Corrections - GI Flashcards
FAP vs Gardners syndrome?
Gardner syndrome is a variant of FAP.
Like in FAP, people with Gardner syndrome develop multiple adenomatous colon polyps, but in addition, they also develop other tumors outside the GI organs, e.g. skull osteoma, thyroid cancer, epidermoid cysts.
In which IBD are increased goblet cells seen?
Crohn’s disease
These are simple columnar goblet shaped epithelial cells
In which IBD are crypt abscesses seen?
UC
What type of anaemia can Coeliac disease cause?
Normocytic anaemia - as coeliac disease impairs absorption of minerals e.g. iron, vitamin B12
What stools can be seen in Coeliac disease?
Greasy and foul-smelling (indicate steatorrhoea due to malabsorption of fat)
What drug is used for the prophylaxis of oesophageal bleeding?
Non-cardioselective beta blocker e.g. propanolol
These cause vasodilation in these engorged vessels and reduced heart rate which lowers the BP in the variceal veins and reduces the risk of rupture.
What drug is given to help control variceal bleeding?
Terlipressin
This is a synthetic analogue of vasopressin that acts as a vasoconstrictor. It reduces portal venous pressure by causing splanchnic vasoconstriction, which helps control variceal bleeding.
Presentation of mesenteric ischaemia?
- sudden abrupt onset of abdominal pain
- nausea & vomiting
- diarrhoea (may be bloody)
- may have risk factors e.g. AF
What is an AKI?
Acute kidney injury (AKI) refers to a rapid drop in kidney function
Next investigation in high grade dysplasia on biopsy in Barrett’s oesophagus?
Endoscopic intervention
What type of liver disease is associated with sudden weight loss?
Non-alcoholic fatty liver disease
This is particularly relevant in the context of obese patients with metabolic syndrome undergoing bariatric surgery and sudden weight fluctuations.
Weight loss triggers catabolism of peripheral adipose reserves and importation of toxic lipids to the liver which trigger steatosis, inflammation, and hepatocyte cell death.
Recommendation for immunisation in Coeliac disease?
Recommendation that everyone with coeliac is vaccinated against pneumococcal infection and has booster every 5 years (as risk of hyposplenism)
What is SAAG?
SAAG = serum-ascites albumin gradient.
A physiological clinical diagnostic tool for the evaluation of ascites.
What does an increased SAAG indicate?
An increased SAAG (> 1.1 gm/dL) value indicates the presence of portal hypertension.
This is because increased hydrostatic pressure forces fluid out of the vascular spaces, concentrating serum albumin.
Main cause of a high SAAG ascites?
Liver cirrhosis
Management of severe alcoholic hepatitis?
Corticosteroids
Features of vitamin C deficiency?
Essential for collagen synthesis so can lead to:
1) Impaired wound healing
2) Gum disease
3) Pale conjunctivae
4) Other connective tissue abnormalities
Management of severe flare of UC?
IV corticosteroids
If the AST:ALT ratio is greater than 2, what does this suggest?
Alcoholic hepatitis
If the AST:ALT ratio is less than 1, what does this suggest?
NAFLD
Patient with obesity and abnormal LFTs, what condition do you think?
NAFLD
Management of suspected upper GI bleed?
OGD within 24 hours
What medication can reduce mortality in cirrhotic patients with GI bleeding?
Antibiotic prophylaxis, usually quinolones (in addition to terlipressin)
What is a pharyngeal pouch?
Where a small sac forms in throat just above oesophagus
Symptoms of pharyngeal pouch?
1) Dysphagia
2) Halitosis (bad breath): due to bacterial breakdown of retained food
3) Nocturnal coughing: due to aspiration of trapped food in pouch, may cause aspiration pneumonia
N.B. these symptoms are often intermittent (i.e. won’t cause significant weight loss)
What is a benign oesophageal stricture?
Typically results from long standing acid reflux causing scarring and narrowing of lower oesophagus
Presentation of oesophageal stricture?
Progressive dysphagia (from liquids to solids)
History of longstanding heartburn
1st line therapy in C. diff infection?
Oral vancomycin for 10 days
Also current antibiotic therapy should be reviewed and antibiotics stopped if possible.
2nd line therapy in C. diff infection?
oral fidaxomicin
3rd line therapy in C. diff infection/severe C. diff infection?
oral vancomycin +/- IV metronidazole
What should be prescribed in all patients with suspected hepatic encephalopathy?
Lactulose
Why should lactulose be prescribed in all patients with suspected hepatic encephalopathy?
Lactulose works to inhibit production of ammonia in intestine
Features of oesophageal carcinoma?
1) Progressive dysphagia
2) Weight loss
3) May be hoarseness of voice due to laryngeal nerve damage
What is considered in C. diff cases not responding to oral vancomycin?
Oral fidaxomicin (particularly for recurent cases within 12 weeks of symptom resolution)
What is the only test recommended for H. pylori post-eradication therapy?
Urea breath test
Most appropriate blood test for coeliac disease diagnosis?
Total IgA + IgA tTG
Who should coeliac testing be offered to?
1) persistent unexplained abdo or GI symptoms
2) faltering growth
3) prolonged fatigue
4) unexpected weight loss
5) severe or persistent mouth ulcers
6) unexplained iron, vit B12 or folate deficiency
7) T1D at diagnosis
8) autoimmune thyroid disease at diagnosis
9) IBS (in adults)
10) 1st degree relatives of people with coeliac
What is spontaneous bacterial peritonitis (SBP)?
Ascitic fluid infection without an evident treatable intra-abdominal source.
Who does SBP typically occur in?
Those with known cirrhosis and ascites, commonly as a result of alcoholic liver disease, hep B, hep C, and NAFLD.
Presentation of SBP?
- known liver disease
- fever
- abdo tenderness
- vomiting
- altered mental state
Investigations of choice in primary sclerosing cholangitis?
ERCP/MRCP
Give some causes of abdo pain
1) Peptic ulcer disease
2) Appendicitis
3) Acute pancreatitis
4) Biliary colic
5) Acute cholecystitis
6) Diverticulitis
7) Abominal aortic aneurysm
8) Intestinal obstruction
Are duodenal or gastric ulcers more common?
Duodenal
Location of duodenal ulcer pain?
Epigastric
describe impact of eating on epigastric pain in:
a) duodenal ulcer
b) gastric ulcer
a) epigastric pain relieved by eating
b) epigastric pain worsened by eating
What other features may be seen in peptic ulcer disease?
Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)
Location of pain in appendicitis?
Pain initial in the central abdomen before localising to the right iliac fossa
Other possible findings in appendicitis?
1) Anorexia is common
2) Tachycardia, low-grade pyrexia, tenderness in RIF
3) Rovsing’s sign: more pain in RIF than LIF when palpating LIF
Most 2 common causes of acute pancreatitis?
1) Alcohol
2) Gallstones
Describe pain in acute pancreatitis
Severe epigastric pain
Other findings in acute pancreatitis?
- Vomiting is common
- Examination may reveal tenderness, ileus and low-grade fever
- Periumbilical discolouration (Cullen’s sign) and flank discolouration (Grey-Turner’s sign) is described but rare
Describe pain in biliary colic
Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal.
Other features of biliary colic?
- Obstructive jaundice may cause pale stools and dark urine
- Afebrile
Typical patient with biliary colic?
female, forties, fat and fair although this is obviously a generalisation
Pain in acute cholecystitis?
Continuous RUQ pain
Other features of acute cholecystitis?
- History of gallstones
- Fever, raised inflammatory markers and white cells
- Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
Describe pain in diverticulitis
Colicky pain typically in the LLQ
Other features of divertiulitis?
Fever, raised inflammatory markers and white cells
Describe pain in an AAA
Severe central abdominal pain radiating to the back
Clinical features of acute upper GI bleed?
1) haematemesis
2) melena
3) raised urea
4) features associated with a particular diagnosis e,g, oesophageal varices: stigmata of chronic liver disease, peptic ulcer disease: abdominal pain
Description of haematemesis in acute upper GI bleed?
often bright red but may sometimes be described as ‘coffee gound’
Description of melena in acute upper GI bleed?
typically black and ‘tarry’
Cause of raised urea in upper GI bleed?
a raised urea may be seen due to the ‘protein meal’ of the blood
2 most common causes of upper GI bleed?
1) oesophageal varices
2) peptic ulcer disease
Give 4 oesophageal causes of upper GI bleed
1) Oesophageal varices
2) Oesophagitis
3) Cancer
4) Mallory Weiss tear
Haematemesis & melena in oesophageal varices vs oesphagitis vs Mallory Weiss tear?
Oesophageal varices:
- Usually a large volume of fresh blood.
- Swallowed blood may cause melena
- Often associated with haemodynamic compromise.
Oesophagitis:
- Small volume of fresh blood, often streaking vomit
- Melena rare
- Often GORD type history
Mallory Weiss:
- Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting.
- Melena rare
Who are oesophageal varices more common in?
Liver disease (e.g. advanced cirrhosis)
Who are Mallory Weiss tears more common in?
Alcoholics, bulimia, cyclic vomiting syndrome (CVS)
How would a bleeding gastric ulcer typically present?
Small low volume bleeds are more common so would tend to present as iron deficiency anaemia.
(Erosion into a significant vessel may produce considerable haemorrhage and haematemesis)
Glasgow-Blatchford score vs Rockall score?
Glasgow-Blatchford score at first assessment: helps clinicians decide whether patient patients can be managed as outpatients or not
Rockall score used after endoscopy: provides a percentage risk of rebleeding and mortality
Which score provides a percentage risk of rebleeding and mortality in upper GI bleeds?
Rockall
Location of tenderness typically in UC?
Left lower quadrant
What is most common extra-intestinal feature in both CD and UC?
Arthritis
Type of resection in anal verge cancers?
Abdomino-perineal excision of rectum (no anastomosis)
Patients are at increased risk of which cancers following radiotherapy for prostate cancer?
bladder, colon, and rectal cancer
How is chronic urinary retention characterised?
by being painless and insidious.
Cause of high pressure urinary retention?
Typically due to bladder outflow obstruction e.g. in BPH
Features of high pressure urinary retention vs low?
High:
- impaired renal function
- bilateral hydronephrosis
Low:
- normal renal function
- no hydronephrosis
What commonly occurs after catheterisation for chronic urinary retention?
Decompression haematuria due to the rapid decrease in the pressure in the bladder (no further treatment required)
Management options for localised prostate cancer (T1/T2)?
Depends on patient choice and life expectancy:
1) conservative: active monitoring & watchful waiting (particularly in patients with significant comorbidities)
2) radical prostatectomy
3) radiotherapy: external beam and brachytherapy
Give 4 causes of acute diarrhoea
1) gastroenteritis
2) diverticulitis
3) Abx therapy
4) constipation causing overflow
How does diverticulitis classically present?
Left lower quadrant pain, diarrhoea and fever
What type of abx is diarrhoea common with?
Broad spectrum (also C. diff infection)
Typical history with constipation causing overflow?
A history of alternating diarrhoea and constipation may be given
May lead to faecal incontinence in the elderly
May have mass in left side of abdomen.
LFTs with pancreatic cancer?
Typically cause obstructive pattern on LFTs e.g. elevated bilirubin
What scoring system can be used in suspected upper GI bleeds to determine severity of bleed and whether or not they could be safely managed as an outpatient?
Glasgow-Blatchford
When assessing the severity of liver cirrhosis, what is best indicator in showing functional capacity of liver?
Albumin or coagulation
What classification is used to predict mortality in cirrhosis patients?
Child-Pugh classification
What can liver enzymes indicate?
Where primary disorder is hepatitis or cholestatic in origin
Is prothrombin time or albumin a better measure of acute liver failure? Why?
Prothrombin as has a shorter half life than albumin
Histology in coeliac disease?
- villous atrophy
- raised intra-epithelial lymphocytes
- crypt hyperplasia
1st line management of mild-moderate flare of distal UC?
Topical (rectal) aminosalicylates
What triad is seen in mesenteric ischaemia?
1) CVD
2) high lactate
3) soft but tender abdomen
In a mild-moderate flare of UC extending past the left-sided colon, what should be added to rectal aminosalicylates?
Oral aminosalicylates
What is carcinoid syndrome?
Features of diarrhoea, flushing, and palpitations.
This is caused by secretion of serotonin by cancer.
It is more common when the tumour has spread to the liver and releases hormones such as serotonin into the bloodstream.
What weight loss over 3-6 months is diagnostic of malnutrition?
Unintentional weight loss >10% of body weight over 3-6 months
In ascites 2ary to liver cirrhosis, what is the preferred diuretic?
Spironolactone (aldosterone antagonists) - combat sodium retention.
In T2DM with abnormal LFTs, what condition should you consider?
Non alcoholic fatty liver disease
What are the options for management of uninvestigated dyspepsia symptoms?
Either:
1) Prescribe a full dose PPI for 1 month
OR
2) Test for H. pylori infection if status is unknown: if positive then 1st line eradication
Whichever option is tried first and fails, try the second one next.
What is the AST/ALT ratio in alcoholic hepatitis?
2:1
Clinical features of alcohol hepatitis?
jaundice, anorexia, fever, tender hepatomegaly
may have RUQ pain/epigastric pain, hepatic encephalopathy, signs of malnutrition etc
What is used to monitor treatment in haemochromatosis?
Ferritin & transferrin saturation
What is the characteristic iron study profile in haemochromatosis?
Raised transferrin saturation & ferritin with low total iron binding capacity
What is transferrin?
An iron transport protein in plasma which INCREASES in iron deficiency to maximise the utilisation of available iron.
What does total iron binding capacity reflect?
Reflects the availability of iron-binding sites on transferrin.
Levels INCREASE in iron deficiency and DECREASE in iron overload.
Most common cause of travellers diarrhoea?
enterotoxigenic Escherichia coli
What is small bowel overgrowth syndrome (SBBOS)?
A disorder characterised by excessive amounts of bacteria in the small bowel resulting in GI symptoms.
What are the 3 risk factors for SBBOS?
1) neonates with congenital gastrointestinal abnormalities
2) scleroderma
3) diabetes mellitus
Features of SBBOS?
Many overlap with IBS:
1) chronic diarrhoea
2) bloating, flatulence
3) abdominal pain
How is a diagnosis of SBBOS made?
hydrogen breath test
Management of SBBOS?
1) correction of the underlying disorder
2) Abx: rifaximin is treatment of choice
How long must patients consume gluten for before they are tested for coeliac disease?
6 weeks
Risk factors for development of gallstones?
- increasing age
- FH
- sudden weight loss e.g. after obesity surgery
- loss of bile salts e.g. ileal resection, terminal ileitis.
- diabetes
- oral contraception
How is Crohn’s a risk factor for gallstones?
Crohn’s disease can result in terminal ileitis, this is the section of the bowel where bile salts are reabsorbed.
When this area is inflamed and the bile salts are not absorbed and people are prone to development of gallstones.
what is zollinger ellison syndrome?
Zollinger-Ellison syndrome is a condition characterised by excessive levels of gastrin secondary to a gastrin-secreting tumour.
Where are the majority of gastrin secreting tumours found in zollinger ellison syndrome?
First part of the duodenum (second most common location is the pancreas)
Features of zollinger ellison syndrome?
1) multiple gastroduodenal ulcers
2) diarrhoea
3) malabsorption
around 1/3 of patients with gastrinomas have what condition?
MEN type I syndrome
Histology features in UC vs Crohn’s?
UC:
- no inflammation beyond submucosa
- crypt abscesses
- depletion of goblet cells
Crohn’s:
- inflammation in all layers from mucosa to serosa
- increased goblet cells
- granulomas
Whatare the causes of Dupuytren’s contracture?
1) manual labour
2) phenytoin treatment
3) alcoholic liver disease
4) diabetes mellitus
5) trauma to the hand
What is hereditary haemorrhagic telangiectasia (HHT)?
An autosomal dominant condition characterised by multiple telangiectasia over the skin and mucous membranes.
What are the 4 main diagnostic criteria for HHS?
1) epistaxis : spontaneous, recurrent nosebleeds
2) telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose)
3) visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM\
4) family history: a first-degree relative with HHT
What is 1st line in maintaining remission in UC patients with proctitis and proctosigmoiditis?
Topical (rectal) aminosalicylate +/- oral aminosalicylate
What is the classical barium enema finding in chronic UC?
Lead pipe appearance of colon: complete loss of haustral markings in the diseased segment, appearing smooth-walled and cylindrical.
What is 1st line in maintaining remission in UC patients with left-sided and extensive ulcerative colitis?
low maintenance dose of an oral aminosalicylate
Following a severe relapse in UC, or >/= 2 exacerbations in the past year, what is the management?
oral azathioprine or oral mercaptopurine to maintain remission.
What is the most common cause of chronic diarrhoea in infants?
cow’s milk intolerance
What is toddler diarrhoea?
Chronic nonspecific diarrhoea in infants –> stools often contain undigested food.
What is used 1st line to maintain remission in patients with Crohn’s?
Azathioprine or mercaptopurine
What is pseudomembranous colitis?
Inflammation of the colon associated with an overgrowth of the bacterium Clostridioides difficile.
Often follows Abx course.
How does C. diff infection present on sigmoidoscopy?
yellow plaques on the intraluminal wall of the colon.
What is giardiasis?
a protozoan parasite transmitted via the faecal-oral route
1st line treatment of giardiasis?
metronidazole
Features of giardiasis?
- history of foreign travel
- often asymptomatic
- non-bloody diarrhoea: steatorrhoea
- bloating, abdominal pain
- lethargy
- flatulence
- weight loss
- malabsorption and lactose intolerance can occur
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates, what should be added?
oral corticosteroids
What is often a presenting feature of CF in the neonatal period (i.e. first manifestation)?
meconium ileus
What are the 4 typical presenting features of cystic fibrosis (CF)?
1) neonatal period (around 20%): meconium ileus, less commonly prolonged jaundice
2) recurrent chest infections (40%)
3) malabsorption (30%): steatorrhoea, failure to thrive
4) other features (10%): liver disease
Ohther features of CF?
- short stature
- diabetes mellitus
- delayed puberty
- rectal prolapse (due to bulky stools)
- nasal polyps
- male infertility, female subfertility
What is the most common symptom of Crohn’s disease in children?
Abdo pain
Who should serum Ca125 be performed in?
Aged >50 and has any of the following symptoms on a regular basis:
1) abdo distension or bloating
2) early satiety or loss of appetite
3) pelvic or abdo pain
4) increased urinary urgency and/or frequency
What are 3 megaloblastic causes of macrocytic anaemia?
1) vit D deficiency
2) folate deficiency
3) 2ary to methotrexate (causing folate deficiency)
What drug is one of the most notable causes of hypomagnesaemia?
PPIs
What IBD does increased goblet cells indicate?
Crohn’s
What is the Mantoux test?
one method of determining whether a person is infected with Mycobacterium tuberculosis
What are some causes of a false negative Mantoux test?
- immunosuppression (miliary TB, AIDS, steroid therapy) e.g. well controlled IBD with long term predisolone
- sarcoidosis
- lymphoma
- extremes of age
- fever
- hypoalbuminaemia, anaemia
In patients with severe colitis, what investigation should be avoided?
Colonoscopy - due to risk of perforation
What investigation is recommended over a colonoscopy in severe colitis?
Flexible sigmoidoscopy
What is Mittelschmerz?
Mid cycle pain that typically occurs because a small amount of fluid is released at the time of ovulation. It will usually resolve over 24-48 hours.
Which IBD is associated with abdo mass palpable in RIF?
Crohn’s
What is the investigation of choice for suspected perianal fistulae in patients with Crohn’s?
MRI pelvis
What should be a top differential for: diarrhoea + fatigue + osteomalacia?
Coeliac disease
How does coeliac lead to osteomalacia?
impaired vitamin D absorption secondary to villous atrophy
Transient lactose intolerance is a common complication of what?
viral gastroenteritis
how can coeliac disease affect a) iron, b) folate, c) vit D deficiency?
Coeliac disease is associated with iron, folate and vitamin B12 deficiency
How is ALP & calcium affected in osteomalacia?
ALP –> raised
Calcium –> low
What is Abx of choice in the management of Crohn’s patients who develop an perianal fistula?
Oral metronidazole –> must have anaerobic organism cover for perianal fistulas
What cancer can Helicobacter pylori infection lead to?
gastric lymphoma (MALT): typically arise in the antrum of the stomach and can present with systemic features such as fevers and night sweats.
How can urea levels help determine between upper and lower GI bleed?
High urea levels can indicate an upper GI bleed versus lower GI bleed
What is the main cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?
Meckels diverticulum
Presentation of chronic pancreatitis?
1) abdo pain following meals
2) steatorrhoea
3) diabetes
What cancer does coeliac disease increase the risk of?
enteropathy-associated T cell lymphoma
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year, what should they be given?
oral azathioprine or oral mercaptopurine
What IBD are crypt abscesses more common in?
UC
What site is most commonly affected in UC?
Rectum
How often should patients with coeliac disease be given the pneumococcal vaccine?
every 5 years
How do thrombosed haemorrhoids present?
1) significant pain & tender lump
2) examination reveals a purplish, oedematous, tender subcutaneous perianal mass
Management of thrombosed haemorrhoids?
1) if patient presents within 72 hours then referral –> consider for excision.
2) otherwise patients can usually be managed with stool softeners, ice packs and analgesia.
Symptoms usually settle within 10 days
Give 5 main causes of rectal bleeding?
1) fissure in ano
2) haemorrhoids
3) Crohn’s
4) UC
5) rectal cancer
Describe bleeding in fissure in ano vs haemorrhoids
Both present with bright red rectal bleeding.
Fissure:
- Painful bleeding that occurs post defecation in small volumes.
- Usually preceded by constipation
Haemorrhoids:
- Post defecation bleeding noted both on toilet paper and drips into pan.
- May be alteration of bowel habit and history of straining.
- No blood mixed with stool or local pain.
Why is Crohn’s disease a risk factor for gallstones?
Because it affects the terminal ileum which is involved in the metabolism of bile salts.
Excessive bile salts escape into the colon and are reabsorbed and return to the liver, resulting in excessive secretion of bile pigments and the production of black stones.
Is there a FH risk with IBD?
There is a seven-fold increased risk of developing IBD for patients with a first-degree relative with IBD.
1st line management step in toxic megacolon?
Insertion of NG tube for decompression of the bowel.
How can coeliac disease affect platelets?
Often causes thrombocytosis
Why is Crohn’s a risk factor for a peri-anal fistula?
In Crohn’s disease the bowel wall is perforated due to chronic inflammation allowing a passage to develop between the bowel and skin
Describe dermatitis herpetiformis
a dermatological manifestation of coeliac disease, characterised by pruritic papulovesicular lesions over the extensor surfaces of the arms, legs, buttocks, and trunk
What cancer can cause acanthosis nigricans?
Gastric adenocarcinoma
What are some causes of acanthosis nigricans?
1) T2DM
2) GI cancer (most commonly gastric)
3) obesity
4) polycystic ovarian syndrome
5) Cushing’s disease
6) hypothyroidism
7) familial
8) Prader-Willi syndrome
9) drugs: COCP, nicotinic acid
What condition is H. pylori infection MOST commonly associated with?
Duodenal ucleration
Management of gastro-oesophageal reflux in infants?
1) position changes during feeds (30 degree head up)
2) ensure infant is not being overfed (as per their weight) - trial of smaller more frequent feeds
3) trial of thickened formula
4) trial of alginate therapy e.g. gaviscon (alginates should NOT be used at same time as thickening agents)
5) consider PPI ONLY if 1 or more of the following apply:
- unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
- distressed behaviour
- faltering growth
What age does intussuception usually affect?
Infants 6-18 months (boys 2x more than girls)
Features of intussusception?
- intermittent, severe, crampy, progressive abdominal pain
- inconsolable crying
- during paroxysm the infant will characteristically draw their knees up and turn pale
- vomiting
- bloodstained stool - ‘red-currant jelly’ - is a late sign
- sausage-shaped mass in the right upper quadrant
Investigation of choice in intussusception in adults?
US - may show a target like mass
Give 4 absolute contraindications to laparoscopic surgery
1) haemodynamic instability/shock
2) raised intracranial pressure
3) acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
4) uncorrected coagulopathy
What is the most common type of oesophageal cancer in UK?
Adenocarcinoma
Who is oesophageal adenocarcinoma more likely to develop in?
GORD or Barrett’s.
Where are the majority of oesophageal adenocarcinomas located?
Near the gastroesophageal junction
Where are the majority of squamous cell oesophageal cancers located?
Upper two-thirds of the oesophagus
What is the most common type of oesophageal cancer in developing world?
Squamous cell carcinoma
Risk factors for oesophageal adenocarcinoma vs squamous cell?
Adenocarcinoma:
- GORD
- Barrett’s oesophagus
- Smoking
- Obesity
Squamous cell cancer:
- Smoking
- Alcohol
- Achalasia
- Plummer-Vinson syndrome
- Diets rich in nitrosamines
When should PPIs be trialled in infants with GORD?
In those who do not respond to alginates/thickened feeds and who have
1. feeding difficulties,
2. distressed behaviour or
3. faltering growth
Fistula formation is a possible complication of diverticular disease.
What happens?
a diverticular abscess ruptures into an adjacent organ
What is the most common fistula to form in diverticular disease?
This most frequently happens between the sigmoid colon and the urinary bladder (i.e. colovesical), causing symptoms such as pneumaturia, faecaluria or recurrent urinary tract infections.
Symptoms of a colovesical fistula?
- pneumaturia
- faecaluria
- recent UTIs
What condition does right sided tenderness during a DRE indicate?
acute appendicitis
How long before an upper GI endoscopy should PPIs be stopped?
2 weeks
Where does biliary colic pain radiate into?
interscapular region
Patients with diverticulitis flares can be managed with oral antibiotics at home.
What is the 2nd line if they do not improve within 72 hours?
Admit for IV ceftriaxone + metronidazole
What is the investigation of choice for stable children with suspected Meckel’s diverticulum?
A technetium scan
