Block 32 Week 4 Flashcards
false high blood glucose
It is the glycerine in the newspapers, glossy magazines and hairspray that causes the false highs. Basically anything that shines may contain the sugar glycerine – hand cream, moisturisers etc.
false low blood glucose?
Wet hands and perspiration can dilute samples and give false low results – take care with patients who have a high temperature.
over-estimation of cap blood glucose to do w Txs?
IV Ascorbic Acid (vitamin C), used in cancer therapy or chronic alcoholism (Pabrinex), causes over estimation of CBG
what else can falsely cause low blood glucose levels?
High triglyceridelevels cause falsely lowblood glucosevalues as they tend to take up volume in the sample reducing theglucoselevels.
what can cause sample dilution when taking cbg?
Squeezing the patients finger releases interstitial fluid, which dilutes the sample and generates false lows.
when should cbg not be taken?
- peripherally shut down patients
- venous blood sample required
peripheral circ shutdown occurs bc:
· severe dehydration (e.g. due to diabetic ketoacidosis)
· hypotension
· shock
· hyperosmolar hyperglycaemic state (known previously as H.O.N.K.)
· decompensated heart failure
meds that interfere w cbg?
- medications that can interfere with blood glucose readings eg. statins, corticosteroids, beta blockers and thiazide diuretics.
acute, chronic and acute on chronic abdo pain?
- acute: no previous history, sudden
- chronic: recurrent pain
- acute on chronic: sudden onset, had similar pain recently or before
acute onset abd = emergency
- volvulus - a twist
- ischaemia
- perforation
- obstruction
- bleeding - ruptured AAA
colic pain?
- colic = obstruction. muscular contractions
- e.g. bowel colic, biliary colic, ureteric colic, in labour
- comes and goes, frequency
itis pain?
- itis = inflammatory
- cholecystitis, gastritis, pancreatitis
- persistent pain
colic and then later itis?
- colic and then later itis - biliary colic, later cholecystitis/ pancreatitis
pain that is initially in the epigastrium and then moves to the RUQ?
cholecystitis
pain that starts in epi and moves to back?
pancreatitis
periumbilical pain that moves to RIF?
appendicitis
pain that is periumbilical and moves lower?
meckles diverticulitis
pain that starts lower and moves to LIF?
diverticulitis
epigastric pain that moves to RIF and upper?
perforated duodenal ulcer
visceral pain?
- non specific
- poorly localised
- not affected by movement
parietal pain?
- localised
- peitonitic
- worse by movement
factors assoc w abd pain caused by a GI pathology?
- vomiting, bowel changes, bleeding, weight loss, fever
factors associated with abdo pain associated w gynae pathology?
- PV bleeding, dysmenorrhoea
factors associated with abdo pain caused by urology pathology?
- fever, freq, UTI, bleeding
features associated w abdo pain caused by a vascular pathology?
- dizziness, sweaty, palpitations
cholecystitis radiation?
shoulder tip pain
ureteric colic pain radiation?
pain from loin to groin
herpes zoster pain radiation?
back to front
extraperitoneal pain can be caused by ?
e.g. by warfarin which allows them to bleed
diff pain causes
abdo pain history?
PMH`
* e.g. prev surgery, recurrent pain, trauma
FH
* cancers, IBD
DHx
* laxatives, recreational drugs
SH
* smoking alcohol
SOCRATES
riglers sign?
- If there is free intra-abdominal gas adjacent to a gas-filled loop of bowel then both sides of the bowel wall are well-defined. This is known as ‘Rigler’s sign’.
- PERFORATION
investigation for abdo pain?
- erect CXR
- Abdominal X ray
management of abdo pain?
- resus, analgesia, +/- antibiotics
- VTE prophylaxis
- ABG
- NGT/ urinary catheter
cholecystitis -> panc?
- RUQ pain - cholecystitis
- then epigastric pain that radiates to the back, dark urine pale stools, vomiting -> stone moved into CBD - pancreatitis
Small bowel obstruction
4 signs of obstruction?
colicky, vomiting, no bowel movement, distension
causes of SBO?
- appendix removal
- surgery
- hernias
why does vomiting occur late in LBO?
- Ileocecal valve holding back the contents -> no vomiting
Perforated ulcer scan
tachycardia and anemia in young adults?
suspect bleed
glandular fever?
check for this if theyre fainting spontaneously
intussuception?
- right abd - caecum
- the doughnut sign - intussuception
- intussuception - bowel within a bowel
what can cause mid abd pain?
- small bowel
- large bowel to splenic flexure
- right IF pain
- midline hernias
- inguinal and femoral hernias
surgical outpatient clinic?
- further investigations
- explanation and information leaflets
- waiting list for surgery
- consent
consent?
- verbal
- written - surgery e.g.
- informed consent
when is consent not required?
- emergency treatment to save their life when the patient is incapacitated
- additonal emergency procedure needed to be done during an operation
- risks to public health
what makes consent valid
- patient needs to have capacity
- needs to understand the procedure and complications
- allowed time to think and weigh up risks and benefits
- not being forced to give consent
pre-op assessment?
- may be seen by pre-op nurse/ doc
- go through meds and RFs
- anaesthetist review
- pre-op Ix - bloods, imaging, MRSA/ C diff
blood transfusion/ clotting factors?
- for patients who have a high risk of bleeding
- for patients who have bled
- procedures that may potentially bleed
WHO surgical safety checklist?
- WHO surgical safety checklist - improves safety of surgical procedures by brining thw heol team together to perform key safety checks during perioperative care, prior to induction of anaesthesia, prior to skin incision and before the team leaves the operating room
- debriefing - what has gone well and what can be improved - identifies human factors
why can malabs occur w CD?
- malabs w CD bc small bowel can be affected
IBD is mostly diagnosed in which age gr?
20-30s
what increases risk of iBD?
appendicectomy
what can malabs from CD lead to?
osteoporosis and anemia - osteoporosis from malabs and steroids used in Tx
what can worsen IBD?
oral preperations of iron
microscopic colitis?
- inbetween
- bowel normal on colonoscpy but histological changes present
microscopic colitis symptoms?
persistent watery diarrhoea without blood is the most common symptom
CD?
- mouth ulcers
- fistulas, strictures
- peri-anal comps
IBD in children?
- weight loss, lethargy, anorexia, FTT
- only half have diarrhoea
calprotectin can also be raised w?
- raised w NSAIDs and infection
first line for a UC flare up?
mesalazine
crohns flare up first line?
steroids, enteral feeding
Celiac?
steatorhoea, diarhoea, bloating, abd pain
celiac screen?
tTG
noctural diarrhoea is more suggestive of?
IBD
CRC contributes ? of all cancer cases?
13%
Order of cancers in terms of prevalence?
lung, breast, prostate, CRC
CRC incidence and death rates?
incidence increasing but death rates falling
aetiology of CRC?
- most arise from adenomatous polyps - adenoma carcinoma sequence
genetic mutations in CRC?
APC, K-ras, DCC, p53
Herediary causes of CRC?
HNPCC and FAP
majority of cases of CRC occur?
spontaneously
RF for CRC?
- obesity
- red meat
- processed meat
- alc
- smoking
- animal fat
- long standing IBD
Protective factors for CRC?
- regular exercise
- dietary fibre
- non starchy vegetables
- calcium, garlic
Sites of CRC?
- rectum
- sigmoid colon
- right colon
Spread of CRC - direct invasion…
of adjacent organs e.g. bladder, small bowel
spread of CRC - nodes
- lymphatic drainage to adjacent lymph nodes
CRC spread - haematogenous to
distant organs e.g. liver, lungs
other ways CRC spreads?
- haematogenous to distant organs e.g. liver, lungs
- trans-coelomic e.g. peritoneum, ovaries
how soon do patients referred for cancer need to be seen?
within 14 days and need to commence Tx within 62 days
left sided cancer symptoms?
- change in bowel habits - frequency, consistency
- bleeding PR
- abd pain
right sided CRC symptoms?
- iron deficiency anemia due to chronic occult bleeding
- abd pain - late symptom
investigations for CRC?
- colonoscopy
- CT colonography (virual colonoscopy) - but can’t take biopsy
- conventional CT - doesn’t require full prep
Screening for CRC?
- 60-74 yrs
- FOB testing kit every 2 years
- positive patients offered a colonoscopy
Staging =
measure of spread
pre-op staging?
- all patients need to have a CT, chest, abdomen, pelvis to assess primary tumour and look for distant mets
- serum carcinoembryonic antigen (CEA) - raised suggested metastatoc disease
MR rectum?
to assess extent of spread through the rectal wall and mesorectal nodes for rectal cancers
TNM?
- T = extent of spread
- Node = nodal involvement
- M = distant mets
Curative Tx for CRC?
- surgery
- w chemo
- rectal cancers only: radiotherapy
Surgery for CRC?
- curative Tx of CRC almost always involves surgical resection - often laparoscopically
- resection of the segment of the colon/ rectum containing the tumour plus blood supply and draining lymph nodes
what do all CRC surgery patients require?
- all patients need prophylactic ab and VTE prophylaxis (e.g. LMWH)
Duke’s staging
- Duke C = lymph node involvement
- TNM used now
chemotherapy?
- usually given post-op in higher risk patients e.g. nodes involved, vascular invasion, poorly diff, young patients
- commence within 6-8 weeks of surgery
- sometimes given as a neo-adjuvant pre-op to downstage tumour to allow surgical resection
enhanced recovery
radiotherapy?
- used to treat rectal cancr but non colon cancer due to moving target and risk of damage to the small bowel
- usually given pre-op (NA) as tissues are more radiosensitive, anatomy is preserved and small bowel is out of the pelvis
non surgical treatment of CRC?
- some early rectal cancers may be dealt w by TEMS
- local excision of a rectal cancer can be supplemented by radiotherapy
Secondary surgery?
- surgery can be done even if they have metastatic disease
- liver and lung mets can be resected
- locally recurrent rectal cancer and localised intra-abd recurrence can be resected
CRC emergency treatment?
- approx 20% present acutely usually due to obstruction
- distended and tender caecum -> acutal or imminent perforation considered
what is the alt to surgery for left sided obstruction?
- self expanding metal stent inserted endoscopically is the alt to surgery for left sided obstruction
palliative tx?
- usually due to inoperable mets but sometimes bc patient isn’t fit enough
- options: resection, defunctioning stoma or bypass procedure
MDT?
- every hosp must have an MDT team for each cancer type
- meets every week
- aims to ensure a co-ordinated and consistent approach to diagnosis and treatment of patients
Peer review =
process by which MDT is assessed according to set of national measures, occurs on an annual basis
CRC MDT core members?
- CRC surgeons
- radiologist
- histopathologists
- oncologists
- specialist nurses
Post op surveillance?
- aim is to identify recurrent disease earlier, allowing further curative tx
- consists of regular serum CEA, and chest abdo pelvis CT
- patients followed up for 5 years bc it usually recurs within 2-3yrs
Mx of infective diarrhoea?
- fluid replacement - oral or IV
- public health management
constipation - aetiology?
- dietary
- functional
- metabolic
- neuropathy
- medication
- structural
- anal outlet
management of constipation?
- correct cause
- laxatives
- colonic irrigation
- surgery in severe cases only
CD features?
- all layers of gut
- small and LI
- discontinous
- in most patients affects small bowel and colon
CD granulomas?
- Discrete non caseating granulomas
mucosal appearance of CD?
cobblestone
other features of CD?
- Fat creeping on mesentery
- Skip lesions
- Fistulation
Ethnic groups which have a higher risk of iBD?
Caucasian and jews
CD - intestinal complications?
- Small bowel obstruction
- Perianal fistulas and fissure
- Bowel fistulas
- Bowel perforation
- Gastrointestinal blood loss
- Malignant neoplasm
CD - EIM?
- Arthritis
- Ankylosing spondylitis
- Iritis
- Aphthous ulcers
- Erythema nodosa
- Nephrolithiasis
ulcerative colitis?
- Inflammation confined to mucosa
- crypt abcesses
- mucosal ulceration
- pseudopolyps
UC complications?
- Bleeding
- Toxic megacolon
- Colonic perforation
- Risk of colon cancer
IBD Ix?
- Clinical history & examination
- FBC/BCP/CRP/stool culture
- Rigid sigmoidoscopy (biopsy)
- Colonoscopy (biopsy) / Barium enema
- Small bowel enema
- CT scanning
UC - surgery Ix?
Failed medical management
Toxic megacolon
Perforation
Dysplasia
CD - surgery Ix?
Obstruction
Fistulation
Perforation
Defunctioning
IBS affects who more?
- female predominance 2:1
What is IBS?
- Disorder of increased intestinal motility with heightened visceral sensitivity
- No biochemical or structural test
- DIAGNOSIS OF EXCLUSION
symptoms of IBS - bowel movements?
- fewer than 3 bowl movements a week
- more than 3 bowel motions per day
other IBS symptoms?
- Hard or lumpy stools
- Loose or watery stools
- Straining during bowel movement
- Urgency
- Passing mucus
- Abdominal bloating and swelling
Tx of IBS?
- Bulking agents
- Smooth muscle relaxants
- Loperamide
- 5HT receptor antagonists
3 phases of malabs?
- luminal
- mucosal
- postabsorptive
Malabs history?
- Diarrhoea
- Steatorrhoea
- Weight loss
- Abdominal distension & flatulence
- Oedema
- Anaemia
- Bleeding
- Bone disorders
Celiac disease?
- Hyper sensitivity to gluten
- Immune reaction induced by ingested gluten
- Reaction causes damage to small intestine (villous atrophy)
Treatment of celiac disease?
gluten free diet
CF of right colon cancer?
- Anaemia (iron deficiency)
- Midgut colic
- Diarrhoea
- Abdominal bloating
CFs of left colon cancer?
- Constipation
- Dark red rectal bleeding
- Passing mucus
- Tenesmus
Diverticular disease complications?
- pericolic abscess
- pelvis abcess
- purulent peritonitis
- feculent peritonitis
Mx of diverticular disease?
- HFD
- resection (with anastomisis)
FAP - clues to early diagnosis?
- These abnormalities may include bumps or lumps on the bones of the legs, arms, skull, and jaw;
- cysts of the skin;
- teeth that do not erupt when they should;
- and freckle-like spots on the inside lining of the eyes.
what helps reduce risk of CRC in ppl w Lynch syndrome?
daily aspirin for > 2 yrs
diarrhoea investigations
infective diarrhoea causes
constipation investigations
O-G cancer incidencr?
- incidence is rising faster than any other solid organ maligancy in the uk
O-G cancer symptoms?
- IDA - GOJ which typically bleed at a low level
- weight loss
- dysphagia
- dyspepsia
- mets e.g. RUQ pain
- aspiration, fistulas etc
- hoarnessness - LN compression or recurrent LN
Dyspepsia?
- indigestion
- epigastric pain/ discomfort/ burning
- heartburn or acid reflux
- bloating or fullness post prandial
- nausea and or vomiting
Functional dyspepsia?
symptoms in a patient without structural or biochemical disease process
red flag symptoms for dyspepsia?
- weight loss
- overt GI bleeding
Pancreatic cancer symptoms?
- diarrhoea
- abd pain radiating to back
- constipation
- new onset diabetes
- weight loss & over 60
Other symptoms of pancreatic cancer?
- nausea
- vomiting
dyspepsia summary
criteria for CRC referral
oesophageal and gastric cancer?
- upper abd mass
- dysphagia in any age
- over 50 and upper abd pain, reflux and dyspepsia
GB cancer?
- Upper abd mass consistent w enlarged GB
Dyspepsia flowchart
Liver cancer
- upper abd mass w enlarged liver
investigations for UGI symptoms
common causes of dyspepsia?
- functional dyspepsia
- GORD
- PUD
- GALLSTONES
referral critera
Dysphagia?
- subjective difficulty swallowing
odynophagia?
painful swallowing
globus sensation
- globus sensation = non painful sensation of a lump, foreign body, food bolus in the phayrngeal or cervical area (proximal)
globus?
- Globus = a functional oesophageal disorder characterised by globussensation in the absence of underlying structural pathology, GORD or major oesophageal dysmotility disorder
key history of dysphagia?
- Progressive dysphagia?
- Solid/Liquids/Both
- Chronic GORD symptoms
- Weight loss
- Anaemia
- Hematemesis
- Respiratory symptoms
dysphagia with solids alone?
suggests a mechanical problem
dysphagia with solids and liquids?
motor disorder
oropharyngeal dysphagia?
- Oropharyngeal dysphagia: difficulty initating a swallow associated w coughing, choking or nasal regurgitation
oesophageal dysphagia?
- oesophageal dysphagia - sensation of food getting stuck in the oesophagus (seconds after initating a swallow) - more concerning
MDT?
- Communication between diagnostic, primary, secondary & tertiary care
- Improve outcomes and compliance with guidelines
- Enter patients into high quality research projects
- Holistic approach to patients and their cancer
Adenocarcinomas?
- Most common in developed world
- Distal 1/3 oesophagus
- BO
risk factors of adenocarcinomas?
- Risk: GORD, Obesity, EtOH
- Commonly arises from metaplastic epithelium in the distal oesophagus – Barrett’s O which progresses to dysplasia and invasive carcinomas
Squamous cell carcinoma (oesophageal cancer)
- More common in the developing world
- Middle and upper 1/3 oesophagus
risks of SCC?
smoking, alcohol
diagnosis of dysphagia - orophrayngeal?
diagnosis of dysphagia - esopheageal dysphagia?
staging for oesophageal cancer?
- first line OGD and CT TAP
- PET for distant mets for those eligible for curative therapy
other methods for staging O cancer?
- endoscopic ultrasound for accurate staging
- bronchoscopy - involevement of bronchus is sig
why do O cancer often need to be downstaged?
- most present at advanced non curable stage so we aim to downstage the tumour w chemo and radio
Upper oesophgeal cancer?
cervical oesophagus from UOS to lower border of azygos vein
middle oesophageal cancer?
lower border of azygos vein to lower border of inferior pulmonary vein
lower oesophageal cancer?
lower border of inferior pulmonary vein to stomach, including gastroesophageal junction
resectable vs operable?
- resectable = surgically possible to resect
- operable - patient fit and willing to undergo surgery
Z line?
- Z line defines transition from pale white epithelium of oesophagus to pink columnar epithelium of the stomach
Siewert tumours?
- junctional tumours in the oesophagus
- for a siewert 1 or 2 tumour -> oesophagogastrectomy - doesn’t require thoracic incision
- siwert 3 -> total gastrectomy
which stage are siwert tumours most commonly seen at?
T3 - generally present w dysphagia
Adenocarcinomas - curatuve management?
- neoadjvant chemo and chemoradiotherapy
- surgical resection
- adjuvant chemo or radio
SCC curative management?
- radical chemoradiotherapy
- but can have surgical resection too
- t4 and metastatic disease not resectable
palliative management of O cancer?
- chemo
- radio - local control of tumours e.g. dysphagia and bleeding
- stenting - improving oral intake
emerging concepts for O cancer?
- endosponge - screening for Barrett’s
- advanced endoscopy for early diagnosis
- genetics and tumour biology
- immunotherapy
gastric cancer gene ?
- consider familal gastric cancer
- CDH1 or e-cadherin
non metastatic gastric cancer management?
- early stage = endoscopic resection
- > T2 tumour -> gastrectomy
- mets - chemo palliation
acute panc?
- acute inflammatory process of the pancreas
- usually accompanied by and pain and elevated serum pancreatic enzymes
signs and symptoms of acute panc?
- abd pain - epigastrium and can go to left or right UQ
- nausea and vomiting
- low grade fever
- tachycardia and hypotension
- mild jaundice
causes of panc - top 3?
- gallstones most common
- microlithiasia - small stones 2nd most common
- alcoholism - 3rd most common
other causes of pancreatitis - trauma?
- Trauma e.g. iatrogenic - ERCP (for gallstones)/Sphincter of Oddi Dysfunction
causes of panc - infection?
- Infection- viral, bacterial, and parasitic infectious causes may lead to pancreatitis with mumps and Coxsackie B viruses being the most common.
other causes of panc?
- Hypercalcemia - metabolic causes
- post-op, pancreatic cancers, pancreas divisium - 2 ducts drain into minor ampulla
gallstones and pancreatitis?
- half of all cases of acute pancreatitis
- older women
drugs causing pancreatitis?
- Azathioprine
- Asacol
- Estrogens
- Isoniazid
- 6-mercaptopurine
- Thiazide diuretics
- trimethoprim
- valproic acid
- tetracycline
Bloods for panc?
- Hyperglycemia
- Hypocalcemia
- hypertrigylceridemia
LFTs in panc?
inc AST, inc ALT, inc AlkPhos, inc Bilirubin
serum amylase inc with panc?
2-3x elevation
gallstone panc results?
- ALT or ALP 3x upper limit of normal + elevated amylase is highly sensitive for gallstone pancreatitis
scoring of panc?
- glasgow scoring
- 3 or above means that its severe -> need cont monitoring
- meeting one of the criteria give a score of 1
gastric cancer investigations
advanced metastatic gastric cancer
Radiology for panc?
- ultrasound - best (looks for gallstones - cause) and CT
- MRI - MRCP for stones in the bile duct
what is very sensitive for detection of gallstones, bile duct stones and bile duct dilatation?
US
What is the best diagnostic test for acute panc?
- CT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is good for diagnosis of pancreatic necrosis.
Tx for acute panc?
- analgesia
- IV fluids - close input/output monitoring required
- oxygen if needed
- anti-emetics for vomiting
nutrition for panc?
- pancreatitis is catabolic state
- enteral nutrition
complications of panc?
- Pancreatic Necrosis
- Pancreatic Abscess
- Haemorrhagic Pancreatitis
- Pancreatic Pseudocysts
- Diabetes - bc the pancreas secretes glucagon and insulin
pancreatic necrosis?
- most imp comp - CT is good for this
- When there is frequent attack of acute pancreatitis, then some of the pancreatic tissues might die.
- medically referred as Acute Necrotising Pancreatitis.
pancreatic pseudocysts?
- when the pancreatic juice leaks, the fluid accumulates
- can form cyst like pockets on the pancreas
- In general, the pseudocysts appears after 4-6 weeks of acute pancreatitis attack.
signs of panc?
- Cullens
- Grey turner
Cullens sign?
- superficialedema and bruising in the subcutaneous fatty tissue around the umbilicus.
- This sign takes 24–48 hours to appear and can predict acute pancreatitis
- predictor of high mortality
grey turner sign?
- sign of retroperitoneal haemorrhage
- to bruising of the flanks, the part of the body between the last rib and the top of the hip.
- The bruising appears as a blue discoloration,and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum, which is a lining of the abdominal cavity.
how long does grey turner sign take to appear?
24–48 hours to develop, and can predict a severe attack of acute pancreatitis.
chronic panc?
- repeated severe abd pain which often starts after eating
- related to alcohol intake
chronic panc pain?
- pain usually develops in the middle or left side of abdomen and can radiate to back
- It’s been described as a burning or shooting pain that comes and goes, but may last for several hours or days.
- often no trigger for pain
as chronic panc progresses…
- As the condition progresses, the painful episodes may become more frequent and severe.
- Eventually, a constant dull pain can develop, between episodes of severe pain.
5 yr survival for pancreatic cancer?
3%
cholangiocarcinoma?
cancer of bile duct
extrahepatic cholangiocarcinomas =
occur after the cystic duct inserts into CBD
Pres of HPB cancers?
- new onset DM
- jaundice - 20% malignancy in over 40s
- weight loss
- abd/ back pain
- nausea and vomiting
- change in BH - e.g. steathorrhea from lack pancreatic enzymes
mets from HPB cancer?
lung, liver, LNs
biliary system
cancer incidence graph
breast > prostate > lung > bowel
types of jaundice table
tests for pancreatic cancer?
- CT
- Tumour markers CA19.9
exocrine pancreatic cancer?
- 95% pancreatic cancer exocrine –>80% ductal adenocarcinoma
endocrine pancreatic cancer?
- 5% pancreatic cancers endocrine pNET (Insulinoma, Gastrinomas, VIPomas)
pancreatic cancer - >80% of cases in
over 60s
RFs for panc cancer?
- smoking
- chronic panc
- obesity
- FH
- DM
genetics relating to pancreatic cancer?
- BRCA2
- HNPCC
where does pancreatic cancer usually occur?
head - Whipples
oncogene in 90% of pancreatic cancers?
- KRAS oncogene in 90%
- TP53 or SMAD4
majority of pancreatic cancers are?
adenocarcinomas
courvoisier sign?
palpable gallbladder in patient with painless jaundice (presumed malignancy as stone disease is very unlikely)
obstructive jaundice features?
- dark urine
- pale stools
- steatorrhea
- ALP> ALT
- high GGT
dark urine w jaundice
- dark urine is caused by high levels of conjugated bilirubin as its water soluble - renal excretion -> dark urine
- not urobilinogen bc small amounts of this are in the GI tract so small amounts reabs
tests results for post hepatic jaundice?
- conjugated bilirubin inc
- urine urobilinogen decreases
- ALT/AST normal/ mild inc
what inc in hepatic vs obstructive jaundice?
- ALT/ AST more raised in hepatic jaundice
- ALP/GGT - inc in obstructive jaundice
pre-hepatic jaundice?
- excessive amount of bilirubin due to hemolysis
- elevated unconjugated bilirubin in serum
what cause spre-hepatic jaundice?
- transfusion reactions, sickle cell anemia, thalassemia
test results for pre-hepatic jaundice?
- normal urine and stool, no pruitis, elevated bilirubin
hepatic jaundice?
- impaired cellular uptake, defective conjugation or abn secretion of bilirubin by the liver cell
- both conjugated and unconjugated bilirubin may be elevated in serum
causes of hepatic jaundice?
- hepatitis, cancer, cirrhosis, drugs
test results for hepatic jaundice?
- dark urine and normal stool, no pruritus
post hepatic jaundice?
- impaired excretion due to the mechanical obstruction to bile flow
- elevated conjugated bilirubin in serum
Causes of post hepatic jaundice?
- gallstones, tumours blocking outflow of bile into intestines
test results for post hepatic jaundice?
- dark urine, pale stools and pruitis
imaging for <40 jaundice?
USS - stones, biliary dilatation
imaging for > 40 jaundice which is painless?
CT r/o malignancy
> 40 jaundice w pain?
USS
Adjunct imaging for jaundice?
- Stone – MRCP +/- ERCP
- Cancer – Staging CT/ERCP/EUS/Liver MRI/PET-CT
staging of PC?
- CT pancreas (triple phase) and thorax
- enodsopic US + biopsy
PC - MRCP and ERCP?
- MRCP to assess strictures
- ERCP for strictures and therapeutic intervention stent
CBD and PD dilatation (double duct dilatation) with jaundice =
HPB cancer
gold standard for staging PC?
- triple phase CT pancreas and thorax is the gold standard
- MRCP for assessing strictures
PC staging - EUS and PT?
- EUS for vascular assessment
- PET for distant mets
GORD?
- dyspepsia patients with predominant symptoms of reflux
- reflux is physiological - TLESRs
determining if someone has mucosal damage (erosive) from GORD:
- Grade C or D oesophagitis
- peptic stricture - recurrent bouts of inflammation that heal w fibrosis which narrows the lumen
- Barrets oesophagus - squamous -> redder columnar epithelium cells
symptoms of GORD?
- heartburn, regurg are typical
- atypical: chest pain
- dysphagia
- odynophagia
- water brash
- globus
Extra-oesophageal symptoms of GORD?
cough, laryngeal - hoarseness, wheeze, dentition
if GORD Tx fails…
- OGD if treatment fails, rebound, med issues
barium swallow?
for hiatal hernias and emptying of stomach (for surgery)
impedence monitoring for GORD?
- pH monitored in O and they get a button to press when they have synptoms
- number and duration of efflux episodes, if its postural etc
- helpful for testing when theyre on a PPI or if its not acid reflux
? for motility disorders of the oesophagus?
- mannometry for motility disorders
- paticularly achalasia
PUD?
- Defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall
- 70% asymptomatic
symptoms of PUD?
- Dyspepsia (epi pain)
- DU - pain 2-3hrs post meal or overnight (circadian acid secretion absence food/ chyme)
Gastric ulcer pain?
- GU - pain provoked by food
complications of ulcers?
- haemorrhage
- perforation
- GOO/ stricture
which type of ulcer is more common?
- DU 4x more common than GU
- DU are more common in men and tend to present in younger patients
90% of ulcers are from?
H pylori or NSAIDs
Dyspepsia rome IV criteria
GU vs DU?
PUD pathogenesis
rare causes of ulcers?
- stress
- lymphoma
- CD
- zollinger elison syndrome
- ischeaemic - espec smokers
- MEN1
Zollinger elison syndrome?
gastrin secreting tumour of the duodenum or pancreas which results in increased stimulation of acid secreting cells
MEN-1?
characterized by tumors of the parathyroids, pancreatic islet cells, and the anterior pituitary
Drugs that can lead to ulcers?
cocains or OTC meds
H pylori - urease?
- protects from Hcl
- generates ammonia which damages the mucosa
H pylori testing?
- stool antigen test - screening and confirmation of eradiation
- histology
- rapid urease test
- urea breath test
rapid urease test?
reduced accuracy in patients w active GI bleeding
urea breath test?
ab and PPIs can increase false negative results
maintenance antisecretory therapy?
- require NSAIDs/ aspirin
- over 50 and have co-morbities
- rebound symptoms on cessation of Tx
- recurrent ulcers - >2 per year
- H pylori or NSAID negative ulcers
Tx of functional dyspepsia?
- test and treat H pylori
- PPI +/- H receptor antagonist
- SSRI/SNRI/5-HT antagonist
- low fodmap diet, CBT
gallstones prev?
10%
Complicated gallstones?
- acute cholecystitis
- empyema
- perforation
- cholangitis
- pancreatitis
- Mirrizi syndrome
typical biliary colic?
- intense pain in RUQ/ epigastrium
- radiates to back or right scapula
- intermittent
- post prandial (fatty) or nocturnal
onset of biliary colic?
- onset 30mins to hrs post meal
- lasts at least 30mins - sev hours
biliary colic assoc symptoms ?
- associated w sweating, nausea and vomiting
- not relieved by movement, bowel opening of flatulence
atypical biliary colic?
- bloating
- flatulence
- epigastric burning
- nausea/vom alone
- fullness
functional biliary disorders?
- subset of disorders in patients without gallstones that can present w dyspeptic symptoms
- functional GB disorder
- sphincter of Oddi dysfunction
meds that can cause GORD?
- calcium antagonists
- nitrates
- theophyllines
- bisphosphonates
- corticosteroids
- NSAIDs
Treatment of GORD?
full dose PPI
What should not be given w barretts oesophagus?
- don’t offer aspirin to prevent progression to oesophageal dysplasia and cancer
oesophageal cancer ref criteria?
crc cancer ref criteria?
pancreatic cancer ref criteria?
stomach cancer ref criteria?
what do patients complain of w dyspepsia?
- symptoms: nausea, vomiting, pain or distension
- patients likely to complain of indigestion
common causes of dyspepsia?
- Non-ulcer dyspepsia
- GORD (gastro-oesophageal reflux disease)
- Peptic ulcer disease
- Rarely gastric cancer
Which cells secrete acid?
- Parietal cells secrete acid into the stomach via H+/K+-ATPase
stimulants of Hcl secretion?
- Acetylcholine from parasympathetic fibres
- Gastrin, hormone released from G-cells into the bloodstream
How can gastrin and ACh act on parietal cells?
- directly on parietal cells
- indirectly via paracrine cells which release histamine which acts on pareietal cells to stimulate the pump
mucus production
- Forms a physical barrier over surface of stomach and consists of a gel rich in HCO3 (bicarbonate)
- This bicarbonate helps neutralise the acid creating a pH gradient
- Prostaglandins are synthesized by gastric mucosa + protect the mucosa by stimulating secretion of mucus/bicarbonate
PPIs?
- Act directly on H/K-ATPase responsible for pumping H+ out of parietal cell (which would then go on to form HCL)
- It irreversibly inhibits the enzyme, therefore acid secretion only resumes on synthesis of new enzymes
PPIs examples?
Omeprazole, Lansoprazole + Pantoprazole
histamine 2 receptor antagonists?
- Block the action of histamine from paracrine cells acting via receptors on parietal cells which has an inhibiting effect on the H/K-ATPase channel
example of H2 receptor antagonist?
Cimetidine + Ranitidine
antacids?
- Raise luminal pH of stomach
- Can cause an acid rebound
when are antacids given?
- Usually given between meals +at bedtime
- Normally contain aluminium/magnesium compounds
alginates?
- Increase the viscosity of stomach contents + protect the oesophageal mucosa from reflux
- Include Peptac +Gaviscon
GORD CFs?
- Cough
- Nocturnal asthma
- heartburn - aggrevated by bending/ lying down
RF for PUD?
- H.pylori
- NSAIDs, Aspirins, Steroids, Bisphosphonates
- Smoking
- Gastrinomas
- Genetic factors
Classic descriptions of PUD vs DU?
- Gastric ulcer – pain soon after meals – not relieved by eating
- Duodenal ulcer – pain 2-3 hrs after meal, relieved by eating and my wake patient up at night
H pylori?
- Linked with gastritis, peptic ulceration, gastric cancer + gastric lymphoma
- Usually acquired in childhood with transmission likely via oral-oral or faecal-oral
- More common in lower socioeconomic staus
Lifestyle advice for uninvestigated dyspepsia?
- Healthy eating
- Weight reduction
- Smoking cessation
- Avoid known precipitants – alcohol, coffee, chocolate, fatty foods
- Raising head of the bed
- Early main meal before going to bed
