Abdo core conditions Flashcards
Which drugs are a risk factor for reflux
(3) ?
Antimuscarinics, Ca blockers and nitrates
what are the risk factors for reflux? (5)
Pregnancy fatty food, alcohol, chocolate obesity achlaasia hiatus hernis
What aggravates the pain in reflux?
lying down/ bending over
Drinking what makes reflux worse?
alcohol or hot drinks
What is the word for pain on swallowing ?
odynophagia. You get this with reflux
what investigations would you do in reflux?
Upper GI endoscopy
Intraluminal monitoring
What results would you need to get in intraluminal monitoring for it to count as excessive reflux?
pH<4 for >4% of the time
What drugs would you treat reflux with?
Alginate- containing antacids (magneisum trisiclate or gaviscon)
Prokinetic agents- metocloperamide
h2-receptor anatgonists: cimetidine
PPI- omeprazole
What do you use Prokinetic agents for? Give an example
Reflux, increase gastric emptying
metocloperamide
What do you use H2-receptor anatgonists for? Give an example
Reflux, acid suppression
cimetidine
What surgery do you use in reflux?
Nissen Fundoplication
where is the pain in reflux?
Burning retrosternal pain
What is the definition of an ulcer?
A breach in the epithelium that penetrates the muscularis mucosae
What are the main causes of peptic ulcers?
H.pylori infections, NSAIDs} most common
Rare: Zollinger-Ellison syndrome
Crohn’s disease
How does a H.pylori infection cause stomach ulcers?
Causes inflammation of mucosal lining therefore depleting the alkaline mucosa
Also impairs the cells that produce somatostatin which limits the secretion of gastric acid
What are the 4 main risk factors for peptic ulcers?
NSAIDs, smoking, aspirin, alcohol
Where is the pain in peptic ulcers? And where does it radiate?
Burning epigastric pain
radiates up to the neck, down to the umbilicus or to the back
Aside from pain what are the other symptoms of peptic ulcer?
Indigestion
heartburn
weightloss and loss of appetite
nausea
How does food affect gastric ulcer pain?
It makes it worse
It improves duodenal ulcer pain
What are the 3 tests for H.pylori?
Urea breath test
stool antigen test
Laboratory serology testing
What are the criteria for being able to have a urea breath test or stool antigen test?
Can’t have had PPI in the past 14 days or antibiotics in the past 28 days
How do you treat peptic ulcers due to NSAIDs?
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
If PPI isn’t sufficient in peptic ulcers what do you give?
H2-receptor anatgonists e.g. cimetidine
How do you treat peptic ulcers due to H.pylori?
7 day triple therapy regimen with twice daily dosing
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)
What is the second course of eradication of H.pylori in peptic ulcers?
Antibiotics previously given
for 14 days as quadruple therapy
what is the most common cause of an upper GI bleed?
Peptic ulcer disease
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
What are the risk factors for an upper GI bleed? (7)
age heart failure IHD renal disease Liver disease malignant disease ulcer
What is the scoring system for upper GI bleeds?
Rockall from 0-8+
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
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
What causes massive lower GI bleeds? (2)
These are rare
diverticular disease
ischaemic colitis
What causes small lower GI bleeds?(5)
haemorrhoids anal fissures IBD Crohn's Cancer
What investigations do you do in a lower GI bleed?
Protoscopy
flexible sigmoidoscopy
colonoscopy
angiography
What do you use protoscopy for?
Lower Gi bleeds- haemorrhoids
for anus, anal canal, rectum and sigmoid colon
What do you use flexible sigmoidoscopy or colonoscopy for?
Lower GI bleeds due to IBD, cancer, ischaemic colitis, diverticular disease or angiodysplasia
Is crohn’s continuous or discrete?
Discrete- it has skip lesions
Where in the GI tract does Crohn’s affect?
Anywhere from the mouth to the anus
How much of the intestinal wall is affected in Crohn’s?
the FULL thickness
in UC it’s only the mucosa
What are the risk factors for Crohn’s? (5)
Smoking Family history appendectomy NSAIDs oral contraceptives (small)
When does crohn’s commonly present?
adolesence and early adulthood
Is crohn’s more common in men or women?
M=F
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
Where does abdominal pain typically present in Crohn’s?
In the right lower quadrant
A mass may also be felt
What are the extra-intestinal manifestations of Crohn’s?(6)
Irits Post-articular arthrtitis erythema nodosum apthous ulcers pyoderma gangrenosum episcleritis
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
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
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
When should people with Crohn’s be treated as an emergency?
If they have bloody diarrhoea and fever or tachycardia
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
What lifestyle change should people with Crohn’s make?
stop smoking
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
What immunosuppressants can be used in Crohn’s? (3)
Azathioprine
mercaptopurine
methotrexate
What can you use instead of immunsuppressants in Crohn’s?
Cytokine-modulating drugs
Infliximab
adalimumab
What aminosalicylates can be used in Crohn’s?
Mesalazine and sulfasalazine
What do you offer adolescents or children who are failing to grow due to Crohn’s?
Enteral nutrition
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
Where does UC affect?
The mucosa of the rectum and variable lengths of the colon
Where does Ulcerative proctitis (subtype of UC) affect?
Inflammation is limited to the rectum
Where does Left-sided colitis (subtype of UC) affect?
inflammation affects rectum and doesn’t extend proximally beyond the splenic flexure
Where does extensive colitis/ pan colitis (subtype of UC) affect?
Inflammation extends beyond splenic flexure to affect entire colon
What are the risk factors for UC? 3
Oral contraceptives
FH
Not smoking
When is the peak incidence of UC?
15-25 years
smaller peak 55-65
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
Where is the pain in UC?
Left lower quadrant
Crohn’s is on R
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
What investigations do you do in UC? 7
FBC CRP and ESR U&Es LFTs Tissue transglutaminase stool microscopy and culture Faecal calprotectin
What would LFTs show in UC?
Reduced albumin, which suggests hypoproteinaemia due to malabsorption or intestinal losses
Why do you test tissue transglutaminase in UC and crohn’s?
to rule out coeliac disease
What bugs would you request testing for in a stool microscopy and culture for UC? 3
C-dif toxin
campylobacter
E.Coli O157
Why do you test faecal calprotectin in UC?
to distinguish IBS and IBD, will be raised in IBD
What is the first treatment option for mild or moderate UC?
Aminosalicylates (5-ASAs)
suphalazine
mesalazine
When do you use corticosteroids in UC?
With or instead of 5-ASAs for flare ups if 5-ASAs aren’t enough
prednisolone
What 3 drug types can you use to induce remission in UC?
Aminosalicylates
corticosteroids
immunosuppressants
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
What is the downside of immunosuppressants in treating UC?
They take a while to work
usually 2-3 months
What immunosuppressant do you use to treat severe flare ups of UC?
ciclosporin
stronger and faster than the others (tacrolismus and azathioprine)
given IV
How do you treat severe flare ups of UC?
1- ciclosporin If that doesn't work: Biologic medications: infliximab adalimumab golimumab vedolizumab
What are the surgical options for UC?
Colectomy
May have an ielostomy–> stoma bag
or an ileo-anal pouch–> allows stool to pass normally
What are the complications of UC? (4)
Toxic megacolon
colorectal cancer
venous thromboembolism
osteoporosis
What age range is IBS most common in?
20-30year olds
Is IBS more common in males or females?
F>M
What is abdominal pain associated with in IBS?
Either relieved by defecation
or associated with altered bowel frequency or altered stool form
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
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
If IBS symptoms don’t repsond to first line treatment options what can you give?
Low dose tricylcic antidepressant
e.g. amitriptyline
at night
What classifies as acute diarrhoea?
three or more episodes lasting for less than 14 days
What classifies as persistent diarrhoea?
lasts for more than 14 days
What is dysentery?
loose stools, with blood and mucus, often with pyrexia and abdominal cramps
What organisms cause bloody diarrhoea? 5
Campylobacter Entamoeba histolytica E.Coli Salmonella serotypes shigella
Is gastroenteritis caused most commonly by bacteria, virus or parasites?
Virus
What is the most common cause of infantile gastroenteritis?
rotavirus
Transmitted by faecal oral route
worse nov-apr
what is the most common cause of gastroenteritis in adults?
Norovirus
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
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
What are the symptoms of gastroenteritis caused by toxins?
rapid onset diarrhoea and vomiting which usually lasts for less than 12 hours
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
what are the symptoms of a rotavirus gastroenteritis? 3
Starts with fever and vomiting followed by water diarrhoea
lasts 3-8 days
What are the symptoms of norovirus gastroenteritis? 5
nausea followed by watery diarrhoea
vomiting, raised temperature and aching limbs may be present
How long do the symptoms of rotavirus gastroenteritis last?
3-8 days
How long after infection does it take for norvirus to present?
24-48hours
How long do the symptoms of norovirus last?
12-60 hours
What are the symptoms of campylobacter? 5
diarrhoea- may be bloody nausea vomiting cramping abdominal pain fever
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)
Which bacteria can cause haemorrhagic colitis? and what can it lead to?
E.coli
Haemolytic uraemic syndrome (HUS)
What are the symptoms of salmonella?6
Water and sometimes bloody diarrhoea abdominal pain headache nausea vomiting fever
What are the symptoms of shigellosis? 2
Diarrhoea- often with blood and mucus= dysentery
abdominal cramps
What are the symptoms of crytosporidium? 6
water diarrhoea stomach cramps dehydration nausea and vomiting fever weight loss
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)
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
Do you give Abx to adults with diarrhoea of unknown pathology?
NO
how do you treat amoebiasis (caused by entamoeba histolytica)?
Metronidazole 3/day for 5-10 days
followed by diolxamide 3/day for 10 days
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
How do you treat E.Coli?
NO abx
entirely supportive
Avoid antimotillity drugs and NSAIDs
How do you treat giardiasis?
metronidazole
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
When and how do you treat shigellosis?
When: severe disease, immunocompromised, bloody diarrhoea
How: ciprofloxacin, azithromycin
Don’t prescribe antimotillity drugs
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
What organisms cause reactive complications of gastroenteritis? 4
salmonella
campylobacter
Yersinia enterocolictica
shigella
What are the reactive complications of gastroenteritis?
arthtis carditis urticaria erythema nodosum conjunctivitis Reiter's syndrome= urethritis, arthritis and uveitis
What is a complication of rotavirus?
toxic megacolon (rare)
What are complication of salmonella? 2
Septicaemia
focal infections e.g. septic arthritis
What is a complication of shigella?
haemolytic uraemic syndrome
What causes acute pancreatitis? 2
Gallstones
alcohol missuse
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
Where is the pain in acute pancreatitis?
epigastric region
may radiate to the back (less commonly to the chest or flanks)
What makes the pain better and worse?
Worse: movement
Better: foetal position
Aside from pain what other symptoms are there in acute pancreatitis? 3
nausea
vomiting
anorexia
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
What do Cullen’s and Grey-Turner’s sign indicate?
Haemorrhagic pancreatitis- late serious complication of acute pancreatitis
What investigations do you do in acute pancreatitis?
Lipase or amylase levles
CT, MRI, USS
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
What causes endocrine pancreatic insufficiency? and what is the result of it?
Damage to the islet of langerhans
–> no insulin
What causes exocrine pancreatic insufficinecy? And what is the result of it?
Damage of the acinar cells
–> no digestive enzymes
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
What drugs are risk factors for chronic pancreatitis? 7
thiazide diuretics azathioprine tetracyclines oestrogens calproic acid cimetidine dipeptidylpeptidase inhibitors
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
What makes the pain better and worse in chronic pancreatitis?
better: sitting forward
worse: may be precipitated by eating
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
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
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
What are the surgical options for chronic pancreatitis?
endoscopy- to remove obstructive pancreatic stones or to dilate strictures
splanchnicetomy
What are the medical options for chronic pancreatitis?
Enzyme supplementation- help steatorrhea and malnutrition
Corticosteroids- if the cause is autoimmune
Treatment of diabetes
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
What is cholecystolithiasis?
Gallstones in the gallbladder
What is choledocholithiasis?
Gallstones in the common bile duct
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
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
What is the most common presentation of gallstones?
biliary colic - caused by the gallbladder, cystic duct or common bile duct contracting around gallstone
Where is the pain in biliary colic?
upper abdomen or right quadrant
How long does the pain last for in biliary colic?
More than 30 minutes but less than 8 hours
What is biliary colic associated with? 2
nausea or vomiting
Is biliary colic associated with fever or abdominal tenderness?
NO
What is the second most common presentation of gallstones?
Acute cholecystitis = acute inflammation of the gallbladder
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
is obstructive jaundice a sign of gallstones?
yes
What is Cholangitis?
An infection of the gallbladder, and an uncommon presentation of gallstones
How does cholangitis present? 3
Charcot’s Triad:
Fever- often with rigors
Jaundice
Upper quadrant pain
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
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
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
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
How is Hep A spread?
faecal-oral route
How long is a person infective for with Hep A?
14-21 days before and up to 8 days after the onset of jaundice
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
What are the 3 phases of hep A infection?
Prodromal phase
Icteric phase
Convalescent phase
How long does the prodromal phase last in Hep A?
2 days- 2 weeks
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)
How long is the icteric phase in Hep A?
1-3 weeks
can persist for >12 weeks
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
How long does the convalescent phase, in hep A, take?
up to 6 months
What are the features of the convalescent phase, in hep A? 4
malaise
anorexia
muscle weakness
hepatic tenderness
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
What happens to prothrombin time in hep A?
May be prolonged- 5 secs or more
What heaptitis A serology tests do you do?
HAV-IgM and HAV-IgG
What does a postive HAV-specific IgM indicate?
That hep A infection is likely
What does a positive HAV-IgG indicate?
current or past infection or immunity from vaccine
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
What can be given to ease nausea in hep A?
metoclopramide
What can be given to ease itch in hep A? 4
chlorphenamine
ursodeoxycholic acid
colestryamine
corticosteroids
What do you monitor in follow up care of hep A? 2
LFTs
Prothrombin time
How common is relapse in hep A?
15% of people relaspse 4-15weeks post original illness
How long does the illness from hep A last?
Typically 2 months, it’s self limiting
However complete clinical recovery may take 6 months
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
Is hep A a notifiable disease?
yes
Is hep B a notifiable disease?
yes
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
How is hep B transmitted? 3
blood-blood
sexually
mother-baby
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
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
What do you test in serological testing for hep B?
Hepatitis B surface antigen - HBsAg
Antibody to hepatitis B core antigen - anti-HBc
What will HBsAg show in hep B?
It’s the first marker to rise in hep B
will show if there is current infection
What does anti-HBc show in hep B?
indicates recovery from hep B
will persist for life
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
How do you treat babies born to mothers infected with hep B?
Vaccine prophylaxis at 0, 1 and 2 months
what are the complications of hep B? 6
jaundice for 1-3 months fatigue may persist chronic hep B infection glomerulonephritis vasculitis polyarteritis
How is hep C transmitted?
blood
small risk of sexual transmission
What are the risk factors for hep C? 2
needles stick injuries
blood and organ receivers prior to 1991
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
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
How do you treat Hep C?
Interferon started between 3-6 months after diagnosis
What are the complications of Hep C?
Acute fulminant heaptitis- rare
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
What are the bacteria that commonly overgrow in appendicitis?
bacteroides fragilis
E.coli
What age do most appendicitises occur
10-20
Is an appendicitis more common in M or F?
M
What are the risk factors for an appendicitis ? 2
frequent antibiotic use
smoking
Where is the pain in an appendicitis? Where does it migrate?
Peri-umbilical or epigastric pain= McBurney’s point
Migrates to right iliac fossa
Where exactly is McBurney’s point?
2/3rds of the way along a line drawn from the umbilicus to the anterior superior iliac spine
What makes the pain worse in an appendicitis?
movement
Aside from pain what are the other symptoms of an appendicitis? 4
Anorexia
nausea
constipation
vomiting
What signs may be seen on examination of an appendicitis? 7
guarding rebound tenderness Facial flushing dry tongue halitosis low grade fever tachycardia
What is Rovsing’s sign in an appendicitis?
palpation of the L lower quadrant increases the pain felt in the r lower quadrant
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
What is the Obturator sign in appendicitis?
internal rotation of the flexed right thigh elicits pain in r lower quadrant
What are the signs of a perforated appendix?2
Tachycardia and sudden relief of pain
What are the signs of an appendix abscess? 2
palpable abdominal mass
swinging pyrexia
What are the signs of peritonitis? (which can be a complication of appendicitis) 4
profuse vomiting
high fever
severe abdominal tenderness
absent bowel sounds
How can older people present with an appendicitis?2
pain may be minimal and fever absent
may present with confusion and shock
How can young children and infants present with an appendicitis?2
vague abdominal pain and anorexia
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
what is the treatment of an appendicitis?
appendicetomy
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
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
What are the causes of paralytic ileus bowel obstruction? 7
Abdominal surgery pancreatitis spinal injury hypokalaemia hyponatraemia uraemia drugs e.g. tricylics
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
What are the 4 cardinal symptoms of bowel obstruction?
vomiting
colicky pain
constipation
distension
What are the associated symptoms in bowel obstruction vomiting? 3
Relief
nausea
annorexia
When does faeculent vomiting occur?
When there is a colonic fistula with the proximal gut
When is constipation absolute in bowel obstruction?
If the obstruction is distal
What bowel sounds can be heard in distension?
tinkling bowel sounds
Does the pain get better or worse in long standing obstruction?
better
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
How do you tell the difference between an ileus or a mechanical obstruction?
In ileus there is no pain and bowel sounds are absent
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
What investigations can you do in bowel obstruction?
AXR
Water soluble enema - demonstrates site
CT - investigation of choice
Colonoscopy- may reduce preforation
What will SI obstruction show on an AXR?
central gas shadows
no gas in LI
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)
What will a CT scan show in bowel obstruction?
Dilated, fluid filled bowel
Which bowel obstructions need surgery?
LI
completer and strangulation
(manage ileus and incomplete conservatively)
What is the immediate action in bowel obstruction?
Drip and suck
NGT and IV fluids
How are patients with volvulus managed?
Using flexi sig to un-kink bowel
Are inguinal or femoral hernias more common?
inguinal
which sex and age group are femoral hernias more common in than inguinal ones?
Middle aged to elderly F
What is an indirect inguinal hernia?
pass through the deep/ inguinal ring and if large extend through the superficial/ external inguinal ring
What is a direct inguinal hernia?
push directly forward through the posterior wall of the inguinal canal into a defect
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)
What’s the risk of a femoral hernia?
It’s likely to be strangulated due to canals borders
What are the risk factors for hernias? 7
M>F - inguinal chronic cough constipation urinary obstruction heavy lifting ascites past abdominal surgery
Are hernias more common on the L or R?
R
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
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
Are femoral hernias more common in M or F?
F
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
What are the surgical options for inguinal hernias?
Lichtenstein repair- mesh technique, suture ant and post walls of canal
Laproscopic repair- not recommended
What are the surgical options for femoral hernias?
Herniotomy- ligation and excision of sace
Herniorrhaphy- repair of hernia defect
what are the complications of hernias?
strangulation –> ischaemia
Obstruction
What are the two main types of oesophageal carcinoma?
squamous cell
adenocarcinoma
Where in the oesophagus are the majority of cancers?
The middle
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
What investigations do you do in oesophageal carcinoma? 3
Barium swallow
CXR
Oesophagoscopy with biopsy
What are the features of oesophageal carcinoma?6
dysphagia weight loss retrosternal chest pain lymphadenopathy If in upper 1/3rd hoarseness cough
What are the treatment options for oesophageal carcinoma?
If localised: radical curative oesophagectomy
What type of cancer is bowel carcinoma usually?
adenocarcinoma
Is Gastric carcinoma more common in M or F?
M
How is gastric carcinoma classified?
Borrman classification
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
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
What investigations do you do in gastric cancer?
Gastroscopy and ulcer edge biopsies
what are most pancreatic cancers?
Adenocarcinoma
Why are pancreatic cancers sod deadly (5 year survival <2%)?
Because they met early and present late
What sex and age group are pancreatic cancers most common in?
M >60
What is the cause of 95% of pancreatic cancers?
mutations of the KRAS2 gene
What are the risk factors for pancreatic cancers? 5
smoking alcohol diabetes chronic pancreatitis possibly high fat diet
Where in the pancreas are the majority of tumours found?
the head (then the body, then tail, then ampulla of vater)
How do tumours of the head of the pancreas present?
Painless, obstructive jaundice
How do tumours of the tail/ body of the pancreas present?
epigastric pain radiating to the back
relieved by sitting forward
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
What is the treatment option for pancreatic cancer?
Most present with mets so <10% can have surgery
whipple’s; pancreatic-duodenectomy
What age group gets colorectal cancers?
> 70
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
How do left sided colorectal cancers present? 4
Bleeding, mucus PR
altered bowel habit
tenesmus
Mass of PR 60%
How do Right sided colorectal cancers present? 3
weight loss
decrease HB
abdominal pain
How do any colorectal cancers present? 5
abdominal mass obstruction perforation haemorrhage fistual
What investigations should you do in colorectal cancer? 7
FBC- microcytic anaemia
Faecal occulut blood
Protoscopy, sigmoidoscopy, barium enema or colonoscopy
liver USS
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
What are the invective causes of chronic liver failure?3
Viral hepatitis- B, C, CMV
yellow fever
leptospirosis
What drug can cause chronic liver failure?
paracetamol OD
What toxins cause chronic liver failure? 2
amanita phalloides mushroom
carbon tetrachloride
What vascular problems cause liver failure?
Budd-Chari syndrome
What are the other causes of liver failure? 7
alcohol primary biliary cirrhosis cirrhosis haemochromatosis autoimmune hepatitis alpha-1 antitrypsin deficiency Wilson's disease
What are the signs of chronic liver failure? 5
jaundice hepatic encephalopathy fector hepaticus- smells like pear drops Asterixis- liver flap constructional apraxia
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
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
What are the symptoms and signs of ascites? 3
massive stomach
shifting dullness
fluid thrill
What investigations do you carry out in ascites?
Aspirate ascetic fluid- paracentesis for:
cytology
culture
protein level
Protein level will be raised >30g/l in which causes of ascites? 4
Malignancy
infection
pancreatitis
Budd-chiari syndrome
How do you treat ascites?
decrease dietary Na
Give spirolactone= aldosetrone antagonist–> lose Na
what causes kwashikor?
fair to normal energy intake but inadequate protein
What causes marasmus?
inadequate energy and protein
Insufficient iodine leads to what?3
goitre
hypothyroidism
growth restriction
Insufficient vitamin A leads to what? 2
Night blindness
immune deficiency
Insufficient zinc leads to what?2
immune deficiency,
acrodermatitis
Insufficient vitamin C leads to what?1
scurvy
Insufficient vitamin B1 *thiamine) causes what?
Beri Beri
Wet Beri-Beri= heart failure with general oedema
Dry Beri-Beri= neuropathy
Insufficient nicotinic acid leads to what?
Pellagra :
diarrhoea
dementia
dermatitis
What is the BMI for mild malnutrition?
17-18.5
what is the BMi for moderate malnutrition?
16-17
what is the BMI for severe malnutrition?
<16
What are the generic features of malnutrition? 4
listlessness
fatigue
cold sensitivity
non-healing wounds and decubitus ulcers
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
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
What investigations should be done for a perforated viscus ?
Plain radiography- detects pneumoperitoneum
CT- more senstive
USS
How do you manage a patient with a perforated viscus?
resuscitation
broad spectrum antibiotics - ciprofloxacin, metronidazole, piperacillin/tazobactam or imipenem
crystalloid fluids
surgery-laparotomy
What are the risk factors for coeliac disease?4
FH
link to HLA- human leukocyte antigens
Linked to DM1
autoimmune thyroid disease
Is it more common in F or M
F
What are the GI symptoms of coeliac disease? 4
diarrhoea
abdominal pain
bloating
constipation
What are the non-GI symptoms? 9
fatigue anaemia dermatitis herpetiformis osteoporosis fertility problems short stature delayed puberty peripheral neuropathy DM1
What serology test do you do in coeliacs?
IgA tissue transglutaminase antibody
IgA endomysial antibody
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
