Gastro Flashcards
What is coeliac disease?
autoimmune reaction where exposure to gluten causes immune reaction = inflammation of epithelial cells in intestines
Pathology of coeliac?
immune system activated - cytokines released & epithelial cells damaged
anti gliadin + anti TTG + anti (EMA) endomysium antibodies
Histopathological presentation for coeliac?
villous atrophy
raised intra-epithelial lymphocytes,
crypt hyperplasia
Coeliac symptoms?
bi-phasal: babies (intro to bread) & older
malabsorption
iron deficiency anaemia
stomach bloating
diarrhoea - pale and greasy
dermatitis herpetiformis on arms and legs (deposit of IgA in skin)
Investigations for coeliac disease?
patient needs to have ≥ 1 gluten meals per day for 6 weeks
serology
1st - total IgA + tTG + anti-gliadin
2nd - anti-endomysial antibodies (EMA)
gold = gastroscopy - duodenal biopsies
Genetic & antibodies association of coeliac?
anti-TTG (1st line), anti-EMA (2nd line)
HLADQ8 & HLADQ2
Associated diseases with coeliac?
thyrotoxicosis + hypothyroidism
addison’s
osteoporosis
treatment for coeliac?
exclusive diet for life
What’s a diverticulum?
outpouches of colonic mucosa through a muscular wall
Differentiate diverticular disease with diverticulitis?
diverticular disease = symptomatic conditions of outpouches
diverticulitis = inflammation of the outpouches
Differentiate diverticulosis with diverticulum?
diverticulum = outpouches
diverticulosis = asymptomatic conditions of the outpouches
Diverticulitis risk factors?
low fibre diet !!
COPD
NSAIDs
old age
connective tissue disease
Diverticulitis - symptoms?
Left lower quadrant tenderness
low grade fever
rectal bleeding / blood in diarrhoea
constipation
Investigations for diverticulitis?
CT or colonoscopy
Treatment for diverticular diseases?
Diverticulosis (asymptomatic):
high fibre diet - whole grains + fluid
- *Diverticular disease**
- *1st line** bulk forming laxatives
- *gold** standard surgery
- *CI** = stimulants (sena)
Treatment for diverticulitis
(inflammation of the outpouches)?
- *Mild**
- 5 days co-amoxiclav, if allergic give cephalexin with metronidazole
- analgesic = not opiates or NSAIDs
- *Severe - blockage**
- nil by mouth or clear fluids
- IV fluids + antibiotics
- CT + surgery
Common causes of obstruction related to blockage?
tumour, gallstones
diaphragm disease - NSAID
inflammation - Crohn’s
fibrosis - contract then obstruct
Diverticulitis
(faeces trapped in inflamed wall)
What is bowel obstruction?
complete or partial disruption of the normal flow of gastrointestinal content
Common causes of obstruction from contraction?
inflammation
intramural tumours
hirschsprung’s disease
nerve to contract gone
no poo, swollen belly, green vomit (bile)
Common causes of obstruction related to pressure?
adhesions
common!!!
volvulus = bowel twist on itself
intussusception = intestine slide into another, redcurrent jelly stool, 6m-2y M
Symptoms of bowel obstruction?
vomiting, consti / abdo pain
tenesmus
= wanna poo but dont have any
tympanic percussion = air
distension, bloating and swelling
Investigations for bowel obstruction?
DRE = large bowel
X ray: erect chest radiograph, abdominal radiograph → gas
CT abdomen / pelvis
FBC, U&E, lactate
How would you manage bowel obstruction and what are some red flags?
Drip and suck = IV fluids & placement of NG tube
Surgical if obstructing lesion, evidence of ischaemia or perforation, or a closed-loop
🚩 = + HR, hypotension, fever, tenderness and swelling
What is irritable bowel disease?
chronic functional GI symptoms (in absence of organic disease) but no obvious cause
Symptoms of IBS?
Lower abdo pain
spasms, belly button or lower
Bloating commonly associated
Altered bowel habit
Investigations for IBS?
FBC, CRP, Coeliac serology!
Stool faecal calprotectin
= differentiates IBS x IBD
if 50-150 = interm = repeat
Stool microscopy, culture & sensitivity
then lower GI endoscopy
Treatment for IBS?
- *1st**
- *Loperamide** = antimotility for diarrhoea
- *Laxatives** for constipation - avoid lactulose
- *Antispasmodics** = hyoscine butylbromide
2nd = tricyclic antidepressants 3rd = SSRI
What is Inflammatory Bowel Disease?
chronic relapsing inflammatory disorder, primarily affecting gastrointestinal tract
Differentials of IBS?
Coeliac disease, IBD
Colorectal cancer
in women who are over 45 / post menopausal: ovarian cancer
Management IBD?
prophylactic low molecular weight heparin
= prevent DVT & PE
IV steroids = hydrocortisone
Complications of IBD?
anterior uveitis - painful red eyes, blurry vision
enteropathic arthritis
What is ulcerative colitis?
a type of IBD
autoimmune = p-ANCA positive!
continuous inflammation of the colonic mucosa
Present - ulcerative colitis?
diarrhoea - bloody, frequent bowel movements
LUQ Pain!
can present with clubbing & aphthous ulcers, erythema nodusum & amyloidosis
Investigations for UC?
GOLD = colonocscopy with mucosal biopsy
stool samples to exclude c diff & campylobacter
faecal calprotectin = indicates IBD
if too severe - abdominal X ray
What might you find on a biopsy for ulcerative colitis?
mucosa + submucosa only → ulcers
crypt abscess
depleted goblet cells
uniform heavy lymphoid infiltrates
continuous inflammation, no healthy regions
How might you treat a mild to moderate flare of UC?
1st line = 5-Aminosalicylates
sulphsalazine, mesalazine
2nd line = add corticosteroids
= gradually change dose based on severity, can’t use long term
3rd line = calcineurin inhibitor
= cyclosporin with corticosteroids
step up if no effect 2-4 weeks
How might you treat a severe flare of UC?
1st line = calcineurin inhibitor (cyclosporin) with steroids
adjuvant = immunosuppresive drugs if ≥ 2 flares / year, also remission!
1st azathioprine 2nd methotrexate
last = biological therapy
TNF alpha / infliximab / subcut golimumab
Surgical tx for UC?
if not responding to any tx
colectomy (colon removed) // panproctocolectomy
3 types of ulcerative colitis
by region affected?
What is Crohn’s disease?
chronic inflammatory GI disease characterised by transmural (all layers of mucosa) granulomatous inflammation with healthy sections of the gut in between = skip lesions
Key presentations of Crohn’s disease?
young, 20’s, positive fam history
mouth ulcers
right iliac fossa pain
mucus and watery diarrhoea
General extra intestinal symptoms for IBD?
erythema nodosum - leg rash
mouth ulcers & psoriasis = crohn’s
episcleritis, uveitis
arthritis / ankyspon
How might you investigate Crohn’s?
endoscopy + biopsy
faecal calprotectin (inflam marker) / faecal occult blood test
What might you find on a biopsy of crohn’s disease?
TRANSMEMBRANOUS inflammation
Skip lesions → not continuous
non-caseating granulomas → cobblestone appearance
Goblet cells present
lymphoid aggregates
Treatment in acute Crohn’s disease?
- *Steroids**
- *mild** = corticosteroids = budesonide
- *moderate** = glucocorticoids = prednisolone
severe = corticosteroids = IV hydrocortisone
if rectal disease = per rectum
if perianal abscess or perianal disease = metronidazole
last = anti-TNF = infliximab or adalimumab
Mechanism of anti-TNF antibodies in Crohn’s disease?
= infliximab, adalimumab
= reduce disease activity by countering neutrophil accumulation, granuloma formation, and activating complement
How might you maintain remission in Crohn’s disease?
1st = Azathioprine
2nd = Methotrexate (+ folic acid)
Methotrexate: mechanism of action?
inhibit dihydrofolate reductase
= converts folic acid → FH4
= prevent cellular replication
antiinflammatory & immunosuppression effects against ILs & cytokines
Why must folic acid be prescribed alongside methotrexate?
counteract folate-antagonist action of methotrexate
= reduce toxicity & improve compliance
= alt days to avoid reducing effectiveness of methotrexate
Crohn’s associations
changes in NOD-2 gene!!
Criteria for assessing severity in IBD?
Truelove & Witt’s criteria
Definitive tx IBD?
Surgical resection of inflammation
azathioprine with metronidazole 3m post-op
contraception during serious flare = methotrexate 3m after + monoclonal antibody & TNF alpha (F only, 6m after, cant breast feed)
What is a tropical spure and how will it present?
Severe malabsorption of 2 or more substances with malnutrition or diarrhoea
bloods = anaemia ( - B12, folate, iron)
jejunal biopsy = partial villous atrophy
Types of diarrhoea and what they signify
floating = fat (coeliac?)
watery = infection
blood = inflammation or cancer!
What investigations would you order for diarrhoea?
bloods - culture and CRP
Stool - culture and test for blood
General treatment for diarrhoea?
Fluid + electrolyte placement
antibiotics = vancomysin
barrier nursing = side room with gloves and apron
antimotility agents + antiemetics
How might you investigate colon cancer?
GOLD = endoscopy with biopsy
faecal occult blood screen
CT, barium enema
tumour markers = monitor progress
How might you treat colon cancer?
resection
mets could travel up
What is ischaemic colitis?
inflammation in large intestine or colon (from blocked arteries)
typically elderly, co-morbid patients with arrhythmia’s, hypotension or on vasopressors
Causes of ischaemic colitis?
atherosclerosis of superior or inferior mesenteric artery (most common)
thrombosis or emboli
decreased cardiac output & arrhythmias
How might ischaemic colitis present?
LLQ pain
bloody diarrhoea
How might you investigate ischaemic colitis?
GOLD = colonoscopy + biopsy
CT / MRI angiography
How might you treat ischaemic colitis?
fluid replacement
antibiotics
surgery for gangrene or perforation
What is gastritis?
Inflammation of the lining of the stomach
causes an UGIB
Causes of gastritis?
Mucosal ischaemia
helicobacter pylori
urease + protease
aspirin or NSAIDs induced
autoimmune gastritis
Risk factors for gastritis?
diabetes
travel + alcohol + older
NSAIDs + aspirin
stress + autoimmune
Presentation for gastritis?
epigastric pain (top middle)
diarrhoea - sudden, 3x per 24 hours
indigestion, vomiting, nausea
dever and malaise
dehydration
Investigations for gastritis?
GOLD = endoscopy
H pylori tests:
pylori stool antigen OR urea breath test
Faecal occult blood, CRP
How might you treat non-h pylori gastritis?
Fluid intake, small light non fatty meals, antimotility agents (CI if infective cause!!)
NSAID or aspirin cause - PPI or H2 receptor antagonist!!
How might you treat infective gastritis?
h pylori
Clarithromycin + amoxicillin (alt erythro) + PPI (omeprazole)
after last diarrhoea
miss work for 48 hours
no swimming 2 weeks
e coli
after 48hrs symptom free - 2 negative stool samples 24hrs apart - work
campylobacter jejuni
self limiting but if severe clarithromycin
Histopathology results
for peptic ulcer disease?
Abrupt lesions with normal adjacent mucosa
Villous abnormalities
Brunners gland hypertrophy - reduces the acidity of duodenum
Causes of peptic / duodenal ulcers?
Prolonged NSAID or aspirin use
H pylori infection = urease + protease
Zollinger Ellison syndrome = gastrinoma
How might you differentiate between a peptic / duodenal ulcer?
DUODENAL gets BETTER with eating
gastric gets worse when eating
Investigation for peptic ulcer?
1st line + gold standard
= endoscopy with biopsy
Investigations for duodenal ulcers?
1st line
urea breath test or faecal antigen test
= 2 weeks without PPI, 4 weeks without antibiotics
Symptoms of ulcers?
epigastric pain (differential = gastritis)
eating related pain
weight change
bloating
vomiting and nausea
Complications of the ulcers?
bleeding → hypovolaemic shock
perforation → inflam of surround
anterior = peritonitis
posterior = pancreatitis
respiratory distress = sepsis, air under diaphragm
gastric outlet obstruction = oedema + scarring
Differentiate between the location and arteries affected by each ulcer?
Gastric ulcer = left gastric artery
= lesser curve of stomach
Duodenal = gastroduodenal artery
= posterior wall
How might you treat a gastric ulcer?
3 STOP - caff alco smoke
also NSAIDs
PPI (alt H2 antagonist) 4 weeks
e.g. zole ending meds
Antibiotics for h pylori if needed
rescope 6-8 weeks after tx to check
If a gastric ulcer is healed post treatment following scope?
low dose PPI preventative
persistent symptoms = low dose PPI
PPI not tolerated = H2 antagonist
If a gastric ulcer is not healed post treatment?
suspect malignancy
try another h pylori regime
PPI for 4 more weeks
Cause of gastric cancer
Mutation in CDH1 = 80%
smoked foods, pickles
h pylori
pernicious anaemia
Symptoms of gastric carcinoma?
Haematemesis
melaena = black / dark red stool
from bleeding
dysphagia
jaundice = mets!
Investigations for gastric carcinoma?
Gastroscopy with biopsy
CT / MRI
Laparoscopic exploration
Treatment for gastric carcinoma?
3 cycles of chemo + surgery + lymph node removal
if surgical
proximal cancer = full gastrectomy
distal cancer = partial gastrectomy
after = B12 supplement as lack of intrinsic factor to prevent pernicious anaemia
What is GORD?
Gastro-oesophageal reflux disease (GORD)
reflux of stomach contents into the oesophagus
Pathology of GORD?
Inappropriate lower oesophageal sphincter relaxation
Acid = inflammation → scarring → esophageal stenosis
damage to lining = risk of neoplasia
Risk factors for GORD?
Meds
- CCB, antidepressants, glucocorticoids, antihista, benzodiazepines
hiatal hernia, scleroderma, zollinger-ellison
What is the Zollinger-Ellison syndrome?
Syndrome where excessive gastrin secretion, usually from a gastrinoma (at head pancreas, duodenum, com bile duct) , causes peptic ulcers - unusual place (jejunum) & refractory to tx
What is scleroderma?
= hardening of the skin
most patients also have systemic sclerosis = autoimmune inflam connective tissue disease
Symptoms of GORD
WORSE when lying flat
dysphagia, dyspepsia
chronic cough, nocturnal asthma
Investigations of GORD?
GOLD = oesophageal manometry
24h monitoring with probe down throat
1st = PPI
others
x ray with barium contrast
= shows stenosis and ulcers
gastroscopy if red flag
serum gastrin
Treatment for GORD?
GOLD = anti-reflux surgery - laparoscopic Nissen fundoplication
1st = PPI for a month (omeprazole)
2nd = H2 antagonist (ranitidine)
Lifestyle
- alcohol, small meals, - smoke, - weight
Complications of GORD?
Barrett’s esophagus
erosive oesophagitis / stricture
esophageal adenocarcinoma
laryngitis or asthma = acid moving into larynx
cardiopulmonary issues
perforation / bleed
What is dyspepsia?
Indigestion!
Causes of Dyspepsia?
excess: meals, acid
prolonged NSAIDs
obesity, smoking, alcohol
pregnancy
cancer
Non- red flag symptoms of dyspepsia?
Heartburn
bloating
acid taste
reflux when lying down
What are some red flag symptoms of dyspepsia?
unexplained weight loss
anaemia
dysphagia
persistent vomiting
bleeding
upper abdo mass
How should you treat dyspepsia with no red flags?
review meds, lifestyle advice
full dose PPI for a month
test and treat H pylori infection
How should you treat dyspepsia with red flags?
Endoscopy!
What is Barrett’s oesophagus?
squamous** epithelial lining of oesophagus being replaced by **metaplastic columnar epithelium
from persistent injury due to chronic reflux of stomach content
Risk factors & cause of Barrett’s oesophagus?
white male, smoking alcohol, obesity and GORD
cause = GORD
Change in cell type & name of the process from GORD → Barrett’s?
Squamous → metaplasia (goblet cells) → dysplastic (precancer) → neoplastic (cancer)
stratified squamous to columnar!!
Barrett’s oesophagus - symptoms & investigations?
dyspepsia, dysphagia
chest pain rare
endoscopy with biopsy
Barrett’s oesophagus - treatment
Non-dysplastic = PPI + surveillance
Low grade dysplasia = radiotherapy with mucosal resection
High grade dysplasia = radiotherapy with esophagectomy
Oesophageal carcinoma - risk factors?
Risk = GORD, Barrett’s, Alcohol, smoking, male, hiatal hernia
Oesophageal carcinoma - symptoms?
Dysphagia to solids then liquids
Odynophagia = painful swallowing
hoarse voice, hiccups, paroxysmal cough
GI bleed, reflux
typical cancer symptoms
Oesophageal carcinoma - investigations?
GOLD = endoscopy with biopsy
Barium swallow test
CT / MRI / PET for staging
Oesophageal carcinoma - treatments?
fit + mets = chemo + operate
unfit + mets = palliative care, stents help
What is achalasia?
Damage to the oesophageal nerves → lower eso sphincter fails to relax
dysphagia to solids and liquids
Symptoms of achalasia?
dysphagia
regurgitation
change in posture to help swallowing
pain in the chest
Investigations for achalasia?
Endoscopy
Barium swallow - will show birds beak shape (curved narrowing)
Treatment for Achalasia?
GOLD = surgery = pneumatic dilatation
cut valve / botox to relax valve / meds to relax valve
What are esophageal varices?
abnormal, dilated veins that occur at the lower end of the oesophagus
usually due to chronic liver disease & portal hypertension
Symptoms of oesophageal varices
haematemesis & maelena
Investigations for oesophageal varices?
Endoscopy
Treatment for oesophageal varices
small = watch & wait
m to L = non-selective beta blocker
+ band ligation
if acute bleed follow acute GI bleed protocol!
Acute GI bleed protocol?
ABATED
A- ABCDE (secure airway etc)
B - bloods
A - access
ideally 2x L bore cannulas
T - transfusions
antibio, blood
E - Endoscopy
urgent in 24 hours
D - Drugs
stop anticoag & NSAIDs
Other acute GI bleed things to do?
(and special for oesophageal varices?)
Rockall score to assess for rebleed
- *for oesophageal varices**:
- terlipressin / somatostain analogue
- broad spectrum antibiotics
Mallory Weiss tear - risk factors?
alcohol, chronic cough, bulimia
gastroenteritis
weight lifting
hyperemesis gravidarum
Mallory Weiss tear - symptoms?
haematemesis after vomiting
maelena - dark sticky faeces with digested blood
hypovolaemic shock
Treatment for Mallory Weiss tear?
resus + antiemetic + PPI
most heal in 24 hours as they’re minor
Summary - major causes of upper GI bleeds?
Peptic / duodenal ulcers - 50%
Gastritis = 20%
Oesophageal varices = 10%
Mallory Weiss tear = 5-10%
classic = haematemesis & melaena
Rarer causes of UGIB?
haemorrhagic telangiectasia (HHT)
= mucocutaneous telangiectasias (small, visible dilated blood vessels) & AV fistula. auto-dom
Gastric antral vascular ectasia (GAVE)
= severe acute and chronic gastrointestinal bleeding, watermelon look on endoscope = red tortuous ectatic vessels along the folds of the antrum
What is pancreatitis?
Inflammation of the pancreas
acute - from autodigestion by trypsin, released by pancreatic acinar cells
Causes of pancreatitis?
I GET SMASHED
idiopathic
gallstones, ethanol, trauma
steroids, mums/malignancy, autoimmune, scorpion stings, hypercalcaemia/hyperlipidemia, ERCP,
drugs - NSAIDs + diuretics + steroids
Most common causes of pancreatitis (3)?
Gallstones - women, older
Alcohol - men, younger
Post-ERCP
Pathology for alcohol caused pancreatitis?
low fluid + low bicarbonate + increase of zymogen secretion = thick pancreatic juices causing increase in pressure → release of trypsin & autodigestion
Pathology for gallstone caused pancreatitis?
If gallstone is lodged at sphincter of Oddi, then pancreatic duct is blocked → high pressure leads to release of trypsin and autodigestion
Acute pancreatitis - symptoms?
Epigastric pain radiation to the back - severe
nausea / vomiting
jaundice / scleral icterus
- *Cullen’s sign** = bruising around belly button,
- *Grey turner’s sign** = bruising around the flank
CI MORPHINE!! increase P of sphincter of oddi
Investigations for acute pancreatitis?
GOLD = ERCP (only if no obstruction!!)
1st line = LDH + amylase (3x) urine or serum! + lipase (more sens)
Criteria to assess severity of pancreatitis?
Glasgow score
determines mild, moderate or severe
Diagnosis of acute pancreatitis is based on?
2 out of 3:
characteristic severe epigastric pain radiating to the back
raised serum amylase and lipase
abdo contrast CT scan pathology
Acute pancreatitis - complications?
Pancreatic pseudocyst
palpable, CT, can rupture
Pancreatic abscess
by infection. fever + high WBC
sepsis, hypovolaemic shock = bleed, DIC, acute respiratory distress syndrome
= inflam = systemic leaky vessel = hard to breath = death
Acute pancreatitis - treatment?
Analgesia / fluids / bowel rest
Shock = catheter, ABC
Infection = antibiotics, oedematous = drain
Stones = ERCP
Causes of chronic pancreatitis (4)?
Inflammation - fibrosis - cirrhosis
acute to chronic
repeated alcohol abuse
cystic fibrosis
Symptoms of chronic pancreatitis?
can be asymptomatic
if epigastric pain - discrete attacks earlier, persistent later
pancreatic insufficiency = triad!!
= steatorrhea + pancreatic diabetes + calcifications
Investigations for chronic pancreatitis?
Abdo XR & CT = calcifications
ERCP / MRCP = HOLD
CRP
HbA1c = diabetes screen
do not check amylase & lipase! (normal or anything)
Treatment for chronic pancreatitis?
Abstinence + Analgesia
Obstruction = ERCP stent
Pancreatic enzyme replacement
Surgery - for pseudocysts, abscesses, severe obstruct / pain etc
Pancreatic cancer - risk factors?
Chronic pancreatitis
smoking, caffeine
alcohol diabetes
aspirin
Symptoms of pancreatic cancer?
Painless jaundice (head)
Body and tail symptom
= epigastric radiating to the bad, relieved by sitting forward
acute pancreatitis
weight loss
Investigations for pancreatic cancer?
Biopsy
ultrasound / CT
Cause of appendicitis?
Main cause = obstruction
faecolith (poo) / food / lymphoid hyperplasia
Infection and vaccines → stimulate follicle growth (e.g. pinworm)
Pathology for appendicitis?
Blockage → compression → ischaemia & necrosis
Infection → pus formation → WBC + → cells die → wall rupture
Symptoms of appendicitis?
Umbilical pain, migrate to right iliac fossa
worse on coughing!
McBurney’s point - tenderness
GI upset / constip / loss of app
vom naus / low grade fever / right iliac fossa pain = Murphy’s triad
Signs for appendicitis (3)?
Rosving’s sign = pressing left iliac fossa causes pain in right iliac fossa
Obturator sign = internal rotation of the flexed right thigh causes pain
Psoas sign = sit in left lateral position, extension of right thigh causes right iliac fossa pain
(Hop test - hopping or jumping causes abdo pain)
Complications for appendicitis?
Rupture = bacteria → peritoneum = peritonitis
→ rebound tender & abdo guarding
= muscle tense when apply P
Periappendiceal abscess = most common
Subphrenic abscess
Investigations for appendicitis?
CT / US
MRI if pregnant
(pregnant test before!)
Bloods = WBC + CRP + ESR raised
Treatment for appendicitis?
Appendectomy - laparoscopic, occasionally open
antibiotics
drain abscess
What are hernias?
When a body organ within the wall passes out of the cavity wall
Causes of hernias?
Muscle weakness
Body strain
= chronic cough, constipation, weight lifting
age
pregnancy
Classify the hernias and their treatment?
Reducible = can push back = no tx
Irreducible = cannot push back = tx
with surgery
Types of hernia?
Obstructed = bowel out of abdomen
Strangulation = out of wall, wall compromises blood supply
What is a hiatal hernia and classify it?
Sliding hiatal hernia = stomach and esophagus slide up into chest through diaphragm
Paraesophageal hernia = stomach squeeze through hiatus so it is paralell with part of esophagus = stangulation hernia!
Investigations for a hiatal hernia?
Barium swallow test → X ray
gastroscopy
Complications & tx of hiatus hernia?
gastric volvulus = twist on itself, bleeding
surgery
Differentiate between the locations of an inguinal hernia and a femoral hernia?
Inguinal hernia = superior and medial to pubic tubercle (UPCLOSE)
Femoral hernia = inferior and lateral to pubic tubercle
What are inguinal hernias?
Intestines & peritoneum push through and forms a bulge
more common in men!!
Differentiate between direct & indirect inguinal hernias?
Direct = medial to inferior epigastric muscles - thru superior inguinal ring
caused by weak abdo muscles, rarely strangulates
Indirect = lateral to inferior epigastric muscles - thru deep inguinal ring
caused by failure of process vaginalis to regress, can strangulate!!
Differentiate between direct & indirect inguinal hernias?
Direct = medial to inferior epigastric muscles - thru superior inguinal ring
caused by weak abdo muscles, rarely strangulates
Indirect = lateral to inferior epigastric muscles - thru deep inguinal ring (→ scrotum)
caused by failure of process vaginalis to regress, can strangulate!!
What are femoral hernias?
more common in females
below and lateral to pubic turbercle
often irreducible & strangulates
often with a cough impulse!!
(without = thrombophlebitis of a saphena varix)
What is an anal fissure?
tear in the anal sphincter
usually from hard stool
Symptoms of an anal fissue?
blood on wiping - red, light & streaky
often constipated, itchy bum, pain during defecation
Treatment for anal fissures?
1st line = stool softeners
What is a perianal abscess?
Infection in anal gland
Risk factors for perianal abscess?
Immunosuppression, IBD, IBM
Symptoms of a perianal abscess?
Pus in stool
constant anal pain
fever or chills
Nothing on physical examination!!
Treatment for perianal abscess?
Surgical removal & drain abscess
→ antibiotics might not work on something that’s walled off
What is a fistula?
Abnormal connection from one place to another
How is a fistula formed?
crypts inside colon → something stuck → infection → forms abscess → bigger = connection from inside colon to outside → fistula
Symptoms of a fistula?
Blood in stools, pus = infection
WILL be able to see from outside!!
Treatment for a fistula?
Drain infection, remove tract
If the hair in natal cleft irritates the skin, cyst is called?
Pliondial cyst
(abscess as it might make one)
How might you treat a pliondial cyst?
Asymptomatic watch and wait
Symptomatic = incision and drainage + analgesic
What are hemorrhoids?
Buldgy veins in anus which prolapse out of it
Risk factors for haemorrhoids?
constipation
increased abdominal pressure
Symptoms of haemorrhoids?
Bulging pain in anus, itchiness, bleeding (bright red on wiping)
Differentiate between internal & external haemorrhoids?
Internal = can’t see (unless prolapse)
less pain, can feel fullness in anus (not totally emptied)
External = can see
can’t sit down! much more painful
How might you investigate & treat a haemorrhoid?
Investigate - Anoscopy
Stool softeners & rubber band ligation
What is pseudomembranous colitis?
= not a real infection, usually by antibiotic abuse or c diff
Symptoms & treatment of pseudomembranous colitis?
watery diarrhoea (mind dehydration!)
fever
tx = stop antibiotics
Risk factors for a C Difficile infection?
Antibiotic use, C starting
PPI
Old, comorbidity
Long hospital stays
C diff infections - antibiotic causes?
clindamycin co-amoxiclav [cephalosporins] ciprofloxacin
[classes are - cephalosporin, fluoroquinolone, ampicillin / amoxicillin]
Investigations for a suspected C. Difficile infection?
GOLD = stool sample
severity = FBC & serum creatinine
Treatment for C Diff infections?
1st = oral vancomycin
2nd = oral fidaxomicin
if not = up dose vanco, add oral metronidazole
if 2 or more = consider faecal microbiota transplant
H pylori - type of bacteria?
Gram negative bacili with flagella
produces urease → ammonia which damages gastric mucosa
H pylori triggered diseases?
Gastritis
Peptic ulcer
gastric cancer
H pylori + low gastric acid
duodenal ulcer
H pylori + high gastric acid
Symptoms of H pylori infection?
Aches or burning pain
worse when empty stomach!
Bloating, weight loss and nausea
How would you investigate an H pylori infection
Urea breath test
Pylori stool antigen test
[1st line duodenal ulcer!]
Endoscopy
Blood test
How would you treat an H pylori infection?
Clarithromycin + Amoxicillin + PPI (omeprazole)
PPI selection indicators?
NOT omeprazole if with clopidrogrel
(- activation of latter, CYP450)
= lansoprazole, pantoprazole
SE Gi disturbances, headache, + risk fracture, prolonged = hypomagnesium = tetany & ventricular arrhy
PPI Indications of use?
1st tine tx & prev - peptic ulcer disease
symptomatic relief - GORD & dyspepsia
eradication of H pylori
Mechanism of action. PPI\s
Irreversibly inhibiting H+/K- ATPase in gastric parietal cell (= proton pump responsible for secreting H+ & generate gastric acid)
= complete suppression as to partial by H2 receptor antagonists
Indications for H2 antagonists?
= ranitidine
2nd tx prev - peptic ulcer disease
(1st = PPI )
2nd tx - GORD & dyspepsia
(PPI 1st & if more severe)
Mechanism of action, H2 antagonists?
= ranitidine
Reduces gastric acid secretion by regulating histamine = H2 receptor (on gastric parietal cell) which would activate the proton pump
partial suppressive as opposed to PPI = complete suppressive
What is a schistosomiasis?
(aka bilharzia)
Infection caused by a parasitic worm living in fresh water of tropical regions
Symptoms and tx of schistosomiasis?
fever, itchy red and raised rash
cough, diarrhoea
muscle and joint pain, tummy pain
self eliminating, but tx Praziquantel
If it’s just diarrhoea and water sports then?
Shigella
(esp if travel to Spain)
(symptom = infective gastroenteritis / dysentry)
Chest virus with diarrhoea in a child is likely caused by?
Rotavirus
General diarrhoea in an elderly person?
Norovirus
If watery diarrhoea and neurological signs?
Guillan-Barre
Causing organism if someone has diarrhoea and has had
- ingested raw chicken
- been near dirty water
- drank unpasteurised milk
- had shellfish
Campylobacter jejuni
Causing organism if someone has diarrhoea and has had
-uncooked poultry, dairy, eggs, meat, reptiles, seafood
Salmonella (spp. or enteritidis!)
Causing organism if someone has diarrhoea and has had ground beef & salads?
E coli
If rapid dementia and ingested ‘cooked’ beef?
Cruetzfeldt-Jakob disease
(umbrella including mad cow disease)
