Diseases Flashcards
What are the signs of spontaneous bacterial peritonitis?
Renal impairment
Signs of sepsis
Tachycardia
Temperature
What is spontaneous bacterial peritonitis?
infection of ascitic fluid
What investigations are done for spontaneous bacterial peritonitis?
Ascitic tap
What is the neutrophil count in spontaneous bacterial peritonitis?
>0.25x109/L
What sex metabolises alcohol slower?
Women
What are the risk factors for fatty liver disease?
Obesity
Diabetes
Hypercholesterolaemia
Alcohol
What are the symptoms of Non alcoholic steatohepatitis (NASH)?
Asymptomatic
What is the treatment for NASH?
Weight loss
Exercise
What is the protein count is spontaneous bacterial peritonitis?
<25g/l
What are the treatment options for spontaneous bacterial peritonitis?
IV antibiotics
Ascitic fluid drainage
IV albumin infusions
What is seen on blood tests for NASH?
Raised alanine amino transferase
What are the signs of alcoholic hepatitis?
Jaundice
Encephalopathy
Decompensated hepatic function
What is common in alcoholic hepatitis?
Infection
What is steatohepatitis?
fatty liver with inflammation
What is steatosis?
fatty liver
What is seen on the blood test for alcoholic hepatitis?
Raised bilirubin
Raised GGT and AlkP
What are the causes of hepatic encephalopathy?
Infection
Drugs
Constipation
GI bleed
Electrolyte disturbances
What are the supportive treatments for hepatic encephalopathy?
ITU
Airway support
Nasogastric tube
What is the mortality of alcoholic hepatitis?
40%
What are the medical treatments for hepatic encephalopathy?
Bowel clear out
Lactulose
Enemas
Antibiotics
What is seen in lab tests due in alcoholic liver disease?
AAT/ALT ratio >2
Raised Gamma GT
Macrocytosis
Low platelets
What is hepatic encephalopathy?
impaired brain function associated with hepatic insufficiency
What are the treatment options for alcoholic hepatitis?
Treat infection
Treat encephalopathy
Treat alcohol withdrawal
Protect against GI bleed
When would you give steroids for alcoholic hepatitis?
If grading severe
Glasgow alcoholic hepatitis score >9
Why would steroids only be given in severe alcoholic hepatitis?
Due to increased risk of GI bleed and infection
What percentage of those with alcoholic hepatitis are malnourished?
100%
What are the symptoms of spontaneous bacterial peritonitis?
Abdominal pain
Fevers
Rigours
What vitamin are those with alcoholic hepatitis deficient in?
Thiamine
What are the nutritional requirements of those with alcoholic hepatitis?
Frequent feeds
High energy requirement
What is bilirubin general by?
Senescent RBC’s in spleen
What are unconjugated bilirubin bound to?
Albumin
What are the signs of post-hepatic jaundice?
Palpable gall bladder
What is bilirubin?
Byproduct of haeme metabolism
What are the causes of hepatic jaundice?
Defective uptake of bilirubin
Defective conjugation
Defective excretion
What is alkaline phosphatase?
Enzyme present in bile duct
What is the most important investigation for jaundice?
Ultrasound of abdomen
What can liver screen determine?
Hep B and C serology
Autoantibody profile
Ferritin
What solubisises bilirubin to conjugate it?
Liver
What are the causes of post-hepatic jaundice?
Defective transport of bilirubin by the biliary ducts
Where is alkaline phosphatase found?
Bone
Placenta
Intestines
Liver
When is alkaline phosphatase elevated?
With obstruction of liver infiltration
Which CP can only image ducts?
ERCP
What is Gamma GT?
Non specific liver enzyme
What are the detoxification functions of the liver?
Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones
When is Gamma GT elevated?
With alcohol use
What drugs can raise levels of Gamma GT?
NSAIDS
What are the post hepatic causes of bilirubin elevation?
Obstructive
What are the signs of pre-hepatic jaundice?
Pallor
Splenomegaly
What are the pre hepatic causes of bilirubin elevation ?
Haemolysis
What does low levels of albumin suggest?
Chronic liver disease
What are the functions of the carbohydrates in the liver?
Gluconeogenesis
Glycogenolysis
Glycogenesis
What are the hepatic causes of bilirubin elevation?
Parenchymal damage
What are aminotransferases?
Enzymes present in hepatocytes?
What does the prothrombin time tell?
Degree of liver dysfunction
What are the hormones of the liver?
Angiotensinogen
Name the aminotransferases?
ALT
AST
What CP does not use radiation?
MRCP
What aminotransferase is more specific?
ALT
What is the prothrombin time used to calculate?
Stage of liver disease
What can therapeutic ERPC be used for?
Acute gallstone pancreatitis
Stenting of biliary tract obstructuin
Post-op biliary complications
What does creatinine determine?
Survival from liver disease
What does the AST/ ALT radio suggest?
Parenchymal involvement
What are the procedure related complications of ERCP?
Pancreatitis
Cholangitis
Sphincterotomy
What are the uses of PTC?
ERCP not possible due to duodenal obstruction
Hilar stenting
What are the functions of the lipids in the liver?
Cholesterol synthesis
Lipoprotein
TG synthesis
What results in low platelet count?
Cirrhosis
what are the functions of the proteins in the liver?
Albumin synthesis
What are the symptoms of liver failure?
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
What are the disadvantages of PTC?
More invasive
What are the immune functions of the liver?
Combating infections
Clearing the blood of particles and infections, including bacteria
Neutralising and destroying all drugs and toxins
When is jaundice detectable?
When total plasma bilirubin >34umol/l
What does the liver store?
Glycogen
Vitamins
Copper
Iron
What is an endoscopic ultrasound used for?
Characterising pancreatic masses
Staging of tumours
What is the differential diagnosis for jaundice?
Carotenemia
What are the signs of hepatic jaundice?
Stigmata of CLD
Ascites (fluid in abdo)
Asterixis (flap)
What vitamins does the liver store?
A, D, E, K, B12
What are the causes of pre-hepatic jaundice?
Increased quality of bilirubin
Impaired transport
What can choledocholithiasis lead to?
Acute pancreatitis
Ascending cholangitis
What are the blood tests done to investigate gallstone?
LFT’s
Amylase
Lipase
WCC
What are the palliative options cholangiocarcinoma?
Surgical bypass
Stenting
Palliative radiotherapy
Chemotherapy
PDT
What are the imaging investigations done for gallstones?
CT scan
USS
EUS
HIDA
What is the gold standard of operative treatments of gallstones?
Laparoscopic cholecystectomy +/- OTC
What are the functions of the gallbladder?
Bile reservoir
Concentrates bile
Secrete CCK after meal
What are the treatments of CBD stones?
Lap/ open exploration
ERCP
Transhparic stone retrieval
Name congenital benign biliary tract diseases?
Biliary atresia
Cholecdochal cysts
Name benign biliary structure biliary tract disease?
Iatrogenic
Gallstones related
Inflammatory
What are the imaging investigations done for cholangiocarcinoma?
USS
EUS
CT
MRA
MRCP
What is cholangiocarcinoma?
bile duct cancer
How common is gallbladder cancer?
Rare
2-5% of GI cancers
What are the non operative treatment of gallstones?
Dissolution
Lithotripsy
Where is most cholangiocarcinoma found?
Extrahepatic hilar
Describe the prognosis of gallbladder cancer?
Poor except if detected early
What are does cholangiocarcinoma peak?
80 years
What are the treamtent options for ampullary tumours?
Endoscopic excision
Trans-duodenal excision
Pancreatico-duodenectomy
What are the risk factors for cholangiocarcinoma?
PSC
Congenital cystic disease
Biliary enteric drainage
Thorotrast
What is the treamtent for intrahepatic cholangicarcinoma?
Surgery
What is the composition of gallstones?
Cholesterol
Pigment
Name the types of intrahepatic cholangiocarcinomas?
Mass forming
Peri-ductal
Intra-ductal
What are the symptoms of cholangiocarcinoma?
Obstructive jaundice
Itching
What are the risk factors for gallstones?
Age
Gender
Parity
Cholesterol
Pigment
What are the symptoms of gallstones?
Dyspeptic symtpoms
Jaundice
Perforation
Empyema
What is choledocholithiasis?
gallstones in the common bile duct
What are the symptoms of obstructive jaundice due to choledocho-litiasis?
Pain
Jaundice
Dark urine
Pale stool
Pruritus
Steatorrhoea
What is IBD-U?
Unclassified
Symptoms of both Crohn’s and UC
What do genes that cause IBD affect?
Epithelial barrier
Immune responses
Bacterial handling
What causes genetic susceptibility to IBD?
Single nucleotide polymorphism
What is the change of an offspring developing IBD if the parent has it?
10% chance
Give examples of genes that can cause IBD?
NOD2
XBP1
What are the symptoms of UC?
Bloody diarrhoea
Abdominal pain
Weight loss
Fatigue
What is present in microbial communities in IBD?
Dysbiosis
Where does continuous inflammation in UC occur?
Only colon
Define inflammatory bowel disease
Chronic relapsing, remitting inflammation of GI tract
What percentage of patients will be a colectomy within ten years of diagnosis of UC?
20-30%
What is proctitis?
inflammation of the rectum
What age does IBD commonly present?
Teens and twenties
What are the symptoms of proctitis?
Increased Frequency
Increased urgency
Incontinence
Tenesmus
What is the treatment for proctitis?
Topical therapy
What is found in the stool in proctitis?
Small volume mucus and blood
How many people in the UK have IBD?
620,000
What is the risk of emergency colectomy in acute severe colitis?
20-30%
name the types of inflammatory bowel disease
Chohn’s
Ulcerative colitis
When is UC classed as mild?
<4 stools a day +/- blood
No signs of toxicity
When is UC classed as moderate?
4-6 stools a day
Occasional blood
CRP > 30mg/l
What would bloods show in UC?
What are treatments options for Hepatitis B?
Pegylated interferon
Oral antiviral drugs
What antibodies is present in primary biliary cholagnits?
Anti-mitochondrial antibody
What are the organ therapies available for hepatitis B?
Lamivudine
Adefovir
Tenofovir
Entercavir
Teldivudine
What sex does primary sclerosing cholangitis affect more?
Men
What are the biochemical tests done for diagnosis fo NAFLD?
AST/ ALT radio
What are the imaging tests done for the diagnosis of NAFLD?
MR
CT
Ultrasound
What are the pharmacological treatments of NAFLD?
Insulin sensitisers
GLP-1
Farnesoid X nuclear receptors ligand
Vit E
Give examples of contraindications for liver transplant?
Active substance of alcohol abuse
Malignancy
Anatomical barriers
When would you list for transplant in acetaminophen-induced ALF?
Arterial ph <7.3
Arterial lactate >3
What hepatitis viruses are enteric?
A and E
What percentage of those with Hep C present with jaundice?
10%
When would you list for transplant in non acetaminophen induced ALF?
INR > 6.5 and encephalopathy present
What scores are used in order to determine cirrhosis prioritisation for transplant?
Child’s Pugh scoring A, B and C
MELD
UKELD
What is the treatment for Hep C?
Direct acting antivirals (DAA)
What are the anti-rejection drugs given following a liver transplant?
Steroids
Azathioprine
Tacrolimus/ cyclosporine
What hepatitis viruses are parenteral?
B, C and D
What does HBcAg indicate?
Active replication
Not detected in blood
What is the transmission of hepatitis A?
fecal-oral
Sexual
Blood
What are the difficulties in treating hepatitis D?
Very resistant to treatment
Name the drugs used to treat hepatitis C?
Ledipasvir
ABT-267
What is the most common cause of acute hepatitis in NHS Grampian?
Hepatitis E
what age is hepatitis A most common?
5-14
What is the treatments for primary sclerosing cholangitis?
Liver transplant
Biliary stents
where is Hepatitis E mostly found?
Tropical countries
What does Anti-HBs (hep B surface antibody) indicate?
Recovery from infection or immunization
What conditions would a liver transplant be considered?
Acute liver failure
Hepatocellular carcinoma
Chronic liver disease
Genetic diseases
What is acute hepatitis A diagnosed by?
IgM antibodies
What are the surgical treatments for NAFLD?
Weight reduction surgery
What is hepatitis F?
Variant of hepatitis B
What immunoglobulin in increased in autoimmune hepatitis?
IgG
who do we immunize for hep A?
Travellers
Patients with chronis liver disease
Haemophiliacs
Occupational exposure
Men who have sex with men
What type of virus is hepatitis D?
Small RNA virus
What does the NAFLD term encompass?
Simple steatosis
Non-alcoholic steatohepatitis
Fibrosis and cirrhosis
What sex is autoimmune hepatitis most predominant in?
Females
What does IgM anti-HBc indicate?
acute infection
What antibodies are present in autoimmune hepatitis?
ANA
SMA
LKM1
SLA
What does IgG anti-HBc indicate?
Chronic infection/ exposure
What is found in the inner protein core of Hepatitis B?
HBV DNA
DNA polymerase
What investigation is used to diagnose autoimmune hepatitis?
Liver biopsy
What is the treatment for autoimmune hepatitis?
Azathioprine
What immunoglobin is elevated in primary biliary cholangitis?
IgM
What does Anti-HBe indicate?
Inactive virus
What is the inner core of hepatitis B made of?
HBeAg
What duct is involved in primary biliary cholangitis?
Intrahepatic bile duct
What does HBsAg indicate?
Active HBV infection
What are the symptoms of primary biliary cholangitis?
Pruritus
Fatigue
What does HBeAg indicate?
Active replication
What antibodies is found in primary sclerosing cholangitis?
PANCA
What is the test of choice to diagnose primary sclerosing cholangitis?
MRCP
What genes give an increased risk of NAFLD?
PNPLA3
What type of condition is hereditary pancreatitis?
Autosomal dominant
What are the clinical features of chronic pancreatitis?
Abdominal pain
Exocrine insufficiency
Endocrine insufficiency
What are the investigations done to diagnose chronic pancreatitis?
CT
MRI
EUS
What are medical managements for chronic pancreatitis?
Non opioid analgesics
Antiodixens
What are the imaging investigations done for pancreatic cysts?
CT
MRI
EUS
Define chronic pancreatitis
Continuing inflammatory disease characterised by irreversible glandular destruction and typically causing pain or loss of function
What are the non pharmacological treatments of chronic pancreatitis?
Well balanced diet
Cessation of alcohol and tobacco
What are the high risk factors of pancreatic cysts?
Jaundice
>10mm
What does EUS determine in pancreatic cysts?
Mucinous vs non- mucinous
Benign vs malignant
What is the incidence of chronic pancreatitis?
5-8 cases per 100,000
What are the causes of chronic pancreatitis?
Alcohol
CF
Congenital anatomical abnormalities
Hypercalcaemia
What are the DNA bio markers foe pancreatic cysts?
GNAS
KRAS
What amylase level would be found in a lab test for pancreatic cysts?
<250
What are the symptoms of carcinoma of the pancreas?
Upper abdominal pain
Jaundice
Weight loss
Anorexia
What happens to the fat nodules in carcinoma in the pancreas?
Tender subcutaneous fat nodules due to metastatic
Give examples of congenital anatomical abnormalities that may cause chronic pancreatitis
Annular pancreas
Pancreas divisum
Where would the cancer of the pancreas most likely be if a patient presented with abdominal pain?
Body and tail
What are the signs of carcinoma of the pancreas?
Thrombophlebitis migrants
Ascites
Portal hypertension
What is used for block is EUS Guided coeliac plexus block and neurolysis?
0.25% Bupivacaine
Triamcinolone
What is used for neurolysis in EUS Guided coeliac plexus block and neurolysis?
0.25% Bupivacaine
Absolute alcohol
What are the BD-IPMN indications for surgery of mucinous cystic neoplasia of the pancreas in the elderly?
>3cm without high risk stigmata
What are the BD-IPMN indications for surgery of mucinous cystic neoplasia of the pancreas in younger patients?
>2cm
What are the symptoms of head of pancreas cancer?
Obstructive jaundice
Diabetes
Abdominal pain
Anorexia
Weight loss
Name the methods of reception of mucinous cystic neoplasia of the pancreas
Pancreatectomy
Focal
Laparoscopic
Robotic
Total
What are the tumour bio markers for head of pancreas cancer?
CA19-9
When is CT scanning useful in acute pancreatitis?
In severe disease
To acccess for complications
What are the general investigations done for head of pancreas cancer?
Blood tests
CXR
When is CT scanning done for acute pancreatitis?
Days 4-10 to identify necrosis
What is the nutritional management of those with acute pancreatitis?
Nasogastric feeding
what are the imaging investigations done for head of pancreas cancer?
USS
CT
MRCP
How can acute pancreatitis be prevented in future?
Management of gallstones
Investigations of non gallstone pancreatitis
Alcohol abstinence
Name the types of surgery’s used for head of pancreas cancer?
Kausch- Whipple’s
PPPD
What is the management of infected necrosis in acute pancreatitis?
Laporotomy
What is the treatment for obstructive jaundice in palliative head of pancreas cancer?
Palliative bypass
ERCP
PTC stent
What is the treatment for duodenal obstructive in the palliative head of pancreas cancer?
Palliative bypass
Duodenal stent
What are the late complications of acute pancreatitis?
Haemorrhage
Portal hypertension
What are the causes of chronic pancreatitis?
Obstruction
Autoimmune
Toxin
Idiopathic
Genetic
Environmental
Recurrent injuries
What dominates genes if present give an increased risk of Ch pancreatitis?
Condon 29 and 122
What recessive genes if present give and increased risk of Ch pancreatitis?
CFTR
SPINK1
Codon 1
Define acute pancreatitis
Acute inflammatory process of the pancreas
What are the complications of surgery for chronic pancreatitis?
Pancreatic duct stenosis
Cyst
Biliary track obstructive
Splenic vein thrombosis
What age is head of pancreas cancer most common?
60-80 years
What are the intervential produces done for chronic pancreatitis?
Endoscopic PD sphincetotomy dilation and lithotripsy
Coeliac plexus block
What is severe acute pancreatitis associated with?
Organ failure
Local complication
What are the local complications of acute pancreatitis?
Acute fluid collections
Pseudo cyst
Pancreatic abscess
Pancreatic necrosis
What are the main causes of acute pancreatitis?
Gallstones
Alcohol
How does alcohol cause acute pancreatitis?
Direct injury
Increased sensitivity to simulation
Oxidation pro cuts
Non oxidative metabolism
How does gallstones cause acute pancreatitis?
Raises pancreatic ductal pressure
What are the symptoms of acute pancreatitis?
Abdominal pain
Nausea
Vomiting
Collapse
What are the risk factors for head of pancreas cancer?
Smoking
Chronic pancreatitis
Diabetes
Hereditary pancreatitis
What are the types of resection surgery for chronic pancreatitis?
DPPHR
PPPD
Whipples pancreatic-duodenectomy
What are the signs of acute pancreatitis?
Pyrexia
Dehydration
Abdominal tenderness
Circulatory failure
What is the initial management for acute pancreatitis?
Analgesia
IV fluids
Periampullary cancer is a feature of which genetic marker?
FAP
What are the MD-IPMN high risk stigmata features of mucinous cystic neoplasia of the pancreas?
MPD >10mm
Enchanted solid component
What are the MCN high risk stigmata features of mucinous cystic neoplasia of the pancreas?
>1cm with enchhanced solid component
MPD >1C,
What are the imaging investigations done for acute pancreatitis?
CXR
USS
CT
What markers indicate severe acute pancreatitis?
CRP > 200
IL 6
TAP
What faecal calprotectin is classed as normal?
0-50ug/g
What faecal calprotectin is classed as elevated?
>200
What are the investigations done for UC?
Bloods
Stool culture
Faecal calprotectin
Colonoscopy
What is faecal calprotectin?
Marker for inflammation in GI tract
What drugs are given in acute severe colitis?
Low weight molecule heparin
IV glucocorticoids
IV hydration
What investigations of done for acute severe colitis?
Blood tests
Stool chart
4 stool cultures for C. Diff
What imaging investigation is done for acute severe colitis?
Abdo XR
What can precipitate toxic mega colon?
Low potassium or magnesium
What are the symptoms of Crohn’s disease?
Diarrhoea
Abdominal pain
Weight loss
Malabsorption
What may malabsorption due to Crohn’s disease lead to?
Anaemia
Vitamin deficiency
What are the investigations done for Crohn’s disease?
Bloods
Stool culture
Faecal calprotectin
Colonoscopy
MRI small bowel study
Capsule endoscopy
What are the complications of Crohn’s disease due to?
Transmural inflammation
Which type of IBD shows granulomas in its histology
Crohn’s disease
What cells are depleted in UC?
Goblet cells
Which IBD has more crypt abscesses?
UC
What are the symptoms of perianal Crohn’s disease?
Perianal pain
Pus secretion
Unable to sit down
what are the investigations done for perianal Crohn’s disease?
MRI pelvis
Examination under anaesthetic
What are the medical treatment(s) of perianal Crohn’s disease?
Antibiotics and biblical therapy
Surgery
v
What are some extra-intestinal manifestations of IBD?
Mouth ulcers
Skin rashes
Eye problems
Musculoskeletal problems
Primary sclerosing cholangitis
What are other causes of chronic diarrhoea?
Malabsorption
IBS
Overflow diarrhoea
What are the long term complications of colitis?
Colonic carcinoma
Give examples of aminosalicylates (5-ASAs)
Mesalazine
Ethylcelluluse microgranules
How does 5-ASAs work?
Blocking prostaglandin and Leukotrienes
Release mechanisms lead to colonic delivery
How much 5ASAs are given for induction of remission?
>3g orally per day
What is 1st line therapy for UC?
5ASA
What IBD is 5ASA effective in?
UC
Why are steroids not long term use for IBD?
Adverse side effects
Give examples of steroids to induce remission in IBD?
Prednisolone
Budesonide
What is the optimal dose of prednisolone to give for IBD?
40mg a day
What immunomodulators are used in IBD?
Azathioprine
What are the side effects of Azathioprine?
Leukopenia
Hepatotoxic
Pancreatitis
What is methotrexate used for?
Crohn’s
What are the risks of methotrexate?
10-18% intolerant
Teratogenic
What patients are methotrexate used for?
Steroid dependant patients
Give examples of Anti TNF antibodies used for IBD?
Infliximab - 8 weekly IV
Adalimumab - 2 weekly injection
Give examples of 4b7 integrins blockers used for IBD?
Vedolizumab
8 weekly IV infusions
What is tofacitinib an inhibitor of?
Pan JAK
Describe use of elemental feeding in IBD?
Can be as effective as steroids
More efficacious in children
When would you operate in an emergency for IBD?
Acute severe colitis not responding to therapy
Complications such as perforation, obstruction and abscess
When would you electively operate for IBD?
Frequent relapses despite medical therapy
Not able to tolerate medical therapy
Steroid dependant
Patient choice
What are the options of subtotal colectomy?
Pouch procedure
Completion proctectomy
How does pouch surgery work?
Mobilise and lengthen small bowel
Construct pouch
Insert stapler
What are the surgical indications for Crohn’s disease?
Failure of medical management
Management of fistula
Failure to thrive
Relief of obstructive symptoms
What is the prognosis of functional GI disorders?
Long term prognosis good
What is the difference between structural and functional GI disorders?
Structural has detectable pathology
Functional does not
Where can functional GI disorders affect?
Whole of GI tract
How are most functional GI disorders diagnosed?
From history and examination
What is non-ulcer dyspepsia?
Typical ulcer pain without presence of ulcer
What bacteria is needed to be checked in non-ulcer dyspepsia?
H pylori
What is the treatment for non-ulcer dyspepsia if there is no H.pylori present?
Treat symptomatically
What is important to ask in the history of a patient presenting with vomiting?
Length of time after food
What is vomiting and 1 or more after food suggestive of?
Pyloric obstruction
Motility disorders
f
What is vomiting immediately after food suggestive of?
Psychogenic
What is vomiting 12 hours after food suggestive of?
Obstruction
What are the causes of vomiting?
Drugs
Pregnancy
Migraine
Cyclical vomiting syndrome
Alcohol
When is the onset for cyclical vomiting syndrome?
Childhood
What are the alarm symptoms for functional GI disorders?
Age >50
Short symptom history
Unintentional weight loss
Nocturnal systems
Family history
What are the investigations done for functional GI disorders?
FBS
Blood glucose
U+ E
Thyroid status
Coeliac serology
FIT
Sigmoidoscopy
What are the organic causes of constipation?
Strictures
Tumours
Diverticula disease
Proctitis
Anal fissue
What are the functional causes of constipation?
Mega colon
Idiopathic constipation
Depression
Psychosis
What are the systemic causes of constipation?
Diabetes
Hypothyroidism
Hypercalcaemia
What are the neurogenic causes of constipation?
Autonomic neuropathies
Parkinson’s disease
Strokes
MS
Spina bifida
What are the clinical features of IBS?
Abdominal pain
Altered bowel habit
Abdominal bloating
What is the ROME III diagnostic criteria of IBS?
Recurrent abdominal pain for >3 days/ months in the past 3 months associated with two or more of
Improvement with dedication
Onset asssocited with changes in stool frequency
Onset associated with change in stool form
Where does abdominal pain occasionally radiate to in IBS?
Lower back
What is the feature present in IBS-C?
Constipation
What is the feature present in IBS-D?
Diarrhoea
What is IBS-M?
mix of diarrhea/constipation
What is bloating in IBS due to?
Relaxation in abdominal wall muscles
What is seen in the stool in IBS?
Mucus
What are the investigations done for IBS?
Blood
Stool culture
Calprotectin
FIT testing
What is calprotectin released by?
Inflamed gut mucosa
What is calprotectin used for?
Differentiating IBS and IBD
What makes diarrhoea worse?
Tea
Coffee
Alcohol
Sweetener
What are the treatment for IBS?
Dietetic review
Lactose, gluten exclusion trial
FODMAP
What are the drugs used to relieve of diarrhoea in IBS?
Antimotlity agents
What are the drugs used to relieve pain in IBS?
Antispasmodics
Linacloide
What are the drugs used to relieve bloating in IBS?
Probiotics
Linaclotide
What are the drugs used to relieve constipation in IBS?
Laxatives
Linaclotide
What are the psychological interventions used for IBS?
Relaxation training
Hypnotherapy
CBT
What may cause IBS?
Altered motility
Visceral hypersensitivity
Stress
How may intestinal motility cause IBS?
In IBS-D muscular contractions may be stronger and more frequent
How may gut responses to triggers be altered in IBS?
May be stronger in IBS-D or weaker in IBS-C
What are the majority of colorectal cancers histologically?
Adenocarcinomas
What are most colorectal cancers caused by?
Sporadic
What genes are risk factors for development of colorectal cancer?
HNPCC
FAP
What are the risk factors for colorectal cancer?
Age
Male
Previous adenoma
Environmental
What are the environmental influences on colorectal cancer?
Diet
Obesity
Lack of exercise
Smoking
Diabetes
What are colorectal polyps?
Protuberant growth
What do the majority of colorectal cancers arise from
Pre-existing polyps
What do adenoma polyps look like morphologically
Peduunculated or sessile
What are high-risk features of polyps?
Size
Number
Degree of dysplasia
Villous architecture
What oncogenes promote cell growth?
K-ras
C-myc
What causes cell growth leading to colorectal cancer?
Activation of oncogenes
Loss of tumour suppressor gene
Defective DNA repair pathway genes
Give examples of tumour suppressor genes that may be lost giving rise to colorectal cancer?
APC
P53
DCC
What are the symptoms of colorectal cancer?
Rectal bleeding
Altered bowel opening to loose stools >4 weeks
Iron deficiency anemia
What is a sign that the colorectal cancer tumour is stenosing?
Acute colonic obstruction
What are the systemic symptoms of malignancy?
Weight loss
Anorexia
What is the investigation of chose for colorectal cancer?
Colonoscopy
What are the disadvantages of colonoscopy?
Sedation
Bowel preparation
What are the risks of colonoscopy?
Perforation
Bleeding
What is the radiological imaging investigation of choice for colorectal cancer?
CT colonoscopy
What are the staging investigations done for colorectal cancer?
CT scan
MRI
PET
What percentage of patients with colorectal cancer will have surgery?
80%
When would endoscopic or local resection be offered to treat colorectal cancer?
Dukes A and cancer polyps
What is formed during colorectal cancer surgery?
Stoma formation
What is removed during colorectal cancer surgery?
Lymph nodes
Liver for metastasis
When would chemotherapy be given in colorectal cancer?
Dukes C
Adjuvant
What is the reason chemotherapy is given after colorectal cancer surgery?
Mops up micrometastases
When would radiotherapy be given for colorectal cancer?
Neoadjuant
Rectal cancer only
What test is now done for screening colorectal cancer?
FIT test
What are the benefits of FIT screening over the Scottish bowel screening program?
Provides flexibility to alter the cut off to accomate risk factors inducing age and gender
What high risk groups are screened for colorectal cancer?
Heritable groups
IBD
Familial risk
Previous adenoma/ colorectal cancer
What age is invited to bowel screening?
50-74 years
What type of condition if FAP?
Autosomal dominant
What is FAP due to?
Mutations of the APC gene on chromosome 5
What is given to those with the FAP gene to reduce their risk of getting colorectal cancer?
Annual colonoscopy from age 10-12
Prophylactic proctocolectomy age 16-35 years
What type of condition is MAP?
Autosomal recessive
what is MAP caused by
Pathogenic variants in the MUTYH base excision repair gene
What side is CRC most likely to be on if due to MAP?
Right
What is done for those who have MAP gene to reduce their risk of CRC?
Upper GI surveillance starting age 35
Annular colorectal surveillance from 18-20 years
What is HNPCC due to?
Mutation in DNA mismatch repair genes
What type of condition is HNPCC?
Autosomal dominant
What do tumours caused by HNPCC typically have?
Microsatellite instability
What age do people with HNPCC gene get screening for CRC from?
25
2-year colonoscopy
What are the functions of the colon?
Water and electrolytes absorption
Production and absorption of vitamins
Storage of faeces
Hosts gut microbiota
What vitamins does the colon absorb?
K and B
What are the factors that ensure anorectal continence?
Anorectal sensation
Central control
Stool consistency
Renal compliance
Give examples of types of polyps?
Flat
GI rant
Pedunucalated
What is the protocol for a patient coming in with low-risk features of rectal bleeding lasting less than 6 weeks?
Watch and wait for 6 weeks before reviewing
What is the gold standard investigation done for colorectal cancer?
Colonoscopy +/- biopsies
What radiological imaging is done for suspected colorectal cancer?
CT colongraphy
Plain CT with contract
Where are most colorectal cancers found?
Proximal colon
Why is MRI important in rectal cancer?
Could dictate if neoadjuvant chemotherapy/radiotherapy is needed
What is needed to be recessed to reside local recurrence rate in rectal cancer?
Rectum and surrounding me sore Tim
What is the rectum surrounded by?
Mesorectum
Contains all lymph nodes of rectum
How long is surgery after neoadjuvant treatment for rectal cancer?
8-10 weeks
What are the principles for bowel anastomoses?
Tension free
Well perfused
Well oxygenated
Clean surgical site
Acceptable systemic state
where are ileostomies typically located?
Right iliac fossa
Where are colostomies located?
Left iliac fossa
Describe the apperance of an ileostomy
Spouted
Describe the appearance of a colostomy?
No spout
Flush with skin
What is the contents of an ileostomy?
Liquid
Looser stools
What are the contents of a colostomy?
Solid stools
What are the complications of rectal surgery?
Bleeding
Infection
Anastomotic leak
Stoma problems
What are the complications in lower anterior resections?
Damage to pelvic nerves
Impaired fecundity in younger women
What may be required post-op in rectal surgery?
Adjuvant chemotherapy
What are the signs of bowel obstruction?
Abdominal pain
Vomiting
Absolute constipation
Abdominal distension
When would vomiting occur in bowel obstruction?
If ileocaecal valve is not competent
What are the causes of large bowel obstruction?
Malignant
Strictures
Volvulis
Faecal impact ion
What investigations are done for bowel obstruction?
CT
Blood gase
Bloods
What are the nutritional needs of someone presenting with bowel obstruction?
NBM
Nasogastric tube if vomiting
fluid resucitation
What is the medical management of bowel obstruction?
Analgesia
Antiemetic
IV antibiotics
What is the function of the anorectum?
Control of defaecation
Maintenance of continence
What does the anorectum require in order to carry out its functions?
Pelvic floor
Rectal compliance
Intact pelvic neurology
What are the surgical treatments for haemorrhoids?
HALA
Anopexy
Haemorrhoidectomy
What are the characteristics of haemorrhoids?
Bleeding
Painless
Straining
What are the underlying causes of haemorrhoids?
Constipation
What is the OPD treatment for haemorrhoids?
Rubber band ligation
What is the characteristic of a fissure?
Pain
Bleeding
Glass splinters
What is the medical management for fissures?
GTN/ Diltiazem + Lignocaine
What are the surgical treatments for fissures?
Botox
Sphinncterotomy
What are the symptoms of a perianal abscess?
Excruciating pain
Signs of sepsis
When would you give antibiotics for a perianal abscess?
If septic
What are the risk factors for perianal abscess?
Diabetes
BMI
Immunosuppression
Trauma
What is the treatment for perianal abscess?
Incision and drainage
What are the symptoms of a fistula in ano?
Peri-anal sepsis
Persistent pus discharge with flare up
+/- faecal soiling
What is the failure rate of surgery for a fistula in ano?
50%
Name the treatments for fistula in ano?
Seton
Sphincter preservation techniques
Lay open
Why should a lay open not be done on women?
Due to thinner muscular walls
What test is positive when there is rectal cancer present?
FIT test
What are the routine investigations for rectal cancer?
PR examination
Proctoscopy
Rigid sigmoidoscopy
Colonoscopy
What are the imaging investigations for rectal cancer?
CT colonoscopy
CT scan
MRI rectum
What is pelvic floor dysfunction?
Collection of wide spectrum of symptoms related to defection
What are the categories of causes of pelvic floor dysfunction?
Child birth-related
All other causes - surgery, abuse etc
Who does pelvic floor dysfunction primarily affect?
Parous women
What are the causes of pelvic floor dysfunction in non-parlours women and men?
Surgical misadventure
Neurological/ connective tissue disorders
Psychological/ behavioural issues
Name the types of chronic constipation
Dietary
Drugs
Organic
Functional
Name the types of functional chronic constipation?
Slow transit
Evacuation related
Combination
Give examples of drugs that can cause constipation
Opioids
Verapamil
Diuretics
What investigations are done for chronic constipation to exclude sinister pathology?
Colonic imaging
Bloods
Symptomatic qFIT
Coeliac serology
Faecal calprotectin
What are first-line drugs for chronic constipation?
Regular baseline laxatives
Name the second-line drugs for chronic constipation?
Prucalopride
Lubiprostone
Linaclotine
What second-line drug for chronic constipation is for women only?
Proculopride
When would you give second-line drugs for chronic constipation?
Failure treatment with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered
What are the surgical options for slow transit chronic constipation?
Subtotal colectomy with end ileostomy
Subtotal colectomy with ileorectal anastomoses
What are the other management options for chronic constipation?
Persistent irrigation system
Qufora irrigation
Name the types of faecal incontinence?
Passive
Urge
Mixed
Overflow
What investigations may be done for faecal incontinence?
Endo-anal USS
Defaecatory proctogram
what does an anal manometry measure?
Anal sphincter function
Length of the anal canal
Changes in anal pressure during the dedication
Recto-anal inhibitory reflex
Anorectal pressure responses
What may recto-anal inhibitory reflex be used to detect?
Congenital Hirshsprung
Systemic sclerosis
What does the defaecating proctogram provide information on?
Pelvic floor mobility
The pathological function of the musculature
Changes to form and axis or organs
Internal hernias
What are the non-pharmacological treatments of FI?
Low fibre diet
Pelvic floor exercises
Anal plug
What are the pharmacological treatments of FI?
Loperamide
Irrigation
What are the surgical treatments of FI?
Sphincter repair
Correct anatomical defect
Sacral nerve stimulator
What is rectocoel?
Passive loss of stool from being trapped due to incomplete evacuation
What is the treatment for internal rectal prolapse?
Improve rectal evacuation
Enemas
Loperamide
What is the choice of operation for rectal prolapse in a fit patient?
Rectopexy
