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Year 3 DPD > DPD Amir Sam 3 > Flashcards

DPD Amir Sam 3 Flashcards

Gastro

1
Q

What may you see on general inspection around the patient in a GI exam?

A 
Jaundice
Pallor
Medication
Vomit bowls
Stoma bags
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2
Q

What may you see in on general inspection of the patient in a GI exam? (ABCDEFGHIJKL)

A 
Asterixis
Bruising
Clubbing
Dupuytren's contracture
Erythema (palmar)
Fetor
Gynaecomastia
Hair loss
Icterus
Jaundice
Koilonychia
Leukonychia
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3
Q

What should you look for in the forearms in a GI exam and what do they indicate?

A

AV fistulae- renal impairment

Excoriation- pruritus: cholestasis

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4
Q

What may gum hypertrophy indicate?

A

Cyclosporine after renal transplant

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5
Q

What happens when you press and let go of a spider naevi?

A

Goes pale, will refill from centre

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6
Q

What should you look for on the abdomen in a GI exam?

A

Caput medusae
Distension
Scars

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7
Q

What does a left subcostal scar indicate?

A

Biliary surgery

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8
Q

What does a Mercedes-Benz scar indicate?

A

Liver transplant

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9
Q

What does a midline laparotomy scar indicate?

A

GI/major abdo surgery

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10
Q

What does a J shaped scar indicate?

A

Renal transplant

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11
Q

What does a McBurney’s scar indicate?

A

Appendectomy

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12
Q

What are the causes of hepatomegaly?

A 
Cancer
Cirrhosis (early, usually alcoholic; chronic cirrhosis has small liver)
Cardio:
-congestive cardiac failure
-constrictive pericarditis

Infiltration
-fatty, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative disease

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13
Q

What are the causes of amyloidosis?

A

Chronic infection
Chronic inflammation
Malignancy

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14
Q

What are the causes of liver disease?

A 
Alcohol
Autoimmune
Drugs
Viral 
Biliary Dx
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15
Q

What should you ask when suspecting alcoholic hepatitis?

A

How much alcohol they drink

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16
Q

What should you ask when suspecting autoimmune hepatitis?

A

Whether they/their family have autoimmune conditions

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17
Q

What should you ask when suspecting viral hepatitis?

A

Sexual activity
IVDU
Transfusions
Poor hygiene/recent travel (Hep A)

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18
Q

What should you ask when suspecting drug-induced hepatitis?

A

Are they on any new medication (including OTC)

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19
Q

What associated symptoms should you ask for in a GI exam?

A 
Head to toe
Nausea and vomiting
Difficulty swallowing
Abdo pain
Bowel habits
Stool and urine
FLAWS
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20
Q

what are the causes of splenomegaly?

A

Hypertension (portal)
Haemotological
Infection
Inflammation

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21
Q

What are the causes of abdominal distension?

A 
Flatus
Fluid
Faeces
Foetus
Fat
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22
Q

What is the likely cause of a flatus-induced abdominal distension?

A

Bowel obstruction

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23
Q

What is the likely cause of a fluid-induced abdominal distension?

A

Ascites

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24
Q

How should you classify GI bleed?

A

Upper- dark malaena

Lower- bright red

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25
Q

How is jaundice classified?

A

Pre-hepatic
Hepatic
Post-hepatic

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26
Q

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
A

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.

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27
Q

What are the classifications of abdominal pain?

A

Colicky vs constant

Location

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28
Q

What are the medical causes of abdominal pain?

A

Inflammatory bowel disease
Irritable bowel syndrome
MI (can present as epigastric pain)
Basal pneumonia (can present as upper quadrant pain)

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29
Q

What are the causes of epigastric pain?

A 
GORD
Peptic ulcer disease
Pancreatitis
Gastritis (more likely to be diffuse)
Abdominal aortic aneurysm
Boerhaave's
MI
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30
Q

What may indicate GORD over other causes of epigastric pain?

A

Gets better with antacids

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31
Q

What may indicate a peptic ulcer over other causes of epigastric pain?

A

Pain worse on eating

NSAIDs

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32
Q

What may indicate a duodenal ulcer over other causes of epigastric pain?

A

Pain worse a few hours after eating

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33
Q

What may indicate pancreatitis over other causes of epigastric pain?

A

Hx of gallstones
Alcohol
GET SMASHED

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34
Q

What are the letters that represent GET SMASHED?

A 
Gallstones
Ethanol
Trauma
Steroids
Mumps, EBV, CMV
Autoimmune eg. SLE
Scorption sting
Hypertriglyceridaemia/hypercalcaemia
ERCP
Drugs eg. azothioprine, furosemide, thiazide
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35
Q

What may indicate gastritis over other causes of epigastric pain?

A

Retrosternal pain

Alcohol consumption

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36
Q

How do you differentiate acute vs chronic pancreatitis?

A

Acute:

  • epigastric pain
  • high amylase

Chronic:

  • abnormal endocrine and exocrine function
  • normal amylase
  • high faecal elastase
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37
Q

What are the causes of RUQ pain?

A 
Hepatitis
Abscess
Cholecystitis
Cholelithiasis
Acute cholangitis
Basal pneumonia
Appendicitis (retrocaecal appendix)
38
Q

What are the causes of RIF pain?

A

Appendicitis
Mesenteric adenitis
Colitis (IBD)
Renal colic
Meckel’s divertuculum (congenital abnormality)
Ovarian torsion/ruptured cyst/ectopic pregnancy

39
Q

What are the causes of suprapubic pain?

A

Cystitis

Urinary retention

40
Q

What are the causes of LIF pain?

A

Diverticulitis
Mesenteric adenitis
Colitis (IBD)
Renal colic
Meckel’s divertuculum (congenital abnormality)
Ovarian torsion/ruptured cyst/ectopic pregnancy

41
Q

What are the causes of diffuse abdominal pain?

A 
Obstruction
Infection: peritonitis, gastroenteritis
Inflammation: IBD
Ischaemia: mesenteric ischaemia
Medical:
-DKA
-Addison's
-Porphyria
-Lead poisoning
42
Q

What does the coeliac artery supply?

A 
Liver
Stomach
Abdominal oesophagus
Spleen
Superior duodenum
Superior pancreas
43
Q

What does the superior mesenteric artery supply?

A

Distal duodenum
Jejuno-ileum
Ascending colon
Transverse colon

44
Q

What does the inferior mesenteric artery supply?

A

Large intestine from the splenic flexure

Upper rectum

45
Q 
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
A

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.

46
Q

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
A

D. ascites neut >=250 cells/mm^3

47
Q

What are the signs of compensated liver disease?

A

Palmar erythema
Dupuytren’s contracture
Gynaecomastia

48
Q

What are the signs of decompensated liver disease?

A

Hepatic encephalopathy
Asterixis
Jaundice

49
Q

What will you expect to see in a Pt with ascites?

A

Shifting dullness

Features of liver disease

50
Q

What will you expect to see in a Pt with an obstruction?

A 
Nausea and vomiting
High pitch tinkling bowel sounds
Not opening bowels
Previous surgery -> indicates adhesions
Tender irreducible lump -> hernia
51
Q

What is an alternative name for an irreducible lump?

A

Incarcerated

52
Q

What are the causes of transudative ascites?

A

Cardiac- cardiac failure, constrictive pericarditis
Liver- cirrhosis
Ovarian- tumour
Kidney- CKD, nephrotic syndrome
Budd-Chiari syndrome- hepatic vein thrombosis

53
Q

What are the causes of exudative ascites?

A

Pancreatitis (A+C)
Infection- TB, pyogenic
Malignancy- abdominal, pelvic, peritoneal mesothelioma

54
Q

What are the causes of haemorrhagic ascites?

A

Malignancy
Acute pancreatitis
Trauma

55
Q

What is transudative ascites?

A

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

56
Q

What is exudative ascites?

A

Increased protein in the peritoneal cavity

eg. inflammatory proteins

57
Q

What is modernly used in replacement for the terms “transudative” and “exudative” ascites?

A

Serum-ascites albumin gradient

58
Q

What is the cut-off point for a serum-ascites albumin gradient?

A

11

59
Q

How is the serum-ascites albumin gradient calculated?

A

Serum albumin - albumin level in ascitic fluid

60
Q

What does a SAAG <11 indicate?

A

Exudative ascites (except nephrotic syndrome)

61
Q

What does a SAAG >11 indicate?

A

Transudative ascites

62
Q 
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
A

E. Low stercobilinogen

63
Q

What are the causes of pre-hepatic jaundice?

A

Haemolysis eg. haemolytic uraemic syndrome

Defective conjugation eg. Gilbert’s syndrome

64
Q

What are the causes of hepatic jaundice?

A

Hepatitis

65
Q

What are the causes of post-hepatic jaundice?

A

CBD obstruction

  • gallstones
  • stricture
  • cholangiocarcinoma
  • head of pancreas Ca
66
Q

What is the pathway of bilirubin?

A 
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
67
Q

Why do you get dark urine and pale stools in a CBD obstruction?

A

Decreased levels of stercobilinogen as it cannot pass out the CBD
Increased levels of urobilinogen as the CBR leaks out of hepatocytes

68
Q 
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

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.

69
Q

What are the causes of bloody diarrhoea?

A 
Infective colitis- CHESS
Inflammatory colitis- young, extra-GI manifestations 
Ischaemic colitis- elderly
Diverticulitis
Malignancy
70
Q

What are the common infective colitis organisms?

A 
Campylobacter jejunii
Haemorrhagic Escherichia coli
Entomoeba histolytica
Salmonella
Shigella
71
Q

What does thumb-printing indicate?

A

Bowel wall thickening/inflammation of haustral folds

AKA colitis

72
Q

What does lead-piping indicate?

A

Chronic ulcerative colitis

73
Q

What are the criteria for a diagnosis of toxic megacolon?

A

Distended bowel >6cm on AXR
Temperature
Hypertension
Tachycardia

74
Q

What is spurious/overflow diarrhoea?

A

Diarrhoea due to faecal impaction/constipation

Impaction causes watery stool to leak out around the impaction

75
Q

How should you manage an acute GI bleed?

A

ABC
IV access large bore cannula (grey)
Group and save, X-match blood
OGD

Variceal bleed

  • antibiotics
  • terlipressin (splanchnic vasoconstriction)
76
Q

What is the management for an acute abdo Pt?

A 
NBM
Fluids
Analgesia
Anti-emetic
Antibiotic
Monitor vitals and urine output
CT and erect CXR
77
Q

When is the best time to do an ultrasound of the gall bladder and why?

A

After fasting
The gall bladder is contracted when you eat to release bile, hence a distended bladder will allow for easier visualisation.

78
Q

When a Pt presents with anaemia, when would you do an OGD and biopsy, and when would you do a colonoscopy?

A

OGD- dysphagia, malaena

Colonoscopy- PR bleed

79
Q

What would you prescribe a Pt with asterixis secondary to encephalopathy?

A

Lactulose 30mL PO TDS

80
Q

What is the treatment for ascites?

A 
Diuretics (spironolactone +/- frusemide)
Dietary sodium restriction
Fluid restriction if hyponatraemic
Monitor weight
Therapeutic paracentesis w/ IV human albumin
81
Q

What is the management for encephalopathy?

A 
Lactulose
Phosphate enema
Avoid sedation
Treat infections
Exclude a GI bleed
82
Q

What are the possible post-operative complications?

A

Wound infection
Anastamotic leak
Pelvic abscess eg. post-appendectomy

83
Q

What are the features of a wound infection?

A

Erythematous

Discharge

84
Q

What are the features of an anastamotic leak?

A

Diffuse abdominal tenderness
Guarding, rigidity
Hypotensive
Tachycardic

85
Q

What are the features of a pelvic absces?

A

Pain, fever, sweats, mucus, diarrhoea

86
Q

What is the presentation and treatment of a perianal abscess?

A

Tender, red swelling

Incise and drain

87
Q

What is the presentation and treatment of an anal fissure?

A

Rectal pain esp. on defecation
Stool coated with blood
Advice regarding diet (high fibre, fluids)
GTN cream

88
Q

What are the features of IBS?

A

Recurrent abdominal pain and bloating
Improves with defecation
Change in frequency/consistency of stool
No red flags

89
Q

Do Pts with IBS get nocturnal symptoms?

A

No

90
Q

Do Pts with IBD get nocturnal symptoms?

A

Yes (great question to ask in OSCEs)

91
Q

What is the management for IBS?

A

Diet and lifestyle modification
Abdo pain- anti-spasmotics
Constipation- laxatives
Diarrhoea- anti-diarrhoeals

Year 3 DPD (5 decks)

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