Gashtro 2 Flashcards
1
Q
Describe the epidemiology of small bowel obstructions (SBO)
A
Most common bowel obstruction (60-75%)
2
Q
What are 4 causes of SBO?
A
- Adhesion (~60%) (due to previous abdo/pelvic surgery or abdo infection)2. Hernias (intestinal contents cannot pass through strangulated loop)3. Malignancy4. Crohn’s disease
3
Q
Describe the pathophysiology of intestinal obstructions
A
- Obstruction of bowel leads to distension above blockage due to build-up of fluid and contents- Causes increased pressure which pushes on the blood vessels within the bowel wall causing them to become compressed- Compressed vessels cannot supply blood resulting ischaemia and necrosis and eventually perforation
4
Q
What are 3 signs of SBO?
A
- Abdominal distension2. Increased bowel sounds (tinkling)3. Tenderness (suggests strangulation/risk of perforation)
5
Q
What are 3 symptoms of SBO?
A
- ‘Colicky’ pain higher in abdomen2. Profuse vomiting3. Constipation with no passage of gas (occurs later)
6
Q
What are the investigations for patients with SBO?
A
- Abdominal x-ray (1st line)- Examination of hernia orifices and rectum- FBC- Non contrast CT (gold standard - localises obstruction)
7
Q
What does an abdominal x-ray look like in patients with SBO?
A
- Central gas shadow that completely crosses lumen- No gas seen in large bowel- Distended loops proximal to obstruction- May see fluid levels within bowel
8
Q
What is the treatment for intestinal obstructions?
A
- Aggressive fluid resuscitation- Decompression of bowel (drip and suck, IV fluids with NG tube)- Analgesia and anti-emetics- Antibiotics- Laparotomy
9
Q
Describe the epidemiology of large bowel obstructions (LBO)
A
LBO due to malignancy much more common in the EU/West than in Africa
10
Q
What are 5 causes of LBO?
A
- Malignancy2. Volvulus (rotation/twisting of bowel on its mesenteric axis - commonly sigmoid colon)3. Diverticulitis4. Crohn’s disease5. Intussusception (bowel rolls inside of itself - almost exclusively in neonates/infants due to ‘softer’ bowels)
11
Q
What are 3 signs of LBO?
A
- Abdominal distension (much more than SBO)2. Palpable mass e.g. hernia (most common in LIF)3. Normal bowel sounds initially and eventually silent
12
Q
What are 3 symptoms of LBO?
A
- Abdominal pain in lower abdomen, especially LIF (more constant and diffuse than SBO)2. Vomiting3. Constipation with no passage of gas
13
Q
What are the investigations for patients with LBO?
A
- Abdominal x-ray (1st line)- Digital rectal exam (DRE)- FBC- CT (gold standard)
14
Q
What does an abdominal x-ray look like in patients with LBO?
A
- Peripheral gas shadows proximal to blockage- Caecum and ascending colon = distended
15
Q
What does a digital rectal exam (DRE) look like in patients with LBO?
A
- Empty rectum- Hard, compacted stools- Might be blood
16
Q
What is a pseudo-obstruction?
A
Condition in which a patient has symptoms of intestinal obstruction but does not actually have anything blocking the intestines
17
Q
What are 5 causes of pseudo-obstructions?
A
- Intra-abdo trauma2. Post-operative states e.g. paralytic ileus3. Intra-abdo sepsis4. Drugs e.g. opiates/antidepressants5. Electrolyte imbalances
18
Q
How do pseudo-obstructions present?
A
Identically to SBO/LBO
19
Q
What is the treatment for pseudo-obstruction?
A
Treat underlying cause
20
Q
What is Crohn’s disease?
A
Intermittent chronic inflammation of the entire GI tract
21
Q
Describe the epidemiology of Crohn’s disease
A
- Presentation mostly in 20s-40s- Common in Northern European- Jewish people = most affected group- 400/100,000 in UK- Affects females more than males
22
Q
What are 5 risk factors for Crohn’s disease?
A
- Smoking (2-4x greater risk)2. NSAIDs3. Jewish4. Female5. Family history
23
Q
What are 4 causes of inflammatory bowel disease?
A
- Genetics (stronger association in Crohn’s than UC)2. Stress3. Depression4. Immune response
24
Q
Describe the pathophysiology of Crohn’s disease
A
- Transmural inflammation with granulomata- Occurs anywhere in the GI tract- Skip lesions- Deep ulcers and fissures (cobblestone appearance)
25
What are 3 signs of Crohn's disease?
1. Bowel ulceration2. Abdominal tenderness3. Abdominal mass
26
What are are 2 symptoms of Crohn's disease (in the small bowel)?
1. Weight loss2. Abdominal pain
27
What is a symptom of Crohn's disease (in the terminal ileum)?
Right iliac fossa pain mimicking appendicitis
28
What are 2 symptoms of Crohn's disease (in the colon)?
1. Blood and mucous with diarrhoea 2. Pain
29
What are 2 extra-intestinal symptoms of Crohn's disease?
1. Clubbing2. Oral aphthous ulcers
30
What are 6 investigations for inflammatory bowel disease?
1. Sigmoidoscopy2. Colonoscopy with rectal biopsy (gold standard)3. Bloods (raised WCC/platelets/CRP/ESR)4. Stool samples5. Abdominal x-ray6. Faecal calprotectin = raised
31
What is the treatment for Crohn's disease?
- Stop smoking- Corticosteroids e.g. prednisolone (remission)- Anti-TNF antibodies e.g. infliximab, adalimumab (if no response to steroids)- Thiopurines e.g. azathioprine (maintain remission)- Surgery - resection/temporary ileostomy
32
What are 8 complications of Crohn's disease?
1. Bowel obstructions from strictures2. Short stature in children3. Osteoporosis4. Malabsorption5. Toxic dilatation6. Bowel perforation7. Abscess/fistula formation8. Colorectal cancer
33
What is ulcerative colitis?
Continuous chronic inflammation of only the colon
34
Describe the epidemiology of ulcerative colitis
- Higher incidence than Crohn's- Presentation mostly in teens-20s- Common in Northern European- Jewish people = most affected group- 400/100,000 in UK- Incidence is 3x higher in non-smokers
35
What are 3 risk factors for ulcerative colitis?
1. Family history2. NSAIDs3. Jewish
36
Describe the pathophysiology of ulcerative colitis
- Mucosal inflammation only- No granulomata - Starts at rectum, can progress as far as the ileocecal valve- Circumferential and continuous inflammation (no skip lesions)- Ulcers and pseudo-polyps in severe disease- Crypt abscesses and depleted goblet cells
37
What are 5 signs of ulcerative colitis?
1. 90% have PSC2. Tender, distended abdomenExtra-GI manifestations:3. Arthralgia4. Fatty liver5. Gallstone
38
What are 7 symptoms of ulcerative colitis?
1. Malaise2. Fever3. Anorexia4. Weight loss5. Pain in LLQ6. Abdominal cramps/discomfort7. Recurrent diarrhoea often with blood and mucus
39
What is the treatment for ulcerative colitis?
- Aminosalicylates e.g. mesalazine (intestinal anti-inflammatory - remission and relapse prevention)- Corticosteroids e.g. prednisolone (remission)- Thiopurines e.g. azathioprine and methotrexate (maintain remission)- Surgery - colectomy
40
What are 8 complications of ulcerative colitis?
1. Psychosocial and sexual problems2. Frequent relapse3. Colorectal cancer (risk doubled)4. Blood loss5. Perforation6. Toxic dilatation7. Pyoderma gangrenosum (painful ulcers)8. Erythema nodosum (tender red bumps)
41
What is the acronym for remembering Crohn's?
NESTSN - no blood/mucusE - entire GI tractS - skip lesionsT - terminal ileum is most affected, transmural inflammationS - smoking is a RF
42
What is the acronym for remembering ulcerative colitis?
CLOSE UPC - continuous inflammationL - limited to colon and rectumO - only superficial mucosa affectedS - smoking is protectiveE - excrete blood and mucusU - use aminosalicylatesP - primary sclerosing cholangitis association
43
What is irritable bowel syndrome (IBS)?
Mixed group of abdominal symptoms with no organic cause
44
Describe the epidemiology of IBS
- Age of onset under 40 years- More common in females- 1/5 in the Western World
45
What are 5 risk factors for IBS?
1. GI infections2. Previous severe long-term diarrhoea3. Anxiety and depression4. Psychological stress/trauma/abuse5. Eating disorders
46
What are 4 pathophysiology theories of IBS?
1. Disorders of intestinal motility2. Enhanced visceral perception3. Dysfunction of brain-gut axis4. Microbial dysbiosis (imbalance)
47
What are 7 differential diagnoses for IBS?
1. Coeliac disease2. Lactose intolerance3. Bile acid malabsorption4. IBD5. Colorectal cancer6. GI infection7. Pancreatic insufficiency
48
What is the diagnosis criteria of IBS?
Abdominal pain/discomfort associated with 2+ of:- Relieved by defecation- Altered stool form- Altered bowel frequency
49
What are 3 main symptoms of IBS?
ABC- Abdominal pain/discomfort- Bloating- Change in bowel habit
50
What is the difference between IBS-C, IBS-D and IBS-M?
IBS-C = with constipationIBS-D = with diarrhoeaIBS-M = mixed with alternating constipation and diarrhoea
51
What 4 things exacerbate symptoms of IBS?
1. Stress2. Menstruation3. Gastroenteritis4. Food
52
What are 8 symptoms of IBS?
1. Painful periods2. Bladder symptoms (frequency, urgency, nocturia, incomplete emptying)3. Back pain4. Joint hypermobility5. Fatigue6. Nausea7. Mucus in rectum/stool8. Hard/soft/mixed stool
53
What are 3 investigations for patients with IBS?
1. Bloods2. Faecal calprotectin = raised3. Colonoscopy
54
What is the treatment for mild IBS?
Dietary modifications:- Regular meals OR small frequent meals- Plenty of fluids- Avoid caffeinated, alcoholic, fizzy drinks- Avoid fermentable oligosaccharides, disaccharides, monosaccharides and polyols
55
What is the treatment for moderate IBS?
Pharmacotherapy- Antispasmodics (for pain/bloating) e.g. mebeverine, buscopan- Loperamide (for diarrhoea) e.g. imodium- Laxatives (for constipation) e.g. macrogol, docusate, sena
56
What are alternative laxative options for moderate IBS?
- Linaclotide if 12 months constipation not relieved by 2 different max dose laxative classes- Prucalopride when all other laxatives fail
57
What is the treatment for IBS-C?
Soluble fibre:- Dissolves in water- Broken down by bacteria- Soften stool- E.g. barley, oats, beans, prunes, figs
58
What is the treatment for IBS-D?
AVOID soluble fibre:- Makes diarrhoea worse- Doesn't dissolve in water- Passes through gut unchanged- Bulks up faeces- Increases gut motility- E.g. cereal, whole-wheat bread, lentils, apples, avacados
59
What is the treatment for IBS if ineffective?
- Tricyclic antidepressants (dampens down gut severity) e.g. amitriptyline, nortriptyline- SSRIs- CBT
60
What is coeliac disease?
Inflammation of the mucosa of the upper small bowel in response to gluten
61
Describe the epidemiology of coeliac disease
- ~1% of population in UK- Any age, peaks in infancy and 40-60 years- Familial link and risk - HLA-DQ2 and HLA-DQ8 association
62
What are 2 risk factors for coeliac disease?
1. Other autoimmune diseases2. IgA deficiency
63
Describe the pathophysiology of coeliac disease
- Autoimmune - T cell mediated- Intolerance to prolamin (in wheat, barley, rye, oats - component of gluten protein)- a-gliadin (type of prolamin) is resistant to digestion from protease enzymes (pepsin and chymotrypsin) in SI lumen- This passes through damaged epithelial walls into cells- Deaminated by transglutaminase- Interacts with APCs and activate gluten-sensitive CD4+ T cells- T cell produces pro inflammatory cytokines --> inflammatory cascade- Causes villous atrophy and crypt hyperplasia
64
What are the autoantibodies present in majority of coeliac patients?
Anti-TTG and anti-EMA (attack enzymes that repair damage in the body)
65
What are 5 signs of coeliac disease?
1. Malabsorption2. Steathorrhoea (increase in fat excretion in stools)3. Anaemia4. Failure to thrive (children)5. Osteomalacia
66
What are 9 symptoms of coeliac disease?
1. Weight loss2. Fatigue and weakness3. Diarrhoea4. Abdominal pain5. Bloating6. Nausea/vomiting7. Aphthous ulcers8. Angular stomatitis9. Dermatitis herpetiformis (raised red patch of skin)
67
What is the first line investigation for patients with coeliac disease?
Serum antibody testing:- IgA tissue transglutaminase (TTG)- IgA anti-EMA- Total IgA- Very high sensitivity and specificity
68
What is the gold standard investigation for patients with coeliac disease?
Duodenal biopsy- Endoscopically- +ve findings = villous atrophy, crypt hyperplasia, increased epithelial WBCs
69
What are other investigations for coeliac disease?
- FBC (low Hb/folate/ferritin/B12)- Genetic testing (HLA-DQ2 and HLA-DQ8)- DEXA scan
70
What is the treatment for coeliac disease?
- Lifelong gluten-free diet (avoid foods containing wheat, barley, rye, oats)- Correct vitamin deficiencies- Pneumococcal vaccine given (hyposplenism)
71
What are 5 complications of coeliac disease?
1. Anaemia2. Osteoporosis3. Hyposplenism4. Neuropathies5. Increased risk of malignancy
72
Which malignancies do patients with coeliac disease have a higher risk of?
1. T cell lymphoma (increased T cells in GI wall)2. Gastric, oesophageal, small bowel, colorectal cancer (increased cell turnover)
73
What is gastritis?
Inflammation of the stomach's mucosal lining
74
What are 6 causes of gastritis?
1. H. Pylori infection2. Autoimmune gastritis3. Viruses4. Duodeno-gastro reflux5. NSAIDs6. Stress
75
Describe the pathophysiology of gastritis
- H. Pylori lives in the gastric mucus- Secretes urease which splits urea in the stomach into CO2 and ammonia- Ammonia + H+ = ammonium- Ammonium, proteases, phospholipases and vacuolating cytotoxin A damages gastric epithelium- This causes an inflammatory response reducing mucosal defence- This also causes increased acid secretion
76
Describe the pathophysiology of autoimmune gastritis
- Affects the fundus and body of stomach - This leads to atrophic gastritis and loss of parietal cells with intrinsic factor deficiency - This results in pernicious anaemia
77
Describe the pathophysiology of gastritis due to aspirin/NSAIDs
- Aspirin/NSAIDs inhibit prostaglandins via the inhibition of cyclo-oxygenase- This results in less mucus production
78
What is the difference between acute and chronic gastritis?
Acute = associated with neutrophilic infiltrationChronic = associated with mononuclear cells (lymphocytes, plasma cells, macrophages)
79
What are 7 symptoms of gastritis?
Usually asymptomatic1. Functional dyspepsia (indigestion)2. Upper abdominal pain3. Nausea and vomiting4. Loss of appetite5. Haematemesis6. Abdominal bloating7. Autoimmune pernicious anaemia
80
What are the investigations for patients with gastritis?
- Endoscopy- Biopsy- H. Pylori urea breath test- H. Pylori stool antigen test
81
What is the treatment for gastritis?
- Eradication of H. Pylori (triple therapy): - Clarithromycin - Omeprazole - MetronidazoleORH2 antagonists (to reduce acid release)
82
What is a complication of gastritis?
Peptic ulcer
83
What is gastro-oesophageal reflux disease (GORD)?
Prolonged or current reflux of the gastric contents through the lower oesophageal sphincter to the oesophagus
84
Describe the epidemiology of GORD
2-3 times more common in men
85
What are 5 causes of GORD?
1. Complication of a hiatus hernia2. Smoking3. Alcoholism4. Obesity5. Pregnancy
86
Describe the pathophysiology of GORD
- Increase in transient lower oesophageal sphincter relaxations (due to reduced tone of LOS)- This results in reflux of gastric contents (gastric acid, bile, pepsin etc.)
87
What is the normal epithelial lining of the oesophagus and stomach?
Oesophagus = squamous (sensitive to effects of stomach acid)Stomach = columnar (more protected against stomach acid)
88
What are 6 symptoms of GORD?
1. Heartburn (related to lying down and meals)2. Odynophagia (pain when swallowing)3. Acid regurgitation4. Nocturnal asthma5. Chronic cough6. Laryngitis, sinusitis
89
What are 2 investigations for patients with GORD?
1. Endoscopy2. Barium swallow
90
What is the treatment for GORD?
- Smoking/alcohol cessation- Weight loss- Antacids - Proton pump inhibitors e.g. omeprazole- H2 receptor antagonist- Surgery to tighten the lower oesophageal sphincter (laparoscopic fundoplication)
91
What are 2 complications of GORD?
1. Oesophageal stricture formation (worsening dysphagia)2. Barrett's oesophagus (can develop into oesophageal cancer)
92
What is Barrett's oesophagus?
Normal squamous epithelium of distal oesophagus is replaced by abnormal columnar epithelium
93
What is the treatment for Barrett's oesophagus?
- Proton pump inhibitors e.g. omeprazole- Radiofrequency ablation (burn epithelial cells so they regenerate as normal stratified squamous cells)
94
What is a peptic ulcer?
Break in the gastric or duodenal mucosa in or adjacent to acid bearing area
95
Describe the epidemiology of peptic ulcers
Duodenal peptic ulcers are 2-3 times more common than gastric
96
What are 4 risk factors for gastric peptic ulcers?
1. H. Pylori (80% association)2. Smoking3. Drugs4. Stress
97
What are 4 risk factors for duodenal peptic ulcers?
1. H. Pylori (95% association)2. Smoking3. Drugs4. Alcohol
98
Describe the pathophysiology of peptic ulcers due to H. Pylori
- Increases gastric acid secretion- Disrupts mucous protective layer- Reduced duodenal bicarbonate production- Leads to acidic contents of the stomach/duodenum breaking down the mucosa
99
Describe the pathophysiology of peptic ulcers due to NSAIDs
- Reduced production of prostaglandins (which provide mucosal protection)- Leads to acidic contents of the stomach/duodenum breaking down the mucosa
100
What are 5 symptoms of peptic ulcers?
1. Burning epigastric pain2. Nausea3. Heartburn4. Flatulence5. Occasionally painless haemorrhage
101
What is the difference in burning epigastric pain between people with gastric peptic ulcers and duodenal peptic ulcers?
Gastric = worse on eating, relieved by antacidsDuodenal = worse when hungry/at night, relieved by eating/milk
102
What are 3 investigations for patients with peptic ulcers?
1. H. Pylori urea breath test2. H. Pylori stool antigen test3. Endoscopy
103
What is the treatment for peptic ulcers?
- Avoid NSAIDs- Smoking cessation- Eradication of H. Pylori (triple therapy): - Clarithromycin - Omeprazole - Metronidazole
104
What are 4 complications of peptic ulcers?
1. Upper GI bleed2. Haemorrhage3. Perforation4. Gastric outflow obstruction
105
What is a Mallory-Weiss Tear?
Mucosal lacerations in the upper GI tract causing bleeding/haematemesis
106
Describe the epidemiology of Mallory-Weiss Tears
- More common in males mainly between 20-50- 4-8% of all upper gastrointestinal bleeding
107
What are 4 causes of Mallory-Weiss Tears?
1. Hyperemesis gravidarum (severe nausea/vomiting in pregnancy)2. Gastroenteritis3. Bulimia4. Chronic cough
108
What are 3 risk factors for Mallory-Weiss Tears?
1. Excessive alcohol consumption2. Male3. NSAID abuse
109
Describe the pathophysiology of Mallory-Weiss Tears
- Sudden increased intragastric pressure within non-distensible oesophagus can cause tearing of the mucosa- Blood is able to enter the oesophagus
110
What is a sign of Mallory-Weiss Tears?
Postural hypotension
111
What are 5 symptoms of Mallory-Weiss Tears?
1. Haematemesis2. Melaena (black coloured stool)Symptoms of hypovolaemic shock:3. Dizziness4. Light headedness5. Syncope
112
What are 3 investigations for patients with Mallory-Weiss Tears?
1. Endoscopy2. Rockall score (assess blood level - <3 = low risk)3. FBC (haematocrit)
113
What is the treatment for Mallory-Weiss Tears?
- ABCDE- Tears/bleeds tend to heal rapidly (24 hours)- Surgery
114
What are 3 complications of Mallory-Weiss Tears?
1. Hypovolaemic shock2. Rebleeding3. MI
115
What are oesophageal varices?
Dilated veins at the junction between the portal and systemic venous systems leading to a variceal haemorrhage
116
Describe the epidemiology of oesophageal varices
- 90% of patients with cirrhosis develop this over 10 years (but only a third bleed)- 10-20% of all upper GI bleeding
117
What are 2 pre-hepatic causes of oesophageal varices?
1. Portal hypertension2. Portal vein thrombosis/obstruction
118
What are 2 hepatic causes of oesophageal varices?
1. Chronic liver disease (cirrhosis)2. Schistosomiasis
119
What are 4 post hepatic causes of oesophageal varices?
1. Budd Chiari2. RHF3. Constrictive pericarditis4. Compression
120
Describe the pathophysiology of oesophageal varices
- High pressure in portal vein- Vessels are thin and not meant to transport higher pressure blood- This causes damage and can lead to bleeding from the varices into the oesophagus- Rupture --> haematemesis --> blood digested --> melaena
121
Describe 6 clinical presentations of oesophageal varices
1. Liver disease2. Shock (low BP, high HR)3. Haematemesis (vomiting blood)4. Melaena5. Epigastric discomfort6. Pallor
122
What is the investigation for oesophageal varices?
Upper GI endoscopy
123
What is the medicinal treatment for oesophageal varices?
- Resuscitation/maintain airway- Beta blocker (to reduce CO and portal pressure)- Nitrate (to reduce portal pressure)
124
What is the surgical treatment for oesophageal varices?
- Band ligation- Trans jugular intrahepatic portosystemic shunt (TIPSS)
125
What are 2 complications of oesophageal varices?
1. 70% chance of rebleeding2. Significant risk of death
126
What is achalasia?
Oesophageal aperistalsis and failure of LOS to relax impairing oesophageal emptying
127
Describe the pathophysiology of achalasia
- Decreased ganglionic cells in the nerve plexus of the oesophageal wall- Degeneration of vagus nerve- Causes failure of small muscle relaxation
128
What are 4 symptoms of achalasia?
1. Long history of dysphagia for solids and liquids2. Retrosternal chest pain3. Weight loss4. Regurgitation
129
What are 2 investigations for patients with achalasia?
1. Barium swallow2. Oesophageal manometry
130
What is the treatment for achalasia?
- No cure- Treat symptoms- Surgical division of LOS and endoscopic balloon dilatation- Nitrates or botox (if surgery not an option)
131
What are 2 complications of achalasia?
1. Untreated --> inhalation of material in oesophagus --> choking2. Oesophageal cancer
132
What is ischaemic colitis?
Lack of blood supply to the colon causing inflammation and injury
133
Describe the epidemiology of ischaemic colitis
- More common in elderly- Related to underlying atherosclerosis and vessel occlusion
134
What are 5 causes of ischaemic colitis?
1. Atherosclerosis2. Thrombosis3. Emboli4. Decreased cardiac output and arrythmias5. Vasculitis
135
What are 3 risk factors for ischaemic colitis?
1. Contraceptive pill2. Vasculitis3. Thrombophilia
136
Describe the pathophysiology of ischaemic colitis
- Occlusion of a branch of the superior mesenteric artery or inferior mesenteric artery- = reduced blood flow (watershed area) to areas of the colon (usually splenic flexure and caecum)
137
What are 3 symptoms of ischaemic colitis?
1. LLQ abdominal pain2. Rectal bleeding (blood diarrhoea)3. Occasionally shock
138
What are 4 investigations for patients with ischaemic colitis?
1. Colonoscopy and biopsy (GOLD STANDARD)2. CT/MRI angiography3. Stool analysis4. Ultrasound and abdominal CT
139
What is the treatment for ischaemic colitis?
- Treat symptoms- Fluid replacement- Antibiotics (to reduce infection risks)- Possible anticoagulants- Surgery may be required for complications
140
What are 3 complications of ischaemic colitis?
1. Gangrene2. Perforation3. Stricture formation
141
What is acute mesenteric ischaemia?
Lack of blood supply to the small intestine
142
Describe the epidemiology of acute mesenteric ischaemia
>50 years
143
What are 6 causes of acute mesenteric ischaemia?
1. Superior mesenteric artery thrombosis2. Superior mesenteric artery embolism (due to AF)3. Mesenteric vein thrombosis4. Aortic dissection5. Hypotension6. Vasopressive drugs
144
What is a risk factor for acute mesenteric ischaemia?
Atrial fibrillation
145
Describe the pathophysiology of acute mesenteric ischaemia
- Rapid blockage in blood flow through the superior mesenteric artery- Prolonged ischaemia to the bowel will result in necrosis of bowel tissue and perforation
146
What is a sign of acute mesenteric ischaemia?
Rapid hypovolaemic shock
147
What is the main symptom of acute mesenteric ischaemia?
Acute, severe, non-specific abdominal pain
148
What are 4 investigations for patients with acute mesenteric ischaemia?
1. Contrast CT/MRI angiography2. Abdominal x-ray (to rule out bowel obstruction)3. Laparoscopy4. Bloods (metabolic acidosis, raised lactate)
149
What is the treatment for acute mesenteric ischaemia?
- Fluid resuscitation- Antibiotics e.g. metronidazole, gentamicin- IV heparin (to reduce clotting)- Surgery (remove necrotic bowel OR remove/bypass thrombus in blood vessel)
150
What are 3 complications and the mortality rate for acute mesenteric ischaemia?
1. Shock2. Sepsis3. PeritonitisPoor outcome with treatment = 50-80% mortality
151
What is chronic mesenteric ischaemia?
Lack of blood supply to the small intestine (a.k.a intestinal angina)
152
Describe the epidemiology of chronic mesenteric ischaemia
Average presentation of 60
153
What is the main cause of chronic mesenteric ischaemia?
Atherosclerosis
154
What are 5 risk factors for chronic mesenteric ischaemia?
Same usual CVD risk factors:1. Increased age2. Family history3. Smoking4. Hypertension5. Hypercholesterolaemia
155
Describe the pathophysiology of chronic mesenteric ischaemia
- Narrowing of mesenteric blood vessels via atherosclerosis- Can be all three major mesenteric arteries (coeliac, superior mesenteric, inferior mesenteric)
156
What is a sign of chronic mesenteric ischaemia?
Abdominal bruit upon auscultation
157
What are 2 symptoms of chronic mesenteric ischaemia?
1. Central colicky abdominal pain after eating2. Weight loss
158
What is the investigation for patients with chronic mesenteric ischaemia?
CT angiography
159
What is the treatment for chronic mesenteric ischaemia?
- Reduce modifiable risk factors e.g. smoking cessation- Surgery (revascularisation)- Nitrates and anticoagulants (if surgery is contraindicated)
160
What is appendicitis?
Inflammation of the appendix
161
What are 5 causes of appendicitis?
Obstruction within appendix due to:1. Faecoliths (mass of compacted faeces)2. Bezoars/foreign bodies3. Trauma4. Intestinal worms5. Lymphoid hyperplasia
162
Describe the pathophysiology of appendicitis
- Obstruction of appendix- = invasion of gut organisms into appendix wall- = inflammation, necrosis and eventually perforation
163
What are 3 signs of appendicitis?
1. Guarding2. Tender mass in RIF3. Peritonism (infection of inner lining of abdomen)
164
What are 4 symptoms of appendicitis regarding pain?
1. Early pain/discomfort around umbilicus that migrates to the RIF2. Severe, localised pain at McBurney's point3. Rosving's sign (RLQ pain elicited by pressure applied to LLQ)4. Moving/coughing causes pain
165
What are 3 symptoms of appendicitis (not pain)?
1. Anorexia2. Pyrexia (fever)3. Nausea and vomiting
166
What are 4 investigations for appendicitis?
1. Bloods (raised WCC/ESR/CRP)2. Ultrasound3. CT (GOLD STANDARD)4. Pregnancy test and urinalysis (to exclude pregnancy/UTI)
167
What is the treatment for appendicitis?
- Appendicectomy (GOLD STANDARD)- IV antibiotics and fluids both pre- and post-operatively e.g. metronidazole, cefuroxime
168
What are 6 complications of appendicitis?
1. Perforation2. Appendix mass (small bowel and omentum adhere to appendix)3. Appendiceal abscess4. Adhesions5. Pelvic inflammatory disease6. Peritonitis
169
What is a diverticulum (diverticula pl.)?
An out pouch/pocket of gut mucosa in the bowel wall (usually range from 0.5-1cm)
170
What is diverticulosis?
Presence of diverticula without inflammation or infection
171
What is diverticular disease?
Diverticulosis with patients experiencing symptoms
172
What is diverticulitis?
Inflammation and infection of diverticula
173
Describe the epidemiology of diverticular diseases
- Very common >50years- Two types = true and false
174
What are 5 risk factors for diverticular diseases?
1. Low fibre diet2. Obesity3. Age >404. Smoking 5. NSAIDs
175
Describe the pathophysiology of diverticular diseases
- Blood vessels penetrate circular muscle in the wall of the large intestine- When there is increased pressure in the lumens over time, gaps form- Mucosa herniates through the muscle layer and forms pouches (diverticula)- This mostly occurs in areas not covered by teniae coli (sigmoid and descending colon)- This can become inflamed (diverticulitis)
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What is the difference between true and false diverticular diseases?
True = all 3 layers of gutFalse = does not include muscularis layer therefore are thin walled (typically colonic diverticula)
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What are 2 signs of diverticulitis?
1. Tachycardia2. Palpable LIF mass
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What are 3 symptoms of diverticular disease?
1. Lower left abdominal pain2. Constipation3. Rectal bleeding
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What are 5 symptoms of diverticulitis?
1. LIF pain with tenderness2. Constipation/diarrhoea3. Nausea and vomiting4. Rectal bleeding5. Fever
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What are 4 investigations for patients with diverticular diseases?
1. CT2. Colonoscopy3. Bloods (raised WCC/ESR/CRP)4. CXR/AXR
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What is the treatment for diverticular disease?
- High fibre diet- Fluids +/- laxatives- Surgery
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What is the treatment for diverticulitis?
- Oral/IV antibiotics e.g. ciprofloxacin, metronidazole- Analgesia and liquid diet +/- fluid resuscitation- Surgical resection (rare)
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What are 6 complications of diverticulitis?
1. Perforation2. Peritonitis3. Peridiverticular abscess4. Large haemorrhage5. Fistula6. Ileus/obstruction
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What is Meckel's Diverticulum?
Congenital malformation of distal ileum caused by an incomplete obstruction of the vitelline duct
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Describe the epidemiology of Meckel's Diverticulum
- 2-3% of the population- Most common in 2 year olds
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Describe the pathophysiology of Meckel's Diverticulum
- True diverticula (all 3 layers of small intestines)- Out pouch/pocket of gut mucosa in bowel wall
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What is a symptom of Meckel's Diverticulum?
Usually asymptomatic- Painless bleeding due to ulcer caused by heterotopic gastric tissue
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What is the investigation for patients with Meckel's Diverticulum?
Nuclear medicine scan
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What is the treatment for Meckel's Diverticulum?
Removal if found incidentally during other abdominal operations
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What are 3 complications of Meckel's Diverticulum?
1. Rupture2. Volvulus (intestine twists around itself)3. Intussusception (part of intestine slides into adjacent part)
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What is diarrhoea?
Abnormal passage of loose/liquid stool more than 3 times daily
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What are the 3 main causes of diarrhoea?
1. Virus (majority)2. Bacteria3. Parasites
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What are 2 viral causes of diarrhoea?
1. Rotavirus (children)2. Norovirus (adults)
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What are 5 bacterial causes of diarrhoea?
1. Clostridium difficile (C. diff)2. Campylobacter jejuni (C. jejuni)3. E. Coli4. Salmonella5. Shigella
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Which 3 bacterial infections are associated with bloody diarrhoea?
1. E. Coli2. Salmonella3. Shigella
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What are 3 parasitic causes of diarrhoea?
1. Giardia lamblia2. Entamoeba histolytica3. Cryptosporidium
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What is the difference between acute and chronic diarrhoea?
Acute = <2 weeksChronic = >2 weeks
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What is the treatment for diarrhoea?
Usually self limiting- Treat underlying cause (bacterial diarrhoea = metronidazole)- Oral rehydration therapy - Anti-emetics e.g. metoclopramide- Anti-motility agents e.g. loperamide
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Describe the pathophysiology of Helicobacter Pylori
- Bacteria that lives in the gastric mucosa- Secretes urease which splits urea into CO2 and ammonia- Ammonia + H+ --> ammonium- Ammonium, proteases, phospholipases and vacuolating cytotoxin A = all damage gastric epithelium (disrupt mucous protective layer)- Gastric acid secretion increased (gastrin release, reduced duodenal bicarb production etc.)
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What are the investigations for patients with Helicobacter Pylori?
- H. Pylori urea breath test- H. Pylori stool antigen test
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What is the treatment for Helicobacter Pylori?
Triple therapy:- Clarithromycin- Omeprazole- Metronidazole
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Describe the epidemiology of colorectal cancer
- 4th most prevalent cancer in UK- Most common in rectum and sigmoid colon (left side of colon)
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What are 8 risk factors for colorectal cancer?
1. Family history2. Genetics3. IBD4. Increasing age5. Diet high in red/processed meat and low in fibre6. Obesity/sedentary lifestyle7. Smoking8. Alcohol
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What are the 2 genetic risk factors for colorectal cancer?
1. Familial adenomatous polyposis (FAP)2. Hereditary nonpolyposis colorectal cancer (HNPCC) a.k.a Lynch syndrome
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What is familial adenomatous polyposis?
- Autosomal dominant- Malfunctioning of tumour suppressor gene (APC)- = lots of adenomas develop along large intestine
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What is hereditary nonpolyposis colorectal cancer a.k.a Lynch syndrome?
- Autosomal dominant- Mutations in DNA mismatch repair genes
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What are the 6 red flags for colorectal cancer?
1. Change in bowel (usually looser/more frequent)2. Unexplained weight loss3. Rectal bleeding (left side)4. Unexplained abdominal pain5. Iron deficiency anaemia (right side)6. Abdominal/rectal mass on examination
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What are 3 other symptoms of colorectal cancer?
Obstruction:1. Vomiting2. Abdominal pain3. Absolute constipation
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What are the 2 main investigations for patients with colorectal cancer?
1. Faecal immunochemical test (FIT)2. Colonoscopy with biopsy
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What are 4 other investigations for patients with colorectal cancer?
1. Sigmoidoscopy2. CT colonography3. Staging CT scan (CT TAP)4. Carcinoembryonic antigen (CEA) tumour marker blood test (used for predicting relapse)
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Describe TNM classification
T - tumour- TX = unable to assess size- T1 = submucosa involvement- T2 = involvement of muscularis propria - T3 = involvement of subserosa and serosa- T4 = spread through serosa (4a), reached other tissues/organs (4b)N - nodes- NX - unable to assess nodes- N0 = no nodal spread- N1 = spread to 1-3 nodes- N2 = spread to more than 3 nodesM - metastasis- M0 = no metastasis- M1 = metastasis
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What is the treatment for colorectal cancer?
- Surgical resection- Chemotherapy- Radiotherapy- Palliative care
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What are 3 complications of colorectal cancer?
1. General surgery complications2. Low anterior resection syndrome3. Local invasion and distant metastases often to liver and lung
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What is low anterior resection syndrome?
May occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectumCauses:- Increased urgency/frequency of bowel movements- Faecal incontinence- Difficulty controlling flatulence
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What are 6 risk factors for gastric cancer?
1. Male2. H. Pylori3. Chronic/atrophic gastritis4. Genetics5. Smoking6. Pernicious anaemia
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Describe the pathophysiology of gastric cancer
- 90% are adenocarcinomas- Most involve pylorus
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What are 3 signs of gastric cancer?
1. Epigastric mass2. Hepatomegaly3. Troisier's sign (enlarged left supraclavicular nodes)
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What are 6 symptoms of gastric cancer?
1. Epigastric pain2. Dyspepsia/dysphagia3. Nausea/vomiting/diarrhoea4. Weight loss/anorexia5. Anaemia6. Jaundice
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What are 2 investigations for patients with gastric cancer?
1. Gastroscopy with biopsy2. CT/MRI to stage cancer
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What is the treatment for gastric cancer?
- Gastrectomy (partial/total) with perioperative chemo- Nutritional support
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What are 3 risk factors for squamous oesophageal cancer?
1. Smoking2. Alcohol3. Nitrous amines (barbecue food, tobacco)
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What are 2 risk factors for adenocarcinoma oesophageal cancer?
1. Barrett's oesophagus2. Obesity
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What are 5 symptoms of late oesophageal cancer?
1. Dysphagia2. Weight loss3. Heartburn4. Haematemesis5. Hoarse voice
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What are 2 investigations for patients with oesophageal cancer?
1. Oesophagoscopy with biopsy2. CT/MRI to stage cancer
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What is the treatment for oesophageal cancer?
Oesophagectomy with perioperative chemo
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What is pseudomembranous colitis?
Swelling/inflammation of the large intestine due to a bacterial/viral infection
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What is the main cause of pseudomembranous colitis?
Overgrowth of clotridioides difficile bacteria induced with antibiotic use
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What is another less common cause of pseudomembranous colitis?
Cytomegalovirus (CMV) infection
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What is Clostridioides/Clostridium difficile a.k.a C. diff?
Gram +ve spore forming bacteria
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Describe the pathophysiology of pseudomembranous colitis
- Antibiotic use kills normal gut flora allowing C. diff to over grow - This causes inflammation of the colon- Highly infectious
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What are 2 symptoms of pseudomembranous colitis?
1. Severe diarrhoea --> dehydration (MAIN)2. CMV --> owl's eye appearance of inclusion bodies
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What is the treatment for pseudomembranous colitis?
Stop using antibiotics and take vancomycin instead (antibiotic likely to be effective against C. diff)
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What are haemorrhoids (piles)?
Enlarged vascular mucosal cushions in the anal canal
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What are 4 risk factors for haemorrhoids (piles)?
1. Constipation2. Prolonged straining3. Increased abdominal pressure (ascites)4. Heavy lifting
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Describe the pathophysiology of haemorrhoids (piles)
- Vascular mucosal cushions function to maintain anal continence- When they enlarge, the vessels are brought close to abrasion and can bleed into the anus
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What is the difference between internal and external haemorrhoids (piles)?
Internal = above dentate lineExternal = below dentate line
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What are the clinical presentations for haemorrhoids (piles)?
Internal = painless unless strangulatedExternal = painful, itchy and visible on external examination
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How are internal haemorrhoids (piles) classified?
1st degree = no prolapse2nd degree = prolapse on straining, spontaneous reduction3rd degree = prolapse on straining, manual reduction4th degree = permanently prolapse, no reduction
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What are the investigations for patients with haemorrhoids (piles)?
- Digital rectal examination- Proctoscopy
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What is the treatment for haemorrhoids (piles)?
- Increase fluids and fibre- Pain relief- Rubber band ligation- Haemorrhoidectomy
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What are 3 complications of haemorrhoids (piles)?
- Skin tags- Strangulation (internal)- Gangrene (external)
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What is an anal fistula?
Abnormal 'passage' between inside of anus and elsewhere, commonly subcutaneous skin
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What are 2 symptoms of anal fistulae?
1. Bloody/mucus discharge2. Pain
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What is the treatment for anal fistulae?
- Surgical removal/drainage- Antibiotics if infected
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What is an anal fissure?
Tear in the mucosa of the anal canal
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What are 3 causes of anal fissures?
1. Constipation = hard stool can tear anal mucosa2. IBD = ulceration as part of inflammation3. Rectal malignancy
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Describe the pathophysiology of anal fissures
- Blood vessels of anal mucosa are very close to the surface- Lesions can cause bleeding under the pressure of defecation
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What are 2 symptoms of anal fissures?
1. Pain on defecation2. Bright red blood on defecation
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What is the treatment for anal fissures?
- Pain releief- Increase fibre and fluids
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What are 2 complications of anal fissures?
1. Recurrence2. Anorectal/perianal abscess
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What is a perianal/anorectal abscess?
Collection of pus in anal/rectal region
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What is the cause of perianal/anorectal abscesses?
Infection of an anal fissure
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What are 5 risk factors for perianal/anorectal abscesses?
1. Diabetes2. STI3. Immunocompromised4. IBD5. Male
254
Describe the pathophysiology of perianal/anorectal abscesses
- Infection of one of the anal sinuses- Leads to inflammation- Causes formation of abscess
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What are 6 clinical presentations of perianal/anorectal abscesses?
1. Painful, hardened tissue in perianal area2. Discharge of pus from rectum3. Lump/nodules4. Tenderness5. Fever6. Constipation
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What is the investigation for perianal/anorectal abscesses?
Digital rectal examination (DRE)
257
What is the treatment for perianal/anorectal abscesses?
- Surgical drainage- Pain relief
258
What is a complication of perianal/anorectal abscesses?
Anal fistula (40%)
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What is a pilonidal sinus/abscess?
Obstruction of natural hair follicles above the anus (congenital)
260
Describe the epidemiology of pilonidal sinuses/abscesses
- 10:1 male to female ratio- More common in Caucasian people
261
What are 3 risk factors for pilonidal sinuses/abscesses?
- Male- Obese - Caucasian
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What is the clinical presentation of non infected pilonidal sinuses/abscesses?
- Small hole about 6cm above anus - No symptoms
263
What are 4 extra clinical presentations of infected pilonidal sinuses/abscesses?
1. Pus filled abscess2. Pain3. Redness4. Swelling
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Describe the pathophysiology of pilonidal sinuses/abscesses
Ingrowth of hair excites a foreign body reaction and causes abscess with foul smelling discharge
265
What is the treatment for pilonidal sinuses/abscesses?
Asymptomatic = keep clean and shave hair around areaInfected = excision of sinus tract and closure (skin flap used to cover defect)
