Amir Sam: GI Med/Surg Flashcards
Causes of hepatomegaly
3 C’s plus infiltration:
Cancer (primary or secondary deposits)
Cirrhosis (early, usually alcoholic- otherwise shrunken)
Cardiac: Congestive cardiac failure OR Constrictive pericarditis
Infiltration: fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
Causes of liver disease
Alcohol
Autoimmune
Drugs
Viruses
Biliary disease (not affecting hepatocytes)
Patient with ALT of 300 (high)
Liver cell damage: Alcohol, Autoimmune, Drugs, Viruses
Causes of splenomegaly
2 Hs, 2 Is:
H (portal Hypertension- chronic liver disease)
H (Haemotological- cancers, lymphoma)
Infection (UK: IE, Infectious mononucleosis (EBV), TB, brucelosis. Abroad: malaria, schistosomiasis, leishmaniasis)
Inflammation (sarcoidosis)
Chronic liver disease signs:
A-J ABCDE in hands:
A: asterixis
B: bruising
C: clubbing
D: Dupuytren’s contracture
E: palmar Erythema
F: fetor hepaticus (pear drops)
G: gynaecomastia
H: hair loss (over chest)
I/J: Icterus/Jaundice
Causes of abdominal distension
Lots of F’s
Flatus (air, obsturction)
Fluid (ascites)
Foetus
Faeces
Fat
Casues of Diarrhoea
Infection (colitis)
Inflammation (IBD)
Malignancy
Casues of Diarrhoea
Infection (colitis)
Inflammation (IBD)
Malignancy
Framework for abdominal pain 2 Q’s
Location (9 areas or 4 quadrants)
Character: Intermittent (obstruction), Constant (inflammation)
75 year old man
Epigastric pain
Back pain
PR: 130 bpm
BP: 80/50 mmHg
Ruptured Aortic Aneurysm
epigastric pain
back pain
tachycardic and hypotensive (blood loss)
Causes of epigastric pain (not stomach/pancreas):
Above, below, left right:
Heart: MI, pericarditis
Aorta: ruptured aortic aneurysm
Liver/gall bladder: cholecystitis, hepatitis
Spleen: splenic rupture
Presentation of acute pancreatits
pain
high amylase
Pain
High amylase
Acute pancreatitis
Chronic pancreatitis
Pain weight loss
loss of exocrine function
loss of endocrine function
Normal amylase
Faecal elastase
5 causes of epigastric pain (things there):
2 organs there:
Stomach:
- PEPTIC ULCER (NSAID use)
- GORD (better with antacids)
- Gastritis (retrosternal, alcohol) - malignancy
Pancreas:
-Acute pancreatitis (gallstones, alcohol, high amylase)
Epigastric pain
High amylase
Acute pancreatitis
Chronic pancreatitis
Chronic epigastric pain
weight loss
loss of exocrine function
loss of endocrine function
Normal amylase
Faecal elastase
5 causes of epigastric pain (things there):
2 organs there:
Stomach: - PEPTIC ULCER (NSAID use)
- GORD (better with antacids)
- Gastritis (retrosternal, alcohol)
- malignancy
Pancreas:
-Acute pancreatitis (gallstones, alcohol, high amylase)
50 year old man
history of excess alcohol
chronic epigastric pain
losing weight
On insulin
On creon
chronic pancreatitis (creon is pancreatic enzymes)
50 year old man
history of excess alcohol
chronic epigastric pain
losing weight
On insulin On creon
Which investigation?
Fecal elastase (will be low in chronic pancreatitis- measure elastase in stool)
50 year old man history of excess alcohol
chronic epigastric pain
losing weight
On insulin On creon
Which investigation?
Fecal elastase (will be low in chronic pancreatitis- measure elastase in stool)
Causes of RUQ pain:
Liver: Hepatitis Abscesses Malignancy (HCC)
Gall bladder: Cholecystitis Cholangitis Gallstones
Above: Lung (Basal pneumonia)
Left: Stomach/pancreas (peptic ulcer/pancreatitis)
Below: Appendicitis (long appendix- retrocaecal)
Right: Kidney (pyelonephritis)
Causes of RUQ pain:
Liver: Hepatitis Abscesses Malignancy (HCC)
Gall bladder: Cholecystitis Cholangitis Gallstones
Above: Lung (Basal pneumonia)
Left: Stomach/pancreas (peptic ulcer/pancreatitis)
Below: Appendicitis (long appendix- retrocaecal)
Right: Kidney (pyelonephritis)
Causes of RIF pain:
Bowel:
Appendicitis
Colitis (IBD)
Malignancy (some dull pain- not PC)
Mesenteric adenitis (in children- infective)
Gynaecological:
Ectopic pregnancy (pregnancy test- urinary hCG)
Ovarian cyst: rupture, tortion or bleed Pelvic inflammatory disease (PID)
Causes of suprapubic pain:
Bladder: Cystitis (inflammation)
Urinary retention (stones, clot, malignancy, neurological, constipation)
Causes of LIF pain:
Bowel: Diverticulitis Colitis (IBD) Malignancy
Gynaecological: Ectopic pregnancy (pregnancy test- urinary hCG)
Ovarian cyst: rupture, tortion or bleed
5 causes of epigastric pain (things there):
2 organs there:
Stomach: - PEPTIC ULCER (NSAID use)
- GORD (better with antacids)
- Gastritis (retrosternal, alcohol)
- malignancy
Pancreas:
-ACUTE PANCREATITIS (gallstones, alcohol, high amylase)
Causes of RIF pain:
Bowel:
APPENDICITIS
Colitis (IBD)
Malignancy (some dull pain- not PC)
Mesenteric adenitis (in children- infective)
Gynaecological:
Ectopic pregnancy (pregnancy test- urinary hCG)
Ovarian cyst: rupture, tortion or bleed Pelvic inflammatory disease (PID)
Causes of suprapubic pain:
Bladder:
Cystitis (inflammation)
Urinary retention (stones, clot, malignancy, neurological, constipation)
Causes of LIF pain:
Bowel:
DIVERTICULITIS
Colitis (IBD)
Malignancy
Gynaecological:
Ectopic pregnancy (pregnancy test- urinary hCG)
Ovarian cyst: rupture, tortion or bleed
Causes of LIF pain:
Bowel:
DIVERTICULITIS
Colitis (IBD)
Malignancy
Gynaecological:
Ectopic pregnancy (pregnancy test- urinary hCG)
Ovarian cyst: rupture, tortion or bleed
Causes of diffuse abdominal pain:
Obstruction
Infection: peritonitis, gastroenteritis (viral or bacterial)
Inflammation: IBD
Ischaemia: mesenteric ischaemia (clot in a mesenteric artery)
Medical causes:
DKA (may be first presentation of T1 diabetes)
Addison’s disease (adrenal insufficiency)
Hypercalcaemia
Porphyria (rare)
Lead poisoning (rare)
65 year old man AAA repair 2 days ago
Diffuse abdominal pain
PR: 120bpm
RR: 30
Blood tests are likely to show:
A. Normal lactate
B. High amylase
C. High bicarbonate
D. High sodium
E. High Calcium
B. High amylase Amylase can go up in any cause of acute abdomen!! (not specific to pancreatitis) Lactate wont be normal (lactic acidosis will occur as he’s sick and hypotensive (tachycardic)) Won’t have high bicarb as lactic acidosis (low bicarb) High sodium is very rare (only in diabetes insipidus or people who can’t drink) Nothing to suggest high calcium
Mesenteric ischaemia: affecting stomach, spleen, liver, gallbladder, duodenum
Coeliac artery
Mesenteric ischaemia: Small intestine, right colon
Superior mesenteric artery
Mesenteric ischaemia: Left colon
Inferior mesenteric artery
55 year old man
Excess ETOH use
Cirrhosis
Confused
Abdominal pain
Abdominal distension
O/E: Ascites, liver flap
Consistent with? Investigation?
Spontaneous Bacterial Peritonitis
Ascitic tap: measure neutrophils
Microbiology: Gram stain and cell count (urgent cell count to start treatment)
Cytology: malignant cells
Biocheem: protein
If >250 neutrophils/mm3–> Start treatment: ciprofloxacin
55 year old man
Excess ETOH use
Cirrhosis
Confused
Abdominal pain
Abdominal distension
O/E: Ascites, liver flap
Which of the following is consistent with SBP:
A. Ascites neut ≥ 25 cells/mm3
B. Ascites neut ≥ 50 cells/mm3
C. Ascites neut ≥ 100 cells/mm3
D. Ascites neut ≥ 250 cells/mm3
E. Ascites neut ≥ 500 cells/mm3
D. Ascites neut ≥ 250 cells/mm3
Abdominal distension: Clues of fluid
Ascites: shifting dullness, features of liver disease
Abdominal distension: Clues of flatus (gas)
Obstruction:
- N&V
- Not opened bowel
- High-pitched tinkling BS
- Previous surgery (adhesions)
- ?Tender irreducible femoral hernia in the groin
Difference between ischaemic colitis and mesenteric ischaemia?
Ishcaemic colitis: blockage of small vessels in colon. Presents with bloody diarrhoea.
Colonoscopy- look at mucosa.
Mesenteric ischaemia: involves large vessels (coeliac, SMA, IMA). Present with Pain from ischaemia (particularly after eating).
CT angiogram- to find blockage
50 year old man
Jaundice
RUQ pain
Dark urine
Pale stool
What is the cause of his pale stool?
- Low biliverdin
- High unconjugated bilirubin
- High conjugated bilirubin
- Low urobilinogen
- Low stercobilinogen
- Low stercobilinogen (makes stool brown- so lack makes a pale stool)
Caused by CBD blockage
Types of causes of jaundice:
Pre-hepatic: (haemolysis, defective conjugation of bilirubin)
Hepatic: (damage to hepatocytes- 4 causes alcohol, autoimmune, drugs, viruses)
Post-hepatic: CBD obstruction
Bilirubin pathway and metabolism:
Normal breakdown of RBCs in spleen –> release of unconjugated bilirubin (from metabolism of haem) —> conjugated in the liver by Glucuronyltransferase —> secreted in the bile —> converted to urobilinogen then stercobilinogen (Brown- makes stool brown) in the gut
Pre-hepatic jaundice causes:
Excess haemolysis (Haemolysis) or reduced glucoronidation (Gilbert’s disease- deficiency of glucronyltransferase enzyme)
Anaemic plus jaundiced (with increased reticulocyte count)–> Haemolysis
Jaundiced
Anaemic (low Hb)
Increased reticulocyte count
Haemolysis
Hepatic causes of jaundice:
Hepatitis (4 causes)
alcohol, autoimmune, drugs, viruses
(leakage of conjugated bilirubin out of hepatocytes into blood- excreted in urine- dark urine)
Well man
Isolated increased bilirubin
Jaundice
Possibly starved/dieting
Gilbert’s disease
Jaundice
Dark urine
Pale stool
Post hepatic jaundice: CBD blockage
Blockage of flow of bile- so leakage of conjugated bilirubin in blood (dark urine)
Low/no stercobilinogen in bowel: pale stool
Post hepatic jaundice
Blockage of flow of bile by:
Gallstones in CBD
Stricture
Cancer in head of pancreas
Differentiation between post hepatic causes of jaundice (jaudnice, dark urine, pale stool)
Pain
Colicky pain: Gallstones in CBD
Painless: pancreatic Ca
Causes of trasudative ascites:
cirrhosis
cardiac failure
nephrotic syndrome
Causes of exudative ascites:
Malignancy (abdominal, pelvic, peritoneal mesothelioma)
Infection (TB, pyogenic)
Hepatic vein thrombosis (Budd-Chiari syndrome), portal vein thrombosis
50 year old man
Painless
Jaundice
Wt loss
Dark urine
Pale stool
O/E: Thrombophlebitis- tracking nodules
Blood tests most likely to show elevated:
- ALP, Ca19-9
- AST, CA 125
- ALP, alfa-fetoprotein
- ALT, alfa-fetoprotein
- ALP, CEA
- ALP, Ca19-9
ALP- sign of obstructive jaundince
Ca19-9 tumour marker for pancreatic cancer (alpha-fetoprotein AFP is HCC marker- hepatic)
Thromboplebitis: Trousseau’s sign of malignancy
Post hepatic jaundice blood test:
Raised bilirubin
Raised AlkPhos and raised GGT
Hepatic jaundice blood test (hepatic damage):
Raised bilirubin
Raised ALT and raised AST
Raised ALT, AST (trasnaminases)
Hepatic damage (alcohol, autoimmune, drugs, virus)
Raised AlkPhos (ALP) DDx
Obstructive jaundice (raised GGT)
Bone (fracture, bony mets)
Others
Raised ALP, Raised GGT
CBD obstruction
Bilirubin raised
ALT very raised
ALP raised slightly
Hepatitic jaundice: ALT is more increased than ALP so it is hepatitic not obstructive)
Bilirubin raised
ALT very raised
ALP raise slightly
Hepatitic jaundice: ALT is more increased than ALP so it is hepatitic not obstructive)
Ca19-9
Pancreatic cancer
alpha-fetoprotein (AFP)
Liver cancer (eg- HCC) Also- testicular cancer
CA 125
ovarian cancer
CA 125
ovarian cancer
Causes of bloody diarrhoea:
Bloody diarrhoea (loss of epithelial integrity):
Infective colitis (CHESS)
Inflammatory colitis (young, extra-GI manifestations)
Ishcaemic colitis (elderly)
Diverticulitis
Malignancy
Infective causes of bloody diarrhoea
Infective colitis: CHESS
Campylobacter
Haemorrhagic E. coli
Entamoeba histolytica
Salmonella
Shigella
Bloody diarrhoea with extra-GI manifestations
Inflammatory colitis
Extra-GI manifestations (arthritis, erythema nodosum, uveitis)
Question to differentiate between IBS and IBD
Do you have to get up in the night to go to the toilet (nocturnal
Management of Acute GI bleed:
- ABC
- IV access
- Fluids
- G&S, cross-match blood- give blood
- OGD
After: IV PPIs (usually peptic ulcer)
Variceal blead (caused by portal hypertension): also give Antibiotics for spread of infection (tazocin), Terlipressin (splanchnic constriction)
Investigations of acute abdomen (general)
Ix:
Blood: FBC (Hb bleeding, WCC infection), U&Es, LFTs, CRP, clotting, G&S, X-match
Erect CXR (air under diaphragm- perforation)
CT
Management of acute abdomen (general):
Nil By Mouth
Fluids
3 A’s:
Analgesics,
Antiemetics,
Antibiotics: Cef and Met
Monitor vitals and urine output
Abx for abdominal surgery
cef and met cephalosporin (to cover Gram +ve and -ve) Metronidazole (to cover anaerobes)
Antiemetics
Ondansetron, cyclosisne, metorocloparamide,
Jaundice: Investigations
Bloods: FBC (Hb) LFTs: raised ALT, AST (hepatitic), raised ALP, GGT (post-hepatic) CRP
Abdominal USS (if raised ALP): after a fast (gallbladder distended and bile-filled so stones visualised better)
Dysphagia, weight loss: Investigations
OGD & Biopsy
PR bleed, weight loss
Colonoscopy
Management of ascites:
- Diuretics (spironolactone +/- furosemide- furosemide only if peripheral oedema)
- Fluid restriction in patients with hyponatraemia
- Ascitic tap: Micro (cell count, infection), Protein, Cytology (tummour cells)
- Monitor weight daily
- Therapeutic paracentesis (with IV human albumin)
(Treat for encephalopathy if present)
(NB. people with cirrhosis have low kidney perfusion and so triggers RAAS, so high aldosterone. Spironolactone is aldosterone inhibitor)
50 year old man
chronic alcoholic liver disease
Ascites
Confused
Management steps:
- Diuretics (spironolactone +/- furosemide- furosemide only if peripheral oedema)
- Fluid restriction in patients with hyponatraemia
- Ascitic tap: Micro (cell count, infection), Protein, Cytology (tummour cells)
- Monitor weight daily
- Therapeutic paracentesis (with IV human albumin)
Management of encephalopathy:
Lactulose (10-20ml TDS)
Phosphate enemas
Avoid sedation
Treat underlying cause (GI bleed or infection):
Treat infections (SBP- tazocin)
Exclude a GI bleed (FBC) Lactulose (reduces transit time in colon- less time for contents to be metabolised by bacteria)
Cause of encephalopathy in liver failure:
Bacteria in colon produce toxic metabolites that are removed by the liver
Wound infection post op
Erythematous Discharge
Anastomotic leak post op
Diffuse abdo tenderness
Guarding, rigidity
Hypotensive/tachycardic
Pelvic abscess postappendicectomy
pain, fever, sweats, mucous diarrhoea
Perianal abscess: Presentation and treatment
Tender, red swelling Incision & drainage
Anal fissure: Presentation and treatment
Rectal pain (defaecation)
Stool coated with blood (not mixed)
Advice on diet (fluids, fibre)
GTN cream
Recurrent pain, bloating (improves with defaecation)
Change in the frquency/form of stool
No PR bleed, anaemia, wt loss or nocturnal symptoms
Most likely diagnosis:
IBS
But need to exclude coeliac disease first.
Recurrent pain, bloating (improves with defaecation)
Change in the frquency/form of stool
Very stressed
No PR bleed, anaemia, wt loss or nocturnal symptoms
Most likely diagnosis:
IBS
But need to exclude coeliac disease first (coeliac test)
IBS treatment:
- Diet & lifestyle modification
- Symptomatic treatment: abdo pain (antispasmodics- buscopan); constipation (laxatives); diarrhoea (anti-diarrhoeals- loperamide)
Recurrent pain, bloating (improves with defaecation)
Change in the frquency/form of stool
Very stressed
No PR bleed, anaemia, wt loss or nocturnal symptoms
Most likely diagnosis:
IBS
But need to exclude coeliac disease first (coeliac test)
Diagnosis of exclusion: need to exclude coeliac, IBD, cancer
What does the X-ray show?
Thumbprinting (thick haustral folds- inflammation). Thickening of the bowel wall.
What does this X-ray show?
Featureless abdo X-ray. Ulcerative Colitis.
What does this X-ray show?
Toxic megacolon (>6cm). Systemic illness
Patient presented with diarrhoea. What does this X-ray show? Diagnosis?
Shows faecal loading (but patient has diarrehoea). Therefore: Overflow (spurious) diarrhoea due to faecal loading.
