Abdominal Prep Flashcards
What are the 6 red flags associated with dysphagia?
- progressive dysphagia
- anaemia (unexplained)
- weight loss
- anorexia
- malaena/haematemesis
- aged over 55 years
What are the differentials for someone presenting with dysphagia?
- stroke
- myasthenia gravis
- motor neurone disease
- oesophageal cancer
- benign oesophageal stricture
- oesophageal web
- achalasia
- oesophageal spasm
- systemic sclerosis
What are the 6 red flags associated with haematemesis?
- Dysphagia
- Anaemia (unexplained)
- Weight loss
- Anorexia
- Aged over 55 years
- Jaundice
What are the differentials for someone presenting with haematemesis?
- oesophagitis
- gastric/duodenal erosion
- bleeding peptic ulcer
- oesophageal varices
- upper GI malignancy
- mallory-weiss tear
- iatrogenic
- arteriovenous malformations
- boerhaaves syndrome
- aorto-enteric fistula
What are the 4 red flags associated with a change in bowel habit?
- anaemia (unexplained)
- unexplained weight loss
- aged over 60
- rectal bleeding
What are the differentials for someone presenting with change in bowel habit?
- colorectal cancer
- inflammatory bowel disease
- irritable bowel syndrome
- gastroenteritis
- diverticular disease
- malabsorption
What are the 6 red flags associated with jaundice?
- confusion
- haematemesis
- fever
- bruising/purpura
- painless jaundice
- unexplained weight loss
What are the differentials for someone presenting with jaundice?
- gilberts syndrome
- malaria
- haemolysis
- hepatitis
- hepatocellular disease
- metastatic disease
- pancreatic carcinoma
- gallstones
- primary biliary cholangitis
- primary sclerosing cholangitis
What are the (i) investigations and (ii) management in a patient with suspected gastroenteritis?
(i) sometimes diagnosed on symptoms alone
Stool cultures, FBC (raised WCC, decreased Hb and platelets), U+Es (raised urea+creatinine, low K+)
(ii) maintain oral hydration
for severe symptoms (not dysentry) = anti-emetics (metclopramide, ondansetron)
Antibiotics only indicated if systemically unwell, immunosuppressed or elderly
What tests are performed in suspected alcoholic liver disease?
Serum AST/ALT = elevated Serum AST/ALT ratio = elevated Serum ALP = normal/elevated Serum bilirubin = elevated Serum albumin/protein = low, INR raised Serum GGT = elevated FBC = macrocytic anaemia, leucocytosis Hepatic USS = splenomegaly and hepatomegaly
How is alcoholic liver disease managed?
- Alcohol abstinence - manage alcohol withdrawal with oxazepam PO (1st line) or lorazepam IM
- Nutritional support and multivitamins e.g. thiamine, Vit K, B vitamins. BUT be aware of re-feeding syndrome
What are the investigations performed in suspected cirrhosis?
BLOODS - LFT: raised bilirubin, raised AST, ALK, AST, GGT and raised INR. Low albumin and WCC
FIND CAUSE - ferritin, TIBC, hep.serology, immunoglobulins, autoantibodies, AFP, alpha-1-antitrypsin
Liver USS, MRI, Ascitic tap, liver biopsy
How do you manage a patient with cirrhosis?
GENERAL = nutrition, stop alcohol, avoid NSAIDs, sedatives and opiates. Colestyramine helps with pruritus.
SPECIFIC:
hep induced cirrhosis = ursodeoxycholic acid
Ascites = bed rest, fluid restrict, low salt diet, spironolactone
SBP = cefotaxime or tazocin or metronidazole
Vit K for any coagulopathy
What are the (i) investigations (ii) management for patients with oesophageal cancer?
(i) oesophagoscopy with biopsy is 1st-line
CT/MRI for staging
(ii) pre-op chemo, then surgery. If not then paliative chemoradiotherapy
What are the (i) investigations (ii) management for patients with achalasia?
(i) CXR - fluid level in dilated oesophagus
Barium swallow - Dilated tapering oesophagus
(ii) endoscopic balloon dilatation then PPIs
Botulinum toxin injection if non invasive
Ca channel blocker and nitrates may also relax sphincter
What are the (i) investigations (ii) management for patients with oesophageal varices?
(i) FBC, U+E, LFTs, coagulation profile
Hep B+C serology if history suggests viral hepatitis
OGC (gastroscopy) is best imaging
(ii) initially = resuscitation, assess airway + obtain venous access. Blood transfusion, volume resus + possible transfusion of FFP+platelets
- during resuscitation, a vasoactive drug should be started - telipressin or somatostatin IV
Endoscopic band ligation performed ASAP
- prophylactic Abx = norfloxacin (oral) or ceftriaxone (IV)
What are the (i) investigations (ii) management for patients with mallory-weiss tear?
(i) Hb, Hct, Platelets, urea, creatinine + electrolytes
Blood type + antibodies
CXR - to rule out other chest pathology
Risk assess - Glasgow-blatchford indicates need for endoscopy or outpatient management, Rockall score assesses risk of adverse outcome after acute bleed
(ii) initial resuscitation - haemoclip placement (OGD) and adrenaline (around bleeding site). 2nd line = endoscopic band ligation + adrenaline
- give PPI (pantoprazole) BEFORE endoscopy
What are the (i) investigations (ii) management for patients with colorectal cancer?
(i) endoscopy (colonoscopy)
CEA tumour marker
CT colonography
(double barium enema as alternative to colonoscopy)
Routine FBC, LFT, bone profile + renal function
(ii) surgical resection
chemo +- radiotherapy pre or post-op depending on stage
What are the (i) investigations (ii) management for patients with ulcerative colitis?
pANCA +ve
(i) FBC, ESR+CRP, U+E, LFT, blood culture
faecal calprotectin
stool culture + sensitivity, c.diff testing
Abdo xray, erect CXR for perforation
Colonoscopy + biopsy (crypt abscesses)
(ii) 1 = topical mesalazine
2 = topical steroids (rectally) OR oral mesalazine
3 = oral steroids +- tacrolimus
REFRACTORY DISEASE:
1 = thiopurines (azathioprine, mercaptopurine)
2 = TNF alpha inhib (inflixumab, adalimumab)
3 = vedolizumab
4 = ciclosporin or methotrexate
5 = colectomy
What are the (i) investigations (ii) management for patients with Crohn’s disease?
ASCA +ve and -ve pANCA
(i) FBC, ESR+CRP, U+E, LFT, INR, ferritin, TIBC, B12, folate
faceal calprotectin
Stool culture + sensitivity + c.diff testing
Colonoscopy + rectal biopsy
Plain abdo xray/CT
(ii) mild attack = budesonide + azathioprine
moderate = oral steroids
severe = admit for IV steroids, nil by mouth + IVI plus metronidazole IV. After 5d switch to oral steroids. If not improving, infliximab and adalimumab have a role
Also used = azathioprine, sulfasalazine, TNF alpha inhib, methotrexate, Abx
What are the (i) investigations (ii) management for patients with Diverticular disease?
(i) colonoscopy or barium enema (there is a risk of perforation in the acute setting with these) so use abdominal xray
in diverticulitis there will be increased WCC and CRP
(ii) high fibre diet and bulk producing laxatives
If diverticulitis = analgesia, oral Abx (amoxicillin or ciprofloxacin AND metronidazole), Iv fluids, NBM, CT guided drainage if abscess present
What are the (i) investigations (ii) management for patients with hepatocellular carcinoma?
(i) FBC, clotting, LFT, hepatitis, serology, AFP
Imaging = US+CT to guide biopsy, MRI to distinguish benign from malignant
ERCP + biopsy if cholangiocarcinoma
Liver biopsy for histological diagnosis
(ii) Surgery - resection
Liver transplant
Transarterial chemo-embolisation (TACE) or radiofrequency ablation (RFA) bridging therapy
What are the (i) investigations (ii) management for patients with pancreatic carcinoma?
(i) CA 19-9 marker US + CT + biopsy Endoscopic sonography (EUS) is best for diagnosis and staging (ii) surgery - pancreatoduodenectomy laparoscopic excision post-op chemotherapy palliation of jaundice = stent insertion
What is the treatment for a jaundice patient with symptomatic gallstone(s)?
Cholecystectomy - often performed laparoscopically
ERCP with stenting or stone extraction or both
- may require lithotripsy modalities, papillary balloon dilatation and long-term biliary stenting
if simple dissolving required use ursodeoxycholic acid
What are the (i) investigations (ii) management for patients with primary biliary cholangitis?
(i) BLOOD: increased ALP GGT and mild rise in AST+ALT
USS to exclude extrahepatic cholestasis
(ii) bile acid analogue = ursodeoxycholic acid
- prednisolone + azathioprine if patient has a more inflammatory variant of the disease (significantly raised IgG)
Give colestyramine as antipruritic treatment
What are the (i) investigations (ii) management for patients with primary sclerosing cholangitis?
(i) raised ALP, then raised bilirubin
AMA -ve but ANA, SMA + ANCA may be +ve
ERCP distinguishes large from from small duct disease
liver biopsy
(ii) liver transplant for end stage disease
ursodeoxycholic acid may protect against colon cancer
colestyramine for pruritis
What drug is used to treat paracetamol overdose?
acetylecysteine
