Ax GIT Flashcards
What’s abdominal recti diastrasis ( ARD ) and how to treat
It’s a separation of lines alba causing abdominal contacts to bulge. (From xiphistrnum to pubis symphisis) Could be congenital.
It’s not true hernia. Could be anywhere between xiphoid to the pubic bone.
Treatment -
1. Physiotherapy for abdominal wall muscles
2. Surgical repair comes next - classic abdominoplasty or endoscopic surgery and stabilize the defect.
Hernioplasty and mesh repair done for true hernias. Abdominal belt or truss used for hernia surgeries only.
What’s the Achalasia presentation
Progressive dysphasia
Sub sternal chest pain during meals
Heart burn
REGURGITATION OF UNDIGESTED FOOD
Modifying eating habits - arching the back when eating, raising arms when swallowing.
It’s due to insufficient relaxation of esophageal sphincter and loss of esophageal peristalsis
Barium swallow study - bird beak appearance.
What’s Peutz Jeghers syndrome ( PJS )
Autosomal dominant
Freckling ( pigments spots over mouth ,lips, fingers,toes) , gastrointestinal polyps ( associated with high risk of small intestinal intussusseption ) and increased risk of certain cancers.
What’s FAP
Familial adenomatous plyposis or Familial polyposis coli.
Inherited disease.
About 1% of all colorectal cancers are due to FAP.
ALMOST ALL people with FAP will develop cancer before 40y of age, if colon hasn’t removed to prevent it.
Also risk of stomach, small intestine, pancreas, liver cancers as well.
What are adenomatous polyps
70% of all polyps are adenomatous.
Only a small percentage becomes cancerous.
But most of the malignancy polyps are adenomatous.
What’s melanosis coli
Caused by chronic laxative abuse.
What’s schostosomiasis
Endemic parasitic infection, from eastern Mediterranean region.
Either GI or urogenital.
May cause various abdominal manifestations including ANAL FISSURES.
First line inn perianal abscess
Immediate surgical intervention ( I&D )
If delayed intervention - chronic tissue destruction, fibrosis, stricture formation that may result in anal incontinence.
Common cause of multi drug regimen failure against H.pylori infection
Antibiotic resistance.
Commonly used antibiotics are Amoxicillin, clarythromycin and metronidazole.
Clarithro and metro resistance is the common cause.
Metronidazole resistance can be overcome with INCREASING DOSE AND DURATION of therapy. But can’t do that with Clarithro resistance.
What’s Mallory Weiss tear
Linear laceration at the gastroesophageal junction.
One or more retching with vomiting could change gastric cardia or mucosa and ultimately lead to a gastric or esophageal tear.
Hemetemesis is the presentation in malleory Weiss tear.
What’s are simple liver cysts
Often congenital and developed from intrahepatic biliary ducts because they have a lining similar to biliary ducts.
Generally asymptomatic but may produce mild RHC pain.
Very rarely jaundice caused by obstruction or rupture of cyst.
Important to differentiate between malignant hepatic lesion from simple hepatic cyst.
If a cystic lesion is found on USS then CECT OF ABDOMEN should be done to characterize the lesion.
How would a hepatic cyst torsion would present
As acute abdomen
How would simple hepatic cyst rupture may present
Secondary infection leading to a presentation similar to hepatic abscess with abdominal pain, fever and leukocytosis.
Young patient with liver disease, neuropsychiatric symptoms and family history of such symptoms.. what to expect
It’s suggestive of Wilson disease
Autosomal recessive
Suggestive of copper accumulation in liver and CNS.
Liver disease( hepatitis, cirrhosis, fulminant liver failure are features )
Neuropsychiatric manifestations - dysarthria, dysphagia, dyskinesia, dementia, Parkinsonism, decreased memory, Labile emotions.
How to diagnose Wilson diesese
Clinical hallmark is Kayser- Fleischer ring of eyes.
Diagnostic test - serum copper ( increased) and serum ceruloplasmin ( decreased)
Gold standard is liver biopsy.
What’s primary eosinophilic esophagitis (EoE) ?
What’s are diagnostic criteria’s?
How to treat it?
Atopic inflammatory disease caused by abnormal immune response.
Characterized by esophageal dysfunction , dysphagia for solid foods, retro sternal pain and food impaction.
Diagnostic criteria for EoE
1. Symptoms related to esophageal dysfunction.
2. >15 EOSINOPHILS on esophageal biopsy
3. Persistent eosinophils after a course of PPIs for 8 weeks.
4. Secondary cause of esophageal eosinophilia is excluded.
Treatment -
1.dietary advice and alteration.
2. Pharmacotherapy ( PPI COURSE—-> if fails —-> topical swallowed steroids - fluticasone,budesonide) —> if still fails —> systemic corticosteroids/ prednisolone can be given)
3. Surgery
Commonest mode of transmission of hep B
Sexual transmission
Secondly needle injuries ,piercing,tattooing
Comment presenting features of rectal cancer
Rectal bleeding ( 60%)
Changes of bowel habits ( 43%)
Back pain - late sign
Malaise
Bowel obstruction
Constipation ,melena are unlikely to be presenting complains.
Commonly affected part for volvulus
Sigmoid colon
Followed by right colon, terminal ileum
Rarely in transverse colon and splenic flexure
Sigmoid volvulus is commonly in patient with-
Elderly debilitated
Bedridden patients
With chronic constipation
CF- cramping colicky abdominal pain , dissension, constipation, progressively increasing abdominal dissension, ( TYMPANIC OVER THE GAS FILLED ,THIN WALLED, COLON LOOP) With progressive obstruction nausea and vomiting may be seen.
Initial investigation for volvulus
Plain abdominal X-ray - massive dilatation of sigmoid colon loop arising from pelvis and extending to diaphragm is typical.
DISTENDED LOOP MIMICKING A COFFEE BEAN OR DILATED U SHAPED COLON with a cut off at the site of obstruction.
Confirmatory diagnostic tool- CECT of abdomen. ( helps find the causing pathology and diagnosis of colonic ischemia.
USS has NO PLACE in volvulus
What’s the commonest cause for small bowel obstruction and investigation to diagnose
Commonest - Adhesions from previous abdominal surgeries
Unlike in large bowel obstruction ,in small bowel obstruction NAUSE AND VOMITING are prominent signs
BARIUM MEAL AND FOLLOW THROUGH is investigation for small bowel obstruction.
Second commonest is malignant tumors
Third is hernias
Other less common causes- strictures by Crohn’s disease, small bowel tumors, trauma, intussusception.
Should we use barium as a contrast if we suspect bowel perforation
NO. Avoid barium if viscus perforation is suspected
Or if the goal is to find postoperative leak.
Treatment of sigmoid volvulus
Definitive is surgery
But endoscopic detortion can be done followed by leaving a rectal tube in place for 1-3 Daya to maintain reduction.
Surveilance of colorectal polyps guidelines
What’s post cholecystectomy syndrome ( PCS)
Dyspepsia manifested by bloating and belching after cholecystectomy is suggestive of PCS.
SYMPTOMS-
Upper abdominal pain, nausea and vomiting , diarrhea, jaundice, bloating, dyspepsia.
These symptoms can be caused by -
1. Choledocolithiasis- stones remained or formed in CBD or cystic duct remnant. ( commonest cause)
2. Biliary dyskinesia
3. Continuously increased bile flow to GI tract
4. Dilatation of cystic duct remnant
Ix of choice - USS if suspected PCS.
Commonest finding of RHC pain in USS
Gallstones
Chronic pancreatitis presentation
Rpigastric pain that radiates to the back.
Pain may or may not be triggered by eating and lasts for several hours.
Serum amylase and lipase are often normal or slightly elevated.
USS may show calcification of pancreas ( only in 60%)
Common presentation of cholecystitis
Pain often aggravated by fatty foods.
Right upper quadrant pain or epigastric pain.
Pain can radiate to tip of right shoulder.
Fever is a common feature.
ALP and Gamma GT can be elevated.
It it unlikely that USS to miss the diagnosis.
Post infectious exposure of hep A. How to advise patient
Incubation period- 30 days
Presentation - fever,malaise,anorexia,abdominal discomfort ( prodromal symptoms) followed by dark urine and jaundice a few days later.
Symptoms usually lasts for several weeks.
Viral load in stools is highest - just before jaundice.
Considered infectious from - a few days before onset of prodromal symptoms to a few days after onset of jaundice.
Non infectious after 1 week from jaundice or 2 weeks from prodromal symptoms onset.
Gold standard of HAV diagnosis
Serum IgM and anti-HAV antibody
Lifestyle advises reguarding GERD
What’s the best method in incomplete colonoscopy
Colonic capsule endoscopy (CCE) or CT colonography can be used. ( CCE is supirior)
Is GERD has relationship with H.pylori infection
Nope
H.pylori Irradiation doesn’t improve GERD.
I’m H.pylori eradication therapy what would you do if patient is allergic to penicillin
Then amoxicillin should be replaced with Clarithromycin or metronidazole and given with PPI.
So chance of treatment failure is higher.
How to investigate for small bowel obstruction
Initially plain abdominal X-ray ( at least two views- upright and supine )
Most accurate diagnostic test is - double contrast Abdominal CT
What are dietary advise for dumping syndrome
Fresh blood covering the stool in history of chronic constipation without pain is highly suggestive of
Internal hemorrhoids
External hemorrhoids and anal fissures associated with severe perianal pain on defecation.
What to do in bleeding with bright red blood covering stools
Initially rectal examination
Then anoscopy or proctoscopy can be used to visualize anorectal area specially if active bleeding.
Presentation of ruptured hepatic adenoma
Acute onset
STRONG ASSOCIATION WITH OCP USE ,OTHER ESTROGENS and ANABOLIC STEROIDS USE.
Pain in right upper quadrant
Could be incidental finding
History of OCPs or anabolic steroid use
Severe acute abdominal pain with bleeding into abdomen.
Hemoperitoneum occurs frequently in patients taking high dose OCPs, actively menstruating , within 6 weeks postpartum
Whats mesenteric artery occlusion
What’s acute colonic pseudo obstruction / Ogilvie syndrome
Gross dilatation of cecum and right hemicolon in the absence of an anatomical lesion obstructing intestinal flow.
Associated with - non operative trauma ( COMMONEST CAUSE) , infection, MI/HF , abdominal pelvic surgery, neurological or medical conditions.
Common among MEN , OVER 60Y
CF-
Nausea vomiting
Abdominal pain
Abdominal distension
Constipation or diarrhea
Tympanic percussion note
Bowel sounds present
Peritoneal signs are absent
Which sign of gallbladder suggests cholecystitis in USS
Gallbladder wall thickening
How to investigate if jaundice present
Initially bilirubin levels ( direct and indirect) , AST,ALT,GGT, coagulation profile.
If obstruction of biliary tree is suggested urgently do USS to look for obstruction by finding of biliary duct dilatation.
Later other investigations can be done - endoscopic USS, abdominal CT, ERCP, MRI.
Hiatus hernia relationship to Barrett’s esophagus
Hiatus hernia predisposes to GERD and ultimately development to Barrett’s esophagus.
Barrett’s esophagus is a premalignant condition of adenocarcinoma of lower esophagus.
Further followup of Barrets esophagus, low grade dysplaisia, high grade dysplasia
What are the contraindications for esophageal cancer surgery
1.Distant Mets- peritoneum, lung, bone, adrenal gland, brain, liver, extraperitoneal ( para aortic or mesenteric)
2.Invasion to adjacent structures - aorta,trachea, heart,great vessels , presence of tracheoesophageal fistula. [ invasion to PLEURA, PERICARDIUM, DIAPHRAGM are considered resectable.
- Severe cvs or respiratory diseases.
What’s charcots triad
Fever, upper abdominal pain, jaundice
Commonest organisms causing cholangitis
E.coli ( commonest )
Klebsiella
Enterobacter species.
Presentation of pelvic appendicitis
Investigations for pelvic appendicitis.
Diagnostic test - CT ( appendiceal CT)
Due to easy access and low radiation exposure USS is the first line ix.
A non compressible tubular structure of 7-9mm diameter.
PAINLESS obstructive jaundice and distended gallbladder ( a mass moving up with respiration) .what’s the diagnosis
Carcinoma head of the pancreas.
Initial imaging study depends on the presenting symptoms-
* if jaundice present - transabdominal USS to see biliary tract dilatation and site of obstruction.
* epigastric pain and weight loss without jaundice- Abdominal CECT
Initial ix for esophageal cancer
Endoscopy ( esophagoscopy) and biopsy
To asses depth - endoscopic USS
Then CT to assess spread and staging.
When oropharyngeal cause is suspected- initially BARIUM SWALLOW.
Management of acute pancreatitis
If fluids, analgesics, antiemetics, KNBM AND NG decompression.
If biliary stones is the underlying cause - early ERCP within 24-48 hours.for acute biliary pancreatitis , acute cholangitis, persistent CBD obstruction.
CT is the most important test to diagnose acute pancreatitis.
How to manage acute biliary pancreatitis
ERCP within 24-48 hours
After if fluids, analgesics and IV antibiotics
What’s the GIT bleeding that persists or reoccurs without an obvious etiology found on upper and lower endoscopy
Obscure GIT bleeding
Treatment option for pyloric stenosis and obstruction
Pyloromyotomy
How to manage Achalasia cardia
What’s the initial test for chronic pancreatitis
CT scan )is the best initial ix)
MRI
USS ( duct calcification, duct dilatation, enlargement of pancreas, fluid collection)
Plain X-ray ( calcifications within pancreatic duct are seen)
ERCP or MRCP can be used for diagnosis
What’s pancreatic pseudo cyst
*Collection of pancreatic juice encased by granulation tissue ( not epithelial tissue like in True pancreatic cysts)
*Single or multiple
*Within or outside of pancreas.
*Most pseudo cysts communicate with duct system.
*Contains high concentrated amylase or lipase.
*Mechanism- necrosis and liquefaction of pancreatic or peri pancreatic tissue.
Seen in following situations-
1.after an episode of acute pancreatitis (in 10%)
2. In chronic pancreatitis - after an acute attacks.
3. After abdominal penetrating trauma or post operatively.
Clinical manifestations of pancreatic pseudo cysts
- Expansion of pseudo cyst causes abdominal pain, duodenal or biliary obstruction.
- Spontaneous infection.
- Digestion of adjacent vessels cause pseudo aneurysm casing sudden painful expansion of cyst.
- Fistula to chest- pancreatic pleural effusion.
- Fistula to abdomen - pancreatic peritonitis
How to diagnose pancreatic pseudocysts
USS or CT scan
Management of pancreatic pseudo cyst
Surgical intervention should be done
1. if patient has severe symptoms due to manifestations
2. If asymptomatic but * >5cm in size ,unchanged and morphology for >6weeks.
*. Diameter >4cm but extrapancreatic complications in chronic alcoholic pancreatitis. * suspected malignancy.
Two surgical methods-
- Endoscopic drainage ( pseudocyst should have a wall >3mm and <1cm, bulging into the lumen and size >5cm ,to be eligible for endoscopic drainage)
Two types- Transmural drainage( endoscopic cystgastrostomy or endoscopic cystsduodenostomy) , Transpapillary drainage ( cyst must communicate with pancreatic duct) - Gold standard laporotomy and cyst excision.
*however if pain is mild. A watchful observation would be the best management. If symptoms become serious a surgical intervention would be needed.
What’s a absolute contraindication for endoscopic drainage for pseudocysts
Pseudoaneurysm
Is percutaneous catheter drainage successful for pancreatic pseudocysts
Nope.
Can be used to collect sample and examine the material initially.
What’s the earliest complication of hemorrhagic pancreatitis
Common complications - pseudocysts, infection, obs jaundice, pancreatic fistula but earliest is renal failure
Femoral canal contents from medial to lateral
LEVAN- Lymph node chain/Lacunar ligament
Vein, Artery, Nerve
If a GORD improves with worsening of dysphagia for solids only. what could be the cause
Stricture of GOJ could be the reason as it could decrease the amount of acid that refluxes
What’s the commonest benign liver tumor
Hemangioma
USS- dense ENHANCEMENT of the lesion during the ARTERIAL PHASE.
Could be solitary or multiple.
How to measure prognosis of chronic liver disease
Child purge score ( calculate 1 year survival rate) prognostic factors
Presence of ascites
Bilirubin levels
Albumin levels
PT/ INR
Encephalopathy
Class A - (5-6) well compensated , 1-2 year survival 100%
Class B - ( 7-9) functional compromise - 1-2 year survival rate 80-60%
Class C ( score 10-15) - decompensated - 1-2 year survival 45-35%
Which complication of diverticulum has highest mortality
What’s the management of acute ascending cholangitis
Fluid resuscitation and IV Antibiotics followed by biliary decompression( decompression done semi-electively during the same admission within 72hours)
About 90% respond to initial resuscitation and antibiotics ( only 10% fails with medical management )
Urgent decompression in cholangitis is needed in -
> 70 yo patients
Diabetic
Other comorbidities
Difference between right and left sided colorectal cancers
Left- altered bowel habits and rectal bleeding.
Right- anemia, fatigue , weakness due to chronic blood loss.
What’s the generic inheritance of Hereditory hemochromatosis
Follows autosomal recessive pattern.
Often no family history
If both parents heterozygous ( carriers of mutation of HFE gene ) 25% chance for children to be affected.
Screening- if one parent is positive , other parent should be tested for IRON STUDIES and HFE GENE TEST.
If he or she is negative then worst case is children being carriers. So no need to screen the children.
What’s the treatment of HH
Venepuncture should be started for patients with abnormal iron studies.
Commonest cause of bile duct obstruction
Choledocolithiasis
Most contributing factor IN TERTIARY HOSPITALS - BILIARY ACCESS/ MANIPULATION BY ERCP OR PTC
Vomiting period of pyloric stenosis
After 1 hour of eating
If 2-4 hours of eating - duodenal obstruction
Commonest cause of hyperechoic mass on liver USS
Hemangioma
Feature of simple hepatic cyst in CT
Homogenous hypoattenuating ( darker than surrounding liver parenchyma)
Hemachromatosis facts
Diagnostic test - transferrin saturation
Ferritin levels- to check iron overload.
45yo patient with poly arthritis, decreased libido and impotence. What’s the next investigation
Important to consider hemachromatosis with DECREASED LIBIDO + other SYSTEMIC DISEASES.
Chronic hepatitis
Liver cirrhosis( commonest cause of death in HH)
Abdominal pain
Arthralgia
Skin darkening
Small testes/impotence/DECREASED LIBIDO
Restrictive cardiomyopathy
HCC
Osteoporosis
Spoon nails
Follow up screening for cancer recurrence in colorectal cancer
If colonoscopy performed at one year revealed ADVANCED ADENOMA —-> next colonoscopy in 3 YEARS
IF one year colonoscopy is NORMAL or identifies NO advanced adenoma —-> colonoscopy in 5 years
Degrees of hemorrhoids
External ( perianal hematoma) vs internal hemorrhoids ( hemorrhoid)
Internal Hemorrhoid( anal cusions)
3,7,11 positions.
Commonest and diagnostic feature of achalasia
Dysphagia for liquids and solids both.
Diseases causing dysphagia
Commonest type of esophageal ca in Australia
In Australia - adenocarcinoma ( barret esophagus is the most imp risk factor for adenocarcinoma)
Worldwide - SCC ( smoking and chronic alcohol as the most significant risk factors )
Further management of esophageal findings in dysphagia patients
Bloody diarrhea shortly after formula milk, presence of eczema , family history of atopy- ??
Cows milk protein allergy( CMPA)
Very rapid reactions ( almost like allergies ) these early reactions may present as urticaria, angioedema, vomiting and acute atopic dermatitis.
Even small amount of protein from breast milk of mothers who take dairy products could course this.
When does tagged red cells used?
For ACUTE LOWER GI BLEEDING.
When colonoscopy cannot spot the bleeding site.
Not useful in tumor detection.
