 4 broad things can endoscopes be used for?
- Investigation - Therapy - Nutrition - Screening
What is a PEG insertion?
Percutaneous Endoscopic Gastroscopy) is a way of introducing food, uids and medicines directly into the stomach by passing a thin tube through the skin and into the stomach
What is the order of investigation for cholecystitis/biliary colic?
US then confirmed with MRCP and/or ERCP
What is the diagnostic feature of pancreatitis?
Raised amylase
What does free sub-phrenic gas indicate?
Perforation
What are the 2 first line investigations for appendicitis?
Pregnancy test and ultrasound
What is the primary investigation for diverticulitis?
CT or barium enema
What are the lines of investigation of GI bleed?
CT with IV contrast when actively bleeding, then endoscopy then angiography
What are the main investigations used with change in bowel habit?
CT colonography (virtual colonoscopy), barium enema or flexible sigmoidoscopy
What is the first line of investigation for jaundice?
Ultrasound (then ERCP/MRCP then CT)
What is the definition of a hernia?
An abnormal protrusion of a viscus outwith its normal body cavity
What is the commonest hernias (in order)?
1) Inguinal (80%) 2) umbilical (8%) 3) incisional (7%) 4) femoral (5%)
What is the main underlying risk factor for hernias, and what can cause this?
Raised intraabdominal pressure; heavy lifting, coughing, constipation, pregnancy and obesity
What are the subdivisions of hernia?
Reducible or non- reducible. And non-reducible can be further classed as incarcerated (more chronic) or obstruction/strangulation
What does a strangulation hernia entail?
Denotes compromise of the blood supply of the contents. The low pressure venous system is occluded first and then the arterial supply becomes occluded, with the development of gangrene
Para-umbilical and umbilical- which occur in adults and which occur in children?
Para-umblical= adults Umbilical = young children
Which group of people are femoral hernias most common in?
Thin, elderly females (males hardly ever have femoral)
What is patent processus vaginalis and what can it result in?
Failure of the closure of the vaginalis process during tests development; can result in communicating hydrocele or hernia
What differentiates a femoral hernia over an inguinal?
Femoral are blow and lateral to the pubic tubercle and usually flatten the groin crease, while inguinal are above the pubic tubercle and increase the groin crease
Where is the anatomical boundary of the deep inguinal ring?
Mid-inguinal point
Where is the anatomical boundary of the superficial inguinal ring?
Above and medial to pubic tubercle
What is Hesselbach’s triangle?
• Inguinal ligament inferiorly • Inf Epigastric vessels laterally • Lateral border of rectus sheath medially
How can you differentiate between a indirect and direct hernia?
•Pressure over the deep inguinal ring and get patient to cough • Place little finger in the canal (behind cord)
What causes an epigastric hernia?
Weakness of the lines alba (fibrous structure down midline of umbilicus)
What is a femoral hernia?
Defect in the femoral canal (an anatomical compartment, located in the anterior thigh, part of the femoral sheath - carries lymphatics)
What is the difference between direct and indirect hernias?
A direct inguinal hernia arises through a weakness of the posterior wall of the inguinal canal medial to the inferior epigastric vessels, specifically through the Hesselbach’s triangle. This type of hernia is termed direct as the hernial sac directly protrudes through the inguinal wall in contrast to indirect ones which arise through the deep ring and enter the inguinal canal.
What are some of the main differences between direct and indirect inguinal hernias?
-Indirect are lateral to the inf epigastric vessels, while indirect are medial Direct is more common in older men, while indirect is more common in younger. -Indirect is controlled by digital pressure over the inguinal ring, while direct is poor controlled by digital pressure -Indirect are more likely to strangulated and have complications than direct
When would you operate on a hernia?
- At risk of complications even if no symptoms (eg femoral) - Previous symptoms of obstruction - Interfering with lifestyle
Which hernias are women more likely to have?
Femoral or inguinal
What hernias are men more likely to have?
Inguinal by far
What is your approximate circulating volume?
5 litres
What are the 4 main causes of upper GI bleeding?
1) Peptic ulcer disease 2) Mallory weiss tear 3) Oesophageal varices 4) Gastritis/oesophagitis
What is the immediate management of acute upper GI bleed?
Insert 2 large bore IV cannuli (grey or brown venflon) - 1 in each cubital fossa
What are the 2 main treatments for bleeding ulcers?
Endoscopic treatment and acid suppression
What are the 4 categories of impact on public health by natural disasters?
1) Direct impact on health of population 2) Direct impact on health care system 3) Indirect impact on health of population 4) Indirect impact on health care system
What are examples of direct impact on health of population by natural disasters?
Injuries directly caused by the disaster, outbreak of communicable diseases, chronic conditions not being cared for (e.g. prescriptions/monitoring), loss of resources psychological effects
What are examples of direct impact on healthcare system by natural disasters?
Damage to internal physical infrastructure (damage to hospitals itself and water supplies etc), loss of resources and loss of personnel
What are examples of indirect impact on health of population by natural disasters?
Loss of primary healthcare (e.g. immunisations, antenatal screening etc) and loss of normal living conditions
What are examples of indirect impact on healthcare system by natural disasters?
Loss of external infrastructure e.g. roads and transport
What are the signs of perforated duodenual ulcers?
Gas under diaphragm and bowel sounds are absent as has hole so bowel in shock/rigid
What are the 3 main causes of pancreatitis?
Gallstones, ethanol and trauma from ERCP
Murphy’s sign
Cholecystitis
Where is diverticulitis most commonly found?
Left iliac fossa
Virchow’s node
First lymph node outside of stomach (only on left). Indicates gastric cancer.
Middle aged women, itchy, jaundiced and lethargic
Primary biliary cirrhosis
Which is more common, PBC or PSC?
PBC
What is the fundamental difference between pathophysiology of PBC and PSC?
PBC = inflammatory
PSC = stricutres
“slate grey”
Haemachromotosis
Charcot’s triad
Fever, jaundice and RUQ pain - Ascending cholangitis
Which symptoms differentiate UC and Crohn’s?
UC - bloody diarrhoea, urgency, relieved by defecation
Crohns - malabsorption
What is the management of IBD based on severity?
- Mild (<4 stools a day) - mesalazine (5-ASA) and prednisolone
- Severe (>8 stools a day) - IV hydrocortisone or enema steroids in exacerbation
Which criteria is used to assess the severity of UC?
Truelove & Witts criteria
When does pyoderma gangrenosum and erythema nodosum occur?
Pyoderma gangrenosum = Crohns only
Erythema nodosum = both
What is TIPSS used for?
Portal hypertension
