Core Conditions Flashcards
Acute Coronary Syndrome
Definition: ACS is ischaemia of the myocardium and includes STEMI, NSTEMI and angina Aetiology: It is usually due to atherosclerotic disease of the coronary vessels Clinical Features: Chest Pain - severe, sudden, at rest, >30mins Not relieved by GTN Sweating, SoB, N&V, Pale / grey, Tachy, HF, Hypotension, ‘Silent’ in 20% Investigations: Simple - ECG Bloods - FBC, U&Es, Trop T/I, Lipids Radiology - ?Angiography (see below) Management: O2 if hypoxic Morphine + antiemetic GTN Aspirin 300mg and continue indefinitely Fondaparinux if low bleeding risk & angio > 24 hours or LMWH if angio NSTEMI & Unstable Angina GRACE score: Lowest Risk - Conservative Low Risk - 300mg loading then 12 months Clopidogrel Intermediate to Highest Risk - As above but also consider GPI (Tirofiban) or Bivalirudin plus Angiography +/- PCI within 96 hours STEMI Cath lab for immediate PCI Long-Term Drugs Aspirin indefinitely Clopidogrel 300mg for 12 months ACEi ß-blocker Statins Admin Assess LVF Follow -up clinic Education Cardiac Rehab Lifestyle Modification
Angina
Definition: Transient symptoms of myocardial ischaemia due to exertion which is relieved by rest. Risk Factors: Age, Male Sex, FH, Hyperlipidaemia, Smoking, HPT, DM, COX 2 inhibitors (celecoxib) Clinical Features: Central Chest Pain - heavy, tight, gripping, radiation to arms and jaw May be silent Investigations: Simple - ECG (normal or previous MI) - Exercise ECG (ST depression >1mm which reverts to normal) Bloods - FBC, U&Es, TFTs Radiology - Angiogram - Thallium Scan Management: GTN ß-blocker or Ca-channel blocker, if not controlled…. Both ß-blocker & Ca-channel blocker (*Nicorandil if not tolerated or cantraindicated*) If not controlled….. Long-acting nitrate (isosorbide) or Nicorandil If not controlled…… Consider revascularisation
Sinus Node Disease
Definition: Variable combinations of fast & slow supraventricular rhythms. Aetiology: Ischaemia Infarction Degenerative Disease Clinical Features: Variable combinations of fast & slow supraventricular rhythms. Investigations: ECG - long interval between P waves >2 seconds Management: Permanent Pacemaker Antiarrhythmics to reduce tachys Anticoagulation
Heart Failure
Definition: Heart is unable to maintain sufficient tissue perfusion despite adequate venous filling pressures. Aetiology: Left HF - ischaemic heart disease, HPT, mitral / aortic valve disease, cardiomyopathy Right HF - lung disease (cor pulmonale), PE, pulmonary HPT, L-R shunt, tricuspid regurgitation Clinical Features: Left HF - fatigue, exersional SoB, orthopnoea, PND, pulmonary oedema, tachy, enlarged heart, gallop rhythm, crackles Right HF - Tiredness, anorexia, nausea, GI upset, raised JVP, pitting oedema, pleural effusion, hepatomegaly, ascites, tricuspid regurgitation Investigations: BNP CXR ECG ECHO - LV ejection fraction Angiography Management: If ejection fraction preserved then control comorbidities. LV dysfunction: 1. ACEi (or ARB) + ß-blocker 2. Add in spironolactone or ARB or hydralazine 3. Consider CRT pacing and digoxin
Orthostatic Hypotension
Definition: A fall in systolic blood pressure of at least 20mm Hg and diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position. Aetiology: The symptom is caused by blood pooling in the lower extremities upon a change in body position and reduction in venous return causing reduced cardiac output. Hypovolaemia Addison’s Atherosclerosis Clinical Features: Dizziness Euphoria or dysphoria Bodily dissociation Distortions in hearing Lightheadedness Nausea Headache Blurred or dimmed vision Seizures Investigations: Management:
Shock
Definition: Circulatory failure resulting in inadequate organ perfusion. Generally systolic BP Aetiology: Pump Failure Primary: Cardiogenic Shock Secondary: PE, tension pneumothorax, cardiac tamponade Peripheral Circulation Failure Hypovolaemia Bleeding: trauma, AAA, ruptured ectopic Fluid Loss: Vomiting, diarrhoea, burns, ‘third spacing’ Anaphylaxis Sepsis Neurogenic Endocrine Failure: Addison’s, Hypothyroidism Iatrogenic: Drugs e.g. anaesthetics, antiHPT Clinical Features: Pallor Inc. Pulse Red. Capillary Return Air Hunger Oliguria Investigations: ABC approach Simple: ECG, dipstix and culture, BM Bloods: FBC, CRP, U&Es, TFTs, LFTs and clotting, Glucose, ABG + lactate, Cultures, X-Match Radiology: CXR, ?echo, USS, abdo CT Management: ABC Raise Foot of Bed IV Access x2 Fluids Stat! Identify Cause Investigations as Above Catheterise
Syncope
Definition: ‘Blackouts’ with multiple clinical pictures and causes. May or may not involve LOC Vasovagal Syncope: reflex bradycardia +/- vasodilation Cough Syncope: weakness + LOC after coughing Effort Syncope: on exercise, cardiac origin e.g. AS Micturition Syncope: mostly men, at night Carotid Sinus Syncope: carotid sinus hypersensitivity, headturning or shaving Epilepsy: most likely Grand Mal presenting with LOC Stokes-Adams Attacks: transient arrhythmias causing low cardiac output & LOC Others: hypoglycaemia, orthostatic hypotension, drop attacks, anxiety Clinical Features: LOC with possible associated symptoms e.g. nausea, pallor, sweating, visual disturbance Investigations: Collateral History CVS with sitting / standing BP Neuro BM ? 24hr ECG Management: Cause dependent
Mitral Stenosis
Aetiology: Rheumatic Fever Clinical Features: Secondary to Pulmonary HPT Progressive SoB PND Orthopnoea Haemoptosis Recurrent Bronchitis Others Malar Flush ⇓Pulse Volume AF Heart Sounds Tapping Apex Beat Loud 1st Heart Sound Opening Snap Rumbling Mid-diastolic Murmur @ Apex Signs of RVF Investigations: CXR – large L atrium, convex L heart border ECG – bifid ‘P’ wave, AF, R ventricular hypertrophy, R axis deviation Echocardiogram – Management: Medical: Diruretics Rate control for AF (β-blockers, Ca2+-blockers, Digoxin) Anticoagulation Endocarditis Prophylaxis Surgical: Balloon Valvotomy Closed Valvotomy Open Valvotomy Replacement Complications AF Emboli Pulmonary HPT Pulmonary Infarction Chest Infections Tricuspid Regurgitation RVF
Mitral Regurgitation
Aetiology: Mitral Valve Prolapse Rheumatic Fever IHD Dilated Cardiomyopathy Infective Endocarditis Clinical Features: Palpitations Exertional SoB Fatigue Cardiac Failure Apex – laterally displaced, hyperdynamic, systolic thrill Heart Sounds Soft 1st heart sound Loud pan-systolic @ apex with radiation to axilla 3rd heart sound Investigations: CXR Echo Cardiac Catheterisation Management: Medical: Symptom management (ACEi, Diruretics) Endocarditis Prophylaxis Surgical: Valve replacement
Aortic Stenosis
Aetiology: Congenital Rheumatic Fever Clacific Clinical Features: Often None Exertional angina, syncope, SoB Small volume, slow-rising pulse Sustained apex beat Systolic Thrill in aortic region Sudden Death Heart Sounds Ejection systolic murmur @ aortic area Radiation to carotids Ejection Click Soft 2nd heart sound Investigations: CXR Echo Management: Conservative: Avoid strenuous exercise Avoid vasodilators Medical: β-blocker for angina Surgical: Valve replacement (mandatory in symptomatic patients)
Aoritc Regurgitation
Aetiology: Rheumatic Fever Marfan’s Syphilis Connective Tissue Disorders Aortic Dissection HPT Clinical Features: Can be asymptomatic Palpitations Angina LVF Collapsing Pulse Pistol Shot Femorals Wide Pulse Pressure Heart Sounds Apex – displaced, diffuse, hyperdynamic Soft, high-pitched early diastolic Left sternal edge Possible systolic aortic flow murmur Visible Carotid or Head Nodding Investigations: Management: Medical: Nifedipine may prolong time before replacement Surgical: Valve replacement at the onset of ventricular dysfunction
Tricuspid Regurgitation
Aetiology: Infective Endocarditis in IV drug users Chronic Lung Disease Pulmonary HPT Dilatation of Right Ventricle Carcinoid Syndrome Clinical Features: Exersional SoB GI upset due to congestion Elevated JVP with giant V wave Pulsatile Hepatomegaly Peripheral Oedema Ascites Pleural effusions Right Ventricular Impulse at Left Sternal Edge Heart Sounds Pansystolic Murmur at lower left sternal edge, louder in inspiration Investigations: Management: Medical: treat right ventricular failure Surgical: resection in infective EC valve repair or replacement
Venous Thromboembolism (DVT)
Definition: Occur in 25-50% of surgical patients, and many none surgical patients. 65% of below knee DVTs are asymptomatic and rarely embolize to the lungs. Risk Factors: Age, pregnancy, synthetic oestrogen, surgery, prev. DVT, malignancy, obesity, immobility, thrombophillia Clinical Features: Calf warmth / swelling / tenderness / erythema Mild Fever Pitting Oedema Investigations: Wells Score >3 - High probability, treat as suspected DVT & USS 1-2 - Intermediate probability, treat as suspected DVT & USS 0 - Low probability, perform D-dimer…. If +ve treat as suspected DVT & USS If -ve DVT is reliably excluded Management: Enoxaparin and Warfarin for ~48 hours and stop Enoxaparin when INR = 2-3 Continue Warfarin for 3/12 post-op, 6/12 if no cause, lifelong if recurrent DVTs IVC filters may be considered later
BCC
Incidence: 1 / 1000 per year M:F 1.3:1.0 Risk Factors: Skin Types 1&2 Sunburn in childhood Immunosuppression Old Age Site: Upper 2/3 of face Features: Pearly papule with telangectasia Eroded centre Slowly increasing in size Management: Surgical Excision Mohs Curettage & Cautery Cryotherapy Photodynamic Therapy Topical 5-fluouracil Superficial Radiotherapy Prognosis: Excellent - rarely local recurrence 50% 2nd BCC at 5 years Does not metastasize
Cellulitis
Clinical Features: Hot, tender area of confluent erythema Often on lower leg Can affect face Caused by streptococci Risk Factors: DM Management: Oral / IV Abx
Eczema
Definition: Acute – inflamed weeping skin with vesicles Subacute – erythema, dry / flaky skin, crusted Chronic – lichinified skin Aetiology: 40% of population have an episode associated with atopy Atopic Individuals have a tendency to: Asthma Eczema Hay Fever Allergic Rhinitis Genetic Environmental – detergents, chemicals, infection, stress, animal fur, food Clinical Features: Itchy erythematous scaly patches Often flexural May be associated with nail pitting Investigations: May have raise IgE or eosinophils Patch Testing Management: Education & Explanation Avoid irritants Emollients Topical Steroids Abx Antihistamines Second-line Agents: UV Oral Steroids Ciclosporin / Azathioprine
Melanoma
Incidence: 1 / 10000 per year Median Age at Presentation 50 Risk Factors: M:F = 1:2 FH Acute Sunburn, esp. childhood Number of pigmented moles Previous Melanoma Features: Irregular pigment and edge Increasing size in adult life Occurs in young adults Types: Superficial Spreading Nodular Sites: Males - back Females - leg Can occur anywhere on the body Management: Excise with wide margins - >1cm
Psoriasis
Definition: Common disorder characterized by red, scaly plaques. 2% of the population. M=F Aetiology: T-cell driven Genetic Environmental Triggers: Infection Drugs e.g. Lithium UV light Alcohol Stress Clinical Features: Chronic Plaque Psoriasis: Purplish / red scaly plaques, particularly on extensor surfaces Scalp Involvement Can occur in areas of skin trauma (Köbner Phenomenon) 50% Associated with nail changes Flexural Psoriasis: Occurs in older patients Patches in groin, natal cleft, submammary Guttate Psoriasis: Raindrop lesions on trunk Occurs in children / young adults 2 weeks post strep sore throat Management: Education & Explanation Avoid irritants Topical steroids Calcipotriol (vit D analogue) Coal tar Phototherapy (PUVA) Methotrexate if severe
SCC
Incidence: 1 / 4000 per year Risk Factors: Skin Type 1&2 Chronic Sun Exposure Outdoor Work & Leisure Activities Immunosuppression Old Age Chronic Skin Ulceration Defects in DNA repair - xeroderma pigmentosum Features: Painful, firm, keratotic / eroded, indurated nodule Increasing size over months Sun exposed sites - scalp, ears, dorsa of hands, lower legs Management: Surgical Excision with 4mm margin Prognosis: More likely than BCC to recur or metastisize Worse: ear, lip, ulcers size >2mm depth >4mm poorly differentiated immunosuppressed
Adrenal Insufficiency
Definition: Primary Hypoadrenalism (Addison’s) Destruction of adrenal cortex causing reduced production of glucocorticoid, mineralocorticoid and sex steroids. Aetiology: Common: Autoimmune disease ~90% TB Surgical removal Uncommon: Haemorrhage / infarction Meningococcal septicaemia Venography Malignancy Amyloid Clinical Features: Tiredness Debility N&V Anorexia / weight loss Abdo pain Diarrhoea Depression Menstrual disturbance Pigmentation – mouth, palmar creases Postural hypotension Dehydration Loss of body hair Investigations: Reduced 9am Cortisol Reduced Synacthen Test Management: Replacement of glucocorticoids and mineralocorticoids with oral hydrocortisone and fludrocortisone
Diabetes
Definition: Syndrome characterized by chronic hyperglycaemia due to relative insulin deficiency or resistance or both. WHO Classification Type 1: β cell destruction usually leading to absolute insulin deficiency Autoimmune or idiopathic Type 2: Variable combination of insulin resistance and defects in insulin secretion Aetiology: Autoimmune Idiopathic Genetic Endocrine problems (e.g. Cushing’s) Pancreatic trauma or disease Drug-induced - corticosteroids, thiazides Clinical Features: Due to hyperglycaemia Thirst Polyuria Weight loss Ketoacidosis ⇓ Energy Visual Blurring Candida Infections Due to Complications Skin infections Retinopathy - haemorrhages, exudates etc… Polyneuropathy - ‘glove&stocking’, autonomic Erectile Dysfunction Arterial Disease - atheroma, stroke, MI, PVD Renal Disease - glomerular sclerosis, pyelonephritis Charcot’s Joints Diabetic Foot Investigations: WHO Criteria For Diagnosis: HbA1c >6.5% is diabetic HbA1c 6.0-6.4% is high risk of developing diabetes - lifestyle advice & yearly monitoring Management: Based on self-monitoring and management by the patient, helped and advised by specialists. Requires good education and understanding of disease by the patient, including: - Monitoring blood sugar - Self-injection of insulin - Managing hypoglycaemic events - How to recognize complications - When to contact specialists for help Type I Drugs Insulin - fast, intermediate, long acting (pumps) Type II Drugs Oral Hypoglycaemics: Biguanides - inc. insulin sensitivity (eg Metformin) Sulfonylureas - inc. insulin secretion (eg Gliclazide) Thiazolidinediones - inc. insuin sensitivity (eg Pioglitazone)
Goitre
Definition: Swelling of the thyroid gland, may be associated with hypo / hyperthyroidism Aetiology: Aetiology in Euthyroid Patient: Simple non-toxic goitre - Iodine Deficiency - Treated Grave’s disease - Puberty Solitary Nodule - Thyroid adenoma - Thyroid cyst - Thyroid carcinoma Aetiology in a Hypothyroid Patient: Hashimoto’s Thyroiditis Radioiodine-treated Grave’s Aetiology in a Hyperthyroid Patient: Grave’s Disease Toxic Multinodular Goitre Clinical Features: Neck swelling and features of hyper / hypothyroidism Management: Treat cause
Hypothyridism
Definition: A condition in which free T4 is reduced due to different potential causes. Aetiology: Hashimoto’s - autoimmune Thyroid destruction Radioiodine-treated hyperthyroidism Thyroidectomy Clinical Features: Weight gain Lethargy Depression Patient feels cold Constipation Poor appetite Menstrual disturbances Myxoedema facies; thickened skin Brittle hair Periorbital puffiness Bradycardia Slow relaxing reflexes Investigations: Biochemistry Haemotology – macrocytosis, anaemia Anti-thyroid antibodies Management: Thyroxine Caution in cardiac disease Monitor TSH
Hyperthyroidism
Definition: Characterised by increased plasma concentration of free T4 Aetiology: Grave’s Disease Toxic multinodular goitre Single toxic nodule Gestational Clinical Features: Heat intolerance Weight loss Increased appetite Diarrhoea Irritability Sleepleessness, tiredness Exertional SoB Goitre Tachy / AF Tremor Hyperkinesia Proximal muscle wasting Cardiac failure Pretibial myxedema Eye Signs (Grave’s): Exopthalmos Lid lag Lid retraction Opthalmoplegia Investigations: T4 up TSH down Management: Carbimazole Propylthiouracil Radioiodine Surgical for: Malignancy Pressure symptoms Failure of medical treatment
Acute Abdomen
Definition: Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen. Aetiology: Clinical Syndromes That Usually Require Laparotomy: Rupture of an organ – spleen, aorta, ectopic pregnancy Peritonitis – perforation of ulcer, diverticulum, appendix, bowel or gall bladder Syndromes That May Not Require Laparotomy: Local Peritonitis – diverticulitis, cholecystitis, salpingitis or appendicitis Colic - Clinical Features: Rupture of an organ – shock, swelling, trauma Peritonitis – prostration, shock, lying still, +ve cough test, tenderness +- rebound/percussion, rigid abdomen, guarding, absent bowel sounds Local Peritonitis – Colic – waxing & waning pain, restlessness Investigations: FBC U&Es Amylase LFTs CRP Urinalysis ABG (mesenteric ischaemia) CXR (gas under diaphragm) AbdoCT / USS Management: ABC approach Fluid Resus Pain relief Nil by mouth Find & treat cause
Alcoholic Liver Disease
Definition: Steatosis > Fibrosis > Cirrhosis Degree of liver damage dependent on genetic factors and coexisting liver disease; women progress to cirrhosis faster Cage Questionnaire: Have you ever felt the need to cut down? Have you ever felt annoyed by criticism of your drinking? Have you ever felt guilty about your drinnking? Have you ever felt the need for an eye-opener? Clinical Features: lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema Investigations: FBC - ⇑MCV, ⇓Platelets LFTs - ⇑GGT, ⇑bilirubin Coag - ⇑PT Others: ⇑Albumin, ⇑cholesterol Liver Screen: ⇑IgA U&Es to check kidney function & provide baseline USS +- biopsy Management: Abstinence Nutrition Vitamin replacement Laxatives Liver Tx
Biliary Colic
Definition: Pain caused by gallbladder contraction against a gallstone stuck in the neck or the cystic duct Clinical Features: Pain in the RUQ / Epigastrium - with radiation around costal margins to back Sweaty Pale Tachycardia Nausea / Vomiting Patients often writhe around with pain, rather than sitting still Attacks lasts < 6hrs Examination is otherwise normal Investigations: FCB, U&Es, LFTs CRP, Urine Dipstix USS gall bladder Management: Analgesia Nil by mouth Laprascopic Cholecystectomy
Cholecystitis
Definition: Inflammation of the gall bladder Aetiology: Caused by chemical irritation within an obstructed gallbladder. Often begins with simple Biliary Colic Clinical Features: Severe RUQ pain Fever Tachycardia Nausea / Vomiting Murphy’s sign +ve - ask patient to take deep breath pressing RUQ under costal margin Patients tend to lay still & take shallow breaths as this is a local peritonitis Investigations: WCC - increased USS - Gallbladder - thickened gallbladder Plain Abdominal X-ray - only show 10% of stones Management: IV Fluid resuscitation IV Antibiotics - Cefuroxime Keep patient NBM Cholecystectomy Time frame is controversial Increasingly surgeons carry out procedure early in the acute phase Some say it’s better to wait until 6-8 weeks later 80-90% of cases of acute cholecystitis will spontaneously resolve over 24-48hrs
Cholestasis
Definition: Obstructive jaundice arising in the biliary tree Aetiology: Main Gallstones Pancreatic Cancer Other Cholangiocarcinoma Chronic Pancreatitis Enlarged lymph nodes in the porta-hepatitis Clinical Features: Yellow appearance of skin + mucous membranes (above 50 micromol/l) Dark urine Pale stools Pruritis Weight loss - due to inability to absorb fat Investigations: FBC U&E LFT - increased alk phos Clotting USS - gallbladder/biliary tree - is a stone or a tumour causing obstruction? Chest X-ray Management: Gallstone Laproscopic cholycystectomy + Laproscopic common bile duct exploration or ERCP with stone extraction + Laproscopic Cholycystectomy Pancreatic Cancer CT should be carried out too assess resectability If it looks favourable then an endoscopic USS should be done: Allow a closer look at head of pancreas Allows cytology sample to be taken If the endoscopic USS also suggests favourobility then Whipple’s should be done If at surgery it’s decided the tumour is not removable, a biliary bypass should still be done If the tumour is not treatable then a stent should be fitted via ERCP to provide symptomatic relief
Crohn’s Disease
Definition: Inflammatory bowel disease which can affect anywhere from the mouth to the anus. It most commonly involves the terminal ileum, which can present as right iliac fossa pain. It affects patients between the ages of 18-30. Aetiology: Autoimmune attack against bowel wall. Causes full thickness infiltration and can therefore result in perforation, adhesions and fistula. It classically on colonscopy demonstrations skip lesions, which helps differentiate it from ulcerative colitis. Clinical Features: Fatigue Weight loss Fever Abdominal pain (classically RIF) Diarrhoea +/- blood Episcleritis Large joint arthropathy Tender abdomen Mass in RIF Episcleritis Erythema Nodosum Episcleritis Anal skin tags Extra-intestinal Manifestations Erythema Nodosum Episcleritis Large joint arthritis / Ankylosing spondylitis Renal stones Primary sclerosing cholangitis Investigations: FBC – Anaemia CRP Antibodies - Anti-S cerevisiae antibodies (more common in crohns than UC) Stool sample – culture & microscopy Ilieo-colonoscopy + Biopsy – skip lesions, deep ulceration Management: Severe abdo pain, diarrhoea, bowel obstruction, or systemically unwell = admit Mesalazine – prophylactic therapy Budesonide – Fewer side effects than prednisolone, but may be less effective Antibiotics for septic disease Immunomodulators Azothiaprine Methotrexate Biologics Infliximab Elemental diet Surgery Maintaining remission Mesalazine – after surgery Azothiaprine Infliximab
Gallstones
Definition: Can be either: Cholesterol stone - 75% Pigment stone - Mixed 90% are Radio-lucent (unable to see on X-ray) Aetiology: Female - 3x more common Age - 10% of over 50’s have gall stones Obesity Hyperlipidaemia Haemolytic anaemia Crohn’s Disease Clinical Features: May Cause: Gallbladder Chronic cholecystitis Biliary colic Acute cholecystitis Mucocele Common bile duct Obstructive jaundice Cholangitis Pancreatitis Gut Gallstone ileus Investigations: Urinalysis, ECG, CXR to rule out other diseases FBC + CRP: infection LFTs: pattern of cholecystitis - ⇑ALP & ⇑GGT Amylase: pancreatitis U&Es: baseline USS to visualize stones ERCP Management: Usually surgical: cholecystectomy
Gastroenteritis
Definition: Diarrhoea with N&V +/- abdo pain. Aetiology: Usually due to viruses (inc. Norovirus) but other infectious agent important - Shigella, Campylobacter Clinical Features: Diarrhoea, N&V, abdo pain, fever, sweating Investigations: Stool culture WCC inc. CRP inc. Management: Fluid replacement Antiemetics Discuss with Micro
GORD
Definition: Decreased lower oesophageal sphincter; sustained or transient. Aetiology: Usually no obvious cause; secondary causes include smoking, pregnancy, scleroderma, drugs, trauma, alcohol, obesity Helicobacter Pylori is not associated with GORD Clinical Features: Heartburn, regurgitation Investigations: OGD, 24hr pH monitoring in difficult cases Management: Conservative: weight loss, avoidance of smoking and alcohol Medical: simple antacids, H2 blockers (Ranitadine), PPIs Surgery: Nissen fundoplication (fundus wrapped around distal oesophagus) Complications Reflux oesophagitis, peptic stricture, Barrett’s oesophagus
Hernias
Definition: The protrusion of a viscus through the walls of it’s containing cavity into an abnormal position Aetiology: Congenital hernias Groin Hernias (most common 75%) Inguinal - direct, enter inguinal canal through transversalis and emerge at superficial inguinal ring - indirect, enter inguinal canal through deep ring and often protrude into scrotum Arise SUPERIOR & MEDIAL to pubic tubercle Femoral - emerge through femoral canal, normally contains only fat & lymph nodes. More prone to strangulation due to sharp edge of lacunar ligament Arise INFERIOR & LATERAL to pubic tubercle
IBS
Definition: GI symptoms in the absence of structural pathology; abnormal autonomic reactivity, visceral hypersensitivity. Aetiology: Post-infective, stress, adverse life events, psychological problems: anxiety, depression. Clinical Features: Abdominal discomfort, relief with defaecation, alternating bowel habit, bloating Investigations: Patient Patient >45, with short history or atypical symptoms – other pathologies should be ruled out Management: Supportive: explanation, reassurance, lifestyle advice Medical: Aimed at specific symptoms – antispasmodics (Mebeverine), antidepressants, anti-diarrhoeals, constipation treatments Dietary: Diary to discover causative foods & exclusion diet Psychological: CBT
Liver Cirrhosis
Definition: Necrosis of hepatic parenchyma with connective tissue proliferation and nodular regeneration Aetiology: Alcoholism by far most common cause follwed by Hep c. Others - Hep B, PSC, PBC, Drugs, NAFLD, AA hep, Wilson’s, Budd-Chiari Clinical Features: Related to underlying cause: lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema Investigations: Aimed at finding cause: • LFTs • FBC • U&Es • Albumin • Coagulation • Biopsy Management: Treat underlying cause Complications of Cirrhosis: Malnutrition Hepatic Encephalopathy Ascites / Oedema Vitamin Deficiency Coagulopathy Impaired Immune System Varices Hepatorenal Syndrome Hepatocellular Carcinoma
Ulcerative Colitis
Definition: Inflammatory bowel disease, affecting the colon only Aetiology: Mucosal inflammation of colon (transmural in crohn’s) Clinical Features: Weight loss Bloody diarrhoea Fever Colicky abdominal pain Tenesmus Constipation Tender abdomen Distension Abdominal mass Extra-gastrointestinal signs Erythema nodosum Pyoderma gangrenosum Ankylosing Spondylitis Episcleritis Primary Sclerosing Cholangitis Investigations: • Bloods o FBC – anaemia o CRP & ESR – disease severity o Antibodies – p Anca • Stool sample o Blood o Microscopy, Culture & Sensitivity • Abdominal X-ray – signs of toxic megacolon • Colonoscopy + Biopsy - diagnosis Management: Local – topical steroids in proctitis Systemic o Corticosteroids – Budesonide (induction of remission) o Mesalazine – induction & maintinence of remission o Azothiaprine – no response to steroids or >2 use of steroids in 1yr o Infliximab – use when no response to azothiaprine (induction of remission) Surgery o Ileal pouch anal anastomoses (removal of colon)
GI Malignancy
Definition: Aetiology: Clinical Features: Investigations: Management:
Nephrotic Syndrome
Definition: A triad of: Proteinuria (>3g/24h) Hypoalbuminaemia ( Oedema Aetiology: 80% due to glomerulonephritis membranous GN most common in adults minimal change GN most common in children Others: DM, amyloidosis, SLE, drugs and allergies Clinical Features: Oedema - peri-orbital, face, arms Frothy urine Ascites Normal JVP Investigations: Simple: 24hour urine, throat swab, Bloods: Albumin, U&Es (urea & Cr), Antibodies Others: CXR (pulmonary oedema) Renal imaging (USS) +- biopsy Management: Sodium restriction Diuretics ACEi Steroids Cyclophosphamide Complications: DVT Sepsis Oliguric Renal Failure Lipid Abnormalities
Oesophageal Disease
Definition: Barrett’s Oesophagus - columnar epithelium with intestinal metaplasia replaces normal squamous mucosa Oesophageal Carcinoma - 40% squamous, 60% adenocarcinoma Achalasia - failure of relaxation of lower oesophageal sphincter Aetiology: Barrett’s Oesophagus - GORD Oesophageal Carcinoma - Barrett’s, smoking Achalasia - Clinical Features: Barrett’s Oesophagus - Oesophageal Carcinoma - dysphagia (solids-liquids), weight loss, anorexia, Virchow’s Achalasia - dysphagia (solids-liquids) Investigations: Barrett’s Oesophagus - Endoscopy Oesophageal Carcinoma - Endoscopy, USS, CT Achalasia - Barium Swallow (Rat’s tail), endoscopy, manometry Management: Barrett’s Oesophagus - watchful waiting Oesophageal Carcinoma - 10% 5 year survival, SCC (radio/chemo, surgery), Adeno (surgery, palliative, ablation, radio) Achalasia - balloon dilatation, botox, Heller’s sphinctotomy
Pancreatitis
Definition: Inflammation of the pancreas, acute or chronic Aetiology: Alcohol Gall Stones Trauma ERCP Drugs - azathioprine, steroids, oral contraceptive Infection - mumos, coxsackie, klebsiella Metabolic - hypercalcaemia, hyperlipidaemia, renal failure Other - hypothermia, malnutrition, scorpion bite Clinical Features: abdo pain radiating to back, N&V, anorexia, abdo tenderness & guarding, Grey-Turner sign, basal crackles Investigations: Abdo Xray inc. neutrophils U&Es - renal failure Calcium & glucose Amylase elevated ABG - hypoxia & acidosis LFTs USS - gallstones CT Management: GLASCOW SCORE ABC Analgesia ERCP HDU
Peptic Ulcer Disease
Definition: Break in the mucosal surface of the stomach or duodenum >5mm Aetiology: 95% of duodenal ulcers & 70% of gastric ulcers are associated with H-pylori. Other associations are NSAIDs, smoking and alcohol. Clinical Features: Dyspepsia Heartburn Anorexia Epigastric tenderness Investigations: OGD if >55 or red flag symptoms Breath test if Stool antigen test Management: PPI, amoxicillin, clarithromycin 500mg or a PPI, metronidazole, clarithromycin 250 mg
Peritonitis
Definition: Inflammation of the peritoneum, locally (eg appendicitis) or generalised. Aetiology: Rupture of abdominal viscus eg perforated duodenal ulcer, perforated appendix. Clinical Features: Sudden onset abdominal pain Shock Still patient Investigations: AXR - air under diaphragm Check amylase Management: Analgesia Surgery
Anaemia
Definition: Reduced Hb concentration (Normal Range 13M, 11.5F) Aetiology: Reduced production - aplastic, pernicious, iron deficiency Increased destruction - congenital, sickle cell, AA, DIC RBC loss - haemorrhage, menstruation Clinical Features: Fatigue SoB Exertional angina Palpitations Pallor Tachy Koilonychia Angular stomatits / glossitis Investigations: WCC may be low in bone marrow failure Reticulocytes - measures bone marrow activity Blood film - shows erythrocyte morphology Management: Treat underlying cause eg iron supplements
Leukaemia
Definition: Malignancy of the blood or bone marrow resulting in an abnormal increase of immature WBCs. Acute - Rare (5 in 100 000) AML & ALL Chronic - Usually older patients, changes to acute with a high 5-yr mortality CML & CLL Aetiology: Mostly unknown Some genetic & environmental factors Clinical Features: Acute: Bone marrow failure Weakness and tiredness due to anaemia Bruising due to thrombocytopenia Repeated infections Chronic Myeloid: Anaemia Night sweats & fever Weight loss Splenomegaly & pain Chronic Lymphocytic: Often incidental Infections due to neutropenia Anaemia Lymphadenopathy Hepatospenomegaly Investigations: Acute: Blood count Blood film - leukaemic blast cells Bone marrow - blast cells Chronic Myeloid: Blood count - raised WCC Multiple myeloid precursors Bone marrow biopsy Genetic testing for Philadelphia Chromosome 9:22 trans. Chronic Lymphocytic: Hb - low or normal WCC - raised 40% lymphocytes Plt - low or normal Serum IG - low Management: Acute: Correct anaemia & thrombocytopenia Treat infections Chemo to achieve remission Bone marrow ablation Chronic Myeloid: Interferons - remission in 10% Hydroxyurea reduced WCC Myeloablation with BM Tx Chronic Lymphocytic: Nothing if asymptomatic Steroids for haemolysis Fludarabine or Chlorambucil
Anorexia
Definition: Reduced nutritional intake and an irrational fear of gaining weight due to distorted fears of body image Aetiology: Genetic Childhood sexual abuse Dietary problems in early life Social - higher class, ballet dancers, medical students Clinical Features: BMI Intense wish to be thin & morbid fear of fattness Amenorrhoea F>>M with adolescent onset Previously fat or chubby Avoids carbs Vomiting / excess exercise / purging Loss of libido Investigations: Clinical diagnosis Management: CBT - goal setting with rewards Psychotherapy Family therapy
