DPD Amir Sam 3 Flashcards
Gastro
What may you see on general inspection around the patient in a GI exam?
Jaundice Pallor Medication Vomit bowls Stoma bags
What may you see in on general inspection of the patient in a GI exam? (ABCDEFGHIJKL)
Asterixis Bruising Clubbing Dupuytren's contracture Erythema (palmar) Fetor Gynaecomastia Hair loss Icterus Jaundice Koilonychia Leukonychia
What should you look for in the forearms in a GI exam and what do they indicate?
AV fistulae- renal impairment
Excoriation- pruritus: cholestasis
What may gum hypertrophy indicate?
Cyclosporine after renal transplant
What happens when you press and let go of a spider naevi?
Goes pale, will refill from centre
What should you look for on the abdomen in a GI exam?
Caput medusae
Distension
Scars
What does a left subcostal scar indicate?
Biliary surgery
What does a Mercedes-Benz scar indicate?
Liver transplant
What does a midline laparotomy scar indicate?
GI/major abdo surgery
What does a J shaped scar indicate?
Renal transplant
What does a McBurney’s scar indicate?
Appendectomy
What are the causes of hepatomegaly?
Cancer Cirrhosis (early, usually alcoholic; chronic cirrhosis has small liver) Cardio: -congestive cardiac failure -constrictive pericarditis
Infiltration
-fatty, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative disease
What are the causes of amyloidosis?
Chronic infection
Chronic inflammation
Malignancy
What are the causes of liver disease?
Alcohol Autoimmune Drugs Viral Biliary Dx
What should you ask when suspecting alcoholic hepatitis?
How much alcohol they drink
What should you ask when suspecting autoimmune hepatitis?
Whether they/their family have autoimmune conditions
What should you ask when suspecting viral hepatitis?
Sexual activity
IVDU
Transfusions
Poor hygiene/recent travel (Hep A)
What should you ask when suspecting drug-induced hepatitis?
Are they on any new medication (including OTC)
What associated symptoms should you ask for in a GI exam?
Head to toe Nausea and vomiting Difficulty swallowing Abdo pain Bowel habits Stool and urine FLAWS
what are the causes of splenomegaly?
Hypertension (portal)
Haemotological
Infection
Inflammation
What are the causes of abdominal distension?
Flatus Fluid Faeces Foetus Fat
What is the likely cause of a flatus-induced abdominal distension?
Bowel obstruction
What is the likely cause of a fluid-induced abdominal distension?
Ascites
How should you classify GI bleed?
Upper- dark malaena
Lower- bright red
How is jaundice classified?
Pre-hepatic
Hepatic
Post-hepatic
75M
Epigastric and back pain
HR 130 BP 80/50
What is the likely diagnosis?
A. Peptic ulcer B. Pancreatitis C. Gastritis D. GORD E. Ruptured abdominal aneurysm
E. Ruptured abdominal aneurysm
Signs of hypovolaemic shock and epigastric pain radiating to the back.
The epigastric-back pain can be indicative of pancreatitis however you would not expect to see signs of hypovolaemic shock.
A peptic ulcer could have perforated, causing internal bleeding, hence tachcardia and hypotension, however you would have more prompts within the question ie. haematemesis, malaena and peritonism.
What are the classifications of abdominal pain?
Colicky vs constant
Location
What are the medical causes of abdominal pain?
Inflammatory bowel disease
Irritable bowel syndrome
MI (can present as epigastric pain)
Basal pneumonia (can present as upper quadrant pain)
What are the causes of epigastric pain?
GORD Peptic ulcer disease Pancreatitis Gastritis (more likely to be diffuse) Abdominal aortic aneurysm Boerhaave's MI
What may indicate GORD over other causes of epigastric pain?
Gets better with antacids
What may indicate a peptic ulcer over other causes of epigastric pain?
Pain worse on eating
NSAIDs
What may indicate a duodenal ulcer over other causes of epigastric pain?
Pain worse a few hours after eating
What may indicate pancreatitis over other causes of epigastric pain?
Hx of gallstones
Alcohol
GET SMASHED
What are the letters that represent GET SMASHED?
Gallstones Ethanol Trauma Steroids Mumps, EBV, CMV Autoimmune eg. SLE Scorption sting Hypertriglyceridaemia/hypercalcaemia ERCP Drugs eg. azothioprine, furosemide, thiazide
What may indicate gastritis over other causes of epigastric pain?
Retrosternal pain
Alcohol consumption
How do you differentiate acute vs chronic pancreatitis?
Acute:
- epigastric pain
- high amylase
Chronic:
- abnormal endocrine and exocrine function
- normal amylase
- high faecal elastase
What are the causes of RUQ pain?
Hepatitis Abscess Cholecystitis Cholelithiasis Acute cholangitis Basal pneumonia Appendicitis (retrocaecal appendix)
What are the causes of RIF pain?
Appendicitis
Mesenteric adenitis
Colitis (IBD)
Renal colic
Meckel’s divertuculum (congenital abnormality)
Ovarian torsion/ruptured cyst/ectopic pregnancy
What are the causes of suprapubic pain?
Cystitis
Urinary retention
What are the causes of LIF pain?
Diverticulitis
Mesenteric adenitis
Colitis (IBD)
Renal colic
Meckel’s divertuculum (congenital abnormality)
Ovarian torsion/ruptured cyst/ectopic pregnancy
What are the causes of diffuse abdominal pain?
Obstruction Infection: peritonitis, gastroenteritis Inflammation: IBD Ischaemia: mesenteric ischaemia Medical: -DKA -Addison's -Porphyria -Lead poisoning
What does the coeliac artery supply?
Liver Stomach Abdominal oesophagus Spleen Superior duodenum Superior pancreas
What does the superior mesenteric artery supply?
Distal duodenum
Jejuno-ileum
Ascending colon
Transverse colon
What does the inferior mesenteric artery supply?
Large intestine from the splenic flexure
Upper rectum
65 M AAA repair 2 days ago Diffuse abdo pain HR 120 RR 30 What will his blood tests show?
A. Normal lactate B. High amylase C. High bicarbonate D. High sodium E. High calcium
B. High amylase
Amylase will always be slightly increased in an acute abdo scenario.
Lactate will likely be high due to anaerobic respiration secondary to a lack of perfusion (assumption made as the Pt is tachycardic post-op, likely to have low perfusion), causing lactic acidosis.
Bicarbonate will be low in acidosis, and there is no reason for hypernatraemia or hypercalcaemia.
55 M
XS ETOH use
Cirrhosis, confused, abdominal pain and distension.
O/E: ascites, asterixis
Which of the following is consistent with SBP?
A. ascites neut >=25 cells/mm^3 B. ascites neut >=50 cells/mm^3 C. ascites neut >=100 cells/mm^3 D. ascites neut >=250 cells/mm^3 E. ascites neut >=500 cells/mm^3
D. ascites neut >=250 cells/mm^3
What are the signs of compensated liver disease?
Palmar erythema
Dupuytren’s contracture
Gynaecomastia
What are the signs of decompensated liver disease?
Hepatic encephalopathy
Asterixis
Jaundice
What will you expect to see in a Pt with ascites?
Shifting dullness
Features of liver disease
What will you expect to see in a Pt with an obstruction?
Nausea and vomiting High pitch tinkling bowel sounds Not opening bowels Previous surgery -> indicates adhesions Tender irreducible lump -> hernia
What is an alternative name for an irreducible lump?
Incarcerated
What are the causes of transudative ascites?
Cardiac- cardiac failure, constrictive pericarditis
Liver- cirrhosis
Ovarian- tumour
Kidney- CKD, nephrotic syndrome
Budd-Chiari syndrome- hepatic vein thrombosis
What are the causes of exudative ascites?
Pancreatitis (A+C)
Infection- TB, pyogenic
Malignancy- abdominal, pelvic, peritoneal mesothelioma
What are the causes of haemorrhagic ascites?
Malignancy
Acute pancreatitis
Trauma
What is transudative ascites?
Increased hydrostatic pressure due to portal hypertension
Causes fluid to “leak” from the vessels into the peritoneal cavity
Serum albumin concentration rises
Peritoneal albumin concentration falls
What is exudative ascites?
Increased protein in the peritoneal cavity
eg. inflammatory proteins
What is modernly used in replacement for the terms “transudative” and “exudative” ascites?
Serum-ascites albumin gradient
What is the cut-off point for a serum-ascites albumin gradient?
11
How is the serum-ascites albumin gradient calculated?
Serum albumin - albumin level in ascitic fluid
What does a SAAG <11 indicate?
Exudative ascites (except nephrotic syndrome)
What does a SAAG >11 indicate?
Transudative ascites
50M Jaundice RUQ pain Dark urine Pale stool Why is the stool pale?
A. Low biliverdin B. High unconjugated bilirubin C. High conjugated bilirubin D. Low urobilinogen E. Low stercobilinogen
E. Low stercobilinogen
What are the causes of pre-hepatic jaundice?
Haemolysis eg. haemolytic uraemic syndrome
Defective conjugation eg. Gilbert’s syndrome
What are the causes of hepatic jaundice?
Hepatitis
What are the causes of post-hepatic jaundice?
CBD obstruction
- gallstones
- stricture
- cholangiocarcinoma
- head of pancreas Ca
What is the pathway of bilirubin?
RBC broken down in the spleen Unconjugated bilirubin (UBR) transported to liver Conjugated by UDPGT Conjugated bilirubin (CBR) excreted with bile Becomes metabolised into urobilinogen Becomes metabolised into stercobilinogen by gut flora
Why do you get dark urine and pale stools in a CBD obstruction?
Decreased levels of stercobilinogen as it cannot pass out the CBD
Increased levels of urobilinogen as the CBR leaks out of hepatocytes
50M Painless jaundice Weight loss Dark urine Pale stool What are his blood tests likely to be raised?
A. ALP, CA19-9 B. AST, CA 125 C. ALP, alfa-fetoprotein D. ALT, alfa-fetoprotein E. ALP, CEA
A. ALP, CA19-9
Raised ALP can indicate obstructive jaundice (together with a raised GGT). CA19-9 is a marker for pancreatic cancer, hence this patient is likely to have post-hepatic jaundice secondary to a pancreatic Ca of the head.
CA 125 is a marker for ovarian cancer.
Raised AST and ALT together indicate hepatitis.
Raised AFP can indicate HCC, testicular teratoma, foetal/placental problems, amongst other conditions.
Raised CEA can indicate liver disease or IBD.
What are the causes of bloody diarrhoea?
Infective colitis- CHESS Inflammatory colitis- young, extra-GI manifestations Ischaemic colitis- elderly Diverticulitis Malignancy
What are the common infective colitis organisms?
Campylobacter jejunii Haemorrhagic Escherichia coli Entomoeba histolytica Salmonella Shigella
What does thumb-printing indicate?
Bowel wall thickening/inflammation of haustral folds
AKA colitis
What does lead-piping indicate?
Chronic ulcerative colitis
What are the criteria for a diagnosis of toxic megacolon?
Distended bowel >6cm on AXR
Temperature
Hypertension
Tachycardia
What is spurious/overflow diarrhoea?
Diarrhoea due to faecal impaction/constipation
Impaction causes watery stool to leak out around the impaction
How should you manage an acute GI bleed?
ABC
IV access large bore cannula (grey)
Group and save, X-match blood
OGD
Variceal bleed
- antibiotics
- terlipressin (splanchnic vasoconstriction)
What is the management for an acute abdo Pt?
NBM Fluids Analgesia Anti-emetic Antibiotic Monitor vitals and urine output CT and erect CXR
When is the best time to do an ultrasound of the gall bladder and why?
After fasting
The gall bladder is contracted when you eat to release bile, hence a distended bladder will allow for easier visualisation.
When a Pt presents with anaemia, when would you do an OGD and biopsy, and when would you do a colonoscopy?
OGD- dysphagia, malaena
Colonoscopy- PR bleed
What would you prescribe a Pt with asterixis secondary to encephalopathy?
Lactulose 30mL PO TDS
What is the treatment for ascites?
Diuretics (spironolactone +/- frusemide) Dietary sodium restriction Fluid restriction if hyponatraemic Monitor weight Therapeutic paracentesis w/ IV human albumin
What is the management for encephalopathy?
Lactulose Phosphate enema Avoid sedation Treat infections Exclude a GI bleed
What are the possible post-operative complications?
Wound infection
Anastamotic leak
Pelvic abscess eg. post-appendectomy
What are the features of a wound infection?
Erythematous
Discharge
What are the features of an anastamotic leak?
Diffuse abdominal tenderness
Guarding, rigidity
Hypotensive
Tachycardic
What are the features of a pelvic absces?
Pain, fever, sweats, mucus, diarrhoea
What is the presentation and treatment of a perianal abscess?
Tender, red swelling
Incise and drain
What is the presentation and treatment of an anal fissure?
Rectal pain esp. on defecation
Stool coated with blood
Advice regarding diet (high fibre, fluids)
GTN cream
What are the features of IBS?
Recurrent abdominal pain and bloating
Improves with defecation
Change in frequency/consistency of stool
No red flags
Do Pts with IBS get nocturnal symptoms?
No
Do Pts with IBD get nocturnal symptoms?
Yes (great question to ask in OSCEs)
What is the management for IBS?
Diet and lifestyle modification
Abdo pain- anti-spasmotics
Constipation- laxatives
Diarrhoea- anti-diarrhoeals
