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CP1 revision > Deck 9 > Flashcards

Deck 9 Flashcards

1
Q

odynophagia

A

painful swallow.

Can be infections but also malignancy

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2
Q

Dyspepsia definition

A

Abdo pain/heartburn/acid reflux for 4+ weeks

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3
Q

Causes of dysphagia

A

Physical (malignancy, obstruction, pharyngeal pouch, tonsilitis, stricture, oesophagitis, eosinophilic/allergic oesophagitis, proximal gastric cancer, lymph node enlargement, retrosternal goitre, bronchial carcinoma)

Can be functional (CNS (MS/stroke, demential, parkinsons), PNS (MG/MND), muscle (CREST), achalasia, globus

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4
Q

CREST

A

Autoimmune CT disorder with calcinosis, Raynaud’s, oesophageal dysmotility, sclerodactyli, telangectasia

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5
Q

Oropharyngeal vs oesophogeal dysphagia

A

Oropharyngeal is difficulty initiating swallow (can have choking/aspiration) - often neurological. (neuro exam + videofluoroscopic swallow)

OEsophageal dysphagia is food sticking after swallow. Can be achalasia, stricture, oesophagitis, pharyngeal pouch. Investigate with barium swallow, OGD (unless pouch) and biopsy

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6
Q

Plummer vinson syndrome

A

dysphagia, koilonycia, glossitis (IDA)
Premalignant, as oesophagus becomes hyperkeratinised in oesophageal web formation
Tx with iron and OGD

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7
Q

Sudden dysphagia

A

? stroke

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8
Q

Rapidly progressive dysphagia

A

? cancer

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9
Q

insidious dysphagia

A

?MND/MG

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10
Q

Longstanding dysphagia

A

likely spasm/achalasia

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11
Q

Solids only dysphagia

A

? mechanical

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12
Q

Pain and dysphagia

A

cancer, oesophageal ulcer, candida or spasm

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13
Q

Liquid dysphagia

A

consider motility

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14
Q

PMHx and dysphagia

A

GORD predisposes to oesophageal adenocarcinoma and strictures
Peptic ulcers cause scarring and strictures

Strokes and parkinsons cause functional issues

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15
Q

DHx and dysphagia

A

NSAIDs have ulcer risk, CCB/nitrates relax smooth muscle and make reflux worse. Steroids and bisphosphonates increase ulcer risk

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16
Q

2ww for upper GI endoscopy

A

Any patient with dysphagia
OR
Aged 55+ with wt loss and either upper abdo pain/reflux/dyspepsia
OR
Upper abdo mass consistent with stomach cancer (may only be palpable in thin patients)

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17
Q

O/E, O/I for dysphagia

A

Check fluid balance, palpate neck for large pharyngeal pouch/goitre, anaemia signs, virchow’s node, palpate abdomen for mass, CN/PNS exam
Bloods (IDA, infection, platelets (raised in gastric malignancy), U&E (AKI/dehydration), LFTs (common met for gastric ca)
Imaging - limited role for CXR but may see dilatation in achalasia.
Specialist imaging:
OGD +/- biopsy, manometry, barium swallow (pharyngeal pouch), Staging CT if malignancy

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18
Q

oesophageal malignancy symptoms

A

Progressive dysphagia (solids to liquid - liquid is late sign), weight loss, odynophagia (esp retrosternal), globus, hoarse voice, cough

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19
Q

squamous oesophageal cancer

A

More common worldwide.
Middle and upper 1/3.
RF smoking, alcohol, nitrate rich food, chronic inflammation (hot drinks and achalasia)

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20
Q

oesophageal adenocarcinoma

A

More common in UK
lower 1/3
Overlap with GORD (obesity, alcohol, sphincter relaxing drugs, smoking). Barrett’s oesophagus allows metaplasia to columnar epithelium. Dysplasia leads to adenocarcinoma and endoscopic surveillance required

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21
Q

OEsophageal malignancy diagnosis

A

OGD
Staging CT/PETCT

Tx is surgical, chemo, radio. Poor prognosis

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22
Q

Gastric malignancy RF

A

55+, Males 4x, hypochloria (alkaline stomach - H pylori), pernicious anaemia against parietal cells (atrophic gastritis), post gasterectomy, (stump malgnancy), smoking, blood group A, adenomatous polyps, BNPAA, japanese heritage, nitrate preservatices

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23
Q

Gastric cancer symptoms and signs

A

Dyspepsia, dysphagia (proximal malignancy), early satiety (distal malginanct), vomiting, melaena, anorexia, weight loss, anaemia
May also have jaundice, hepatomegaly, virchow’s node, acanthosis nigricans , palpable epigastric mass

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24
Q

Dyspepsia alarm features

A

New onset, unresponsive to Tx

Anaemia, weight loss, anorexia, melaena, age over 55, haematemesis

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25
Transcoelomic gastric cancer spread
``` Krukenberg tumours (secondary ovarian, may be bilateral) Can also get leiomyomas, meiomyosarcomas from interstitial cells of cajal ```
26
Achalasia
Lower oesophageal sphincter fails to relax during peristalsis (loss of ganglion cells) and food bolus retained in oesophagus. Proximal dilatation and inflammation. Muscle hypertrophy. Can give malignancy risk (squamous). Relatively rare 40s, 50s. Equal sex Progressive, VARIABLE dysphagia on liquids and solids (early liquid involvement, suggests not malignancy), nocturnal cough, weight loss, regurgitation Investigate with OGD (rule out cancer) but mannometry is GSTD (high resting pressure in lower sphincter). Barium swalloq can also be used (bird beak dilated tapering) Slow eating may help, botox injection, endoscopic balloon dilatation (risks perforation), myotomy (definitive, good success)
27
Pharyngeal pouch
Midling pharyngeal wall outpouching C5/C6 Rare 60s-80s, 5x male Dysphagia (S+L), regurgitation, crhonic cough, gurgling on drinking, halitosis, globus, infections (asp neu) Barium swallow for diagnosis (OGD can perforate) Can have carcinoma/inflammation association Surgical management
28
Gold standard diagnostic for achalasia
mannometry
29
Protection of oesophagus from stomach contents
Anatomical (angle of His) sphincter, and physiological sphincter
30
GORD RF
obesity, hiatus hernia, pregnancy, CT disorder (scleroderma), delayed gastric emptying, smoking, large/late meal, fried/fatty food, alcohol, coffee, aspirin
31
Gord symptoms
heartburn, acid reflux, oesophagitis (with odynophagia), water brash, halitosis, bloating/belching, N&V, dysphagia
32
hiatus hernia
sliding (whole stomach moves up) or rolling (paraoesophageal - hernia outpouching. Forms via increased pressure May see on CXR as gastric bubble above diaphragm Rolling is more concerning. Needs investigation.
33
hiatus hernia rolling symptoms
pain, gastric obstruction, bloating, volvulus
34
GORD complications
Oesophageal ulcer (bleeding, pain odynopagia), strictures (dysphagia/odynophagia), Barett's oesophagus (epithelial metaplasia), oesophageal cancer (dysphagia, wt loss, persistent indigestion, hoarseness, persistent cough, haemoptysis, vomiting)
35
GORD referrals
``` ALARM Anaemia Loss of Weight Anorexia Recent onset/progressive Melaena/haematesis Dysphagis and 55+ ``` Don't scope everyone but if dyspepsia and signicant acute GI bleed then same day referral
36
Gord diagnosis/tx
clincally, treated empirally (PPI for 8 weeks - continue as maintenance if severe) unless ALARM
37
Specialist GORD investigations
Oesophageal pH monitoring (24h) and oesophageal mannometry (assess sphincter competence) and barium swallow (exclude stricture, hiatus hernia or motility disorder)
38
Duodenal ulcer
may improve with food as delayed gastric emptying, may present with bleeding if posterior, or perforation if anterior). 4x more common. Often have pain at night. Alcohol intake is risk factor.
39
Gastric ulcer
More painful immediately after food. May present with small or large bleed. Tends to occur in 55+ patients. Can be relieved by antacids.
40
Which upper GI ulcer more likely to bleed
Gastric, then posterior duodenal, then anterior
41
Peptic ulcer RF
``` H pylori (most common cause), long term NSAID/aspirin (COX-1 inhibition prevents protective PGs), steroids (also inhibit protective prostaglandins) , increased acid (Zollinger ellison syndrome - gastrin producing tumour), increased IC pressure (crushing ulcers), post severe burns (Curling ulcer) Worsening factors are smoking (disrupts mucous renewal, nicotine increasing acid secretion), stress, spicy food, alcohol ```
42
Peptic ulcer symptoms
Burning epigastric pain, fullness/bloating/belching, fatty food intolerance, heartburn, waterbrash, nausea. Severe signs of vomiting, haematemesis, melaena, dyspnoea, syncope, weight loss, appetite change and severe abdo pain can suggest perforation
43
H pylori
gram negative helical rod Makes urease, produces ammonia Infection can give chronic gastritis, gastric cancer and MALT lymphoma
44
H pylori investigation
C13 breath test Stool antigen (Hp) IgG serology to Hp If low pre test probability then urea and stool If no alarm fatures and high pretest probability then IgG If alarm features, antral mucosa biopsy (rapid urease test, histology, culutre)
45
2WW referral in upper GI
Anyone with dysphagia Over 55 with upper abdo pain, reflux or dyspepsia
46
Non urgent upper GI assessment
55+ and Tx resistant dyspepsia, OR upper abdo pain with low Hb, OR leukocytosis with N&V, wt loss, reflux, dyspepsia or epigastric pain OR N&V with wt loss, reflux, dyspepsia and upper abdo pain
47
Gastric ulcer FU
endoscopy at 6-8wks. | FU carbon 13 breath test (will become negative)
48
Tx of peptic ulcer
Amoxicillin, clarythromycin or metronidazole with PPI | If not resolved then surgical fundoplication (risk of bleed, obstruction, perforation or malignancy)
49
Malaria types
Parasite Falciparum (most common in subsaharan africa) Ovale Vivax Malariae All via female anopheles (night bite) misquito Initially liver cells infected, replication then blood stream
50
Malaria reservoir
Ovale, vivax, malariae all move from liver to RBCs to replicate Falciparum replicates in organs (kidneys/brain) and is more difficult for the spleen to remove - severe
51
Malaria symptoms
Cyclical fevers (occur during RBC rupture) - every 48-72h (species dependent) Often non specific features Mild is fever, rigors, malaise, headache, GI upset Severe malaria has reduced GCS (hypoglycaemia/cerebral malaria), seizures, ARDS, shock, jaundice, oliguria (AKI), severe anaemia (<50hb), intravascular haemolysis (haemoglobinuria - black urine), acidosis, DIC, thrombocytopoeania (spontaneous bleed)
52
Diagnosis of malaria
Blood film (parasites - gives load and indicates severity) Rapid diagnostic test Basic obs, FBC (Hb/platelets), U&E, LFT (pre-hepatic jaundice), BM (hypoglycaemia), ABG, blood culutre
53
Malaria Tx
Artemisinin, quinine. Primaquine in vivax, ovale for liver stage
54
Bloody diarrhoea
Dysentery - fever and tenesmus are common E coli? Campylobacter? Shigella? Amoebiasis? Mucous suggests large bowel
55
C diff diarrhoea
green tinge
56
Cholera diarrhoea
rice water
57
stool sample for returning traveller diarrhoeaa
may need 3 | Culture, microscopy (ova/cysts/parasites)
58
Blood culture/films in traveller diarrhoea
Typhoid (enteric fever) diagnosed by blood culture | Malaria needs blood film
59
Bacterial causes of diarrhoea with short incubation
Bacilus cereus (rice?) and staphylococcus aureus symptomatic within hours due to toxins
60
Shigellosis
Gram negative 3 day incubation Inflammation, ulceration, microabscesses, bleeding Mild is watery diarrhoea, severe is mucous and dysentery. May have HUS. May have shock. Diagnosis is redcurrant jelly stool., MC&S, rectal swab Supportive management, ciprofloxacin, ?zinc/vit A in kids
61
Camylobacter
Common in UK plus abroad. Flu prodrome, abdo pain, fever, diarrhoea +/- blood Supportive management and ciproloxacin if severe
62
E Coli (GI infection)
Less common UK diarrhoea cause Initially watery diarrhoea, then bloody. nausea, abdo cramps. Can give HUS (Esp in children) Supportive management
63
Enteric fever/typhoid
Salmonella subtypes Week 1 is headache, cough, sore throat, anorexia, fever, and abdo discomfort Week 2 is toxic (fever, rose spots, abdo pain, hepatosplenomegaly, diarrhoea/constipation) Week 3: fever breaks. Either settles or complications (perforation, GI haemorrhage, severe toxaemia, shock) Diagnosis by stool culture, blood culture, serology Fluroquinolones and supportive
64
Giardia
Parasite. 7-10 day incubation (sometimes months). Very common Bloating, flatulence, buping, prolonged watery/greasy diarrhoea
65
Entamoeba
Amoebiasis. Parasite). Days to years incubation. Can be asymptomatic (fulminant colitis, flask ulcers on endoscopy). Liver abscesses can form. May present insidious onset abdo discomofrt and diarrhoea +/- blood/mucous
66
Cryptosporidium/cyclospora
7-10 days incubation Bloating, weight loss, fever, malaise Watery diarrhoea and abdominal cramps
67
Type of diarrhoea indicating parasitic cause
14 days +
68
Yellow fever
Viral, haemorrhagic fever. Mosquitos only, no human-human spread Can be mild, severe is jaundice, fulminant hepatic failure, GI bleed.
69
Leptospirosis
Spirochete. Rodent urine RF are water activity and soil contact May get vasculitis, sudden onset fever, headache, myalgia, conjuntival suffision (no exudate), muscle tenderness Second phase has Weil's diease (jaundice, thrombocytopoenia and AKI) or aseptic meningitis Serological diagnosis
70
Weils disease
Second phase of leptospirosis. | Jaundice, thrombocytopoenia and AKI
71
Calorie needs normal
1.3kcal/kg/h
72
Calorie needs during exercise
8.5kcal/kg/hour extra
73
Fat needs
30% of calories (9kcal/gram)
74
Carbs needs
56% of calories (4ckal/gram)
75
Protein needs
13% calories (4ckal/gram)
76
MUST score
malnutrition universal screenin tool, looks at risk of malnutrition
77
NG tube uses
unsafe swallow, altered consciousness, supplementing oral intake, upper GI stricutre
78
NG tube precautions
protocols govern confirmation (imaging or pH of aspirate) | Long term uses can cause damage and ulceration so need to be removed ASAP
79
BMI limits
<18.5 is underweight 12.6-24.9 is normL 25-29.9 IS OVERWEIGHT 30+ is obese
80
Waist circumference for obesity
88+ female, 102+ male
81
Waist/hip for abdo obesity
1.0+ in male, 0.9+ female
82
pharma for weight loss
orlistat - lipase inhibitor (abdo pain, steorrhoea, anal leak) Liraglutide (GLP-1 agonist in diabetes - injection only)
83
Bariatric surgery recommended
BMI >40, BMI>35 if complications. | FLT for BMI>50
84
Intestinal granulomas
IBD (esp CD) and colonic TB. Not likely in malignancy or gastroenteritis. See inner giant cells, macrophages and then lymphocytes
85
Vitamin A deficiency
night blindness
86
vitamin A excess
terotogen, hepatotoxic
87
B1 deficiency
thiamine deficiency. Polyneuropathy
88
B3 deficiency
niacin. | Pellagra (dermatitis, diarrhoea, dementia)
89
Vitamin C deficiency
gingitivis, bleeding
90
Vitamin D deficiency
Osteomalacia/rickets
91
Vitamin D excess
hypercalcaemia
92
Autoimmune IBD
ulcerative colitis
93
Microbiome linked IBD
CD
94
Smoking and IBD
protective in UC, RF in CD
95
IBD and pANCA
more likely in UC, less likely in CD
96
Imaging difference in CD and UC
CD: fat wraps around bowel due to inflammation | colitis causes thumbprinting from oedema
97
Colonoscopy different in CD and UC
CD gets skip lesions, cobblestone appearance, apthous and serpentine ulcer UC has pseudopolyps (islands of healing tissue)
98
Anti saccaromyces cerevisae antibodies
May be found in CD
99
Features of CD`
Granulomas, fistulas, strictures
100
Extra intestinal features of crohns disease
Mouth ulcer, stomatitis, abdominal tenderness, skin tags, uveitis, pyoderma gangrenosum, fatty liver, venous thrombosis, ankylosing spondylitis (HLA B27)
101
Extra intestinal features of UC
Fatty liver, venous thrombosis, pACNA, PSC, cholangiocarcinoma, colorectal carcinoma, erythema nodosum, pyoderma gangrenosum, uveitis, psoriasis, episcleritis
102
Erythema nodosum
Red patches on shins (can be seen in UC, but also TB, RA)
103
pyodermal gangrenosum
non healing leg ulcer
104
Toxic megacolon
persistant fever, tachycardia, loose blood stained stool Hypoalbuminaeia, hypokalaemia, AXR with filated colon (>6cm) with mucosal islands

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