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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
How is jaundice classified?
Pre-hepatic Hepatic Post-hepatic
26
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.
27
What are the classifications of abdominal pain?
Colicky vs constant | Location
28
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)
29
What are the causes of epigastric pain?
``` GORD Peptic ulcer disease Pancreatitis Gastritis (more likely to be diffuse) Abdominal aortic aneurysm Boerhaave's MI ```
30
What may indicate GORD over other causes of epigastric pain?
Gets better with antacids
31
What may indicate a peptic ulcer over other causes of epigastric pain?
Pain worse on eating | NSAIDs
32
What may indicate a duodenal ulcer over other causes of epigastric pain?
Pain worse a few hours after eating
33
What may indicate pancreatitis over other causes of epigastric pain?
Hx of gallstones Alcohol GET SMASHED
34
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 ```
35
What may indicate gastritis over other causes of epigastric pain?
Retrosternal pain | Alcohol consumption
36
How do you differentiate acute vs chronic pancreatitis?
Acute: - epigastric pain - high amylase Chronic: - abnormal endocrine and exocrine function - normal amylase - high faecal elastase
37
What are the causes of RUQ pain?
``` Hepatitis Abscess Cholecystitis Cholelithiasis Acute cholangitis Basal pneumonia Appendicitis (retrocaecal appendix) ```
38
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
39
What are the causes of suprapubic pain?
Cystitis | Urinary retention
40
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
41
What are the causes of diffuse abdominal pain?
``` Obstruction Infection: peritonitis, gastroenteritis Inflammation: IBD Ischaemia: mesenteric ischaemia Medical: -DKA -Addison's -Porphyria -Lead poisoning ```
42
What does the coeliac artery supply?
``` Liver Stomach Abdominal oesophagus Spleen Superior duodenum Superior pancreas ```
43
What does the superior mesenteric artery supply?
Distal duodenum Jejuno-ileum Ascending colon Transverse colon
44
What does the inferior mesenteric artery supply?
Large intestine from the splenic flexure | Upper rectum
45
``` 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.
46
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
47
What are the signs of compensated liver disease?
Palmar erythema Dupuytren's contracture Gynaecomastia
48
What are the signs of decompensated liver disease?
Hepatic encephalopathy Asterixis Jaundice
49
What will you expect to see in a Pt with ascites?
Shifting dullness | Features of liver disease
50
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 ```
51
What is an alternative name for an irreducible lump?
Incarcerated
52
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
53
What are the causes of exudative ascites?
Pancreatitis (A+C) Infection- TB, pyogenic Malignancy- abdominal, pelvic, peritoneal mesothelioma
54
What are the causes of haemorrhagic ascites?
Malignancy Acute pancreatitis Trauma
55
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
56
What is exudative ascites?
Increased protein in the peritoneal cavity | eg. inflammatory proteins
57
What is modernly used in replacement for the terms "transudative" and "exudative" ascites?
Serum-ascites albumin gradient
58
What is the cut-off point for a serum-ascites albumin gradient?
11
59
How is the serum-ascites albumin gradient calculated?
Serum albumin - albumin level in ascitic fluid
60
What does a SAAG <11 indicate?
Exudative ascites (except nephrotic syndrome)
61
What does a SAAG >11 indicate?
Transudative ascites
62
``` 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
63
What are the causes of pre-hepatic jaundice?
Haemolysis eg. haemolytic uraemic syndrome | Defective conjugation eg. Gilbert's syndrome
64
What are the causes of hepatic jaundice?
Hepatitis
65
What are the causes of post-hepatic jaundice?
CBD obstruction - gallstones - stricture - cholangiocarcinoma - head of pancreas Ca
66
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 ```
67
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
68
``` 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.
69
What are the causes of bloody diarrhoea?
``` Infective colitis- CHESS Inflammatory colitis- young, extra-GI manifestations Ischaemic colitis- elderly Diverticulitis Malignancy ```
70
What are the common infective colitis organisms?
``` Campylobacter jejunii Haemorrhagic Escherichia coli Entomoeba histolytica Salmonella Shigella ```
71
What does thumb-printing indicate?
Bowel wall thickening/inflammation of haustral folds | AKA colitis
72
What does lead-piping indicate?
Chronic ulcerative colitis
73
What are the criteria for a diagnosis of toxic megacolon?
Distended bowel >6cm on AXR Temperature Hypertension Tachycardia
74
What is spurious/overflow diarrhoea?
Diarrhoea due to faecal impaction/constipation | Impaction causes watery stool to leak out around the impaction
75
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)
76
What is the management for an acute abdo Pt?
``` NBM Fluids Analgesia Anti-emetic Antibiotic Monitor vitals and urine output CT and erect CXR ```
77
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.
78
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
79
What would you prescribe a Pt with asterixis secondary to encephalopathy?
Lactulose 30mL PO TDS
80
What is the treatment for ascites?
``` Diuretics (spironolactone +/- frusemide) Dietary sodium restriction Fluid restriction if hyponatraemic Monitor weight Therapeutic paracentesis w/ IV human albumin ```
81
What is the management for encephalopathy?
``` Lactulose Phosphate enema Avoid sedation Treat infections Exclude a GI bleed ```
82
What are the possible post-operative complications?
Wound infection Anastamotic leak Pelvic abscess eg. post-appendectomy
83
What are the features of a wound infection?
Erythematous | Discharge
84
What are the features of an anastamotic leak?
Diffuse abdominal tenderness Guarding, rigidity Hypotensive Tachycardic
85
What are the features of a pelvic absces?
Pain, fever, sweats, mucus, diarrhoea
86
What is the presentation and treatment of a perianal abscess?
Tender, red swelling | Incise and drain
87
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
88
What are the features of IBS?
Recurrent abdominal pain and bloating Improves with defecation Change in frequency/consistency of stool No red flags
89
Do Pts with IBS get nocturnal symptoms?
No
90
Do Pts with IBD get nocturnal symptoms?
Yes (great question to ask in OSCEs)
91
What is the management for IBS?
Diet and lifestyle modification Abdo pain- anti-spasmotics Constipation- laxatives Diarrhoea- anti-diarrhoeals

Year 3 DPD (5 decks)

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