Before exam Flashcards
What is critical limb ischaemia
- can be seen as the extreme of intermittent claudciation
- rest pain (constant pain and opiate analgesia) and tissue loss
- less than 50mmHg at ankle
- blood flow is so little that they get pain without doing anything
- often get pain at night
In critical limb ischaemia what is the blood pressure at the ankle
- less than 50mmHg at ankle
What are the treatment options for peripheral vascular disease
• Conservative
– Lifestyle modification (exercise)
- diets - reduce refined sugar and fats
– Stop smoking
• Medical
– Risk factor optimisation
• Surgical
– Endovascular - Angioplasty
– Open - Surgical bypass
– Adjuncts
list what makes up the Glasgow coma score
- best motor response
- best verbal response
- eye opening
Best motor response 6 - obeying commands 5 - localising to pain 4 - Withdrawing to pain 3 - Flexor response to pain 2- extensor response to pain 1 - No response to pain
Best verbal response 5 - oriented (time, place, person) 4 - confused conservation 3 - inappropriate speech 2 - incomprehensible sounds 1 - None
Eye Opening 4 - spontaneous 3 - In response to speech 2 - in response to pain 1 - None
what is a decorticate posture and what does it mean
(arms bent inwards on chest, thumbs tucked in a clenched fist, legs extended) = implies damage above the level of the red nucleus in the midbrain
What is a deceberate poster and what does it mean
decerebrate posture (adduction and internal rotation of shoulder, pronation of forearm) = implies midbrain damage below the level of the red nucleus
Describe the ASA grades
- grade 1 = normal health patient - wihtout any clinically important comorbidity and without clinically significant past/present medicial history
- grade 2 = a patient with mild systemic disease (any alcohol consumption puts you here)
- grade 3 = a patient with severe systemic disease
- grade 4 = a patient with severe systemic disease that is a constant threat to life
- suffix E = Emergency
- ASA 5 = moribund patient not expected to survive the next 24 hours
- ASA 6 = brain dead
give examples of surgery grades
Grade 1 = minor
- excision of lesion of skin;drainage of breast abscess
Grade 2 = intermediate
- primary repair of inguinal hernia, excision of varicose veins of leg, tonsillectomy, adenotonsillectomy, knee arthroscopy
Grade 3 = major
- total abdominal hysterectomy; endoscopic resection of prostate, lumbar disectomy, thyroidectomy
Grade 4 = major +
- total joint replacement, lung operations, colonic resection, radical neck dissection
Do you stop taking warfarin before surgery
Minor surgery – can be undertaken without stopping (if INR<3.5 it may be safe to proceed)
Major surgery – stop for 3-5d pre-op; vitK ± FFP or Beriplex® may be needed for emergency reversal of INR; one elective option is conversion to heparin (when re-warfarinizing give LMWH until INR is therapeutic as warfarin is initially prothrombotic)
What happens to the contraceptive pill before surgery
- Stop 4 weeks before major/leg surgery
- ensure alternative contraception is used
- restart 2 weeks after surgery
Name the components of the stress response to surgery
- Sympathetic autonomic nervous system which results in an increased secretion of adrenaline
- Anterior pituitary - increased risk of ACTH - leading to increased cortisol risk
- increased ADH
- growth hormone is increase
- increased breakdown of carbohydrates
- protein metabolism is increased
- fat metabolism is increased
describe the blood supply of the dudenum
- strong blood supply and branches are closely realted
- gastroduodenal artery from the right hepatic artery passes behind the 1st section
- this gives rise to the superior pancreaticduodenal artery
- there are recurrent branches from the inferior pancreaticduodenal artery from the superior mesenterci artery
How do you distinguish direct from indirect hernias
- reduce the hernia and occlude the deep inguinal ring with two fingers
Ask the patient to cough or stand
- if the hernia is restrained it is indirect
- if the hernia is not it is direct
- Gold standard for determining type of inguinal hernia is at surgery; direct hernias arise medial to the inferior epigastric vessels, indirect hernia are lateral
how much fluid is in each of the fluid compartments in the body
- for a 70kg man, total body fluid = 42L (60% of body weight)
- 2/3 is intracellular 28L
- 1/3 is extracellular 14L
- different types of IV fluids will equilibrate with the different fluid compartments depending n the osmotic content of the given fluid
What are the two types of IV fluid
- Crystalloids
- Colloids
Name the types of crystalloids
- 5% glucose (dextrose)
- 0.9% sodium chloride (normal saline)
- hypertonic glucose (10% or 50%)
- glucose with sodium chloride (1/5 of normal saline)
- Hartmann’s solution
What are colloids
- have a high osmotic content similar to that of plasma and therefore remain in the intravascular space for longer than other fluids
- therefore appropriate for fluid resuscitation but not for general hydration
- expensive and may cause anaphylactic reactions
What should you use in poor urine output
- aim for >1mg/kg/h, minium is >0.5ml/kg/h
- give fluid challenge , e.g. 500ml 0.9% saline over 1 hour
- recheck urine output
- if not catheterised, exclude retention
- if catheterised ensure catheter is not blocked
What should you do with shock for fluid balance
– resuscitate with colloid or 0.9% saline via large-bore cannulae; identify type of shock
How does pancreatic cancer present if it is in the body and tail of pancreas tumours
- painless obstructive jaundice
- epigastric pain (radiating to back and relieved by sitting forwards) in 75%
What does blood show in pancreatic cancer
- cholestatic jaundice
- increase in CA-19-9 - non specific but helps assess prognosis
What chemotherapy agents are used in colonic cancer
FOLFOX regiment
- fluorouracil
- Folinic acid
- Oxaliplatin
What are the signs of gastric cancer
Suggests incurable disease
- epigastric mass
- hepatomegaly
- jaundice
- ascites
- Virchow’s node
- acanthosis nigricans
What is a Billroth I
- partial gastrectomy with simple gasproduodenal re-anastomosis
What is a billroth II gastrectomy
partial gastrectomy with gastrojejunal anastomosis; duodenal stump is oversewn (leaving blind afferent loop) and anastomosis is achieved by a longitudinal incision into the proximal jejunum
What happens if amylase increases with abdominal pain after a gastrectomy
if with abdominal pain, this may indicate afferent loop obstruction after Billroth II surgery and requires emergency surgery
How do you treat diverticular disease
- Antispasmodics
- Surgical resection
At what stage do you need surgery for diverticulitis
- Stage 1 = pericolic or mesenteric abscess = surgery rarely needed
- Stage 2 = walled off pelvic abscess = may resolve without surgery
- Stage 3 = generalised purulent peritonitis = surgery required
- Stage 4 = generalised faecal peritonitis = surgery required
What are the complications of diverticulitis
- perforation
- haemorrhage
- fistulae
- abscesses
- post-infective strictures
What is the treatment of a perforation of diverticulitis
- Hartmann’s procedure may be performed; primary anastomosis possible in some patients
- emergency laparoscopic management emerging alternative
What are the associated signs with acute appendicitis
- tachycardia
- fever
- peritonism with guarding or rebound tenderness or percussion tenderness in RIF
- anorexia
- vomiting - rare
- Constipation usual - though diarrhoea may occur
What antibiotics are you on appendicitis
- Piperacillin/Tazobactam 4.5g/8h, 1-3 doses IV starting 1h pre-op – reduces wound infections
- Give longer course if perforated
Define jaundice
- yellowing of the skin, sclera and mucosa from an increase in plasma bilirubin
- visible at > 60umol/L
What are the two cases of jaundice
- Unconjugated hyperbilirubinaemia - water insoluble so does not enter urine
- Conjugated hyperbilirubinaemia - water soluble so enters the urine and makes the urine dark, less conjugated bilirubin enters the gut (due to cholestasis) and the faeces become pale
Describe the pathophysiology of pre hepatic jaundice
- excess red blood cell breakdown overwhelms the livers ability to conjugate bilirubin this leads to unconjugated hyperbilirubinaemia
- this is not water soluble so cannot be excreted into the urine
- intestinal bacteria convert some of the extra bilirubin into urobilinogen which is reabsorbed and is excreted by the kidney therefore urinary urobilinogen is increased
Name the pre-hepatic cause of jaundice
Congenital RBC issues Cell shape - sickle cell disease - hereditary spherocytosis - hereditary elliptocytosis Enzyme - GP6D deficiency - pyruvate kinase deficiency Haemoglobin - thalassaemia
Autoimmune haemolytic anaemia
Drugs
- penicillin
- sulphasalazine
- antimalarials
Infections
- malaria
Mechanical
- metallic valve prostheses
- DIC
transfusion reaction s
paroxysmal nocturnal haemoglobinuria
describe the pathophysiology of hepatocellular causes of bilirubi
- disorders of uptake, conjugation or secretion of bilirubin leading to mixed conjugated and unconjugated hyperbilirubinaemia
- cirrhosis
- malignancy - primary or metastases
- viral hepatitis
- Drugs
- Enzymes
What is Dubin-Johnson syndrome
- Autosomal recessive (cMOAT gene) with excretion of conjugated bilirubin – leads to pigmented liver
- Increase in conjugated bilirubin with no other enzyme changes
- High coproporphyrin
Name the causes of post hepatic jaundice
- Billary tree obstruction
- primary biliary cirrhosis (ANA and anti-microbial Abs)
- primary sclerosis cholangitis (ANCA, anti-smooth muscle Abs, 80% have UC, association with cholangiocarcinoma)
- Drugs
What are the causes of jaundice in a previously stable patient with cirrhosis
- Sepsis (UTI, pneumonia, peritonitis)
- malignancy (hepatocellular carcinoma)
- alcohol
- Drugs
- GI bleeding
How do you define constipation
- defined as the passage of less than or equal to 2 bowel motions a week often passed with difficulty, straining or pain and a sense of incomplete evacuation
What does it mean if you have constipation and
- rectal bleeding
- distension and active bowel sounds
- menorrhagia
- rectal bleeding = cancer
- distension and active bowel sounds = stricture and GI obstruction
- menorrhagia = hypothyroidism
What are the general causes of constipation
- poor diet +- lack of exercise
- poor fluid intake/dehydration
- IBS
- old age
- post-operative pain
- hospital environment (lack of privacy, having to use a bed pan)
What are the endocrine causes of constipation
- hypercalcaemia
- hypothyroidism
- hypokalaemia
- porphyria
- lead poisoning
How does bulking agents work
- this is when you increase in faecal mass so stimulating peristalsis
- this must be taken with plenty of fluids and may take days to act
What are the contraindications of bulking agents
- difficulty in swallowing
- GI obstruction
- colonic atony
- faecal impaction
Name some examples of stimulant laxatives
- Bisacodyl tablets (5-10mg at night) or suppositories (10mg in morning)
- Senna (2-4 tablets at night)
- Docusate sodium and Dantron – have stimulant and softening action
- Glycerol suppositories – act as rectal stimulant
- Sodium picosulfate (5-10mg at night) – potent stimulant
How do stimulant laxatives work
increased intestinal mobility so do not use in intestinal obstruction or acute colitis
Name some stool softeners
- Arachis oil enemas – lubricate and soften impacted faeces
- Liquid paraffin – should not be used for prolonged period
What are the side effects of stool softeners
- anal seepage
- lipid pneumonia
- malabsorption of fat soluble vitamins
How does lactulose work
Synthetic disaccharide, produces osmotic diarrhoea of low faecal pH that discourages growth of ammonia-producing organisms
What do osmotic laxatives do
retain fluid in the bowel
name the types of osmotic laxatives
- Lactulose 30-50mL/12h (initial dose)
- Macrogel e.g. Movicol
- magnesium salts e.g. magnesium hydroxide, magnesium sulfate
- sodium salts e.g. microlette and microlax enemas
- phosphate eneams
What is the thumbprinting sign
if someone was to put there thumbs on either side of the bowel this is thumb printing of the bowel this represents diffuse oedema of the bowel
PRESNET IN ISCHAEMIC COLITIS
What are the causes of thumbprinting sign
- ischaemic/inflammatory bowel diease
- pseudomembranous colitis
- diverticulitis
- lymphoma
- amyloid
- typhoid
What is pneumobilia
gas within the biliary tree
What can cause gas within the biliary tree
- incompetent sphincter of oddi; sphinterectomy (50% at 1 year)
- pancreatitis
- gallstone disease
- Biliary - enteric anastomosis
- biliary entery fistula
- infection: cholangitis
What is sacral ilietus
- when you cannot see the sacral ileus joint and it increases in whitness
- associated with ankolysing spondylitis and IBD
- fusing of the sacral ileus joint
What structures lie in the retroperitoneum
- D2
- D3
- Ascending colon
- descending colon
- rectum
- adrenal glands
- aorta
- IVC
- pancreas except tail, ureters and kidneys
What structures are intraperitoneal
- stomach
- D1
- D4
- Jejunum
- ileum
- transvere colon
- sigmoid colon
what is CT KUB only used for
- renal/ureteric calculi
How do you manage acute pancreatitis
Aggressive fluid resuscitation
- 1-2L bolus
- 250-300ml/h
- titrate to urine output and other parameters
Analgesia
- opioid based
empirical antibiotics
- consider if greater than 30% pancreatic necrosis, max 14 days
- but no proven role
Nutrition
- early enteral feeding preferable
- may need to be nasojejunal
What is chronic pancreatitis associated with
- pancreatic atrophy
- fibrosis
- calcification
describe the modified Glasgow scale and how it is used to work out the severity of acute pancreatitis
3 or more factors detected within 48 hours of onset suggests severe pancreatitis and should prompt transfer to ITU/HDU (mnemonic PANCREAS) - PaO2 = <8kPa - Age = >55 years - Neutrophillia = WBC >15X109/L - Calcium = <2mmol/L - Renal function = Urea > 16mmol/L - Enzyme = LDH>600iu/L; AST>200iu/L - Albumin = <32g/L - Sugar = Glucose >10mmol/L
Name the early complications of acute pancreatitis
- Shock
- ARDS
- renal failure
- DIC
- sepsis
- calcium decreased
- increase in glucose
What are the late complications of acute pancreatitis
- Pancreatic necrosis and pseudocyst
- abscesses
- bleeding - from elastase eroding a major vessel such as a splenic artery
- thrombosis - may occur in the splenic/gastroduodenal arteries or colic branches of the SMA causing bowel necrosis
- Fistulae - normally closes spontaneously, if purely pancreatic they do not irritate the skin
- Recurrent oedematous pancreatitis - may require near-total pancreatectomy
What surgery is offered to patients with acute pancreatitis
- Necrosectomy - stops the progress of infection and release of pro-inflammatory mediators
- Percutaneous drainage
What are the risk factors of gallstones
5Fs - fat, 40s, fair, female, fertile
- family history
- drugs - Oral Contraceptive Pill, fibrates
- associated conditions - sickle cell disease, cirrhosis, Crohn’s
What are the symptoms of chronic cholecystitis
- flatulent dyspepsia = vague abdominal discomfort, distension, nausea, flatulence and fat intolerance
- fat stimulates cholecystokinin release and gallbladder contraction
what does the blood tests look like in cholecystitis
- FBC - elevated WCC
- CRP - elevated
- LFT - Elevated ALT/ALP
- patient should not be jaundice as there is no blockage to the flow of the bile
- U&E, clotting and blood gas should be normal
What is the treatment that is used in Chronic cholecystitis
- cholecystectomy
- ERCP and sphincterotoy before surgery - if US shows a dilated CBD with stones
- if symptoms persist post-op consider hiatus hernia/IBS/peptic ulcer/chronic pancreatitis/tumour
What are the symptoms of biliary colic
- colicky RUQ pain
- radiation to the right shoulder
- time - only last for hours as it is a temporary blockage of the bile or cystic ducts
- repeated episodes
- brought on after eating fatty foods
what is the treatment for biliary colic
- remove the stones (ERCP)
- Remove the cause of the stone - removal of the gallbladder - surgery - cholecystectomy
What is the cause of obstructive jaundice
- anything that blocks the drainage of bile
- gallstones - commonest cause
- extraluminal - malignant/benign, e.g. pancreatic cancer/pancreatic cysts
- intraluminal/stricutres such as cholangiocarcinoma
What are the symptoms of obstructive jaundice
- Jaundice
- dark urine - increased bilirubin
- pale stool - decreased bilirubin
- itching
- Nausea & Vomiting
- +/- pain
What do the blood look like in pancreatitis
FBC - elevated WCC/platelets
- U&E - possible renal impairment
- LFT - may have jaundice and ALP/ALT elevation
- CRP - often elevated
- blood gas - elevated lactate
- pancreatic enzymes - lipase/amylase are elevated
What do you need to diagnose pancreatitis
2 out of 3 of:
- typical symptoms
- pancreatic enzymes > 3x upper limit of normal
- radiographic evidence
What are the symptoms of chronic pancreatitis
- pain
- nausea and vomiting
- malabsorption: weight loss, steatorrhoea
what is the treatment for chronic pancreatitis
- analgesia
- antiemetics
- pancreatic enzyme replacement
- treat the cause
- treat the complications - pseudocysts, CBD/duodenal obstruction, venous thrombosis, ascites
What is Murphy’s sign
- Lay 2 fingers over the RUQ, ask patient to breathe in
- This causes pain and arrest of inspiration as an inflamed gallbladder impinges on your fingers
- It is only positive if the same test in the LUQ does not cause pain
Name the causes of GORD
- lower oesophageal sphincter (LOS) hypotension
- hiatus hernia
- oesophageal dysmotility (e.g. systemic sclerosis)
- Obesity
- gastric acid hyper secretion
- Smoking
- alcohol
- pregnancy
- drugs - TCAs, anticholinergics, nitrates
- H.pylori
What classification is used for GORD
Los Angeles classification of esophagitis
- classifies it from mild to severe
- at grade D there is a risk of a stricture developing
What are the risk factors for Gastric uulcers
- H.Pylroi
- smoking
- NSAIDS
- reflux of duodenal contents
- delayed gastric emptying
- stress
- older patietns - greater than 70 years old
- co-morbidity
- other drugs such as anticoagulants
What investigations do you use in GORD
Endoscopy
1) if dysphagia
2) if greater than 55 years old with alarm symptoms
3) if treatment-refractory dyspepsia
24 hour oesophageal pH monitoring and manometry to help diagnose GORD when endoscopy is normal
What is the procedure of fundoplication for GORD
- defect in diaphragm is repaired by tightening the crura
- reflex is prevented by wrapping the gastric fundus around the LOS
- Nissen = 360 degree wrap
- Toupet = 270 degree posterior wrap
- Watson = anterior hemifundoplication
What are the symptoms and signs of duodenal ulcer
Symptoms
- asymptomatic or epigastric pain
- +- weight gain
- gets better when you eat
Signs
- epigastric tenderness
What are the symptoms of a gastric ulcer
- asymptomatic or epigastric pain (relieved by antacids and worsened by eating) +- weight loss
What are the signs of a perforated ulcer
- prostration
- shock
- lying still
- +ve cough test
- tenderness - +/- rebound/percussion pain
- board like abdominal rigidity
- guarding
- no bowel sounds
What drugs can cause oesophageal strictures
- Bisphosphanates
- NSIADS
- tetracyclines
What are the symptoms if the polyps are on the left side of the colon
- frank blood
- constipation
- diarrhoea
- obstruction
What are the symptoms if the polyps are on the right side of the colon
- less overt blood
- intussuscpetion (rare)
- constipation
- diarrhoea
- obstruction
What are hyperplastic polyps
- this is a serrated polyp
- not dysplastic
- asymptomatic
- most common type
What are sessile serrated lesions, polyps, adenomas
- neoplastic polyps with premalignant features
Describe a hamartomatous polyps
- rare
- tend to occur in children and young adults
- normal tissue in abnormal location
- e.g. Peutz Jergher
describe peutz-jegher polyp
hamartomatous polyp with characteristic features; absorbing smooth muscle
- can have dysplasia and adenocarcinoma
WHO criteria
- 3 or more PJ polyps
- any number of PJ polyps with family history of PJS
- characteristic mucocutaneous pigmentation with family history of PJS
- any number of PJ polyps and mucocutaenous pigmentation
What is the most common polyp in children
Juvenile polyps
What is the definition of juvenile polyposis syndrome
- 5 or more juvenile polyps in colorectum
- juvenile polyps throughout GI tract
- any number of polyps and family history
What is malaena
- black tarry stools and has a characteristic smell of altered blood
What is haematochezia and what it is a sign of
- fresh or altered blood passing rapidly PR
- sign of large upper GI bleed
What are the causes of upper GI bleeding
- Peptic ulcer disease 35-50%
- oesophageal varices 5-10%
- mallory-weiss tear 15%
- oesophagitis
- gastritis/ gastric erosions 8-15%
- Drugs - NSIADS, aspirin, steroids, thrombolytics, anticoagulants
- erosive duodenitis
- portal hypertensive gastropathy
- Upper GI malignancy
- vascular malformation
- can be no cause
What are the causes of lower GI bleeding
- diverticular disease
- haemorrhoids
- mesenteric ischaemia
- coliits
- cancer
- rectal ulcers
- angiodysplasia
- radiation
- drugs
- others
What are the complications of massive blood transfusion
- fluid overload
- electrolyte/acid base disturbance
- transfusing products devoid of clotting factors - consider additional FFP/platelets/cryopreciptate
- hypotermia
- patients with repeated blood transfusions may develop iron overload
Describe how the Glasgow blatchford score works
- look at specific blood markers
- looks at history
score of under 2
- low risk UGIB - consider outpatient endoscopy
Score of greater than 6
- 80% required endoscopic treatment due to significant GI bleed
What risk stratification score is used for assess a patient before endoscopy to see if they have a high risk of re-bleeding
- Glasgow blatchford score - 1st line - before endoscopy
- rockall score - calculated in patients who have already had an endoscopy
Describe the Rockall Risk score for upper GI bleeds
Pre- endoscopy
- age
- shock (SBP and HR)
- Comorbidity
Post endoscopy
- Diagnosis
- Sings of recent haemorrhage and at endoscopy
Pre endoscopy 0 points - age = under 60 years old - shock (SBP and HR) = >100mmHg, <100bpm - Comorbidity = Nil Major
1 points
- Age = 60-79 years
- SBP >100mmhg
- HR > 100bpm
- Co morbidity = heart failure and IHD
2 points
- Age = >80 years
- SBP = < 100mmHg
- Co morbidity = renal or liver failure
3 points
- co morbidity = metastases
Post endoscopy
0 points
- mallory-weiss tear
- no signs or a dark red spot at endoscopy
1 point
- all other diagnoses
2 points
- upper GI Malignancy
- blood in upper GI tract, adherent clot, visible vessel
What is the definition of diarrhoea
- 3 and more stools a day and loose
What can cause motility diarrhoea
- thyrotoxicosis
- iBS
- DM
- autonomic neuropathy
What is Clostridum difficile associated with
- use of broad spectrum antibiotics - (clindamycin, cephalosporins, penicillins, fluoroquinolones)
- use of PPIs
TREAT USING VANCOMYCIN
Describe the severity of disease C difficile
Mild - 3 stools a day - normal WCC treatment - Oral metronidazole 400mg/8h PO for 10-14d
Moderate - 3 -5 stools a day - raised WCC treatment - Oral metronidazole 400mg/8h PO for 10-14d
severe - WCC raised - temperature greater than 38.5 degrees - raised CR - abdominal pain or XR acute colitis Treatment - oral vancomycin 125mg/6hr PO
complicated - hypotension - partial ileus - evidence of severe disease on CT Treatment - Oral vancomycin and IV metronidazole
life threatening - complete ileus or toxic megacolon Treatment - oral vancomycin and IV metranidazole - faecal microbiota transplant - consider colectomy if toxic megacolon, raised LDH or deteriorating
What conditions can cause steatorrhoea
- pancreatic insufficiency
- biliary obstruction
- coeliac disease/malabsorption
How do you treat IBS
- reassurance
- FODMAP
- Sparing use of anti-spasmodics
- CBT - in those that need it
- antibiotics in some
- probiotics
- anti-depressants
What is a toxic megacolon
- this occurs when the swelling and inflammation spread into the deeper layers of the colon, therefore the colon stops working and widens, it can rupture in serve cases
- Greater than 6cm
What is the border of clots triangle
- Lateral border = cystic duct
- Medial border = common hepatic duct
- Superior = inferior edge of the liver
What is the double duct sign
- Pancreatic malignancy
What are the different type of stoma
- Loop colostomy
- ileostomy
- colostomy
What are the types of different stoma and the differences between them
Loop Colostomy
- a loop colostomy with double barrelled stoma
Ileostomy
- prominent and sticks out
- Typically in the right side
Colostomy
- sits flush with the skin
- typically in the left iliac fossa
How long do you have to wait between giving the urea breath test with antibiotics and PPI
- no antibiotics in the last 4 weeks
- no PPI in the last 2 weeks
What is the genetics of haemochromatosis and Wilsons disease
autosomal recessive
What is carcinoid tumour
A diverse group of tumours of enterochromaffin cell (neu- ral crest) origin, by definition capable of producing 5HT.
What are the signs and symptoms of carcinoid tumours
GI tumours can cause ap- pendicitis, intussusception, or obstruction. Hepatic metastases may cause RUQ pain. Tumours may secrete bradykinin, tachykinin, substance P, VIP, gastrin, insulin, gluca- gon, ACTH ( Cushing’s syndrome), parathyroid, and thyroid hormones. 10% are part of MEN-1 syndrome (p223); 10% occur with other neuroendocrine tumours.
What test is risen in carcinoid tumours
increase 24h urine 5-hydroxyindoleacetic acid (5HIAA, a 5HT metabolite; levels change with drugs and diet: discuss with lab). CXR + chest/pelvis MRI/CT help locate primary tumours.
What is the treatment of carcinoid tumours
- Octreotide (somatostatin analogue) blocks release of tumour mediators and counters peripheral effects. Long-acting alternative: lanreotide. Loperamide for diarrhoea
- . Tumour therapy: Resection is the only cure for carcinoid tumours so it is vital to find the primary site
Name the blood test used in IBD
- Faecal calprotectin
What are the types of haemorrhoids
- Type 1 = remain in the rectum
- Type 2 = Prolapse through the anus on defecation but spontaneously reduce
- type 3 = As for 2nd-degree but require digital reduction
- type 4 = Remain persistently prolapsed
What is Rigler’s sign
sign of pneumoperitoneum (air under the diaphragm)
What are these a biomarkers used for
- CA19-9
- HCG
- CEA
- Alpha fetoprotein
- CA125
- CA19-9 = Pancreatic cancer
- HCG = pregnancy
- CEA - colon cancer
- Alpha fetoprotein = HCC
- CA125 = ovarian cancer
What is the difference between gastric epithelium and oesophagus epithelia,
gastric type = simple columnar
oesophageal = straitifed squamous epithelium
What is fitz-hugh-curtis syndrome
itz-Hugh-Curtis syndrome is a rare disorder that happens when pelvic inflammatory disease (PID) causes swelling of the tissue around the liver.
What molecules are used in synthetic liver function
- Prothrombin
- platelets
What is flank bruising called
Turners sign
What is periumbilcial bruising called
- cullens sign
What makes up sepsis 6
give 3 take 3
- IV antibiotics
- IV fluids
- oxygen
- Blood cultures
- lactate
- urine input and output
What is Virchow’s node
LEFT supraclavicular lymph nodes
Signs that you can get in appendicitis
Rovsing’s sign = pain > in RIF than LIF when the LIF is pressed
Psoas sign = pain on extending hip if retrocaecal appendix
Cope sign = pain on flexion and internal rotation of the right hip if appendix in close relation to obturator internus
pain on right during DRE - suggests an inflamed, low lying pelvic appendix
What are the three classes of anti emetics
- H1r anatognists = Cyclizine
- D2r antagonists, 5HT4r agonist = Metoclopramide
- 5HT3 antagonists = Ondansetron
What is the mechanism of action of azathioprine
- Inhibits purine synthesis
What does Courvoisier’s law state
Courvoisier’s law states that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
What does aminosalicylate cause
can cause agranulocytosis therefore FBC is a key investigation
What blood tests are used in syntethic liver function
- Albumin
- Prothrombin
At what speed should maintenance fluids be given
30ml/kg/hr
What does a paracetamol over dose look like on a liver screen
High ALT normal ALP, ALT/ALP ratio is high
How do you investigate coeliac disease if IgA deficiency
She has IgA deficiency so interpretation of a normal IgA tTG is impossible. To further investigate if this is the true cause, IgG tTG could me measured, but the definitive investigation would be a duodenal biopsy.
what is choledocholithiasis
choledocholithiasis (gallstones in the biliary tree)
How does isoniazid cause perisperhal neuropathy
Isoniazid therapy can cause a vitamin B6 deficiency causing peripheral neuropathy
What does a raised SAAG indicate in ascites
A raised SAAG (>11g/L) indicates that it is portal hypertension that has caused the ascites.
how does loperamide work
slows down gastric moiltity through stimulation of opioid receptors
What is a better measurement of acute liver failure prothrombin or albumin
Prothrombin has a shorter half-life than albumin, making it a better measure of acute liver failure
How does Wilsons disease present on blood test
- serum caeruloplasmin is decreased
- reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
- free (non-ceruloplasmin-bound) serum copper is increased
- increased 24hr urinary copper excretion
blood profile in haemochromatosis
raised transferrin saturation and ferritin, with low TIBC is the characteristic iron study profile in haemochromatosis
