Abdo core conditions Flashcards
1
Q
Which drugs are a risk factor for reflux
(3) ?
A
Antimuscarinics, Ca blockers and nitrates
2
Q
what are the risk factors for reflux? (5)
A
Pregnancy fatty food, alcohol, chocolate obesity achlaasia hiatus hernis
3
Q
What aggravates the pain in reflux?
A
lying down/ bending over
4
Q
Drinking what makes reflux worse?
A
alcohol or hot drinks
5
Q
What is the word for pain on swallowing ?
A
odynophagia. You get this with reflux
6
Q
what investigations would you do in reflux?
A
Upper GI endoscopy
Intraluminal monitoring
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
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
9
Q
What do you use Prokinetic agents for? Give an example
A
Reflux, increase gastric emptying
metocloperamide
10
Q
What do you use H2-receptor anatgonists for? Give an example
A
Reflux, acid suppression
cimetidine
11
Q
What surgery do you use in reflux?
A
Nissen Fundoplication
12
Q
where is the pain in reflux?
A
Burning retrosternal pain
13
Q
What is the definition of an ulcer?
A
A breach in the epithelium that penetrates the muscularis mucosae
14
Q
What are the main causes of peptic ulcers?
A
H.pylori infections, NSAIDs} most common
Rare: Zollinger-Ellison syndrome
Crohn’s disease
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
16
Q
What are the 4 main risk factors for peptic ulcers?
A
NSAIDs, smoking, aspirin, alcohol
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
18
Q
Aside from pain what are the other symptoms of peptic ulcer?
A
Indigestion
heartburn
weightloss and loss of appetite
nausea
19
Q
How does food affect gastric ulcer pain?
A
It makes it worse
It improves duodenal ulcer pain
20
Q
What are the 3 tests for H.pylori?
A
Urea breath test
stool antigen test
Laboratory serology testing
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
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
23
Q
If PPI isn’t sufficient in peptic ulcers what do you give?
A
H2-receptor anatgonists e.g. cimetidine
24
Q
How do you treat peptic ulcers due to H.pylori?
A
7 day triple therapy regimen with twice daily dosing
25
What are the options for eradication therapy of H.pylori in peptic ulcers?
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)
26
What is the second course of eradication of H.pylori in peptic ulcers?
Antibiotics previously given
| for 14 days as quadruple therapy
27
what is the most common cause of an upper GI bleed?
Peptic ulcer disease
28
What are the causes of an upper GI bleed? (10)
```
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
```
29
What are the risk factors for an upper GI bleed? (7)
```
age
heart failure
IHD
renal disease
Liver disease
malignant disease
ulcer
```
30
What is the scoring system for upper GI bleeds?
Rockall from 0-8+
31
What are the main signs and symptoms of a GI bleed? (5)
```
Dyspepsia (pain)
haematemesis
haematochezia- bright red blood in stool, massive volume loss
Melena
shock
```
32
What are the signs of shock? (8)
```
Dizziness
SOB
pale skin
loss of consciousness
peripherally shut down- cool and clammy, slow cap refill
poor urine output (<25ml/h)
tachycardic >100bpm
hypotensive
```
33
What causes massive lower GI bleeds? (2)
These are rare
diverticular disease
ischaemic colitis
34
What causes small lower GI bleeds?(5)
```
haemorrhoids
anal fissures
IBD
Crohn's
Cancer
```
35
What investigations do you do in a lower GI bleed?
Protoscopy
flexible sigmoidoscopy
colonoscopy
angiography
36
What do you use protoscopy for?
Lower Gi bleeds- haemorrhoids
| for anus, anal canal, rectum and sigmoid colon
37
What do you use flexible sigmoidoscopy or colonoscopy for?
Lower GI bleeds due to IBD, cancer, ischaemic colitis, diverticular disease or angiodysplasia
38
Is crohn's continuous or discrete?
Discrete- it has skip lesions
39
Where in the GI tract does Crohn's affect?
Anywhere from the mouth to the anus
40
How much of the intestinal wall is affected in Crohn's?
the FULL thickness
| in UC it's only the mucosa
41
What are the risk factors for Crohn's? (5)
```
Smoking
Family history
appendectomy
NSAIDs
oral contraceptives (small)
```
42
When does crohn's commonly present?
adolesence and early adulthood
43
Is crohn's more common in men or women?
M=F
44
What are the GI symptoms of Crohn's (12)
```
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
```
45
Where does abdominal pain typically present in Crohn's?
In the right lower quadrant
| A mass may also be felt
46
What are the extra-intestinal manifestations of Crohn's?(6)
```
Irits
Post-articular arthrtitis
erythema nodosum
apthous ulcers
pyoderma gangrenosum
episcleritis
```
47
With what condition do you get post-articular arthritis?And what are it's signs?
Crohn's
affects fewer than 5 large joints
usually asymmetrical
self-limiting and acute
48
what is erythema nodosum associated with?
| And what are it's signs?
Crohn's
Tender, red/violet subcutaneous nodules
usually on anterior tibial or extensor surfaces of legs/ arms
49
What investigations do you do in Crohn's? (6)
```
FBC- assess for anaemia due to blood loss, malabsorption or malnutrition
CRP and ESR
U&Es
LFTs
stool microscopy and culture
tissue transglutaminase
```
50
When should people with Crohn's be treated as an emergency?
If they have bloody diarrhoea and fever or tachycardia
51
Why shouldn't you offer anti-diarrhoeals to people with unconfirmed crohn's?
If it turns out they have UC then anti-diarrhoeals can precipitate toxic megacolon
52
What lifestyle change should people with Crohn's make?
stop smoking
53
What are the drug options in Crohn's? (4)
Corticosteroids
Immuno-Suppressants: azathioprine, mercaptopurine and methotrexate
^ or cytokine-modulating drugs: infliximab and adalimumab
Aminosalicylates- mesalazine and sulfasalazine
54
What immunosuppressants can be used in Crohn's? (3)
Azathioprine
mercaptopurine
methotrexate
55
What can you use instead of immunsuppressants in Crohn's?
Cytokine-modulating drugs
Infliximab
adalimumab
56
What aminosalicylates can be used in Crohn's?
Mesalazine and sulfasalazine
57
What do you offer adolescents or children who are failing to grow due to Crohn's?
Enteral nutrition
58
What are the complications of Crohn's? 8
```
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
```
59
Where does UC affect?
The mucosa of the rectum and variable lengths of the colon
60
Where does Ulcerative proctitis (subtype of UC) affect?
Inflammation is limited to the rectum
61
Where does Left-sided colitis (subtype of UC) affect?
inflammation affects rectum and doesn't extend proximally beyond the splenic flexure
62
Where does extensive colitis/ pan colitis (subtype of UC) affect?
Inflammation extends beyond splenic flexure to affect entire colon
63
What are the risk factors for UC? 3
Oral contraceptives
FH
Not smoking
64
When is the peak incidence of UC?
15-25 years
| smaller peak 55-65
65
What are the GI symptoms of UC? 7
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
66
Where is the pain in UC?
Left lower quadrant
| Crohn's is on R
67
What are the extra-intestinal symptoms of UC? 7
```
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
```
68
What investigations do you do in UC? 7
```
FBC
CRP and ESR
U&Es
LFTs
Tissue transglutaminase
stool microscopy and culture
Faecal calprotectin
```
69
What would LFTs show in UC?
Reduced albumin, which suggests hypoproteinaemia due to malabsorption or intestinal losses
70
Why do you test tissue transglutaminase in UC and crohn's?
to rule out coeliac disease
71
What bugs would you request testing for in a stool microscopy and culture for UC? 3
C-dif toxin
campylobacter
E.Coli O157
72
Why do you test faecal calprotectin in UC?
to distinguish IBS and IBD, will be raised in IBD
73
What is the first treatment option for mild or moderate UC?
Aminosalicylates (5-ASAs)
suphalazine
mesalazine
74
When do you use corticosteroids in UC?
With or instead of 5-ASAs for flare ups if 5-ASAs aren't enough
prednisolone
75
What 3 drug types can you use to induce remission in UC?
Aminosalicylates
corticosteroids
immunosuppressants
76
What do you use immunosuppressants for in UC? and which ones?
Mild to moderate flare-ups
or to induce remission if other meds haven't worked
tacrolimus
azathioprine
77
What is the downside of immunosuppressants in treating UC?
They take a while to work
| usually 2-3 months
78
What immunosuppressant do you use to treat severe flare ups of UC?
ciclosporin
stronger and faster than the others (tacrolismus and azathioprine)
given IV
79
How do you treat severe flare ups of UC?
```
1- ciclosporin
If that doesn't work:
Biologic medications:
infliximab
adalimumab
golimumab
vedolizumab
```
80
What are the surgical options for UC?
Colectomy
May have an ielostomy--> stoma bag
or an ileo-anal pouch--> allows stool to pass normally
81
What are the complications of UC? (4)
Toxic megacolon
colorectal cancer
venous thromboembolism
osteoporosis
82
What age range is IBS most common in?
20-30year olds
83
Is IBS more common in males or females?
F>M
84
What is abdominal pain associated with in IBS?
Either relieved by defecation
| or associated with altered bowel frequency or altered stool form
85
Aside from abdominal pain what are the other common symptoms of IBS? 4
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
86
What are the first line drug treatment options for IBS? 3
Antispamodic- meververine, alverine or peppermint oil
Laxatives - bulk forming ones are preferred e.g ispaghula or sterculla
antimotillity drugs e.g. loperamide
87
If IBS symptoms don't repsond to first line treatment options what can you give?
Low dose tricylcic antidepressant
e.g. amitriptyline
at night
88
What classifies as acute diarrhoea?
three or more episodes lasting for less than 14 days
89
What classifies as persistent diarrhoea?
lasts for more than 14 days
90
What is dysentery?
loose stools, with blood and mucus, often with pyrexia and abdominal cramps
91
What organisms cause bloody diarrhoea? 5
```
Campylobacter
Entamoeba histolytica
E.Coli
Salmonella serotypes
shigella
```
92
Is gastroenteritis caused most commonly by bacteria, virus or parasites?
Virus
93
What is the most common cause of infantile gastroenteritis?
rotavirus
Transmitted by faecal oral route
worse nov-apr
94
what is the most common cause of gastroenteritis in adults?
Norovirus
95
What are the bacterial causes of gastroenteritis? And where are they picked up from? (5)
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
96
What are the parasitic causes of gastroenteritis? And where are they picked up from? 3
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
97
What are the symptoms of gastroenteritis caused by toxins?
rapid onset diarrhoea and vomiting which usually lasts for less than 12 hours
98
Which bacteria produce toxins that causes gastroenteritis? 3
Staph aureus- found in cooed meats and cream products
bacilus cereus- reheated rice
clostridium perfingens- reheated meat dishes or cooked meats
99
what are the symptoms of a rotavirus gastroenteritis? 3
Starts with fever and vomiting followed by water diarrhoea
| lasts 3-8 days
100
What are the symptoms of norovirus gastroenteritis? 5
nausea followed by watery diarrhoea
| vomiting, raised temperature and aching limbs may be present
101
How long do the symptoms of rotavirus gastroenteritis last?
3-8 days
102
How long after infection does it take for norvirus to present?
24-48hours
103
How long do the symptoms of norovirus last?
12-60 hours
104
What are the symptoms of campylobacter? 5
```
diarrhoea- may be bloody
nausea
vomiting
cramping abdominal pain
fever
```
105
What are the symptoms of E.coli infection?2
abdominal cramps
diarrhoea - normally mild and self limiting
(may progressive to haemorrhagic colitis- bloody diarrhoea in infants or elderly- can be fatal)
106
Which bacteria can cause haemorrhagic colitis? and what can it lead to?
E.coli
| Haemolytic uraemic syndrome (HUS)
107
What are the symptoms of salmonella?6
```
Water and sometimes bloody diarrhoea
abdominal pain
headache
nausea
vomiting
fever
```
108
What are the symptoms of shigellosis? 2
Diarrhoea- often with blood and mucus= dysentery
| abdominal cramps
109
What are the symptoms of crytosporidium? 6
```
water diarrhoea
stomach cramps
dehydration
nausea and vomiting
fever
weight loss
```
110
what are the symptoms of giardia infection? 8
```
diarrhoea (acute and chronic- can last 2-6weeks)
malabsorption
weight loss
abdominal pain
annorexia
flatuence
bloating
nausea (vomitting and fever are uncommon)
```
111
What are the criteria for carrying out a stool sample? 6
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
112
Do you give Abx to adults with diarrhoea of unknown pathology?
NO
113
how do you treat amoebiasis (caused by entamoeba histolytica)?
Metronidazole 3/day for 5-10 days
| followed by diolxamide 3/day for 10 days
114
How and when do you treat campylobacter?
When: the symptoms are severe, immuncompromised patient or symptoms >7days
How: erythromycin 4/day 5-7 dyas
or ciprofloxacin if allergic to macrolides
115
How do you treat E.Coli?
NO abx
entirely supportive
Avoid antimotillity drugs and NSAIDs
116
How do you treat giardiasis?
metronidazole
117
When and how do you treat salmonella?
When: >50yrs, immunocompromised, have cardiac valve disease or endovascular abnormalities e.g. prosthetic vascular grafts
How: ciprofloxacin 2/day for 1 day
118
When and how do you treat shigellosis?
When: severe disease, immunocompromised, bloody diarrhoea
How: ciprofloxacin, azithromycin
Don't prescribe antimotillity drugs
119
What are the complications of gastroenteritis ? 6
1- dehydration and electrolyte disturbances
2-Guillain Barre syndrome
3- malnutrtion
4-IBS
5- aquired or secondary lactose intolerance
6- reduced drug absorption
120
What organisms cause reactive complications of gastroenteritis? 4
salmonella
campylobacter
Yersinia enterocolictica
shigella
121
What are the reactive complications of gastroenteritis?
```
arthtis
carditis
urticaria
erythema nodosum
conjunctivitis
Reiter's syndrome= urethritis, arthritis and uveitis
```
122
What is a complication of rotavirus?
toxic megacolon (rare)
123
What are complication of salmonella? 2
Septicaemia
| focal infections e.g. septic arthritis
124
What is a complication of shigella?
haemolytic uraemic syndrome
125
What causes acute pancreatitis? 2
Gallstones
| alcohol missuse
126
What are the risk factors for acute pancreatitis?8
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
127
Where is the pain in acute pancreatitis?
epigastric region
| may radiate to the back (less commonly to the chest or flanks)
128
What makes the pain better and worse?
Worse: movement
Better: foetal position
129
Aside from pain what other symptoms are there in acute pancreatitis? 3
nausea
vomiting
anorexia
130
What are the signs of acute pancreatitis?
```
Abdominal tenderness
Abdominal distension
Cullen's sign- bluish discolouration around umbilicus
Grey-Turner's sign- ^ on the flank
Shock- tachycardia and hypotension
```
131
What do Cullen's and Grey-Turner's sign indicate?
Haemorrhagic pancreatitis- late serious complication of acute pancreatitis
132
What investigations do you do in acute pancreatitis?
Lipase or amylase levles
| CT, MRI, USS
133
What are the complications of acute pancreatitis? 10
```
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
What causes endocrine pancreatic insufficiency? and what is the result of it?
Damage to the islet of langerhans
| --> no insulin
135
What causes exocrine pancreatic insufficinecy? And what is the result of it?
Damage of the acinar cells
| --> no digestive enzymes
136
What are the causes of chronic pancreatitis? 8
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
What drugs are risk factors for chronic pancreatitis? 7
```
thiazide diuretics
azathioprine
tetracyclines
oestrogens
calproic acid
cimetidine
dipeptidylpeptidase inhibitors
```
138
Where is and what is the character of the pain in chronic pancreatitis?
deep, severe, dull pain in epigastric region
| May radiate back or may be localised to right or left upper quadrant
139
What makes the pain better and worse in chronic pancreatitis?
better: sitting forward
worse: may be precipitated by eating
140
Aside from pain what are the other symptoms of chronic pancreatitis ? 7
```
bloating
abdominal cramps
flatulence
weight loss
malnutrition
steatorrhea
diabetes and impaired glucose regulation
```
141
What are the examination findings in chronic pancreatitis? 5
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
What investigations should be done in chronic pancreatitis?
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
What are the surgical options for chronic pancreatitis?
endoscopy- to remove obstructive pancreatic stones or to dilate strictures
splanchnicetomy
144
What are the medical options for chronic pancreatitis?
Enzyme supplementation- help steatorrhea and malnutrition
Corticosteroids- if the cause is autoimmune
Treatment of diabetes
145
What are the complications of chronic pancreatitis? 11
```
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
What is cholecystolithiasis?
Gallstones in the gallbladder
147
What is choledocholithiasis?
Gallstones in the common bile duct
148
What are the risk factors for gallstones? 9
```
obesity
age
high levels of serum triglycerides and low HDL
weight cycling
diabetes
oral contraceptives
HRT
smoking
Crohn's disease
```
149
What are the three types of gallstones?
cholesterol stones- most common in western countries
pigmented stones- dark stones made of bilirubin and calcium stones
mixed stones-combination of the above
150
What is the most common presentation of gallstones?
biliary colic - caused by the gallbladder, cystic duct or common bile duct contracting around gallstone
151
Where is the pain in biliary colic?
upper abdomen or right quadrant
152
How long does the pain last for in biliary colic?
More than 30 minutes but less than 8 hours
153
What is biliary colic associated with? 2
nausea or vomiting
154
Is biliary colic associated with fever or abdominal tenderness?
NO
155
What is the second most common presentation of gallstones?
Acute cholecystitis = acute inflammation of the gallbladder
156
What are the signs and symptoms of acute cholecystitis?
Same as biliary colic: pain in upper abdomen, nausea or vomiting
Plus: fever and abdominal tenderness
157
is obstructive jaundice a sign of gallstones?
yes
158
What is Cholangitis?
An infection of the gallbladder, and an uncommon presentation of gallstones
159
How does cholangitis present? 3
Charcot's Triad:
Fever- often with rigors
Jaundice
Upper quadrant pain
160
What investigations should be done in suspected gallstones?
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
What are the surgical options for gallstones? 2
Laparoscopic cholecystectomy- removal of the gallbladder
Cholecystotomy- draining of the blocked gallbaldder, temporary measure until well enough for cholecystectomy
162
How quickly should a laparoscopic cholecystectomy be performed? And how quick is the recovery
Within a week following the onset of acute cholecystitis
| recover time is 2 weeks
163
What are the complications of gallstones? 10
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
How is Hep A spread?
faecal-oral route
165
How long is a person infective for with Hep A?
14-21 days before and up to 8 days after the onset of jaundice
166
What are the risk factors for hep A? 5
travelling
clotting factor disorders- receiving factor VII and IX --> higher risk of contamination
risky sexual behaviour
IV drug users
Occupational risk
167
What are the 3 phases of hep A infection?
Prodromal phase
Icteric phase
Convalescent phase
168
How long does the prodromal phase last in Hep A?
2 days- 2 weeks
169
What are the signs and symptoms of the prodromal phase in Hep A? 10
Flu like symptoms
```
Gi symptoms:
nausea
anorexia
vomiting
right, upper quadrant discomfort
```
```
Other:
headache
cough
sore throat
itch
uriticaria (hives)
```
170
How long is the icteric phase in Hep A?
1-3 weeks
| can persist for >12 weeks
171
How does the icteric phase, in hep A, present? 12
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
How long does the convalescent phase, in hep A, take?
up to 6 months
173
What are the features of the convalescent phase, in hep A? 4
malaise
anorexia
muscle weakness
hepatic tenderness
174
What will LFTs show in Hep A?
ALT and AST will be significantly increased >1000IU/L
| Bilirubin may be elevated up to 500 micromols/l
175
What happens to prothrombin time in hep A?
May be prolonged- 5 secs or more
176
What heaptitis A serology tests do you do?
HAV-IgM and HAV-IgG
177
What does a postive HAV-specific IgM indicate?
That hep A infection is likely
178
What does a positive HAV-IgG indicate?
current or past infection or immunity from vaccine
179
Who gets the Hep A vaccine?
```
Travellers to endemic areas
chronic liver disease
clotting factor disorders
IV drug users
occupational risk- lab workers, residential institutions, sewage workers
```
180
What can be given to ease nausea in hep A?
metoclopramide
181
What can be given to ease itch in hep A? 4
chlorphenamine
ursodeoxycholic acid
colestryamine
corticosteroids
182
What do you monitor in follow up care of hep A? 2
LFTs
| Prothrombin time
183
How common is relapse in hep A?
15% of people relaspse 4-15weeks post original illness
184
How long does the illness from hep A last?
Typically 2 months, it's self limiting
| However complete clinical recovery may take 6 months
185
What are the results of a Hep A infection?
Has no long term sequelae
Doesn't cause chronic liver disease
Doesn't have a chronic carrier state
Results in lifetime immunity
186
Is hep A a notifiable disease?
yes
187
Is hep B a notifiable disease?
yes
188
Is hep B a self-limiting or chronic infection?
Both
In adults and older children it is self-limiting
In infants and younger children it is chronic
189
How is hep B transmitted? 3
blood-blood
sexually
mother-baby
190
what are the clinical features of Hep B? 9
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
What would LFTs show in hep B?
ALT and AST reach 1000-2000 IU/l
ALT is normally higher
Alkaline phsophatase, bilirubin, albumin levels and prothrombin time are usually normal
192
What do you test in serological testing for hep B?
Hepatitis B surface antigen - HBsAg
| Antibody to hepatitis B core antigen - anti-HBc
193
What will HBsAg show in hep B?
It's the first marker to rise in hep B
| will show if there is current infection
194
What does anti-HBc show in hep B?
indicates recovery from hep B
| will persist for life
195
How do you treat hep B exposure?
Rapid vaccine prophylaxis over 21 days, with immunoglobulin prophylaxis at the same time and within 48 hours of exposure
196
How do you treat babies born to mothers infected with hep B?
Vaccine prophylaxis at 0, 1 and 2 months
197
what are the complications of hep B? 6
```
jaundice for 1-3 months
fatigue may persist
chronic hep B infection
glomerulonephritis
vasculitis
polyarteritis
```
198
How is hep C transmitted?
blood
| small risk of sexual transmission
199
What are the risk factors for hep C? 2
needles stick injuries
| blood and organ receivers prior to 1991
200
What are the clinical features of Hep C? 10
```
general malaise with flu-like symptoms
fatigue
myalgia
anxiety
depression
poor memory or concentration
nausea
vomiting
right, upper quadrant pain
jaundice
```
201
What investigations should be done in Hep C?
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
How do you treat Hep C?
Interferon started between 3-6 months after diagnosis
203
What are the complications of Hep C?
Acute fulminant heaptitis- rare
204
What causes an appendicitis?
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
What are the bacteria that commonly overgrow in appendicitis?
bacteroides fragilis
| E.coli
206
What age do most appendicitises occur
10-20
207
Is an appendicitis more common in M or F?
M
208
What are the risk factors for an appendicitis ? 2
frequent antibiotic use
| smoking
209
Where is the pain in an appendicitis? Where does it migrate?
Peri-umbilical or epigastric pain= McBurney's point
| Migrates to right iliac fossa
210
Where exactly is McBurney's point?
2/3rds of the way along a line drawn from the umbilicus to the anterior superior iliac spine
211
What makes the pain worse in an appendicitis?
movement
212
Aside from pain what are the other symptoms of an appendicitis? 4
Anorexia
nausea
constipation
vomiting
213
What signs may be seen on examination of an appendicitis? 7
```
guarding
rebound tenderness
Facial flushing
dry tongue
halitosis
low grade fever
tachycardia
```
214
What is Rovsing's sign in an appendicitis?
palpation of the L lower quadrant increases the pain felt in the r lower quadrant
215
What is the Psoas sign in appendicitis?
extending the right thigh with the person in the left lateral position elicits pain in the r lower quadrant
216
What is the Obturator sign in appendicitis?
internal rotation of the flexed right thigh elicits pain in r lower quadrant
217
What are the signs of a perforated appendix?2
Tachycardia and sudden relief of pain
218
What are the signs of an appendix abscess? 2
palpable abdominal mass
| swinging pyrexia
219
What are the signs of peritonitis? (which can be a complication of appendicitis) 4
profuse vomiting
high fever
severe abdominal tenderness
absent bowel sounds
220
How can older people present with an appendicitis?2
pain may be minimal and fever absent
| may present with confusion and shock
221
How can young children and infants present with an appendicitis?2
vague abdominal pain and anorexia
222
what investigations should you do in an appendicitis? 4
Pregnancy test- exclude ectopic pregnancy
urine dipstick- exclude UTI
FBC - neutrophil predominat leucocytosis present in 80-90%
CRP
223
what is the treatment of an appendicitis?
appendicetomy
224
what are the complications of an appendicitis? 6
```
perforation- likely to occur after 12 hours if inflammation -->
abscess
peritonitis
sepsis
death
premature labour or miscarriage
```
225
What are the causes of mechanical bowel obstruction?
4 common
5 SI
3 LI
```
Common:
constipation
hernias
adhesion (80%)
tumours
```
```
SI
adhesions
hernia
Crohn's
extrinsic cancer
intussusception
```
LI
carcinoma of colon
sigmoid volvulus
diverticular disease
226
What are the causes of paralytic ileus bowel obstruction? 7
```
Abdominal surgery
pancreatitis
spinal injury
hypokalaemia
hyponatraemia
uraemia
drugs e.g. tricylics
```
227
What is pseudo-obstruction of the bowel and what causes it?
Like mechanical but with no found cause
Cause:
Acute colonic pseudo-obstruction= Oglivie's syndrome
Pre-disposing factors:
Peurperium
pelvic surgery
trauma
228
What are the 4 cardinal symptoms of bowel obstruction?
vomiting
colicky pain
constipation
distension
229
What are the associated symptoms in bowel obstruction vomiting? 3
Relief
nausea
annorexia
230
When does faeculent vomiting occur?
When there is a colonic fistula with the proximal gut
231
When is constipation absolute in bowel obstruction?
If the obstruction is distal
232
What bowel sounds can be heard in distension?
tinkling bowel sounds
233
Does the pain get better or worse in long standing obstruction?
better
234
What is the difference between Si and LI obstruction?
SI
vomiting occurs earlier
distension is less
pain is higher in the abdomen
LI
pain is more constant
235
How do you tell the difference between an ileus or a mechanical obstruction?
In ileus there is no pain and bowel sounds are absent
236
What are the signs that the bowel is strangulated? 6
```
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
What investigations can you do in bowel obstruction?
AXR
Water soluble enema - demonstrates site
CT - investigation of choice
Colonoscopy- may reduce preforation
238
What will SI obstruction show on an AXR?
central gas shadows
| no gas in LI
239
What will LI obstruction show on AXR?
Gas proximal to blockage e.g in the caecum but not the rectum (unless you have done a PR)
240
What will a CT scan show in bowel obstruction?
Dilated, fluid filled bowel
241
Which bowel obstructions need surgery?
LI
completer and strangulation
(manage ileus and incomplete conservatively)
242
What is the immediate action in bowel obstruction?
Drip and suck
| NGT and IV fluids
243
How are patients with volvulus managed?
Using flexi sig to un-kink bowel
244
Are inguinal or femoral hernias more common?
inguinal
245
which sex and age group are femoral hernias more common in than inguinal ones?
Middle aged to elderly F
246
What is an indirect inguinal hernia?
pass through the deep/ inguinal ring and if large extend through the superficial/ external inguinal ring
247
What is a direct inguinal hernia?
push directly forward through the posterior wall of the inguinal canal into a defect
248
What is a femoral hernia?
```
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
What's the risk of a femoral hernia?
It's likely to be strangulated due to canals borders
250
What are the risk factors for hernias? 7
```
M>F - inguinal
chronic cough
constipation
urinary obstruction
heavy lifting
ascites
past abdominal surgery
```
251
Are hernias more common on the L or R?
R
252
How do you tell the difference between an indirect and direct hernia?
Get them to cough or stand, if hernia pops out it is direct
253
Are direct or indirect more common? And what are their respective features?
Indirect 80%- can strangulate, don't reduce easily
| Direct 20%- rarely strangulate, reduce easily
254
Are femoral hernias more common in M or F?
F
255
What are the features of a femoral hernia? and where can they be felt?
Frequently strangulate
don't reduce easily
Inferior and lateral to pubic tubercle
256
What are the surgical options for inguinal hernias?
Lichtenstein repair- mesh technique, suture ant and post walls of canal
Laproscopic repair- not recommended
257
What are the surgical options for femoral hernias?
Herniotomy- ligation and excision of sace
Herniorrhaphy- repair of hernia defect
258
what are the complications of hernias?
strangulation --> ischaemia
| Obstruction
259
What are the two main types of oesophageal carcinoma?
squamous cell
| adenocarcinoma
260
Where in the oesophagus are the majority of cancers?
The middle
261
What are the risk factors for oesophageal carcinoma? 8
```
diet low in vit A&C
obesity
alcohol excess
smoking
achlasia
Pulmmer-Vinson syndrome
nitrosamine exposure
Reflux oesophagitis +/- Barrett's
```
262
What investigations do you do in oesophageal carcinoma? 3
Barium swallow
CXR
Oesophagoscopy with biopsy
263
What are the features of oesophageal carcinoma?6
```
dysphagia
weight loss
retrosternal chest pain
lymphadenopathy
If in upper 1/3rd hoarseness
cough
```
264
What are the treatment options for oesophageal carcinoma?
If localised: radical curative oesophagectomy
265
What type of cancer is bowel carcinoma usually?
adenocarcinoma
266
Is Gastric carcinoma more common in M or F?
M
267
How is gastric carcinoma classified?
Borrman classification
268
What are the risk factors for gastric carcinoma? 10
```
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
what are the symptoms and signs of gastric carcinoma? 9
```
Dyspepsia
weight loss
vomiting
dysphagia
anaemia
epigastric mass
hepatomegaly-jaundice-ascites
Virchow's node- left supraclavicular node
acanthiosis nigrans
```
270
What investigations do you do in gastric cancer?
Gastroscopy and ulcer edge biopsies
271
what are most pancreatic cancers?
Adenocarcinoma
272
Why are pancreatic cancers sod deadly (5 year survival <2%)?
Because they met early and present late
273
What sex and age group are pancreatic cancers most common in?
M >60
274
What is the cause of 95% of pancreatic cancers?
mutations of the KRAS2 gene
275
What are the risk factors for pancreatic cancers? 5
```
smoking
alcohol
diabetes
chronic pancreatitis
possibly high fat diet
```
276
Where in the pancreas are the majority of tumours found?
the head (then the body, then tail, then ampulla of vater)
277
How do tumours of the head of the pancreas present?
Painless, obstructive jaundice
278
How do tumours of the tail/ body of the pancreas present?
epigastric pain radiating to the back
| relieved by sitting forward
279
What symptoms and signs can all pancreatic tumours have? 14
```
anaemia
weight loss
diabetes
acute pancreatitis
jaundice
palpable gall bladder
epigastric mass
hepatomegaly
splenomegaly
lymphadenopathy
ascites
```
rare
thromboplhebitis migrans
Hypercalcaemia
portal hypertension
280
What is the treatment option for pancreatic cancer?
Most present with mets so <10% can have surgery
| whipple's; pancreatic-duodenectomy
281
What age group gets colorectal cancers?
>70
282
What are the risk factors for colorectal cancers? 7
```
neoplastic polyps
IBD
familial adenomatous polyposis
HNPCC (lynch syndrome)= hereditary non-polyposis colorectal cancer
previous cancer
low fibre diet
FH
```
283
How do left sided colorectal cancers present? 4
Bleeding, mucus PR
altered bowel habit
tenesmus
Mass of PR 60%
284
How do Right sided colorectal cancers present? 3
weight loss
decrease HB
abdominal pain
285
How do any colorectal cancers present? 5
```
abdominal mass
obstruction
perforation
haemorrhage
fistual
```
286
What investigations should you do in colorectal cancer? 7
FBC- microcytic anaemia
Faecal occulut blood
Protoscopy, sigmoidoscopy, barium enema or colonoscopy
liver USS
287
What are the surgical options for colorectal cancer? 4
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
What are the invective causes of chronic liver failure?3
Viral hepatitis- B, C, CMV
yellow fever
leptospirosis
289
What drug can cause chronic liver failure?
paracetamol OD
290
What toxins cause chronic liver failure? 2
amanita phalloides mushroom
| carbon tetrachloride
291
What vascular problems cause liver failure?
Budd-Chari syndrome
292
What are the other causes of liver failure? 7
```
alcohol
primary biliary cirrhosis
cirrhosis
haemochromatosis
autoimmune hepatitis
alpha-1 antitrypsin deficiency
Wilson's disease
```
293
What are the signs of chronic liver failure? 5
```
jaundice
hepatic encephalopathy
fector hepaticus- smells like pear drops
Asterixis- liver flap
constructional apraxia
```
294
What is the main complication of liver failure?
Leads to encephalopathy as ammonia builds up --> passes to the brain --> astrocytes convert glutamate to glutamine --> osmotic imbalance --> cerebral oedema
295
What are the causes of ascites? 7
| Ascites with portal hypertesnion: 4
```
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
What are the symptoms and signs of ascites? 3
massive stomach
shifting dullness
fluid thrill
297
What investigations do you carry out in ascites?
Aspirate ascetic fluid- paracentesis for:
cytology
culture
protein level
298
Protein level will be raised >30g/l in which causes of ascites? 4
Malignancy
infection
pancreatitis
Budd-chiari syndrome
299
How do you treat ascites?
decrease dietary Na
| Give spirolactone= aldosetrone antagonist--> lose Na
300
what causes kwashikor?
fair to normal energy intake but inadequate protein
301
What causes marasmus?
inadequate energy and protein
302
Insufficient iodine leads to what?3
goitre
hypothyroidism
growth restriction
303
Insufficient vitamin A leads to what? 2
Night blindness
| immune deficiency
304
Insufficient zinc leads to what?2
immune deficiency,
| acrodermatitis
305
Insufficient vitamin C leads to what?1
scurvy
306
Insufficient vitamin B1 *thiamine) causes what?
Beri Beri
Wet Beri-Beri= heart failure with general oedema
Dry Beri-Beri= neuropathy
307
Insufficient nicotinic acid leads to what?
Pellagra :
diarrhoea
dementia
dermatitis
308
What is the BMI for mild malnutrition?
17-18.5
309
what is the BMi for moderate malnutrition?
16-17
310
what is the BMI for severe malnutrition?
<16
311
What are the generic features of malnutrition? 4
listlessness
fatigue
cold sensitivity
non-healing wounds and decubitus ulcers
312
What is the risk of starting malnourished people on food?
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
What are the signs and symptoms of a perforated viscus?
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
What investigations should be done for a perforated viscus ?
Plain radiography- detects pneumoperitoneum
CT- more senstive
USS
315
How do you manage a patient with a perforated viscus?
resuscitation
broad spectrum antibiotics - ciprofloxacin, metronidazole, piperacillin/tazobactam or imipenem
crystalloid fluids
surgery-laparotomy
316
What are the risk factors for coeliac disease?4
FH
link to HLA- human leukocyte antigens
Linked to DM1
autoimmune thyroid disease
317
Is it more common in F or M
F
318
What are the GI symptoms of coeliac disease? 4
diarrhoea
abdominal pain
bloating
constipation
319
What are the non-GI symptoms? 9
```
fatigue
anaemia
dermatitis herpetiformis
osteoporosis
fertility problems
short stature
delayed puberty
peripheral neuropathy
DM1
```
320
What serology test do you do in coeliacs?
IgA tissue transglutaminase antibody
| IgA endomysial antibody
321
What are the complications of coeliac disease? 10
```
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
```
