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CP1 revision > Deck 6 > Flashcards

Deck 6 Flashcards

1
Q

Red flags for abdominal symptoms

A

Dysphagia, Tx resistant dyspepsia, Anorexia, unintentional weight loss (consider upper GI malignancy)
Anorexia, uninentional weight loss, haematemesis, altered bowel habit, iron deficiency, anaemia, unexplained rectal bleeding (consider lower GI malignancy).

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2
Q

Who might have pain free acute abdomen

A

Extremes of age, immunocompromised or last trimester of pregnancy

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3
Q

Acute abdomen epigastric, midgut and hindgut

A

Epigastric is oesophagus to D2

Midgut is D2 o transverse, rest is hindgut

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4
Q

Ischaemic bowel symptoms

A

Consider in patients with severe pain compared to signs (ischaemic until proven otherwise). Diffuse constant pain. Often unremarkable O/E. May have acidaemia and raised lactate. USe contrast CT to diagnose.

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5
Q

Pancreatitis

A

Look for 3xupper limit of amylase (lower can be perforation, ectopic or DKA). Check calcium and lipase

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6
Q

Appendicitis

A

Blockage of lumen (e.g. faecolith, lymph, tumour, parasites). Rebound tenderness over mcBurney’s point, Rovsigs sign, Psoas sign, obturator sign.
Imaging not essential for diagnosis, but USS/CT might be used.
Mana

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7
Q

Obturator sign

A

Pain on internal rotation of right hip (pelvic appendix)

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8
Q

Psoas sign

A

Pain on right hip extension - seen in retroperitoneal/retrocoecal appendix

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9
Q

Coeliac disease

A

T cell inflammation.

Gluten/prolamin stimulates abnormal mucosal response. Chronic inflammation and villous atrophy.

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10
Q

Coeliac disease histology

A

crypt hyperplasia, villous atrophy, lymphocytes in lamina propria

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11
Q

Coeliac disease clinical features and complications

A

mouth ulcer, diarrhoea, abdo pain, bloating, unexplained weight loss, malaise, weakness, steatorrhoea but 1/3 may be asymptomatic.
Skin manifestation is dermatitis herpetiformis (rare, but subepidermal skin blistering and itch)

Complications include malabsorption, anaemia, GI malignancy risk, T cell lymphoma risk, osteoporosis, hyposplenism

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12
Q

Coeliac disease RF

A

HLA DQ2, FHx, autoimmune (thyroid, T1DM)

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13
Q

Coeliac disease investigations

A

FBC, LFT, U&E, bone profile, Vitamin D, vitamin B12, haematinics, albumin, IgA tissue transglutimase (can do IgA endomysial antibody is only weakly positive).
Definitive by small bowel biopsy

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14
Q

IBS diagnosis

A

Consider if abdo pain/bloating/change in bowel habit for 6 months.

Diagnose if abdo pain either related to defecation and/or associated with altered stool frequency/appearance and 2 of:
- altered stool passage
- abdo bloating/distention/hardness
-symptoms aggrevated by eating
-passage of rectal mucus
In past 12 months with 12 weeks of symptoms

Additional symptoms may be lethargy, nausea, back ache and bladder symptoms

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15
Q

IBS

A

Functional disorder. Symptom based diagnosis.
Diet based Tx (avoid triggers, do more exercise) -loperamide for diarrhoea, antispasmodics for abdo cramps, peppermint oil/laxatives for constipation

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16
Q

Diverticulum definition

A

Outpouchings of bowel wall

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17
Q

Diverticulosis definition

A

Presence of diverticulum

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18
Q

Diverticulitis definition

A

Inflamed diverticulum

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19
Q

Diverticular disease RF

A

NSAIDs, FHx, smoking, obesity, male, Western diet, >50, meat eating, CT disease, PKD

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20
Q

Diverticular disease

A

Symptomatic diverticula
Colicky LLQ pain, relieved by defecation/flatus, made worse by eating. Get altered bowel habit, nausea, bloating and flatulence

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21
Q

Diverticulitis

A

left sided colic, constipation/overflow diarrhoea, symptoms mimic appendicitis but on left. Can get peritonitis symptoms if perforated- but steroids can mask presentation

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22
Q

Diverticular bleed

A

Erodes into vessel, causes large scale, painless bleed (typically dark red)

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23
Q

Ddx for diverticular disease

A

IBD, bowel cancer, ischaemic colitis, gynae causes, renal stones, IBS, coeliac disease

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24
Q

Admissions in diverticulitis

A

Uncontrolled pain, dehydration, significant comorbidities, immunocompromised, significant Pr bleed, 48h+ symptoms, peritonitic

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25
Q

Acute diverticulitis complications

A

Abscess, fistulas, perforation, bowel obstruction (inflammation and strictures)

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26
Q

Meckel’s diverticulum

A

Congenital abnormality
Failed vitiline closure
Affects 2% gen pop, 2:1 M:F, often presents under 2, 2 inches long, 2ft proximal to ileocaecal valve

Typically presents as melaenia followed by obstruction/intussesception. Can mimick appendicitis
Often have 2 different tissue types (gastric tissue present which may ulcerate and can have pancreatic).

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27
Q

Abdominal distension

A

Can be fat, fluid, flatus, mass or foetus. DDx include bowel obstruction, constipation, paralytic ileus, hypokalaemia, sepsis, abscess, toxic megacolon,

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28
Q

Pseudomembranous colitis

A

C diff infection (toxic megacolon)

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29
Q

Bowel obstruction symptoms

A
  • Vomiting (even if NBM)- often early feature of SBO
    • Absolute constipation (early in LBO)
    • Abdominal distension (proximal bowel fluid/gas filled and distends - eventially spreads distal to obstruction)
      Colicky abdominal pain (seen in mechanical, but functional can be painless. SBO often periumbilical, LBO tends to be suprapubic. If constant pain and pain on movement then ?perforation)

Additional signs
- Abdominal distension
- Abdominal tenderness
- Central resonance to percussion
- Tinkling bowel sounds (increased persistalsis)
- Dehydration (vomiting/anorexia, fluid sequestration - hypotension, tachycardia, loss of turgor, low JBP, dry mouth, oliguria, sunken eyes, sleepiness, thirst, muscle weakness, headache, dizziness, dark urine)
3rd spacing causes the dehydration, but can also see AKI and hypokalaemia on bloods

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30
Q

Strangulating obstruction

A

Blockage with ischaemia, can perforate. Can be closed loop with two obstruction points. At ileocaecal valve, more likely if valve is competent. Can also be sigmoid volvulus (coffee bean on AXR)

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31
Q

Sigmoid volvulus RF

A

elderly, constipated male (4:1), psychiatric illness

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32
Q

Mechanical bowel obstruction

A

80% SBO (often previous surgery, but can be hernias and Crohns)
20%LBO (normally malignancy, typically sigmoid ut also diverticular disease, volulus, constipation)

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33
Q

Functional ileus

A

Resolves after a few days, typically painless

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34
Q

Bowel obstruction investigations

A

Hypokalaemia, metabolic acidosis due to bicarbonate secretion, raised uraemia.

AXR has 3/6/9 rule
CT can differentiate from pseudoobstruction.

35
Q

Management of bowel obstruction

A

General is NBM, IV fluids
SVO is drip and suck, but may need surgery (esp hernia)
LBO usually needs surgery
Volvulus needs flatus tube if sigmoid, laparotomy is caecal.
Ischaemia needs urgent surgery

36
Q

RIF mass ddx

A

Inflammation of appendix/abscess, lymphoma, Crohn’s disease, tumour mass (caecal/carcinoid), pelvic kidney
Use CT/USS to confirm.

Abscess needs surgical drainage

37
Q

Cariconoid tumour on appendix

A

Argentaffin cell producing serotinin PGs. May be associated with MEN-1.
Can present in 4th decade with carcinoid syndrome (flushing and diarrhoea)

38
Q

pannus cells

A

small intestine cells

39
Q

Colorectal cancer distribution

A

Most common site is rectum, then sigmoid, then ascending colon, then transverse, then descending

40
Q

Colorectal cancer

A

Commonly adenocarcinoma (signet ring cells on histology), but can be swuamous in rectum

41
Q

CEA blood test

A

Carbinoembryonic antigens, can be marker for colon cancer, rectal cancer, lung cancer, breast cancer, liver cancer, stomach cancer, ovarian cancer but cn also be raised in liver disease and IBD

42
Q

2WW for colorectal cancer

A

40+ with PR bleed or change in bowel habit

OR 45+ with persistent PR bleed and no other cause

43
Q

Colorectal cancer RF

A

Age (esp 40+), male sex for rectal cancer, ethnicity (african), T2DM, crohn’s disease, UC, FHx (HNPCC/lynch, FAP, MUTYH)
Red meat/processed food, obesity, inactivity, alcohol, smoking

44
Q

Right sided colorectal cancer symptoms

A

Typically pain and bleeding, but can be asymptomatic.

45
Q

Left sided colorectal cancer symptoms

A

Annular, so cause earlier obstruction. May cause Pr bleed, mucus, altered bowel habit or tenesmus

46
Q

Colorectal cancer metastases symptoms

A 
Hepatic (jaundice, RUQ pain, early satiety)
Peritoneal (ascites/pain)
Colo-vesicle (pneumaturia/UTI)
Weight loss
Can also get bone and lung mets
47
Q

Colorectal cancer screening

A

Regular colonoscopy for high risk groups (FAP, HNPCC, MUTYH).
FIT/FOB for 50-74, single flex sig at 55

48
Q

DDx for colorectal cancer

A

Other malignancy (lymphoma, carcinoid tumour, kaposi sarcoma, invasive prostate cancer), benign polyps, pseudo polyps in psuedomembranous colitis, endometriosis, lipoma, abdominal TB

49
Q

GSTD investigation for colorectal cancer

A

Colonoscopy as allows biopsy/polypectomy

50
Q

Staging of colorectal cancer

A

Once t4 then through intestine. Previous staging by Dukes A->D, B is invaded muscular layer. C is lymph node, D is distant mets

51
Q

Aggressive colorectal cancers

A

signet ring, mucineous, medullary adenocarcinomas

52
Q

lower anterior resection

A

sigmoid colon and inferior rectum

53
Q

High anterior resection

A

Sigmoif colon and superior rectum

54
Q

Abdomino-peritoneal resection

A

sigmoid, rectum and anus

55
Q

Total protocolectomy

A

colon to anus

56
Q

Subtotal colectomy

A

Ascending, transverse and descending colon

57
Q

Total abdominal colectomy

A

Colon to end of sigmoid

58
Q

Extended right hemicolectomy

A

Ascending colon, hepatic flexure, transverse colon)

59
Q

Upper anal canal

A

muscularis proprium - smooth muscle (involuntary)

upper 2/3s.

60
Q

Lower 1/3 of anal canal

A

external anal sphincter (S4 nerve) - blends with puborectalis

61
Q

dentate line is formed from

A

mucosal gathering into longtidinal folds around anal glands

62
Q

Above dentate line

A

hindgut derived, columnar epithelium. Supplied by superior rectal artery from IMA. Drained by superior rectal vein (IMV).
Drained by internal iliac lymph nodes.
Stretch sensation only (inferior hypogastric plexus)

63
Q

Below dentate line

A

ectoderm, non kertinised (but below verge is) squamous.
Inferior rectal artery (from internal pudendal (internal iliac) and drained by corresponding vein.
Drained by superficial inguinal lymph nodes

Sense pain, pressure, touch and temperature

64
Q

Anal cancer lymph

A

Often squamous, can see lymphadenopathy in superficial inguinal lymph nodes

65
Q

Haemorrhoid locations

A

3/7/11 (vascular cushions)

66
Q

Haemorrhoid RF

A

Straining, low fibre diet, costipation, congestion of superior rectal veins (HF, rectal carcinoma), pregnancy,

67
Q

Haemorrhoid symptoms

A

asymptomatic.
Itching, painless fresh PR bleed, mucous discharge
Can rarely present as painful perianal lumo (when external ones thrombose)

68
Q

Haemorrhoid investigation

A

DRE (feel external ones), protoscopy (visualise internal ones), endoscopy may be needed to exclude cancer
Abdo exam required

69
Q

Haemorrhoid classification

A

Confined to anal canal
Prolapse on defecation but reduce spontaneously
Prolapse outside anal margin on defecation, may reduce manually
Non reducable, outside anus at all times

70
Q

Haemorrhoids management

A 
Supprotive management (ice pack, analgesia, topical instillagel, laxatives).
If bleeding, may need surgical management (sclerosing agents, HALO, haemorrhoidectomy)
71
Q

Anal fissure

A

Normally at 6 oclock (posterior) but can be anterior (12 - more concerning).

Must distinguish from anal cancer, herpes and nicorandil ulceration.

72
Q

Anal fissure presentation

A

Severe pain post defecation, fresh PR and itch
Can’t do PR exam (may need GA to perform)
May see breaks or ulcers on exam.
Typically acute following constipation, but can be chronic in Crohns

73
Q

Anal fissure management

A

Convervative management with diet, laxatives, instillagel, topical diltiazem or GTN. Can do botox in chronic, or lateral sphincterotomy.

74
Q

Pilonidal sinus

A

Natal cleft follicles obstructed 6cm above anus. Hair ingrowth, can getabscess and discharge

75
Q

Peri-anal abscess RF

A

Pregnancy, women (more likely to be recurrent), Corhn’s, DM, malignancy

76
Q

Typical bacterial cause in peri-anal abscess

A

Crytoglandular plugging, infiltration by E.coli, bacteriodes spp, enterococcus spp.

77
Q

Peri-anal abscess symptoms and investigation and management

A

painful, hot, perianal lump, may have pus, may be septic (caution in diabetes)

Clinical, but may need CT/MRI
Surgical incision and drainage with healing by secondary intention

78
Q

Fistula in ano RF and symptoms and investigation

A

IBD, systemic disease (HIV, TB, diabetes), trauma, pelvic radiation

Abscess? blood/pus/mucous drainage. See small opening in perineum, granulation tissue that may discharge on palpation. Thickened fibrous tract in skin

Use proctoscope to investigate. If horseshoe then may do MRI.

79
Q

Goodsall’s rule

A

If external opening is anterior to transverse line (in lithotomy position) then likely short radicular tract
If posterior then likely curved/horseshoe

80
Q

Management of fistula in ano

A

Always surgical. Can use band if muscle involvement, or fistulotomy )

81
Q

Anal cancer

A

Generally SCC

82
Q

Anal cancer RF

A

anoreceptive sex, syphilis, warts, cervical cancer, immunosuppresion

83
Q

Anal cancer above pectinate line

A

Columnar epithelium, drains to internal lymph and ortal venous (hepatic met risk). More common in women. Worse prognosis

84
Q

Anal cancer below pectinate line

A

squamous, drians to superficial lymph nodes and IVC (lung mets more likely). More common in men, better prongosis.

CP1 revision (16 decks)

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