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1
Q

What activates the pancreatic enzymes? What are they called?

What acts to prevent early activation?

A

Zymogens
Enterokinase activates trypsinogen to trypsin which in turn activates chemotrypsinogen, pancratic prolipase, pancreatic proamylase and proelastase
Alpha 1 antitrypsin

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2
Q

Other than enzymes what is another major compent of pancreatic secretion? What controls it?

A

Bicarbonate

Controlled by secretin released from the terminal jejunum in response to low ph and also by cck

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3
Q

What hormones decrease pancreatic secretions post meal?

A

Somatostatin and pancreatic polypeptide

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4
Q

What are the main endocrine pancreas cells? What do they secrete?

A 
Beta - insulin
Alpha - glucagon
PP - pancreatic polypeptide 
D - somatostatin 
Enterochromaffin - seratonin
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5
Q

Test for exocrine pancreas function

A

Faecal elastase

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6
Q

Imaging of the pancreas and what its looking for

A

AXR - calcification of chronic pancreatitis
USS - masses and inflammation
Spiral CT - gold standard
MRCP - pancreatic ducts and biliary tree for gallstones
Endoscopic USS - distal stones id, needle biopsy
ERCP

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7
Q

What is the definition of acute pancreatitis?

A

Acute onset inflammation of the pancreas on the background of a normal pancreas

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8
Q

Causes of acute pancreatitis?

A 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune 
Scorpions 
Hypothermia, hypercalcaemia, hyperlipidaemia 
ERCP
Drugs
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9
Q

What drugs can result in acute pancreatitis?

A

Steroids
Azothioprine
Oestrogen

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10
Q

Causes of chronic pancreatitis apart from getsmashed?

A

CF
Idiopathic
Alpha 1 antitrypsin deficiency

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11
Q

S+S of acute pancreatitis ?

A 
Epigastric pain, spreads to back, relieved by sitting forward 
N+V 
Tenderness to guarding 
Normal vital signs to shock and fever
Cullens and grey turners signs
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12
Q

Blood test changes in acute pancreatitis

A

Serum amylase >3x normal

CRP raised

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13
Q

Pitfall of serum amylase

A

Goes down after several days

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14
Q

Investigations to do in acute pancreatitis

A 
Bloods - FBC, UE, LFTs, amylase, CRP, calcium 
ABG
AXR and CXR erect
USS
Spiral CT
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15
Q

Scoring systems that can be used in chronic pancreatitis

A

Glasgow
EWS
APACHE

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16
Q

What is the glasgow score for pancreatits? Interpret it

A 
PO2 55
Neutrophillia WCC >15
Ca 16
Enyzmes LDH >600
Albumin 10
Sugar >10

3 or more within 48 hours suggests severe - consider HDU/ITU

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17
Q

DDx for acute pancreatitis

A 
Perforated ulcer
Mesenteric infarction
MI
AAA
Cholecystits
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18
Q

What is an issue with pancreatitis, perforated ulcer and mesenteric infarction all presenting in a similar manner?

A

All also cause raised amylase

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19
Q

Treatment of acute pancreatitis?

A 
Iv fluids and electrolytes
Catheter for fluid balance
Analgesia
Antiemetics
Nutrition with NG or NI tube 
Alcohol withdrawal prophylaxis 
ABX consideration if severe 
Precipitating cause once settled 
Consideration to HDU, ITU and central line monitoring
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20
Q

Complications of acute pancreatitis

A 
Shock - organ failure (ARDS, AKI), DIC
Sepsis - infection of necrotic areas 
Haemorrhage
Pulmonary insufficiency (oedema, pain, R-L shunting) 
Fistula 
Pseudocyst 
Stricture
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21
Q

What is an issue if a pancreatic pseudocyst forms post acute pancreatitis?

A

Full of digestive enzymes so can damage structures and cause bleeding

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22
Q

Treatment for infected necrotic areas of pancrease post acute pancreatitis?

A

Remove area

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23
Q

Why does calcification occur in chronic pancreatitis?

A

Enzyme activity leads to protein precipitation in ducts leading to calcification

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24
Q

Presentation of chronic pancreatitis?

A 
Chronic epigastric pain - eased with heat and leaning forwards, can radiate to back.  Fluctuates 
Erythema ab igni from hot waterbottle 
Anorexia and weight loss
Diabetes
Malabsorption and steatorrheoa
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25
Amylase and lipase levels in chronic pancreatitis?
usually normal!
26
Tests to run in suspected chronic pancreatitis?
``` Faecal elastase Abdo xray for calcification MRCP for duct dilation USS Contrast spiral CT ```
27
Treatment of chronic pancreatits
``` Abstain from alcohol Nsaids and opiates Coeliac nerve block Pancreatic enzyme supplementation (creon) Vitamin supplementation Diabetes control ```
28
Complications of chronic pancreatitis?
``` Pancreatic pseudocyst DM Biliary obstruction Splenic vein thrombosis Pancreatic carcinoma ```
29
Risk factors for pancreatic cancer
Smoking Pancreatitis Napthalamine Genetics
30
Types of gallstones?
Cholesterol Pigment Mixed
31
Formation of cholesterol gallstones?
Cholesterol supersaturation - excess cholesterol or insufficient bile salts (e.g. Chrones disease preventing reabsorption in ilium) Gall bladder stasis Nidus for stone formation - e.g. Infection, lipoproteins
32
Presentations of gallstones?
``` Asymptomatic Biliary colic Acute cholecystitis Acute cholangitis Pancreatitis ```
33
Cause and Presentation of biliary colic
Temporary obstruction of cystic or common bile duct by gallstone Abrupt onset and offset Severe constant pain epigastrium to RUQ Nausea and vomiting Generally lasts several hours, usually evening to morning
34
Cause and Presentation of acute cholecystitis
Blockage of the cystic duct causing gallbladder distension, inflammation and secondary infection Similar onset to biliary colic but prolonged and progressive Localises to RUQ with peritonism +/- mass Pyrexia Murphy's sign positive
35
What blood tests would be raised in acute cholecystitis but not biliary colic?
WCC CRP Marginal LFT increases
36
What test is most useful in gallstone disease? What may it show?
Abdo USS gallstones! thickened wall and shrunken gall bladder in cholecystitis
37
What bloods should be done in all gallstone based diseases acutely?
``` Fbc U+e Lft Amylase Alp ```
38
How should acute cholecystitis be managed?
Analgesia IV coamoxiclav Lap chole a few days later once settled
39
Management of biliary colic
Analgesia | Elective lap chole
40
Complications of lap chole?
Biliary leak from cystic duct Damage to bile duct Ascending cholangitis
41
What is and presentation of acute cholangitis
Stone in CBD Biliary colic, fever and jaundice - charcots triad Episodic and fluctuating
42
Investigation of acute cholangitis
Bloods - FBC, CRP (increased), LFTs (transient mild increase), amylase (mild increase), increased prothrombin time (decreased vit. k absorption!) USS - dilation of intrahepatic ducts MRCP or spiral CT ERCP
43
Alternative treatments for gallstones and their issues
Ursodeoxycholic acid - increased risk of small stones entering bile duct, stones reform when stopped Lithotripsy - increased risk of small stones entering bile duct Percutanious drainage of gall bladder - high rate of reoccurence
44
Complications of gallstones
Empyema / gangrene - perforation - peritonitis Pancreatitis Fistula into duodenum - gallstone ilius Compression of cbd by gallstone within bladder
45
Treatment of gallstone cholangitis
Ercp Abx Cholesystectomy
46
Red flags for malignant cause of obstructive jaundice
Very high bilirubin (as nothing can pass whilst stones can bob) Jaundice and palpable gallbladder (in stones it shrinks)
47
A patient has his gallbladder removed due to stones and presents a month later with ruq pain. Possible causes?
Functional large bowel disease Retained cbd stone Hypertension of sphincter of oddi (look for raised lfts)
48
A gallbladder is removed due to acute cholocystitis. It has no gallstones. What is wrong?
Non calculous cholecystitis
49
Other than gallstones another cause of cholangitis? | S+S
``` Primary sclerosing cholangitis Pruritis Fatigue Cholangitis Cirrhosis ```
50
Associated diseases with primary sclerosing cholangitis?
IBD (75%) | Cholangiocarcinoma (15%)
51
Treatment for primary sclerosing cholangitis
Liver transplantation Ursodeoxycholic acid Colestyramine for pruritis
52
Malignancy risks in primary sclerosing cholangitis
Hepatic Colorectal Cholangiocarcinoma
53
Positive bloods in primary sclerosing cholangitis
``` ANA ANCA Alk phos Bilirubin Hypergammaglobulinaemia ```
54
What triggers exocrine release from the pancreas?
Neurological stimuli of the vagus Gastric stretch stimuli of the vagus Intestinal lipids causing cck release from apud cells and stimuli of the vagus
55
Presentation of ischemic colitis
LIF pain and PR bleeding +/- diarrhoea Distended tender abdomen
56
Xray changes in ischemic colitis
Thumb printing
57
Treatment for ischemic colitis
Symptomatic | Urgent surgery if gangrene or perforation
58
Presentation of diverticular disease?
Asymptomatic LIF pain Erratic bowels
59
Complication of chronic diverticular disease
Bowel narrowing with constipation and severe pain
60
Treatment of uncomplicated symptomatic diverticular disease
High fibre diet Mebevarine if required Consideration to bulk forming laxative if constipated High water intake
61
Presentation of acute diverticulitis
LIF pain Fever Constipation Tenderness, guarding and rigidity in LIF
62
CT findings in acute diverticulitis
Colon wall thickening Diverticula Abscesses
63
Treatment of acute diverticulitis
Pain relief Outpatient - oral cephalosporin, oral metranidazole, Inpatient - bowel rest, iv fluids, abx as above but iv
64
Complications of diverticular disease
``` Haemorrhage Perforation Stricture Fistula Obstruction ```
65
Symptoms of appendicitis
Pain N+V Anorexia Diarrhoea
66
Differentials of acute appendicitis
Mesenteric adenitis Inflamed meckels diverticulum Acute terminal ileitis
67
Specific signs of appendicitis
Rovsing sign - LLQ palpation causes RLQ pain Psoas sign - pain on right hip flexion against resistance Obturator sign - pain on internal and external rotation of right hip
68
Causes of small bowel obstruction
``` Adhesions Hernia Chrones Intussusception Extrinsic cancer ```
69
Causes of large bowel obstruction
Cancer Sigmoid volvulus Diverticular disease
70
Features of small bowel obstruction
``` Vomiting Pain in paroxysms Constipation No flatulance Distended abdomen ```
71
How does large bowel obstruction present differently to a small bowel obstruction?
Less vomiting | Increased time between pain
72
Management of bowel obstruction
``` Resucitation NG tube Fluids Catheter Watchful waiting or surgery. ```
73
What sort of bowel obstruction often resolves itself?
Adhesions
74
Indications for surgery in bowel obstruction
No adhesive cause suspected Worsening pain Raised temp, pulse
75
How can a sigmoid volvulus be. Managed?
Pass a ridid sigmoidoscope to. Straighten
76
What HAS to be examined in a case of bowel obstruction
Hernial orifices
77
Characteristic anal fissure pain?
Pain through defication with stinging post defication
78
Physical examination findings with anal fissure?
Fissure usually posterior | Sentinel pile
79
What group of patients may have an anterior anal fissure
Post partum women
80
Bowel changes in someone with an anal fissure?
Constipation | Diarrhoea due to water overflow around constipation
81
Differential diagnosis of anal fissure? When should the main one be considered?
Low lying carcinoma of anus Abnormal appearance, failed first line treatment treatment, systemic illness Also - crohns,
82
What are chronic anal fissures? What is a common causative mechanism? Why may acute fissures persist?
>2 months duration Vigerous wiping Spasm of sphincter decreases blood supply decreasing healing
83
Conservative treatments for anal fissures
Fluids High fibre Salt baths Wash/dab rather than wipe
84
Medical treatments for anal fissures
Fibrogel | Nitrates or calcium channel antagonists
85
Surgical treatments for anal fissures | Mechanism?
Botox injection Incision to the sphincter Relaxes pressure aiding healing
86
Physiological function of haemarrhoidal veins?
Stop flatulance
87
Presentation of haemarrhoids
Bright red rectal bleeding Pruritus Discharge
88
Haemorrhoid stages
1 - internal 2 - prolapse on defication, spontaniously reduce 3 - prolapse on defication, reduced manually 4 - constant prolapse
89
Conservative treatment of haemarrhoids
Fibre | Fluids
90
Symptomatic treatment of haemorrhoids
Anusol
91
Surgical treatment of haemorrhoids
Haemorrhoidal banding Injection sclerotherapy Haemorrhoidal artery ligation Open haemorrhodectomy
92
Complication of haemorrhoids Presentation Treatment
Thrombosed pile Very painful, discoloured, swollen Ice pack and laxatives to reduce oedema, then as normal
93
Definition of a sinus
Blind ended cavity
94
Definition of fistula
Abnormal connection between two epithelial lined surfaces
95
Definition. Of an abscess
Pus filled cavity lined with pyogenic membrane
96
How do anal fistulas form?
From abscess that open at both ends
97
Types of cleanliness in surgery?
Clean - no where near internal organs Clean contaminated - internal organ puncture no leak Contaminated - internal organ leak Dirty - gross contamination
98
Presentation of an anal abscess? | Signs of chronicity?
Tender perianal lump, systemic upset and fever | Chronic with discharge, anal pain
99
Treatment of perianal abscess
Lay open and wash
100
If you suspect an anal fistula what examinations?
MRI EUA Fistulography - squirt in dye and look inside, define path with wires
101
A fistula presents in an emergency - management
Rigid sig Drain and wash Culture Pack
102
Ways to lay open chronic anal fistula
Cut in surgery | Insert a wire loop under tension that slowly cheesewires through to surface
103
How do rectal cancers present?
Fresh blood Pain Tenesmus Discharge
104
How do left sided colon cancers present?
Mixed blood | Change in bowel habits
105
How do transverse and right sided colon cancers present?
Weight loss Anaemia Mass Small bowel obstruction
106
2WW criteria for lower gi symptoms?
All ages - mass, +v occult blood >40 - weight loss and abdo pain 50 - pr bleed >60 - iron deficiency anaemia or change in bowels
107
What examinations should be done on someone arriving on a 2ww pathway initially in clinic?
Pr Sigmoidoscopy Bloods
108
Alternatives to colonoscopy in looking for suspected bowel cancer. Disadvantages?
Flexi sig - only sees so far Barium enema - still needs bowel prep, misses small, still needs biopsy, misses rectum CT abdo/pelvis - may miss small, still needs biopsy, radiation
109
Tumour seen and biopsied in the bowel. What next?
Staging ct chest abdo pelvis | If rectal add mri pelvis for direct spread
110
What is the advantage of a short course of preop chemo in bowel cancer?
Reduces risk of reocurrance
111
What is the advantage of long course pre op chemo in bowel cancer
Reduces reoccurence and makes a locally advanced tumour more operable
112
Elective operations for bowel cancer?
``` R hemicolectomy Extended right hemicolectomy Anterior resection Abdominal peroneal resection TEMS ```
113
What is a tems proceedure for bowel cancer?
Transanal endoscopic microsurgery
114
What emergency procedure can be performed for bowel cancer? Indications? What is it?
Hartmanns - obstruction, perforation | Resection of sigmoid colon and rectum with colostomy formation and closure of rectal stump.
115
Staging for bowel cancer?
``` Dukes A - confined to wall B - through the wall C - involves lymph nodes D - widespread mets ```
116
Late complications of stomas
``` Obstruction Dermatitis Prolapse Parastomal hernia Fistula ```
117
Early complications of stoma
``` Haemorrhage Ischemia High output Adhesions Retraction ```
118
Term for a stoma that rests an anastemosis or distal bowel?
Defuctioning
119
Post stoma what may happen at the anus?
Mucus production
120
Risk factors for gastric cancer?
``` Age Asian Poor FHx High fat diet Preserved foods Smoking H pylori ```
121
What weird risk factor for gastric cancer is there?
Blood group A
122
Pre malignant conditions for gastric cancer
``` Polyps Gastritis Atrophic gastritis Ulcer Gastric surgery ```
123
Complications of parenteral nutrition
Feed - fluid overload, electrolyte imbalance, liver damage, refeeding syndrome Line - infection, pneumothorax, vascular injury, thrombosis
124
Types of entral nutrition
``` Oral Nasogastric Nasojejunal Gastrostomy Jejunostomy ```
125
Advantage of nj feeding over ng
Risk of reflux or delayed gastric emptying mitigated
126
Advantage of gastostomy feeding over ng or nj
Hidden so less embaressment | Longer lasting
127
Assessment scores for upper gi bleed?
Blachford | Rockall
128
Indications for a platelet transfusion in upper gi bleed
Active bleeding or unstable with platelets less than 50x10^9
129
What should be done in a upper gi bleed with INR >1.5 or APPT 1.5x normal?
Ffp | If fribrinogen remains low offer cryoprecipitate
130
What drugs should be given to suspected oesophageal variceal bleeding (assuming normal hb and clotting)
Terlipressin Prophylactic antibiotics Consideration to PPI
131
Surgical/endocopical proceedures for bleeding oesophageal varicies
Band ligation | TIPS
132
What does the blachford score look at in upper gi bleed?
``` Hb Blood urea Systolic pressure Pulse Melena Syncope Hepatic hx Heart failure hx ```
133
Complications of peritonitis
Sepsis Abscess Electrolyte disturbance
134
At what age are people screened for AAA?
65
135
What is the treatment threshold for AAA?
>5.5cm
136
AAA risk factors
Non-modifiable : age, male, FHx | Modifiable : smoking, atherosclerosis, hypertension
137
What surgery requires antibiotic prophylaxis?
Clean with prothesis or implant Clean contaminated Contaminated
138
Management of non urgent dyspepsia?
Review predisposing meds (bisphosphonates, nsaids, corticosteroids, nitrates, calcium antagonists) H pylori breath test +/- eradication 4 week full dose PPI trial If symptoms return post successful 4 weeks start low dose PPI
139
What is achalasia?
Failure of peristalsis and of relaxation of the LOS
140
Symptoms of achalasia
Gradual onset dysphagia Regurgitation Heartburn
141
Diagnosis of achelasia
Barium swallow | Endoscopy
142
Treatment of achelasia
Nitrates Balloon dilation Botox Surgery
143
Complications of achalasia
Oesophageal cancer Aspiration pneumonia Weight loss
144
Types of hiatus hernia
1 - sliding, goj above diaphragm 2 - paraoesophageal, goj normal, fundus herniates next to oesophagus 3 - mixed 1 +2 4 - structures other than stomach also herniate
145
Three types of bowel ischemia
Acute mesenteric Chronic mesenteric Ischemic colitis
146
Pathophysiology and presentation of acute mesenteric ischemia
SMA thrombosis or embolism OR mesenteric venous thrombosis Effects small bowel Illness out of proportion with clinical signs C/O acute abdo pain in RIF or umbilicus O/E no abdo signs and shocked
147
Tests in acute mesenteric ischaemia
Bloods - relative polycythemia due to plasma loss, raised WCC, metabolic acidosis Imaging - arteriography, ct angiography
148
Treatment of acute mesenteric ischaemia
``` Fluids Gentamycin and metronidazole Heparin Local infiltration of thrombolytics Surgical removal of necrotic bowel ```
149
Pathophysiology and presentation of chronic mesenteric ischemia
Atheroma combined with low flow state (e.g. Heart failure) | C/O pain following eating (gut angina), weight loss (as eating hurts) +/- pr bleeding, malabsorption and nausea/vomiting
150
Tests for chronic mesenteric ischaemia
Ct angiography
151
Treatment for chronic mesenteric ischemia
Consider surgery due to risk of acute infarction | Potential for stenting
152
Pathology and presentation of ischemic colitis
Low flow in the IMA | LIF pain, bloody diarrhoea
153
Diagnosis of ischemic colitis
Colonoscopy with biopsy | Barium enema shows thumb printing
154
Treatment of ischaemic colitis
Fluid replacement Antibiotics Surgery if gangrene (peritonitis and shock)

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