Abdominal Flashcards
Refeeding syndrome definition:
- Potentially fatal shift in fluids and electrolytes from rapid artificial feeding in malnourished patients
How does refeeding syndrome work?: (3)
- I S
T U
M R
- Increased insulin secretion drive K+, Mg2+ into cells, reducing them intravascularly
- Increases thiamine utilisation
- Increases metabolic rate which increases strains on CVS and resp.system.
Prevention of refeeding syndrome:
- Monitoring of the patients K, Ca, PO4, Mg
Short bowel syndrome:
- A condition where the body is unable to absorb enough nutrients from food due to lack of small intestine
Consequences of short bowel syndrome: (5)
L D
G D
B O
N D
K D
- Liver disease
- Gallbladder disease
- Bacterial overgrowth (small intestine)
- Nutrient deficiencies
- Kidney disease
Total parenteral nutrition (TPN):
- A method of feeding that bypasses the GI tract
When is TPN useful?
How is TPN delivered?
- When all or part of a persons GI tract doesn’t work
- Into a vein
Urea cycle defect:
- Leads to hyperammonaemia
- Must restrict diet (protein)
- Supplementation required to stop muscle atrophy
Medium chain aceyl-CoA dehydrogenase deficiency (MCAD):
- Defect in fatty acid oxidation
- Can lead to hypoglycaemia, potentially fatal to babies
Clinical features of Acute (fulminant) liver disease:
N
D
J
B E
A
H E
V
S
- Nausea
- Diarrhoea
- Jaundice
- Bleeding easily
- Ascites (fluid in belly)
- Hepatic encephalopathy
- Varices
- Splenomegaly
Chronic liver disease clinical features: (3)
- Similar symptoms to acute
- liver cirrhosis
- Portal hypertension
Chronic liver disease and portal hypertension:
Effects (3)
- Ascites
- Oesophageal varices
- Splenomegaly -> thrombocytopenia
Stigmata of chronic liver disease: (2)
- Spider nevi
- Palmar erythema
Common causes of liver disease:
A
F
H
P B C
P S C
- Alcoholism
- Fat
- Hepatitis A/B/autoimmune
- Primary biliary cholangitis
- Primary sclerosing cholangitis
How to test for liver dysfunction: (3)
- Serum fibrosis score
- Fibrosis markers or fibroscan
- Liver biopsy (best but invasive)
Paracetamol overdose:
- why?
- Treatment
- Narrow therapeutic window, >10g can cause toxicity
- N-acetylcysteine
Rotavirus epidemiology:
- Global prevalence
- Peak incidence group
- Uncommon in ……
- Seasonal peak
- Most common cause of diarrhoea world wide
- 6-24months
- Uncommon in >5 year olds
- Winter peak
Norovirus epidemiology:
- Most common cause where?
- Peak incidence group
- Seasonal peak
- Most common cause in the UK & US
- 6-18 months
- Winter peak
Rotavirus pathophysiology:
- Replicates in….
- Activation of …..
- Replicates in enterocytes, causing damage but little inflammation
- Activation of enteric nervous system may contribute to pathogenesis
Rotavirus clinical features:
(wide spectrum) (4)
▪ severe diarrhoea
▪ Vomiting in 90% children
▪ Fever
▪ Can be Asymptomatic
Rotavirus & norovirus transmission:
- Breathe in aerosolised vomit/faeces and swallow
Rotavirus diagnosis:
S E M
S E I
M D
▪ Stool electron microscopy
▪ Stool enzyme immunoassays
- Molecular diagnosis (PCR of faeces)
Norovirus pathophysiology:
▪ No enterotoxins
▪ Enterocytes infected
▪ Histo blood group antigens (HBGA) may function as a receptor for norovirus
Norovirus clinical features:
V
D
H
M
A C
- Vomiting in children
- Diarrhoea in adults
- Headaches
- Myalgia
- Abdo cramps
Hepatitis A: pathophysiology
- Immune mediated T lymphocyte destruction of hepatocytes
Hepatitis A transmission:
- Faecal-oral (contaminated food and water)
Hepatitis A: clinical features
F
L of A
F
J
H
A
V
- Flu like
- Loss of appetite
- Fever
- Jaundice
- Hepatomegaly
- Anorexia
- Vomiting
Hep A diagnosis:
- Biochem features (3)
- Onset
- LFTs, Clotting, U&Es
- HEP A IS ACUTE
HEP E: pathophysiology
- Single stranded RNA, no envelope
Hep E transmission:
- Faecal-oral, association with pork
Hep E: clinical features
- Similar to ….
- Difference
- Duration
- Similar to Hep A but more severe
- Higher mortality
- Acute in immunocompetent
Diagnosis of Hep E:
- Clinical features not enough, lab tests required
Hep B: pathophysiology (2)
- Immune response causes hepatocellular damage
- HBV DNA persists in the host cell as cccDNA
Hep B transmission: (3)
- Sexual
- mother to child
- Needle sharing, blood products
Hep B clinical features: acute
- Acute: all children and 50% of adults are asymptomatic, if symptomatic, similar to Hep A
Hep B clinical features: chronic
- Low prognosis, likely to cause cirrhosis and hepatocellular carcinoma
Hepatitis C pathophysiology:
- Enters liver cells and reproduces, simultaneously causing cell death
- Via chronic inflammation, immune mediated cytotoxicity, high cell turnover
Hep C transmission: (2)
- Percutaneous (NEEDLE INJURIES)
- Permucosal (sexual)
Hep C clinical features: acute
- all children and 50% adults asymptomatic, if symptomatic, features
similar to Hep A
Hep C clinical features: chronic
- low prognosis, likely to cause cirrhosis and hepatocellular
carcinoma
Hep C diagnosis: (2)
- Picked up by screening risk groups, contacts or as part of liver disease work up
- Antibody or RNA
Hep B & C as chronic illnesses:
- Hep C is much more likely to be chronic, poor prognosis for both cases
Causes of diarrhoea: common
I
G
M
D
C
- Irritable bowel syndrome
- Gastroenteritis
- Medication
- Diet
- Coeliac disease
Uncommon causes of diarrhoea:
M
I B D
D D
B O
o Malignancy
o Inflammatory Bowel Disease
o Diverticular disease
o Bowel Obstruction
Irritable bowel syndrome:
– functional GI disorder categorized by a large group of
symptoms including abdominal pain and changes in bowel movements
Coeliac disease:
- autoimmune disorder, primarily affecting the small intestine, where individuals develop intolerance to gluten
Inflammatory bowel disease:
- group of inflammatory conditions of the colon and small intestine
Diverticular disease:
- the condition of having diverticula (multiple pouches) in the colon that are not inflamed
Causes of obstipation (no flatus or faeces): (2)
- Small/large bowel obstruction
- Paralytic illeus (peristalsis is paralyzed)
Large bowel function: (3)
- Absorb salt and water
- Absorb short chain fatty acids
- Store/expel faeces
Recto-sphicteric reflex:
- Faeces in the rectum stimulates mass movement
- Relaxation of IAS and contraction of EAS,
- If inappropriate to defaecate, IAS contracts and rectal contents return to colon by
retroperistalsis
Pancreatic cancer symptoms:
D
B P
A P
N/V
N D
C
▪ Diarrhoea
▪ Back Pain
▪ Abdo pain
▪ Nausea/vomiting
▪ Constipation
▪ New-onset diabetes
Steatorrhea:
- Pale bulk stools difficult to flush due to increased fat content
Causes of steatorrhea:
- If it affects the …. , ……… production/transport or causes …….
P E D
B D
C D
C
C F
If it affects the pancreas, bile salt production/transport or causes malabsorption
- Pancreatic exocrine deficiency
- Blockage of bile ducts
- Coeliac disease (malabsorption)
- Chron’s (malabsorption)
- Cystic fibrosis
Referred pain:
– Pain felt in a part of the body that is not the source (does not radiate)
Colicky pain:
- Pain characterised by either intermittent nature or variable/cyclic intensity
Peritonic pain:
- Abdominal pain felt due to inflammation of the peritoneum
Biliary colic: definiton
- Where a colic (pain) suddenly occurs due to gallstones temporarily blocking the cystic duct
Biliary colic: pathophysiology
- Distension and contraction of the gall bladder against an obstructed cystic duct due to stones made of cholesterol
biliary colic: pain profile
- Location
- Type
- Onset
- Duration
- Radiation
- Pain in the RUQ
- Colicky
- Often occurs after meals
- 0.5 - 4hrs, can recur every few hrs
- Shoulder or breastbone
Biliary colic: investigation
- Ultrasound
Pancreatitis: pathophysiology
- Inflammation of the pancreas
Pancreatitis pain profile:
- Location
- Description
- Radiation
- Onset
- Duration
- LUQ
- Severe, dull
- To the back
- Fairly sudden, with gradual deterioration
- Constant
Pancreatitis symptoms: (4)
- Pain in LUQ
- Nausea/vomiting
- Steatorrhea/diarrhoea
- Weight loss
Pancreatitis investigations:
- amylase vs lipase
- Bloods for grading
- USS (gallstones)
- CT
Cholecystitis: pathophysiology
- Inflammation of the gall bladder
Cholecystitis: pain profile
- location
- Type
- Duration
- Exasberating
- RUQ/epigastric
- colicky
- constant (lasts hrs to days)
- Worse with moving including deep breaths
Cholecystitis: investigations
- CT scan
Gastro-oesophageal Reflux Disease (GORD): pathophysiology
- Stomach contents and acid rise up into the oesophagus
GORD symptoms: (4)
- Acidic taste in month
- Heartburn
- Regurgitation
- Pain with swallowing
GORD investigation:
- Abdo Xray
Progression of pain in developing appendicitis: pathophysiology
- Inflammation of the appendix
Progression of pain in developing appendicitis: symptoms (4)
- RLQ pain
- Nausea/vomiting
- Fever
- Palpable on inspection
Progression of pain in developing appendicitis: investigation (3)
- Imaging (rule in vs rule out)
- Scoring systems & novel biomarkers
- McBurney’s point
Renal colic: pathophysiiology
- Obstruction of ureter from dislodged kidney stone
Pyelonephritis: pathophysiology
- Inflammation of the kidney
Renal colic: symptoms
- Location
- Characteristics
- Radiation
- L and R iliac pain
- Severe pain
- Below ribs or groin
Pyelonephritis: symptoms
L & R
F
W L
M
H
- L and R iliac pain
- Fever
- Weight loss
- Malaise
- Haematuria
Renal colic and pyelonephritis investigations: (3)
- Urinalysis
- Renal function
- CTKUB
Irritable bowel syndrome (IBS): pathophysiology
- Functional GI tract disorder characterised by a group of symptoms accompanied together including abdominal pain and changes in the consistency of bowel movements
IBS symptoms:
A
C
T
B
- Abdominal pain
- Constipation/frequent diarrhoea
- Tenesmus (phantom shit)
- Bloating
IBS: investigations
S
B T
A U
E
B
- Stool microscopy
- blood tests
- Abdo ultrasound
- Endoscopy
- Biopsy
Inflammatory bowel disease (IBD): pathophysiology (2)
- group of inflammatory conditions of the colon and small intestine
- Crohn’s disease and ulcerative colitis being the principle types
Crohn’s disease:
Type of IBD that may affect any segment of the GI
Ulcerative colitis:
- Type of IBD that leads to inflammation and ulceration of the colon and rectum
IBD symptoms:
A P
D
R B
S I C / M S
W (CD)
T (UC)
- Abdominal pain
- Diarrhoea (varies between crohn’s and UC)
- Rectal bleeding
- Severe intestinal cramps/muscle spasms
- Weight loss (CD)
- Tenesmus (UC)
IBD: investigations (3)
- Biopsy
- Colonoscopy
- LFT’s (Crohn’s)
diverticulitis pathophysiology:
- Presence of diverticula in the colon
Diverticulitis: symptoms
P
F
N
D
C
B
o Pain in LQ, sudden onset
o fever
o nausea
o diarrhoea
o constipation
o blood in stool
Diverticulitis: investigations (3)
- Inflammation markers
- Early CT
- Laparoscopy
Mesenteric Ischaemia: Acute symptoms (4)
▪ Abrupt, severe, abdominal pain
▪ Urgent, need to have a bowel movement
▪ Fever
▪ Nausea and vomiting
Mesenteric ischaemia: chronic symptoms (3)
▪ Abdominal pain that starts 30 minutes after eating ▪ Pain worsens over the hour
▪ Pain goes away with 1 to 3 hours
bowel perforation symptoms; (5)
E P
N/V/H
F
A
pain difference
▪ Epigastric pain worsened by movement
▪ Nausea/vomiting/hematemesis
▪ Fever
▪ Abdomen rigid/rebound tenderness
▪ Pain sudden in small Intestine, gradual in large intestine
Small bowel obstruction:
- General symptom (C)
- ……… varies depending on ……
- First 24 hrs?
- Extra symptom
▪ Crampy central pain, every few minutes
▪ Distention varies depending on site of SBO
▪ May still be opening bowels in first 24hrs
▪ Vomiting often prominent
Large bowel obstruction:
- Duration compared to SBO
- Distension variation
- main symptom
▪ Periodicity of pain longer
▪ Distension varies due to competence of ileocaecal valve
▪ Constipation more common early, including flatus
Bowel obstruction: investigation
- CT
Bowel obstruction: progression (2)
- Mesenteric ischaemia
- Perforation
UGI bleeds: varices
- significantly dilated sub-mucosal veins in GI tract (most commonly in the oesophagus
and stomach)
UGI bleeds: varices causes
rising pressure in portal venous system due liver cirrhosis
UGI bleeds: Mallory-weis tear
- Small laceration on the oesophagus
UGI bleeds: Mallory-weis tear causes
- Several episodes of severe, forceful vomiting
UGI bleeds: peptic ulcer
– breach of the skin, epithelium, or mucous membrane with disintegration and necrosis of epithelial tissue, and often pus
Peptic ulcer causes: (4)
H
N
S
D
- Helicobacter pylori
- NSAIDS
- Stress
- Diet (alcohol)
UGI bleeds: Oesophago-gastric malignancy symptoms
(5)
- Dysphagia (problem swallowing)
- Heart burn
- Nausea
- Weight loss
- Later increase in vomit
LGI bleeds: diverticular disease
- Presence of diverticula on mucosa and submucosa through the muscular layer of the colonic wall
LGI bleeds: Inflammatory bowel disease: (3)
- Often associated with diarrhoea with blood mixed in
- May lead to anaemia due to prolonged low level blood loss
- Malabsorption
LGI bleeds: large bowel malignancy
- Most common type
- Character of blood loss
- most commonly colonic or rectal adenocarcinoma (tumour arising from glandular tissue)
- Usually, slow loss leading to anaemia
LGI bleeds: Haemorrhoids
- vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed.
LGI bleeds: anal fissures
– small tear or ulcer in the mucosa of the anus
What is a microbiome?:
- The collective genomes of the micro-organisms in a collective environment
The gut requires bacteria that are ….. (4):
- Gram-positive
- Gram-negative
- Anaerobic
- Fungi
How to identify bacteria in blood cultures: Gram positive
- How
- Examples
- Gram positive cocci in chains
- Enterococci, streptococci
How to identify bacteria in blood cultures: gram negative
- Aerobic
- ANaerobic
- Gram-negative rods
- e.coli, klebsiella, enterobactar
- Bacteroides, fusarium
GI infections and antibiotic treatment:
- All conditions result in translocation of gut commensal bacteria into sterile spaces
- Antibiotics need to be able to work on the wide array of different microbes
Infectious diarrhoea: texture signs
- Watery with blood: large bowel pathology
- Fatty/foul smelling
Infectious diarrhoea: timing signs
- Acute: bacterial or viral
- Chronic: parasitic/non-infectious
Infectious diarrhoea: general signs (4)
- Fever
- Dehydration
- Hypotension
- Signs of shock
Infectious diarrhoea investigation: bloods (5)
- FBC
- U&Es
- LFT’s
- Clotting
- Blood cultures
Infectious diarrhoea investigations: Imaging
- X-ray/USS/CT
- Exclusion of surgical cases
Infectious diarrhoea investigations: stool samples (4)
- Microscopy
- Culture
- Toxin detection
- Molecular test (PCR)
Salmonella species:
- Description
- Transmission
- Gram-negative, flagellated, bacilli belonging to the enterobacteriaceae
- Faecal-oral
Enteric fever: caused by
- Salmonella enterica serotype Typhi or paratyphi (A,B,C)
Enteric fever: symptoms
F
B
H
R
C
A
- Fever
- Bradycardia
- Hepatosplenomegaly
- Rose spots
- CNS involvement
- Abdominal symptoms
Enteric fever: diagnosis (2)
- Culture: Blood, stool, bone marrow
- Serology
Ectopic pregnancy pathophysiology:
- A pregnancy in which the fetus develops outside the uterus, typicallu in a fallopian tube
Ectopic pregnancy: symptoms (4)
V
P
T
A
- Vaginal bleeding
- Pelvic pain
- Tender cervix/adnexal tenderness
- An adrenal masss
Sings/investigations of Ectopic pregnancy: (2)
- Increased hCG
- Urine hCG test
Other gynaecological causes of abdominal pain:
M
E
O
M
L
P
- Menstrual pain
- Endometriosis
- Ovarian cyst
- Miscarriage
- Ligament pain, labour, placental problems
- Pelvic inflammatory disease
Pelvic inflammatory disease: pathophysiology
- Infection of the upper part of the female reproductive tract
Pelvic inflammatory disease: symptoms
A
P P
D P
M
D
P D
- Often asymptomatic
- Pelvic pain
- Deep dyspareunia
- Malaise
- Dysuria
- Purulent discharge
Diabetic Ketoacidosis (DKA): pathological
- Complication of diabetes where body produces too much blood acids ketones
Diabetic Ketoacidosis (DKA): symptoms
N
P
P
A
H
- Nausea/vomiting
- Polyuria
- Polydipsia
- Abdominal pain
- hyperventilation
DKA investigation:
- Urine analysis for ketones
UTI - sites (3)
- Urethra (urethritis) think STI’s
- Bladder (cystitis) - Lower UTI’s
- Kidney (pyelonephritis) - Upper UTI’s
UTI symptoms: (3)
- Dysuria
- Frequent urination
- Pubic bone and lower back pain
Psychological causes of abdominal pain: (3)
- “butterflies in my stomach”
- Chronic daily pains
- Abdominal migraines
Endocrine causes of abdominal pain:
- Main symptom
- Secondary
- Prevalence
- Mesenteric adenitis
- May be proceeded by flu like illness
- Children>adults
- Diffuse abdo pain > RIF pain
Oesophageal cancer: symptoms
P D
A
H
A
- Progressive dysphagia
- Coughing
- Aspiration
- Hoarseness
- Anaemia
Oesophageal cancer: investigations
- RULE 1
- Rule 1: dysphagia = urgent OGD (gastroscopy/endoscopy)
Gastric cancer symptoms:
E P
D
E M
V N
D
- Epigastric pain
- Dysphagia
- Epigastric mass
- Virchow’s node/lymphadenopathy
- Dermatomyositis
Gastric cancer: Rule 2
- Gastric ulcer = gastric cancer until proven otherwise
Gastric cancer investigations: (2)
- OGD
- Staging with CT, PET-CT, laparoscopy
Pancreatic cancer: symptoms
- E P
- J
- A M
- C S
- T M
- S V T
- Epigastric pain
- Jaundice
- Abdominal mass
- Courvoisier’s sign
- Thrombophlenitis migrans (infl. of veins causes clots)
- Splenic vein thrombosis
Pancreatic cancer: RULE 3
- (Courvoisier): painless jaundice + palpable gallbladder = cancer
Liver cancer: symptoms
A
A M
R P
A
J
H
- Anorexia/weight loss
- Abdominal mass
- RUQ pain
- Ascites
- Jaundice
- Hepatomegaly
Liver cancer: Rule 4
- Most common are metastases
