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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
Q

Transcoelomic gastric cancer spread

A 
Krukenberg tumours (secondary ovarian, may be bilateral)
Can also get leiomyomas, meiomyosarcomas from interstitial cells of cajal
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26
Q

Achalasia

A

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)

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27
Q

Pharyngeal pouch

A

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

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28
Q

Gold standard diagnostic for achalasia

A

mannometry

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29
Q

Protection of oesophagus from stomach contents

A

Anatomical (angle of His) sphincter, and physiological sphincter

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30
Q

GORD RF

A

obesity, hiatus hernia, pregnancy, CT disorder (scleroderma), delayed gastric emptying, smoking, large/late meal, fried/fatty food, alcohol, coffee, aspirin

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31
Q

Gord symptoms

A

heartburn, acid reflux, oesophagitis (with odynophagia), water brash, halitosis, bloating/belching, N&V, dysphagia

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32
Q

hiatus hernia

A

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.

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33
Q

hiatus hernia rolling symptoms

A

pain, gastric obstruction, bloating, volvulus

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34
Q

GORD complications

A

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)

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35
Q

GORD referrals

A 
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

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36
Q

Gord diagnosis/tx

A

clincally, treated empirally (PPI for 8 weeks - continue as maintenance if severe) unless ALARM

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37
Q

Specialist GORD investigations

A

Oesophageal pH monitoring (24h) and oesophageal mannometry (assess sphincter competence) and barium swallow (exclude stricture, hiatus hernia or motility disorder)

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38
Q

Duodenal ulcer

A

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.

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39
Q

Gastric ulcer

A

More painful immediately after food. May present with small or large bleed. Tends to occur in 55+ patients. Can be relieved by antacids.

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40
Q

Which upper GI ulcer more likely to bleed

A

Gastric, then posterior duodenal, then anterior

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41
Q

Peptic ulcer RF

A 
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
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42
Q

Peptic ulcer symptoms

A

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
Q

H pylori

A

gram negative helical rod
Makes urease, produces ammonia
Infection can give chronic gastritis, gastric cancer and MALT lymphoma

44
Q

H pylori investigation

A

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
Q

2WW referral in upper GI

A

Anyone with dysphagia

Over 55 with upper abdo pain, reflux or dyspepsia

46
Q

Non urgent upper GI assessment

A

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
Q

Gastric ulcer FU

A

endoscopy at 6-8wks.

FU carbon 13 breath test (will become negative)

48
Q

Tx of peptic ulcer

A

Amoxicillin, clarythromycin or metronidazole with PPI

If not resolved then surgical fundoplication (risk of bleed, obstruction, perforation or malignancy)

49
Q

Malaria types

A

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
Q

Malaria reservoir

A

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
Q

Malaria symptoms

A

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
Q

Diagnosis of malaria

A

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
Q

Malaria Tx

A

Artemisinin, quinine. Primaquine in vivax, ovale for liver stage

54
Q

Bloody diarrhoea

A

Dysentery - fever and tenesmus are common
E coli? Campylobacter? Shigella? Amoebiasis?

Mucous suggests large bowel

55
Q

C diff diarrhoea

A

green tinge

56
Q

Cholera diarrhoea

A

rice water

57
Q

stool sample for returning traveller diarrhoeaa

A

may need 3

Culture, microscopy (ova/cysts/parasites)

58
Q

Blood culture/films in traveller diarrhoea

A

Typhoid (enteric fever) diagnosed by blood culture

Malaria needs blood film

59
Q

Bacterial causes of diarrhoea with short incubation

A

Bacilus cereus (rice?) and staphylococcus aureus symptomatic within hours due to toxins

60
Q

Shigellosis

A

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
Q

Camylobacter

A

Common in UK plus abroad.
Flu prodrome, abdo pain, fever, diarrhoea +/- blood
Supportive management and ciproloxacin if severe

62
Q

E Coli (GI infection)

A

Less common UK diarrhoea cause
Initially watery diarrhoea, then bloody. nausea, abdo cramps. Can give HUS (Esp in children)
Supportive management

63
Q

Enteric fever/typhoid

A

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
Q

Giardia

A

Parasite.
7-10 day incubation (sometimes months).
Very common
Bloating, flatulence, buping, prolonged watery/greasy diarrhoea

65
Q

Entamoeba

A

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
Q

Cryptosporidium/cyclospora

A

7-10 days incubation

Bloating, weight loss, fever, malaise

Watery diarrhoea and abdominal cramps

67
Q

Type of diarrhoea indicating parasitic cause

A

14 days +

68
Q

Yellow fever

A

Viral, haemorrhagic fever.
Mosquitos only, no human-human spread
Can be mild, severe is jaundice, fulminant hepatic failure, GI bleed.

69
Q

Leptospirosis

A

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
Q

Weils disease

A

Second phase of leptospirosis.

Jaundice, thrombocytopoenia and AKI

71
Q

Calorie needs normal

A

1.3kcal/kg/h

72
Q

Calorie needs during exercise

A

8.5kcal/kg/hour extra

73
Q

Fat needs

A

30% of calories (9kcal/gram)

74
Q

Carbs needs

A

56% of calories (4ckal/gram)

75
Q

Protein needs

A

13% calories (4ckal/gram)

76
Q

MUST score

A

malnutrition universal screenin tool, looks at risk of malnutrition

77
Q

NG tube uses

A

unsafe swallow, altered consciousness, supplementing oral intake, upper GI stricutre

78
Q

NG tube precautions

A

protocols govern confirmation (imaging or pH of aspirate)

Long term uses can cause damage and ulceration so need to be removed ASAP

79
Q

BMI limits

A

<18.5 is underweight
12.6-24.9 is normL
25-29.9 IS OVERWEIGHT
30+ is obese

80
Q

Waist circumference for obesity

A

88+ female, 102+ male

81
Q

Waist/hip for abdo obesity

A

1.0+ in male, 0.9+ female

82
Q

pharma for weight loss

A

orlistat - lipase inhibitor (abdo pain, steorrhoea, anal leak)
Liraglutide (GLP-1 agonist in diabetes - injection only)

83
Q

Bariatric surgery recommended

A

BMI >40, BMI>35 if complications.

FLT for BMI>50

84
Q

Intestinal granulomas

A

IBD (esp CD) and colonic TB. Not likely in malignancy or gastroenteritis.
See inner giant cells, macrophages and then lymphocytes

85
Q

Vitamin A deficiency

A

night blindness

86
Q

vitamin A excess

A

terotogen, hepatotoxic

87
Q

B1 deficiency

A

thiamine deficiency. Polyneuropathy

88
Q

B3 deficiency

A

niacin.

Pellagra (dermatitis, diarrhoea, dementia)

89
Q

Vitamin C deficiency

A

gingitivis, bleeding

90
Q

Vitamin D deficiency

A

Osteomalacia/rickets

91
Q

Vitamin D excess

A

hypercalcaemia

92
Q

Autoimmune IBD

A

ulcerative colitis

93
Q

Microbiome linked IBD

A

CD

94
Q

Smoking and IBD

A

protective in UC, RF in CD

95
Q

IBD and pANCA

A

more likely in UC, less likely in CD

96
Q

Imaging difference in CD and UC

A

CD: fat wraps around bowel due to inflammation

colitis causes thumbprinting from oedema

97
Q

Colonoscopy different in CD and UC

A

CD gets skip lesions, cobblestone appearance, apthous and serpentine ulcer
UC has pseudopolyps (islands of healing tissue)

98
Q

Anti saccaromyces cerevisae antibodies

A

May be found in CD

99
Q

Features of CD`

A

Granulomas, fistulas, strictures

100
Q

Extra intestinal features of crohns disease

A

Mouth ulcer, stomatitis, abdominal tenderness, skin tags, uveitis, pyoderma gangrenosum, fatty liver, venous thrombosis, ankylosing spondylitis (HLA B27)

101
Q

Extra intestinal features of UC

A

Fatty liver, venous thrombosis, pACNA, PSC, cholangiocarcinoma, colorectal carcinoma, erythema nodosum, pyoderma gangrenosum, uveitis, psoriasis, episcleritis

102
Q

Erythema nodosum

A

Red patches on shins (can be seen in UC, but also TB, RA)

103
Q

pyodermal gangrenosum

A

non healing leg ulcer

104
Q

Toxic megacolon

A

persistant fever, tachycardia, loose blood stained stool

Hypoalbuminaeia, hypokalaemia, AXR with filated colon (>6cm) with mucosal islands

CP1 revision (16 decks)

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