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3rd year > Abdo core conditions > Flashcards

Abdo core conditions Flashcards

1
Q

Which drugs are a risk factor for reflux

(3) ?

A

Antimuscarinics, Ca blockers and nitrates

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2
Q

what are the risk factors for reflux? (5)

A 
Pregnancy 
fatty food, alcohol, chocolate 
obesity 
achlaasia 
hiatus hernis
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3
Q

What aggravates the pain in reflux?

A

lying down/ bending over

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4
Q

Drinking what makes reflux worse?

A

alcohol or hot drinks

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5
Q

What is the word for pain on swallowing ?

A

odynophagia. You get this with reflux

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6
Q

what investigations would you do in reflux?

A

Upper GI endoscopy

Intraluminal monitoring

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7
Q

What results would you need to get in intraluminal monitoring for it to count as excessive reflux?

A

pH<4 for >4% of the time

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8
Q

What drugs would you treat reflux with?

A

Alginate- containing antacids (magneisum trisiclate or gaviscon)

Prokinetic agents- metocloperamide

h2-receptor anatgonists: cimetidine

PPI- omeprazole

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9
Q

What do you use Prokinetic agents for? Give an example

A

Reflux, increase gastric emptying

metocloperamide

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10
Q

What do you use H2-receptor anatgonists for? Give an example

A

Reflux, acid suppression

cimetidine

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11
Q

What surgery do you use in reflux?

A

Nissen Fundoplication

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12
Q

where is the pain in reflux?

A

Burning retrosternal pain

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13
Q

What is the definition of an ulcer?

A

A breach in the epithelium that penetrates the muscularis mucosae

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14
Q

What are the main causes of peptic ulcers?

A

H.pylori infections, NSAIDs} most common

Rare: Zollinger-Ellison syndrome
Crohn’s disease

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15
Q

How does a H.pylori infection cause stomach ulcers?

A

Causes inflammation of mucosal lining therefore depleting the alkaline mucosa
Also impairs the cells that produce somatostatin which limits the secretion of gastric acid

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16
Q

What are the 4 main risk factors for peptic ulcers?

A

NSAIDs, smoking, aspirin, alcohol

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17
Q

Where is the pain in peptic ulcers? And where does it radiate?

A

Burning epigastric pain

radiates up to the neck, down to the umbilicus or to the back

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18
Q

Aside from pain what are the other symptoms of peptic ulcer?

A

Indigestion
heartburn
weightloss and loss of appetite
nausea

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19
Q

How does food affect gastric ulcer pain?

A

It makes it worse

It improves duodenal ulcer pain

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20
Q

What are the 3 tests for H.pylori?

A

Urea breath test
stool antigen test
Laboratory serology testing

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21
Q

What are the criteria for being able to have a urea breath test or stool antigen test?

A

Can’t have had PPI in the past 14 days or antibiotics in the past 28 days

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22
Q

How do you treat peptic ulcers due to NSAIDs?

A

1) Stop NSAIDs
2) If no H.pylori give a full dose of PPI for 1 or 2 months
3) If H,pylori present give PPI for 2 months them prescribe eradication therapy.
4) Retest for H.pylor 4-6weeks later
5) repeat endoscopy 6-8weeks after treatment

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23
Q

If PPI isn’t sufficient in peptic ulcers what do you give?

A

H2-receptor anatgonists e.g. cimetidine

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24
Q

How do you treat peptic ulcers due to H.pylori?

A

7 day triple therapy regimen with twice daily dosing

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25
Q

What are the options for eradication therapy of H.pylori in peptic ulcers?

A

1) Amoxicillin + clarithromycin + PPI e.g. lansoprazole, omeprazole or pantoprazole
2) Clathrithromycin + metronidazole + PPI

(If they’ve been treated with clarithromycin or metronidazole within the last year then use the other to prevent resistance)

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26
Q

What is the second course of eradication of H.pylori in peptic ulcers?

A

Antibiotics previously given

for 14 days as quadruple therapy

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27
Q

what is the most common cause of an upper GI bleed?

A

Peptic ulcer disease

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28
Q

What are the causes of an upper GI bleed? (10)

A 
1- peptic ulcer disease 
2-oesophageal varices- due to liver cirrhosis and cancer
3-oesophageal inflammation 
4- mallory Weiss tears
5- angiodysplasia
6- NSAIDs
7- COX-2 inhibitors 
8- Oesophagitis 
9- Duodenitis 
10- Malignancy
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29
Q

What are the risk factors for an upper GI bleed? (7)

A 
age 
heart failure 
IHD 
renal disease 
Liver disease 
malignant disease
ulcer
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30
Q

What is the scoring system for upper GI bleeds?

A

Rockall from 0-8+

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31
Q

What are the main signs and symptoms of a GI bleed? (5)

A 
Dyspepsia (pain) 
haematemesis 
haematochezia- bright red blood in stool, massive volume loss 
Melena 
shock
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32
Q

What are the signs of shock? (8)

A 
Dizziness 
SOB 
pale skin 
loss of consciousness 
peripherally shut down- cool and clammy, slow cap refill 
poor urine output (<25ml/h) 
tachycardic >100bpm 
hypotensive
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33
Q

What causes massive lower GI bleeds? (2)

A

These are rare
diverticular disease
ischaemic colitis

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34
Q

What causes small lower GI bleeds?(5)

A 
haemorrhoids 
anal fissures 
IBD 
Crohn's
Cancer
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35
Q

What investigations do you do in a lower GI bleed?

A

Protoscopy
flexible sigmoidoscopy
colonoscopy
angiography

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36
Q

What do you use protoscopy for?

A

Lower Gi bleeds- haemorrhoids

for anus, anal canal, rectum and sigmoid colon

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37
Q

What do you use flexible sigmoidoscopy or colonoscopy for?

A

Lower GI bleeds due to IBD, cancer, ischaemic colitis, diverticular disease or angiodysplasia

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38
Q

Is crohn’s continuous or discrete?

A

Discrete- it has skip lesions

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39
Q

Where in the GI tract does Crohn’s affect?

A

Anywhere from the mouth to the anus

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40
Q

How much of the intestinal wall is affected in Crohn’s?

A

the FULL thickness

in UC it’s only the mucosa

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41
Q

What are the risk factors for Crohn’s? (5)

A 
Smoking
Family history 
appendectomy 
NSAIDs 
oral contraceptives (small)
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42
Q

When does crohn’s commonly present?

A

adolesence and early adulthood

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43
Q

Is crohn’s more common in men or women?

A

M=F

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44
Q

What are the GI symptoms of Crohn’s (12)

A 
1- Diarrhoea- may be nocturnal, may have urgency, may have tenesmus
2- Blood or mucus in stool 
3- abdominal pain 
4- history of similar episodes 
5- weight loss 
6- anorexia 
7-fatigue 
8-fever 
9- malabsorption 
10- mouth ulcers
11- anal or perianal skin tag
12- fistula or abscess
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45
Q

Where does abdominal pain typically present in Crohn’s?

A

In the right lower quadrant

A mass may also be felt

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46
Q

What are the extra-intestinal manifestations of Crohn’s?(6)

A 
Irits 
Post-articular arthrtitis
erythema nodosum 
apthous ulcers 
pyoderma gangrenosum 
episcleritis
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47
Q

With what condition do you get post-articular arthritis?And what are it’s signs?

A

Crohn’s
affects fewer than 5 large joints
usually asymmetrical
self-limiting and acute

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48
Q

what is erythema nodosum associated with?

And what are it’s signs?

A

Crohn’s
Tender, red/violet subcutaneous nodules
usually on anterior tibial or extensor surfaces of legs/ arms

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49
Q

What investigations do you do in Crohn’s? (6)

A 
FBC- assess for anaemia due to blood loss, malabsorption or malnutrition 
CRP and ESR 
U&amp;Es 
LFTs
stool microscopy and culture 
tissue transglutaminase
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50
Q

When should people with Crohn’s be treated as an emergency?

A

If they have bloody diarrhoea and fever or tachycardia

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51
Q

Why shouldn’t you offer anti-diarrhoeals to people with unconfirmed crohn’s?

A

If it turns out they have UC then anti-diarrhoeals can precipitate toxic megacolon

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52
Q

What lifestyle change should people with Crohn’s make?

A

stop smoking

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53
Q

What are the drug options in Crohn’s? (4)

A

Corticosteroids
Immuno-Suppressants: azathioprine, mercaptopurine and methotrexate
^ or cytokine-modulating drugs: infliximab and adalimumab
Aminosalicylates- mesalazine and sulfasalazine

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54
Q

What immunosuppressants can be used in Crohn’s? (3)

A

Azathioprine
mercaptopurine
methotrexate

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55
Q

What can you use instead of immunsuppressants in Crohn’s?

A

Cytokine-modulating drugs
Infliximab
adalimumab

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56
Q

What aminosalicylates can be used in Crohn’s?

A

Mesalazine and sulfasalazine

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57
Q

What do you offer adolescents or children who are failing to grow due to Crohn’s?

A

Enteral nutrition

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58
Q

What are the complications of Crohn’s? 8

A 
Intestinal strictures 
abscess
fistulas- peri-anal, bladder and vagina 
anaemia 
malnutrition 
growth failure 
colorectal and small intestine cancers 
metabolic bone disease- osteopenia, osteoporosis and osteomalacia
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59
Q

Where does UC affect?

A

The mucosa of the rectum and variable lengths of the colon

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60
Q

Where does Ulcerative proctitis (subtype of UC) affect?

A

Inflammation is limited to the rectum

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61
Q

Where does Left-sided colitis (subtype of UC) affect?

A

inflammation affects rectum and doesn’t extend proximally beyond the splenic flexure

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62
Q

Where does extensive colitis/ pan colitis (subtype of UC) affect?

A

Inflammation extends beyond splenic flexure to affect entire colon

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63
Q

What are the risk factors for UC? 3

A

Oral contraceptives
FH
Not smoking

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64
Q

When is the peak incidence of UC?

A

15-25 years

smaller peak 55-65

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65
Q

What are the GI symptoms of UC? 7

A

1- bloody diarrhoea for more than 6 weeks or rectal bleeding
2- faecal urgency
3- nocturnal defecation
4- tenesmus
5- abdominal pain
6- pre-defecation pain, relieved on passing stool
7- severe may –> malaise and fever, weight loss, faltering growth

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66
Q

Where is the pain in UC?

A

Left lower quadrant

Crohn’s is on R

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67
Q

What are the extra-intestinal symptoms of UC? 7

A 
1- anaemia 
2-pauci-articular arthritis
3- erythema nodosum 
4-apthous ulcers
5-episcleritis 
6- pyoderma gangrenosum 
7- hepatobiliary conditions; primary sclerosing cholangitis, pericholangitis, steatosis, chronic hepatitis, cirrhosis and gallstones
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68
Q

What investigations do you do in UC? 7

A 
FBC 
CRP and ESR 
U&amp;Es 
LFTs
Tissue transglutaminase 
stool microscopy and culture 
Faecal calprotectin
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69
Q

What would LFTs show in UC?

A

Reduced albumin, which suggests hypoproteinaemia due to malabsorption or intestinal losses

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70
Q

Why do you test tissue transglutaminase in UC and crohn’s?

A

to rule out coeliac disease

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71
Q

What bugs would you request testing for in a stool microscopy and culture for UC? 3

A

C-dif toxin
campylobacter
E.Coli O157

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72
Q

Why do you test faecal calprotectin in UC?

A

to distinguish IBS and IBD, will be raised in IBD

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73
Q

What is the first treatment option for mild or moderate UC?

A

Aminosalicylates (5-ASAs)
suphalazine
mesalazine

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74
Q

When do you use corticosteroids in UC?

A

With or instead of 5-ASAs for flare ups if 5-ASAs aren’t enough
prednisolone

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75
Q

What 3 drug types can you use to induce remission in UC?

A

Aminosalicylates
corticosteroids
immunosuppressants

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76
Q

What do you use immunosuppressants for in UC? and which ones?

A

Mild to moderate flare-ups
or to induce remission if other meds haven’t worked
tacrolimus
azathioprine

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77
Q

What is the downside of immunosuppressants in treating UC?

A

They take a while to work

usually 2-3 months

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78
Q

What immunosuppressant do you use to treat severe flare ups of UC?

A

ciclosporin
stronger and faster than the others (tacrolismus and azathioprine)
given IV

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79
Q

How do you treat severe flare ups of UC?

A 
1- ciclosporin 
If that doesn't work: 
Biologic medications: 
infliximab 
adalimumab 
golimumab 
vedolizumab
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80
Q

What are the surgical options for UC?

A

Colectomy
May have an ielostomy–> stoma bag
or an ileo-anal pouch–> allows stool to pass normally

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81
Q

What are the complications of UC? (4)

A

Toxic megacolon
colorectal cancer
venous thromboembolism
osteoporosis

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82
Q

What age range is IBS most common in?

A

20-30year olds

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83
Q

Is IBS more common in males or females?

A

F>M

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84
Q

What is abdominal pain associated with in IBS?

A

Either relieved by defecation

or associated with altered bowel frequency or altered stool form

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85
Q

Aside from abdominal pain what are the other common symptoms of IBS? 4

A

1- altered stool passage:straining, urgency or incomplete evacuation
2- abdominal bloating, distension, tension or hardness
3- symptoms made worse by eating
4- passage of mucus

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86
Q

What are the first line drug treatment options for IBS? 3

A

Antispamodic- meververine, alverine or peppermint oil

Laxatives - bulk forming ones are preferred e.g ispaghula or sterculla

antimotillity drugs e.g. loperamide

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87
Q

If IBS symptoms don’t repsond to first line treatment options what can you give?

A

Low dose tricylcic antidepressant
e.g. amitriptyline
at night

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88
Q

What classifies as acute diarrhoea?

A

three or more episodes lasting for less than 14 days

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89
Q

What classifies as persistent diarrhoea?

A

lasts for more than 14 days

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90
Q

What is dysentery?

A

loose stools, with blood and mucus, often with pyrexia and abdominal cramps

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91
Q

What organisms cause bloody diarrhoea? 5

A 
Campylobacter 
Entamoeba histolytica 
E.Coli 
Salmonella serotypes 
shigella
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92
Q

Is gastroenteritis caused most commonly by bacteria, virus or parasites?

A

Virus

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93
Q

What is the most common cause of infantile gastroenteritis?

A

rotavirus
Transmitted by faecal oral route
worse nov-apr

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94
Q

what is the most common cause of gastroenteritis in adults?

A

Norovirus

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95
Q

What are the bacterial causes of gastroenteritis? And where are they picked up from? (5)

A

Campylobacter- undercooked meat (esp poultry), unpasteurised meat or untreated water

E.Coli- food, faecal-oral and animals

Salmonella- animal or human faeces contaminated environment, food or water. Food: red and white meat, raw eggs, milk and dairy

Shigella- drinking water contaminated with human faeces and food washed in infected water
(more common in young children)

Yersinia enterocolitica- rare

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96
Q

What are the parasitic causes of gastroenteritis? And where are they picked up from? 3

A

Crytopsporidium- animal-human, human-human

Entamoeba histolytics- food or water contamination

Giardia- direct contact with infected animals or humans, consumption of infected food or water.
associated with foreign travel

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97
Q

What are the symptoms of gastroenteritis caused by toxins?

A

rapid onset diarrhoea and vomiting which usually lasts for less than 12 hours

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98
Q

Which bacteria produce toxins that causes gastroenteritis? 3

A

Staph aureus- found in cooed meats and cream products

bacilus cereus- reheated rice

clostridium perfingens- reheated meat dishes or cooked meats

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99
Q

what are the symptoms of a rotavirus gastroenteritis? 3

A

Starts with fever and vomiting followed by water diarrhoea

lasts 3-8 days

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100
Q

What are the symptoms of norovirus gastroenteritis? 5

A

nausea followed by watery diarrhoea

vomiting, raised temperature and aching limbs may be present

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101
Q

How long do the symptoms of rotavirus gastroenteritis last?

A

3-8 days

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102
Q

How long after infection does it take for norvirus to present?

A

24-48hours

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103
Q

How long do the symptoms of norovirus last?

A

12-60 hours

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104
Q

What are the symptoms of campylobacter? 5

A 
diarrhoea- may be bloody 
nausea 
vomiting 
cramping abdominal pain 
fever
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105
Q

What are the symptoms of E.coli infection?2

A

abdominal cramps
diarrhoea - normally mild and self limiting
(may progressive to haemorrhagic colitis- bloody diarrhoea in infants or elderly- can be fatal)

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106
Q

Which bacteria can cause haemorrhagic colitis? and what can it lead to?

A

E.coli

Haemolytic uraemic syndrome (HUS)

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107
Q

What are the symptoms of salmonella?6

A 
Water and sometimes bloody diarrhoea 
abdominal pain 
headache
nausea 
vomiting 
fever
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108
Q

What are the symptoms of shigellosis? 2

A

Diarrhoea- often with blood and mucus= dysentery

abdominal cramps

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109
Q

What are the symptoms of crytosporidium? 6

A 
water diarrhoea 
stomach cramps 
dehydration 
nausea and vomiting 
fever 
weight loss
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110
Q

what are the symptoms of giardia infection? 8

A 
diarrhoea (acute and chronic- can last 2-6weeks) 
malabsorption 
weight loss 
abdominal pain 
annorexia 
flatuence 
bloating 
nausea (vomitting and fever are uncommon)
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111
Q

What are the criteria for carrying out a stool sample? 6

A

1- the person is systemically unwell
2- there is pus or blood in the stool
3- immunocompromised Px
4- history of recent hospitalisation or Abx rx
5- Diarrhoea post travel to anywhere other than western Europe, North America, Australia or New Zealand
6- Diarrhoea is peristent and giardiasis is suspected

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112
Q

Do you give Abx to adults with diarrhoea of unknown pathology?

A

NO

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113
Q

how do you treat amoebiasis (caused by entamoeba histolytica)?

A

Metronidazole 3/day for 5-10 days

followed by diolxamide 3/day for 10 days

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114
Q

How and when do you treat campylobacter?

A

When: the symptoms are severe, immuncompromised patient or symptoms >7days
How: erythromycin 4/day 5-7 dyas
or ciprofloxacin if allergic to macrolides

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115
Q

How do you treat E.Coli?

A

NO abx
entirely supportive
Avoid antimotillity drugs and NSAIDs

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116
Q

How do you treat giardiasis?

A

metronidazole

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117
Q

When and how do you treat salmonella?

A

When: >50yrs, immunocompromised, have cardiac valve disease or endovascular abnormalities e.g. prosthetic vascular grafts

How: ciprofloxacin 2/day for 1 day

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118
Q

When and how do you treat shigellosis?

A

When: severe disease, immunocompromised, bloody diarrhoea

How: ciprofloxacin, azithromycin

Don’t prescribe antimotillity drugs

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119
Q

What are the complications of gastroenteritis ? 6

A

1- dehydration and electrolyte disturbances
2-Guillain Barre syndrome
3- malnutrtion
4-IBS
5- aquired or secondary lactose intolerance
6- reduced drug absorption

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120
Q

What organisms cause reactive complications of gastroenteritis? 4

A

salmonella
campylobacter
Yersinia enterocolictica
shigella

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121
Q

What are the reactive complications of gastroenteritis?

A 
arthtis 
carditis 
urticaria 
erythema nodosum 
conjunctivitis 
Reiter's syndrome= urethritis, arthritis and uveitis
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122
Q

What is a complication of rotavirus?

A

toxic megacolon (rare)

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123
Q

What are complication of salmonella? 2

A

Septicaemia

focal infections e.g. septic arthritis

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124
Q

What is a complication of shigella?

A

haemolytic uraemic syndrome

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125
Q

What causes acute pancreatitis? 2

A

Gallstones

alcohol missuse

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126
Q

What are the risk factors for acute pancreatitis?8

A

1- endoscopic procedures
2- surgery near the pancreas e.g gastric surgery, splenectomy, biliary tract procedures
3- metabolic- hypertriglyceridaemia, hypercalcaemia
4- Infections- mumpc, coxsackie B4 virus, mycoplasma pneumonia infection
5- Drugs; thiazide diuretics, azathiorpine, tetracyclines, oestrogens, valproic acid and dipeptidylpeptidase-4-inhibitors
6- anatomical or functional disorders
7- autoimmune: SLE, Sjorgen’s
8- Pancreatic adenocarcinoma

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127
Q

Where is the pain in acute pancreatitis?

A

epigastric region

may radiate to the back (less commonly to the chest or flanks)

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128
Q

What makes the pain better and worse?

A

Worse: movement
Better: foetal position

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129
Q

Aside from pain what other symptoms are there in acute pancreatitis? 3

A

nausea
vomiting
anorexia

130
Q

What are the signs of acute pancreatitis?

A 
Abdominal tenderness
Abdominal distension 
Cullen's sign- bluish discolouration around umbilicus 
Grey-Turner's sign- ^ on the flank 
Shock- tachycardia and hypotension
131
Q

What do Cullen’s and Grey-Turner’s sign indicate?

A

Haemorrhagic pancreatitis- late serious complication of acute pancreatitis

132
Q

What investigations do you do in acute pancreatitis?

A

Lipase or amylase levles

CT, MRI, USS

133
Q

What are the complications of acute pancreatitis? 10

A 
pancreatic necrosis 
pseudocyst 
abscess 
fistula 
vascular complications- pre-hepatic portal hypertension 
renal failure 
mulitple organ dysfunction 
acute respiratory distress syndrome 
disseminated intravsacular coagulation 
sepsis
134
Q

What causes endocrine pancreatic insufficiency? and what is the result of it?

A

Damage to the islet of langerhans

–> no insulin

135
Q

What causes exocrine pancreatic insufficinecy? And what is the result of it?

A

Damage of the acinar cells

–> no digestive enzymes

136
Q

What are the causes of chronic pancreatitis? 8

A

1- alcohol
2- idopathic 25%
3-Smoking
4- autoimmune disease: Sjorgen’s, IBD, primary biliary cirrhosis
5- genetic
6- drugs: thiazide diuretics, azathioprine, tetracylcines, oestrogens, calproic acid, cimetidine and dipeptidylpeptidase -4 inhibitors
7- obstruction; gallstones, pancreatic ductal strictures
8- tropical causes

137
Q

What drugs are risk factors for chronic pancreatitis? 7

A 
thiazide diuretics 
azathioprine 
tetracyclines 
oestrogens 
calproic acid
cimetidine 
dipeptidylpeptidase inhibitors
138
Q

Where is and what is the character of the pain in chronic pancreatitis?

A

deep, severe, dull pain in epigastric region

May radiate back or may be localised to right or left upper quadrant

139
Q

What makes the pain better and worse in chronic pancreatitis?

A

better: sitting forward
worse: may be precipitated by eating

140
Q

Aside from pain what are the other symptoms of chronic pancreatitis ? 7

A 
bloating 
abdominal cramps 
flatulence 
weight loss 
malnutrition 
steatorrhea 
diabetes and impaired glucose regulation
141
Q

What are the examination findings in chronic pancreatitis? 5

A

signs of chronic liver disease- alcohol

epigastric tenderness

jaundice- either due to alcohol (= cause of both liver and pancreatic damage) or due to head of pancreas blocking bile duct

Abdominal distention- pseudocyst, pancreatic ascites or pancreatic cancer

Firm skin nodules due to disseminated fat necrosis- rare

142
Q

What investigations should be done in chronic pancreatitis?

A

LFTs- may be abnormal due to concomitant liver disease or due to pancreatic head blocking intra-pancreatic bile duct

Abdominal USS- rule out gallstones, show signs of pancreatic calcification

143
Q

What are the surgical options for chronic pancreatitis?

A

endoscopy- to remove obstructive pancreatic stones or to dilate strictures

splanchnicetomy

144
Q

What are the medical options for chronic pancreatitis?

A

Enzyme supplementation- help steatorrhea and malnutrition

Corticosteroids- if the cause is autoimmune

Treatment of diabetes

145
Q

What are the complications of chronic pancreatitis? 11

A 
Malabsorption 
diabetes 
chronic pain --> opiod tendency 
Osteoperosis 
pancreatic calcification 
pseudocyst formation 
Rare: 
duodenal or gastric output obstruction 
fistuale 
pancreatic cancer 
pseudo aneurysm 
splenic or portal vein thrombosis
146
Q

What is cholecystolithiasis?

A

Gallstones in the gallbladder

147
Q

What is choledocholithiasis?

A

Gallstones in the common bile duct

148
Q

What are the risk factors for gallstones? 9

A 
obesity 
age 
high levels of serum triglycerides and low HDL 
weight cycling 
diabetes 
oral contraceptives 
HRT 
smoking 
Crohn's disease
149
Q

What are the three types of gallstones?

A

cholesterol stones- most common in western countries

pigmented stones- dark stones made of bilirubin and calcium stones

mixed stones-combination of the above

150
Q

What is the most common presentation of gallstones?

A

biliary colic - caused by the gallbladder, cystic duct or common bile duct contracting around gallstone

151
Q

Where is the pain in biliary colic?

A

upper abdomen or right quadrant

152
Q

How long does the pain last for in biliary colic?

A

More than 30 minutes but less than 8 hours

153
Q

What is biliary colic associated with? 2

A

nausea or vomiting

154
Q

Is biliary colic associated with fever or abdominal tenderness?

A

NO

155
Q

What is the second most common presentation of gallstones?

A

Acute cholecystitis = acute inflammation of the gallbladder

156
Q

What are the signs and symptoms of acute cholecystitis?

A

Same as biliary colic: pain in upper abdomen, nausea or vomiting

Plus: fever and abdominal tenderness

157
Q

is obstructive jaundice a sign of gallstones?

A

yes

158
Q

What is Cholangitis?

A

An infection of the gallbladder, and an uncommon presentation of gallstones

159
Q

How does cholangitis present? 3

A

Charcot’s Triad:
Fever- often with rigors
Jaundice
Upper quadrant pain

160
Q

What investigations should be done in suspected gallstones?

A

Abdominal USS

LFTS

Magnetic resonance cholangiopancreatography (MRCP)– if USS not good enough

Endoscopic ultrasound (EUS)- if bile duct is dilated and LFTs are abnormal but MRCP is diagnositic

161
Q

What are the surgical options for gallstones? 2

A

Laparoscopic cholecystectomy- removal of the gallbladder

Cholecystotomy- draining of the blocked gallbaldder, temporary measure until well enough for cholecystectomy

162
Q

How quickly should a laparoscopic cholecystectomy be performed? And how quick is the recovery

A

Within a week following the onset of acute cholecystitis

recover time is 2 weeks

163
Q

What are the complications of gallstones? 10

A

Biliary colic
Acute cholecystitis
Obstructive jaundice
Cholangitis
Gallstone pancreatitis
Fistula between inflamed gallbladder and small bowel
Xanthogranulomatous cholecystitis- inflammatory process damages gall blader
Biliary peritonitis- bile in peritoneal cavity
Gallbladder mucocele
Gallbladder cancer

164
Q

How is Hep A spread?

A

faecal-oral route

165
Q

How long is a person infective for with Hep A?

A

14-21 days before and up to 8 days after the onset of jaundice

166
Q

What are the risk factors for hep A? 5

A

travelling

clotting factor disorders- receiving factor VII and IX –> higher risk of contamination

risky sexual behaviour

IV drug users

Occupational risk

167
Q

What are the 3 phases of hep A infection?

A

Prodromal phase
Icteric phase
Convalescent phase

168
Q

How long does the prodromal phase last in Hep A?

A

2 days- 2 weeks

169
Q

What are the signs and symptoms of the prodromal phase in Hep A? 10

A

Flu like symptoms

Gi symptoms: 
nausea
anorexia 
vomiting 
right, upper quadrant discomfort 
Other:
headache 
cough 
sore throat
itch 
uriticaria (hives)
170
Q

How long is the icteric phase in Hep A?

A

1-3 weeks

can persist for >12 weeks

171
Q

How does the icteric phase, in hep A, present? 12

A

Cholestasis:
jaundice
pale stools
dark urine

Pruritus- 40% of jaundice has this too

Fatigue
Anorexia 
Nausea
Vomiting 
^ improve as jaundice occurs

Hepatomegaly
Splenomegaly
Lymphadenopathy
Hepatic tenderness

172
Q

How long does the convalescent phase, in hep A, take?

A

up to 6 months

173
Q

What are the features of the convalescent phase, in hep A? 4

A

malaise
anorexia
muscle weakness
hepatic tenderness

174
Q

What will LFTs show in Hep A?

A

ALT and AST will be significantly increased >1000IU/L

Bilirubin may be elevated up to 500 micromols/l

175
Q

What happens to prothrombin time in hep A?

A

May be prolonged- 5 secs or more

176
Q

What heaptitis A serology tests do you do?

A

HAV-IgM and HAV-IgG

177
Q

What does a postive HAV-specific IgM indicate?

A

That hep A infection is likely

178
Q

What does a positive HAV-IgG indicate?

A

current or past infection or immunity from vaccine

179
Q

Who gets the Hep A vaccine?

A 
Travellers to endemic areas
chronic liver disease 
clotting factor disorders
IV drug users 
occupational risk- lab workers, residential institutions, sewage workers
180
Q

What can be given to ease nausea in hep A?

A

metoclopramide

181
Q

What can be given to ease itch in hep A? 4

A

chlorphenamine
ursodeoxycholic acid
colestryamine
corticosteroids

182
Q

What do you monitor in follow up care of hep A? 2

A

LFTs

Prothrombin time

183
Q

How common is relapse in hep A?

A

15% of people relaspse 4-15weeks post original illness

184
Q

How long does the illness from hep A last?

A

Typically 2 months, it’s self limiting

However complete clinical recovery may take 6 months

185
Q

What are the results of a Hep A infection?

A

Has no long term sequelae
Doesn’t cause chronic liver disease
Doesn’t have a chronic carrier state
Results in lifetime immunity

186
Q

Is hep A a notifiable disease?

A

yes

187
Q

Is hep B a notifiable disease?

A

yes

188
Q

Is hep B a self-limiting or chronic infection?

A

Both
In adults and older children it is self-limiting
In infants and younger children it is chronic

189
Q

How is hep B transmitted? 3

A

blood-blood
sexually
mother-baby

190
Q

what are the clinical features of Hep B? 9

A

May be asymptomatic

fever, arthralgia or rash- occur about 2 weeks before jaundice then resolve

malaise
fatigue
nausea
anorexia

cholestasis= jaundice, pale stools, dark urine

191
Q

What would LFTs show in hep B?

A

ALT and AST reach 1000-2000 IU/l
ALT is normally higher

Alkaline phsophatase, bilirubin, albumin levels and prothrombin time are usually normal

192
Q

What do you test in serological testing for hep B?

A

Hepatitis B surface antigen - HBsAg

Antibody to hepatitis B core antigen - anti-HBc

193
Q

What will HBsAg show in hep B?

A

It’s the first marker to rise in hep B

will show if there is current infection

194
Q

What does anti-HBc show in hep B?

A

indicates recovery from hep B

will persist for life

195
Q

How do you treat hep B exposure?

A

Rapid vaccine prophylaxis over 21 days, with immunoglobulin prophylaxis at the same time and within 48 hours of exposure

196
Q

How do you treat babies born to mothers infected with hep B?

A

Vaccine prophylaxis at 0, 1 and 2 months

197
Q

what are the complications of hep B? 6

A 
jaundice for 1-3 months 
fatigue may persist 
chronic hep B infection 
glomerulonephritis 
vasculitis 
polyarteritis
198
Q

How is hep C transmitted?

A

blood

small risk of sexual transmission

199
Q

What are the risk factors for hep C? 2

A

needles stick injuries

blood and organ receivers prior to 1991

200
Q

What are the clinical features of Hep C? 10

A 
general malaise with flu-like symptoms 
fatigue 
myalgia 
anxiety 
depression 
poor memory or concentration 
nausea 
vomiting 
right, upper quadrant pain 
jaundice
201
Q

What investigations should be done in Hep C?

A

Plain (clotted) blood sample for antibodies to hep C virus (HCV)
+Ve HCV RNA
LFTs
Viral load
clotting studies- clotting may be affected if there is signifcant liver damage

202
Q

How do you treat Hep C?

A

Interferon started between 3-6 months after diagnosis

203
Q

What are the complications of Hep C?

A

Acute fulminant heaptitis- rare

204
Q

What causes an appendicitis?

A

Infection secondary to the obstruction of the lumen of the appendix
Cause of the obstruction:
faecolith- hard mass of faecal matter
normal stool
lymphoid hyperplasia- secondary to viral infection

205
Q

What are the bacteria that commonly overgrow in appendicitis?

A

bacteroides fragilis

E.coli

206
Q

What age do most appendicitises occur

A

10-20

207
Q

Is an appendicitis more common in M or F?

A

M

208
Q

What are the risk factors for an appendicitis ? 2

A

frequent antibiotic use

smoking

209
Q

Where is the pain in an appendicitis? Where does it migrate?

A

Peri-umbilical or epigastric pain= McBurney’s point

Migrates to right iliac fossa

210
Q

Where exactly is McBurney’s point?

A

2/3rds of the way along a line drawn from the umbilicus to the anterior superior iliac spine

211
Q

What makes the pain worse in an appendicitis?

A

movement

212
Q

Aside from pain what are the other symptoms of an appendicitis? 4

A

Anorexia
nausea
constipation
vomiting

213
Q

What signs may be seen on examination of an appendicitis? 7

A 
guarding 
rebound tenderness 
Facial flushing 
dry tongue 
halitosis 
low grade fever 
tachycardia
214
Q

What is Rovsing’s sign in an appendicitis?

A

palpation of the L lower quadrant increases the pain felt in the r lower quadrant

215
Q

What is the Psoas sign in appendicitis?

A

extending the right thigh with the person in the left lateral position elicits pain in the r lower quadrant

216
Q

What is the Obturator sign in appendicitis?

A

internal rotation of the flexed right thigh elicits pain in r lower quadrant

217
Q

What are the signs of a perforated appendix?2

A

Tachycardia and sudden relief of pain

218
Q

What are the signs of an appendix abscess? 2

A

palpable abdominal mass

swinging pyrexia

219
Q

What are the signs of peritonitis? (which can be a complication of appendicitis) 4

A

profuse vomiting
high fever
severe abdominal tenderness
absent bowel sounds

220
Q

How can older people present with an appendicitis?2

A

pain may be minimal and fever absent

may present with confusion and shock

221
Q

How can young children and infants present with an appendicitis?2

A

vague abdominal pain and anorexia

222
Q

what investigations should you do in an appendicitis? 4

A

Pregnancy test- exclude ectopic pregnancy
urine dipstick- exclude UTI
FBC - neutrophil predominat leucocytosis present in 80-90%
CRP

223
Q

what is the treatment of an appendicitis?

A

appendicetomy

224
Q

what are the complications of an appendicitis? 6

A 
perforation- likely to occur after 12 hours if inflammation --> 
abscess 
peritonitis 
sepsis 
death 
premature labour or miscarriage
225
Q

What are the causes of mechanical bowel obstruction?
4 common
5 SI
3 LI

A 
Common: 
constipation 
hernias
adhesion (80%) 
tumours 
SI 
adhesions 
hernia 
Crohn's 
extrinsic cancer 
intussusception

LI
carcinoma of colon
sigmoid volvulus
diverticular disease

226
Q

What are the causes of paralytic ileus bowel obstruction? 7

A 
Abdominal surgery 
pancreatitis 
spinal injury
hypokalaemia 
hyponatraemia 
uraemia 
drugs e.g. tricylics
227
Q

What is pseudo-obstruction of the bowel and what causes it?

A

Like mechanical but with no found cause

Cause:
Acute colonic pseudo-obstruction= Oglivie’s syndrome

Pre-disposing factors:
Peurperium
pelvic surgery
trauma

228
Q

What are the 4 cardinal symptoms of bowel obstruction?

A

vomiting
colicky pain
constipation
distension

229
Q

What are the associated symptoms in bowel obstruction vomiting? 3

A

Relief
nausea
annorexia

230
Q

When does faeculent vomiting occur?

A

When there is a colonic fistula with the proximal gut

231
Q

When is constipation absolute in bowel obstruction?

A

If the obstruction is distal

232
Q

What bowel sounds can be heard in distension?

A

tinkling bowel sounds

233
Q

Does the pain get better or worse in long standing obstruction?

A

better

234
Q

What is the difference between Si and LI obstruction?

A

SI
vomiting occurs earlier
distension is less
pain is higher in the abdomen

LI
pain is more constant

235
Q

How do you tell the difference between an ileus or a mechanical obstruction?

A

In ileus there is no pain and bowel sounds are absent

236
Q

What are the signs that the bowel is strangulated? 6

A 
More ill than would expect 
sharper more constant pain than central colicky pain 
tends to be more localised 
peritonism 
May be fever 
May have raised WCC
237
Q

What investigations can you do in bowel obstruction?

A

AXR
Water soluble enema - demonstrates site
CT - investigation of choice
Colonoscopy- may reduce preforation

238
Q

What will SI obstruction show on an AXR?

A

central gas shadows

no gas in LI

239
Q

What will LI obstruction show on AXR?

A

Gas proximal to blockage e.g in the caecum but not the rectum (unless you have done a PR)

240
Q

What will a CT scan show in bowel obstruction?

A

Dilated, fluid filled bowel

241
Q

Which bowel obstructions need surgery?

A

LI
completer and strangulation
(manage ileus and incomplete conservatively)

242
Q

What is the immediate action in bowel obstruction?

A

Drip and suck

NGT and IV fluids

243
Q

How are patients with volvulus managed?

A

Using flexi sig to un-kink bowel

244
Q

Are inguinal or femoral hernias more common?

A

inguinal

245
Q

which sex and age group are femoral hernias more common in than inguinal ones?

A

Middle aged to elderly F

246
Q

What is an indirect inguinal hernia?

A

pass through the deep/ inguinal ring and if large extend through the superficial/ external inguinal ring

247
Q

What is a direct inguinal hernia?

A

push directly forward through the posterior wall of the inguinal canal into a defect

248
Q

What is a femoral hernia?

A 
Bowel enters the  femoral canal--> mass in upper thigh or above the inguinal ligament where it points down the leg 
normally reducible 
(an inguinal hernia points up towards the groin)
249
Q

What’s the risk of a femoral hernia?

A

It’s likely to be strangulated due to canals borders

250
Q

What are the risk factors for hernias? 7

A 
M>F - inguinal 
chronic cough 
constipation 
urinary obstruction 
heavy lifting 
ascites 
past abdominal surgery
251
Q

Are hernias more common on the L or R?

A

R

252
Q

How do you tell the difference between an indirect and direct hernia?

A

Get them to cough or stand, if hernia pops out it is direct

253
Q

Are direct or indirect more common? And what are their respective features?

A

Indirect 80%- can strangulate, don’t reduce easily

Direct 20%- rarely strangulate, reduce easily

254
Q

Are femoral hernias more common in M or F?

A

F

255
Q

What are the features of a femoral hernia? and where can they be felt?

A

Frequently strangulate
don’t reduce easily
Inferior and lateral to pubic tubercle

256
Q

What are the surgical options for inguinal hernias?

A

Lichtenstein repair- mesh technique, suture ant and post walls of canal

Laproscopic repair- not recommended

257
Q

What are the surgical options for femoral hernias?

A

Herniotomy- ligation and excision of sace

Herniorrhaphy- repair of hernia defect

258
Q

what are the complications of hernias?

A

strangulation –> ischaemia

Obstruction

259
Q

What are the two main types of oesophageal carcinoma?

A

squamous cell

adenocarcinoma

260
Q

Where in the oesophagus are the majority of cancers?

A

The middle

261
Q

What are the risk factors for oesophageal carcinoma? 8

A 
diet low in vit A&amp;C 
obesity 
alcohol excess 
smoking 
achlasia 
Pulmmer-Vinson syndrome 
nitrosamine exposure 
Reflux oesophagitis +/- Barrett's
262
Q

What investigations do you do in oesophageal carcinoma? 3

A

Barium swallow
CXR
Oesophagoscopy with biopsy

263
Q

What are the features of oesophageal carcinoma?6

A 
dysphagia
weight loss 
retrosternal chest pain 
lymphadenopathy 
If in upper 1/3rd hoarseness 
cough
264
Q

What are the treatment options for oesophageal carcinoma?

A

If localised: radical curative oesophagectomy

265
Q

What type of cancer is bowel carcinoma usually?

A

adenocarcinoma

266
Q

Is Gastric carcinoma more common in M or F?

A

M

267
Q

How is gastric carcinoma classified?

A

Borrman classification

268
Q

What are the risk factors for gastric carcinoma? 10

A 
pernicious anaemia 
blood group A
H.pylori 
atrophic gastritis 
adenomatous polyps 
lower social class
smoking 
Diet high in nitrate nd salt and low in vit C
nitrosamine exposure 
E.Cadherin abnormalities
269
Q

what are the symptoms and signs of gastric carcinoma? 9

A 
Dyspepsia
weight loss 
vomiting 
dysphagia 
anaemia 
epigastric mass
hepatomegaly-jaundice-ascites
Virchow's node- left supraclavicular node
acanthiosis nigrans
270
Q

What investigations do you do in gastric cancer?

A

Gastroscopy and ulcer edge biopsies

271
Q

what are most pancreatic cancers?

A

Adenocarcinoma

272
Q

Why are pancreatic cancers sod deadly (5 year survival <2%)?

A

Because they met early and present late

273
Q

What sex and age group are pancreatic cancers most common in?

A

M >60

274
Q

What is the cause of 95% of pancreatic cancers?

A

mutations of the KRAS2 gene

275
Q

What are the risk factors for pancreatic cancers? 5

A 
smoking 
alcohol 
diabetes 
chronic pancreatitis 
possibly high fat diet
276
Q

Where in the pancreas are the majority of tumours found?

A

the head (then the body, then tail, then ampulla of vater)

277
Q

How do tumours of the head of the pancreas present?

A

Painless, obstructive jaundice

278
Q

How do tumours of the tail/ body of the pancreas present?

A

epigastric pain radiating to the back

relieved by sitting forward

279
Q

What symptoms and signs can all pancreatic tumours have? 14

A 
anaemia 
weight loss 
diabetes
acute pancreatitis 
jaundice
palpable gall bladder 
epigastric mass 
hepatomegaly 
splenomegaly 
lymphadenopathy 
ascites

rare
thromboplhebitis migrans
Hypercalcaemia
portal hypertension

280
Q

What is the treatment option for pancreatic cancer?

A

Most present with mets so <10% can have surgery

whipple’s; pancreatic-duodenectomy

281
Q

What age group gets colorectal cancers?

A

> 70

282
Q

What are the risk factors for colorectal cancers? 7

A 
neoplastic polyps 
IBD 
familial adenomatous polyposis 
HNPCC (lynch syndrome)= hereditary non-polyposis colorectal cancer 
previous cancer 
low fibre diet 
FH
283
Q

How do left sided colorectal cancers present? 4

A

Bleeding, mucus PR
altered bowel habit
tenesmus
Mass of PR 60%

284
Q

How do Right sided colorectal cancers present? 3

A

weight loss
decrease HB
abdominal pain

285
Q

How do any colorectal cancers present? 5

A 
abdominal mass
obstruction 
perforation 
haemorrhage 
fistual
286
Q

What investigations should you do in colorectal cancer? 7

A

FBC- microcytic anaemia
Faecal occulut blood
Protoscopy, sigmoidoscopy, barium enema or colonoscopy
liver USS

287
Q

What are the surgical options for colorectal cancer? 4

A

R/L hemicolectomy- caecal or trasnverse tumours

sigmoid colectomy

anterior resection- low sigmoid or high rectal tumours

Adbomino-perineal (A-P) resection- tumours low in rectum

288
Q

What are the invective causes of chronic liver failure?3

A

Viral hepatitis- B, C, CMV
yellow fever
leptospirosis

289
Q

What drug can cause chronic liver failure?

A

paracetamol OD

290
Q

What toxins cause chronic liver failure? 2

A

amanita phalloides mushroom

carbon tetrachloride

291
Q

What vascular problems cause liver failure?

A

Budd-Chari syndrome

292
Q

What are the other causes of liver failure? 7

A 
alcohol 
primary biliary cirrhosis 
cirrhosis 
haemochromatosis 
autoimmune hepatitis 
alpha-1 antitrypsin deficiency 
Wilson's disease
293
Q

What are the signs of chronic liver failure? 5

A 
jaundice 
hepatic encephalopathy 
fector hepaticus- smells like pear drops 
Asterixis- liver flap 
constructional apraxia
294
Q

What is the main complication of liver failure?

A

Leads to encephalopathy as ammonia builds up –> passes to the brain –> astrocytes convert glutamate to glutamine –> osmotic imbalance –> cerebral oedema

295
Q

What are the causes of ascites? 7

Ascites with portal hypertesnion: 4

A 
Malignancy 
Infection- especially TB 
decreased albumim- nephrosis 
CCF- congestive cardiac failure 
pericarditis 
pancreatitis 
myxoedema 
Ascites with portal hypertension:
cirrhosis 
portal nodes
Budd-Chiari syndrome 
IVC or portal vein thrombosis
296
Q

What are the symptoms and signs of ascites? 3

A

massive stomach
shifting dullness
fluid thrill

297
Q

What investigations do you carry out in ascites?

A

Aspirate ascetic fluid- paracentesis for:
cytology
culture
protein level

298
Q

Protein level will be raised >30g/l in which causes of ascites? 4

A

Malignancy
infection
pancreatitis
Budd-chiari syndrome

299
Q

How do you treat ascites?

A

decrease dietary Na

Give spirolactone= aldosetrone antagonist–> lose Na

300
Q

what causes kwashikor?

A

fair to normal energy intake but inadequate protein

301
Q

What causes marasmus?

A

inadequate energy and protein

302
Q

Insufficient iodine leads to what?3

A

goitre
hypothyroidism
growth restriction

303
Q

Insufficient vitamin A leads to what? 2

A

Night blindness

immune deficiency

304
Q

Insufficient zinc leads to what?2

A

immune deficiency,

acrodermatitis

305
Q

Insufficient vitamin C leads to what?1

A

scurvy

306
Q

Insufficient vitamin B1 *thiamine) causes what?

A

Beri Beri
Wet Beri-Beri= heart failure with general oedema
Dry Beri-Beri= neuropathy

307
Q

Insufficient nicotinic acid leads to what?

A

Pellagra :
diarrhoea
dementia
dermatitis

308
Q

What is the BMI for mild malnutrition?

A

17-18.5

309
Q

what is the BMi for moderate malnutrition?

A

16-17

310
Q

what is the BMI for severe malnutrition?

A

<16

311
Q

What are the generic features of malnutrition? 4

A

listlessness
fatigue
cold sensitivity
non-healing wounds and decubitus ulcers

312
Q

What is the risk of starting malnourished people on food?

A

refeeding syndrome
refeeding should be started at no more than 50% of energy requirements for patients who haven’t eaten for more than 5 days

313
Q

What are the signs and symptoms of a perforated viscus?

A

sudden severe abdominal pain

Pain will start focal and become more widespread as contents leak into peritoneum

Board like rigidity
involuntary guarding
significant and diffuse rebound tenderness

Contamination of site can –. SIRS–> shock

314
Q

What investigations should be done for a perforated viscus ?

A

Plain radiography- detects pneumoperitoneum
CT- more senstive
USS

315
Q

How do you manage a patient with a perforated viscus?

A

resuscitation
broad spectrum antibiotics - ciprofloxacin, metronidazole, piperacillin/tazobactam or imipenem
crystalloid fluids
surgery-laparotomy

316
Q

What are the risk factors for coeliac disease?4

A

FH
link to HLA- human leukocyte antigens
Linked to DM1
autoimmune thyroid disease

317
Q

Is it more common in F or M

A

F

318
Q

What are the GI symptoms of coeliac disease? 4

A

diarrhoea
abdominal pain
bloating
constipation

319
Q

What are the non-GI symptoms? 9

A 
fatigue 
anaemia
dermatitis herpetiformis 
osteoporosis 
fertility problems 
short stature 
delayed puberty 
peripheral neuropathy 
DM1
320
Q

What serology test do you do in coeliacs?

A

IgA tissue transglutaminase antibody

IgA endomysial antibody

321
Q

What are the complications of coeliac disease? 10

A 
anaemia 
osteoporosis 
chronic pancreatitis 
heaptobiliary abnormalities e.g. autoimmune hepatitis 
splenic dysfunction 
subfertility 
bacterial overgrowth 
lactose intolerance 
microscopic colitis 
malignancy - lymphoma,intestinal adenocarcinoma and pancreatic cancer

3rd year (9 decks)

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