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Phase 2A > Gastro > Flashcards

Gastro Flashcards

1
Q

What is coeliac disease?

A

autoimmune reaction where exposure to gluten causes immune reaction = inflammation of epithelial cells in intestines

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2
Q

Pathology of coeliac?

A

immune system activated - cytokines released & epithelial cells damaged

anti gliadin + anti TTG + anti (EMA) endomysium antibodies

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3
Q

Histopathological presentation for coeliac?

A

villous atrophy

raised intra-epithelial lymphocytes,

crypt hyperplasia

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4
Q

Coeliac symptoms?

A

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)

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5
Q

Investigations for coeliac disease?

A

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

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6
Q

Genetic & antibodies association of coeliac?

A

anti-TTG (1st line), anti-EMA (2nd line)

HLADQ8 & HLADQ2

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7
Q

Associated diseases with coeliac?

A

thyrotoxicosis + hypothyroidism

addison’s

osteoporosis

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8
Q

treatment for coeliac?

A

exclusive diet for life

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9
Q

What’s a diverticulum?

A

outpouches of colonic mucosa through a muscular wall

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10
Q

Differentiate diverticular disease with diverticulitis?

A

diverticular disease = symptomatic conditions of outpouches

diverticulitis = inflammation of the outpouches

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11
Q

Differentiate diverticulosis with diverticulum?

A

diverticulum = outpouches

diverticulosis = asymptomatic conditions of the outpouches

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12
Q

Diverticulitis risk factors?

A

low fibre diet !!

COPD
NSAIDs
old age
connective tissue disease

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13
Q

Diverticulitis - symptoms?

A

Left lower quadrant tenderness
low grade fever

rectal bleeding / blood in diarrhoea
constipation

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14
Q

Investigations for diverticulitis?

A

CT or colonoscopy

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15
Q

Treatment for diverticular diseases?

A

Diverticulosis (asymptomatic):
high fibre diet - whole grains + fluid

  • *Diverticular disease**
  • *1st line** bulk forming laxatives
  • *gold** standard surgery
  • *CI** = stimulants (sena)
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16
Q

Treatment for diverticulitis
(inflammation of the outpouches)?

A
  • *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
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17
Q

Common causes of obstruction related to blockage?

A

tumour, gallstones

diaphragm disease - NSAID

inflammation - Crohn’s
fibrosis - contract then obstruct

Diverticulitis
(faeces trapped in inflamed wall)

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18
Q

What is bowel obstruction?

A

complete or partial disruption of the normal flow of gastrointestinal content

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19
Q

Common causes of obstruction from contraction?

A

inflammation

intramural tumours

hirschsprung’s disease
nerve to contract gone
no poo, swollen belly, green vomit (bile)

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20
Q

Common causes of obstruction related to pressure?

A

adhesions
common!!!

volvulus = bowel twist on itself

intussusception = intestine slide into another, redcurrent jelly stool, 6m-2y M

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21
Q

Symptoms of bowel obstruction?

A

vomiting, consti / abdo pain

tenesmus
= wanna poo but dont have any

tympanic percussion = air
distension, bloating and swelling

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22
Q

Investigations for bowel obstruction?

A

DRE = large bowel

X ray: erect chest radiograph, abdominal radiograph → gas
CT abdomen / pelvis

FBC, U&E, lactate

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23
Q

How would you manage bowel obstruction and what are some red flags?

A

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

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24
Q

What is irritable bowel disease?

A

chronic functional GI symptoms (in absence of organic disease) but no obvious cause

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25
Q

Symptoms of IBS?

A

Lower abdo pain
spasms, belly button or lower

Bloating commonly associated

Altered bowel habit

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26
Q

Investigations for IBS?

A

FBC, CRP, Coeliac serology!

Stool faecal calprotectin
= differentiates IBS x IBD
if 50-150 = interm = repeat

Stool microscopy, culture & sensitivity

then lower GI endoscopy

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27
Q

Treatment for IBS?

A
  • *1st**
  • *Loperamide** = antimotility for diarrhoea
  • *Laxatives** for constipation - avoid lactulose
  • *Antispasmodics** = hyoscine butylbromide
2nd = tricyclic antidepressants
3rd = SSRI
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28
Q

What is Inflammatory Bowel Disease?

A

chronic relapsing inflammatory disorder, primarily affecting gastrointestinal tract

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29
Q

Differentials of IBS?

A

Coeliac disease, IBD

Colorectal cancer

in women who are over 45 / post menopausal: ovarian cancer

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30
Q

Management IBD?

A

prophylactic low molecular weight heparin
= prevent DVT & PE

IV steroids = hydrocortisone

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31
Q

Complications of IBD?

A

anterior uveitis - painful red eyes, blurry vision

enteropathic arthritis

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32
Q

What is ulcerative colitis?

A

a type of IBD

autoimmune = p-ANCA positive!

continuous inflammation of the colonic mucosa

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33
Q

Present - ulcerative colitis?

A

diarrhoea - bloody, frequent bowel movements

LUQ Pain!

can present with clubbing & aphthous ulcers, erythema nodusum & amyloidosis

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34
Q

Investigations for UC?

A

GOLD = colonocscopy with mucosal biopsy

stool samples to exclude c diff & campylobacter
faecal calprotectin = indicates IBD

if too severe - abdominal X ray

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35
Q

What might you find on a biopsy for ulcerative colitis?

A

mucosa + submucosa only → ulcers

crypt abscess
depleted goblet cells
uniform heavy lymphoid infiltrates

continuous inflammation, no healthy regions

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36
Q

How might you treat a mild to moderate flare of UC?

A

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

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37
Q

How might you treat a severe flare of UC?

A

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

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38
Q

Surgical tx for UC?

A

if not responding to any tx

colectomy (colon removed) // panproctocolectomy

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39
Q

3 types of ulcerative colitis
by region affected?

A
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40
Q

What is Crohn’s disease?

A

chronic inflammatory GI disease characterised by transmural (all layers of mucosa) granulomatous inflammation with healthy sections of the gut in between = skip lesions

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41
Q

Key presentations of Crohn’s disease?

A

young, 20’s, positive fam history

mouth ulcers
right iliac fossa pain

mucus and watery diarrhoea

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42
Q

General extra intestinal symptoms for IBD?

A

erythema nodosum - leg rash

mouth ulcers & psoriasis = crohn’s

episcleritis, uveitis

arthritis / ankyspon

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43
Q

How might you investigate Crohn’s?

A

endoscopy + biopsy

faecal calprotectin (inflam marker) / faecal occult blood test

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44
Q

What might you find on a biopsy of crohn’s disease?

A

TRANSMEMBRANOUS inflammation

Skip lesions → not continuous

non-caseating granulomas → cobblestone appearance

Goblet cells present

lymphoid aggregates

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45
Q

Treatment in acute Crohn’s disease?

A
  • *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

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46
Q

Mechanism of anti-TNF antibodies in Crohn’s disease?

A

= infliximab, adalimumab

= reduce disease activity by countering neutrophil accumulation, granuloma formation, and activating complement

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47
Q

How might you maintain remission in Crohn’s disease?

A

1st = Azathioprine

2nd = Methotrexate (+ folic acid)

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48
Q

Methotrexate: mechanism of action?

A

inhibit dihydrofolate reductase
= converts folic acid → FH4
= prevent cellular replication

antiinflammatory & immunosuppression effects against ILs & cytokines

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49
Q

Why must folic acid be prescribed alongside methotrexate?

A

counteract folate-antagonist action of methotrexate
= reduce toxicity & improve compliance

= alt days to avoid reducing effectiveness of methotrexate

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50
Q

Crohn’s associations

A

changes in NOD-2 gene!!

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51
Q

Criteria for assessing severity in IBD?

A

Truelove & Witt’s criteria

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52
Q

Definitive tx IBD?

A

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)

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53
Q

What is a tropical spure and how will it present?

A

Severe malabsorption of 2 or more substances with malnutrition or diarrhoea

bloods = anaemia ( - B12, folate, iron)
jejunal biopsy = partial villous atrophy

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54
Q

Types of diarrhoea and what they signify

A

floating = fat (coeliac?)

watery = infection

blood = inflammation or cancer!

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55
Q

What investigations would you order for diarrhoea?

A

bloods - culture and CRP

Stool - culture and test for blood

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56
Q

General treatment for diarrhoea?

A

Fluid + electrolyte placement

antibiotics = vancomysin

barrier nursing = side room with gloves and apron

antimotility agents + antiemetics

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57
Q

How might you investigate colon cancer?

A

GOLD = endoscopy with biopsy

faecal occult blood screen

CT, barium enema

tumour markers = monitor progress

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58
Q

How might you treat colon cancer?

A

resection

mets could travel up

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59
Q

What is ischaemic colitis?

A

inflammation in large intestine or colon (from blocked arteries)

typically elderly, co-morbid patients with arrhythmia’s, hypotension or on vasopressors

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60
Q

Causes of ischaemic colitis?

A

atherosclerosis of superior or inferior mesenteric artery (most common)

thrombosis or emboli

decreased cardiac output & arrhythmias

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61
Q

How might ischaemic colitis present?

A

LLQ pain

bloody diarrhoea

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62
Q

How might you investigate ischaemic colitis?

A

GOLD = colonoscopy + biopsy

CT / MRI angiography

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63
Q

How might you treat ischaemic colitis?

A

fluid replacement

antibiotics

surgery for gangrene or perforation

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64
Q

What is gastritis?

A

Inflammation of the lining of the stomach

causes an UGIB

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65
Q

Causes of gastritis?

A

Mucosal ischaemia

helicobacter pylori
urease + protease

aspirin or NSAIDs induced

autoimmune gastritis

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66
Q

Risk factors for gastritis?

A

diabetes

travel + alcohol + older

NSAIDs + aspirin

stress + autoimmune

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67
Q

Presentation for gastritis?

A

epigastric pain (top middle)

diarrhoea - sudden, 3x per 24 hours

indigestion, vomiting, nausea

dever and malaise

dehydration

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68
Q

Investigations for gastritis?

A

GOLD = endoscopy

H pylori tests:
pylori stool antigen OR urea breath test

Faecal occult blood, CRP

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69
Q

How might you treat non-h pylori gastritis?

A

Fluid intake, small light non fatty meals, antimotility agents (CI if infective cause!!)

NSAID or aspirin cause - PPI or H2 receptor antagonist!!

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70
Q

How might you treat infective gastritis?

A

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

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71
Q

Histopathology results
for peptic ulcer disease?

A

Abrupt lesions with normal adjacent mucosa

Villous abnormalities

Brunners gland hypertrophy - reduces the acidity of duodenum

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72
Q

Causes of peptic / duodenal ulcers?

A

Prolonged NSAID or aspirin use

H pylori infection = urease + protease

Zollinger Ellison syndrome = gastrinoma

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73
Q

How might you differentiate between a peptic / duodenal ulcer?

A

DUODENAL gets BETTER with eating

gastric gets worse when eating

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74
Q

Investigation for peptic ulcer?

A

1st line + gold standard

= endoscopy with biopsy

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75
Q

Investigations for duodenal ulcers?

A

1st line

urea breath test or faecal antigen test

= 2 weeks without PPI, 4 weeks without antibiotics

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76
Q

Symptoms of ulcers?

A

epigastric pain (differential = gastritis)

eating related pain

weight change

bloating

vomiting and nausea

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77
Q

Complications of the ulcers?

A

bleeding → hypovolaemic shock

perforation → inflam of surround
anterior = peritonitis
posterior = pancreatitis

respiratory distress = sepsis, air under diaphragm

gastric outlet obstruction = oedema + scarring

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78
Q

Differentiate between the location and arteries affected by each ulcer?

A

Gastric ulcer = left gastric artery
= lesser curve of stomach

Duodenal = gastroduodenal artery
= posterior wall

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79
Q

How might you treat a gastric ulcer?

A

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

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80
Q

If a gastric ulcer is healed post treatment following scope?

A

low dose PPI preventative

persistent symptoms = low dose PPI

PPI not tolerated = H2 antagonist

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81
Q

If a gastric ulcer is not healed post treatment?

A

suspect malignancy

try another h pylori regime

PPI for 4 more weeks

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82
Q

Cause of gastric cancer

A

Mutation in CDH1 = 80%

smoked foods, pickles

h pylori

pernicious anaemia

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83
Q

Symptoms of gastric carcinoma?

A

Haematemesis

melaena = black / dark red stool
from bleeding

dysphagia

jaundice = mets!

84
Q

Investigations for gastric carcinoma?

A

Gastroscopy with biopsy

CT / MRI

Laparoscopic exploration

85
Q

Treatment for gastric carcinoma?

A

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

86
Q

What is GORD?

A

Gastro-oesophageal reflux disease (GORD)

reflux of stomach contents into the oesophagus

87
Q

Pathology of GORD?

A

Inappropriate lower oesophageal sphincter relaxation

Acid = inflammation → scarring → esophageal stenosis

damage to lining = risk of neoplasia

88
Q

Risk factors for GORD?

A

Meds
- CCB, antidepressants, glucocorticoids, antihista, benzodiazepines

hiatal hernia, scleroderma, zollinger-ellison

89
Q

What is the Zollinger-Ellison syndrome?

A

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

90
Q

What is scleroderma?

A

= hardening of the skin
most patients also have systemic sclerosis = autoimmune inflam connective tissue disease

91
Q

Symptoms of GORD

A

WORSE when lying flat

dysphagia, dyspepsia

chronic cough, nocturnal asthma

92
Q

Investigations of GORD?

A

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

93
Q

Treatment for GORD?

A

GOLD = anti-reflux surgery - laparoscopic Nissen fundoplication

1st = PPI for a month (omeprazole)

2nd = H2 antagonist (ranitidine)

Lifestyle
- alcohol, small meals, - smoke, - weight

94
Q

Complications of GORD?

A

Barrett’s esophagus

erosive oesophagitis / stricture

esophageal adenocarcinoma
laryngitis or asthma = acid moving into larynx

cardiopulmonary issues

perforation / bleed

95
Q

What is dyspepsia?

A

Indigestion!

96
Q

Causes of Dyspepsia?

A

excess: meals, acid

prolonged NSAIDs

obesity, smoking, alcohol

pregnancy

cancer

97
Q

Non- red flag symptoms of dyspepsia?

A

Heartburn

bloating

acid taste

reflux when lying down

98
Q

What are some red flag symptoms of dyspepsia?

A

unexplained weight loss
anaemia
dysphagia

persistent vomiting
bleeding

upper abdo mass

99
Q

How should you treat dyspepsia with no red flags?

A

review meds, lifestyle advice

full dose PPI for a month

test and treat H pylori infection

100
Q

How should you treat dyspepsia with red flags?

A

Endoscopy!

101
Q

What is Barrett’s oesophagus?

A

squamous** epithelial lining of oesophagus being replaced by **metaplastic columnar epithelium

from persistent injury due to chronic reflux of stomach content

102
Q

Risk factors & cause of Barrett’s oesophagus?

A

white male, smoking alcohol, obesity and GORD

cause = GORD

103
Q

Change in cell type & name of the process from GORD → Barrett’s?

A

Squamous → metaplasia (goblet cells) → dysplastic (precancer) → neoplastic (cancer)

stratified squamous to columnar!!

104
Q

Barrett’s oesophagus - symptoms & investigations?

A

dyspepsia, dysphagia
chest pain rare

endoscopy with biopsy

105
Q

Barrett’s oesophagus - treatment

A

Non-dysplastic = PPI + surveillance

Low grade dysplasia = radiotherapy with mucosal resection

High grade dysplasia = radiotherapy with esophagectomy

106
Q

Oesophageal carcinoma - risk factors?

A

Risk = GORD, Barrett’s, Alcohol, smoking, male, hiatal hernia

107
Q

Oesophageal carcinoma - symptoms?

A

Dysphagia to solids then liquids

Odynophagia = painful swallowing

hoarse voice, hiccups, paroxysmal cough

GI bleed, reflux

typical cancer symptoms

108
Q

Oesophageal carcinoma - investigations?

A

GOLD = endoscopy with biopsy

Barium swallow test

CT / MRI / PET for staging

109
Q

Oesophageal carcinoma - treatments?

A

fit + mets = chemo + operate

unfit + mets = palliative care, stents help

110
Q

What is achalasia?

A

Damage to the oesophageal nerves → lower eso sphincter fails to relax

dysphagia to solids and liquids

111
Q

Symptoms of achalasia?

A

dysphagia

regurgitation

change in posture to help swallowing

pain in the chest

112
Q

Investigations for achalasia?

A

Endoscopy

Barium swallow - will show birds beak shape (curved narrowing)

113
Q

Treatment for Achalasia?

A

GOLD = surgery = pneumatic dilatation

cut valve / botox to relax valve / meds to relax valve

114
Q

What are esophageal varices?

A

abnormal, dilated veins that occur at the lower end of the oesophagus

usually due to chronic liver disease & portal hypertension

115
Q

Symptoms of oesophageal varices

A

haematemesis & maelena

116
Q

Investigations for oesophageal varices?

A

Endoscopy

117
Q

Treatment for oesophageal varices

A

small = watch & wait

m to L = non-selective beta blocker
+ band ligation

if acute bleed follow acute GI bleed protocol!

118
Q

Acute GI bleed protocol?

A

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

119
Q

Other acute GI bleed things to do?

(and special for oesophageal varices?)

A

Rockall score to assess for rebleed

  • *for oesophageal varices**:
  • terlipressin / somatostain analogue
  • broad spectrum antibiotics
120
Q

Mallory Weiss tear - risk factors?

A

alcohol, chronic cough, bulimia

gastroenteritis

weight lifting

hyperemesis gravidarum

121
Q

Mallory Weiss tear - symptoms?

A

haematemesis after vomiting

maelena - dark sticky faeces with digested blood

hypovolaemic shock

122
Q

Treatment for Mallory Weiss tear?

A

resus + antiemetic + PPI

most heal in 24 hours as they’re minor

123
Q

Summary - major causes of upper GI bleeds?

A

Peptic / duodenal ulcers - 50%

Gastritis = 20%

Oesophageal varices = 10%

Mallory Weiss tear = 5-10%

classic = haematemesis & melaena

124
Q

Rarer causes of UGIB?

A

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

125
Q

What is pancreatitis?

A

Inflammation of the pancreas

acute - from autodigestion by trypsin, released by pancreatic acinar cells

126
Q

Causes of pancreatitis?

A

I GET SMASHED

idiopathic

gallstones, ethanol, trauma

steroids, mums/malignancy, autoimmune, scorpion stings, hypercalcaemia/hyperlipidemia, ERCP,
drugs - NSAIDs + diuretics + steroids

127
Q

Most common causes of pancreatitis (3)?

A

Gallstones - women, older

Alcohol - men, younger

Post-ERCP

128
Q

Pathology for alcohol caused pancreatitis?

A

low fluid + low bicarbonate + increase of zymogen secretion = thick pancreatic juices causing increase in pressure → release of trypsin & autodigestion

129
Q

Pathology for gallstone caused pancreatitis?

A

If gallstone is lodged at sphincter of Oddi, then pancreatic duct is blocked → high pressure leads to release of trypsin and autodigestion

130
Q

Acute pancreatitis - symptoms?

A

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

131
Q

Investigations for acute pancreatitis?

A

GOLD = ERCP (only if no obstruction!!)

1st line = LDH + amylase (3x) urine or serum! + lipase (more sens)

132
Q

Criteria to assess severity of pancreatitis?

A

Glasgow score
determines mild, moderate or severe

133
Q

Diagnosis of acute pancreatitis is based on?

A

2 out of 3:

characteristic severe epigastric pain radiating to the back

raised serum amylase and lipase

abdo contrast CT scan pathology

134
Q

Acute pancreatitis - complications?

A

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

135
Q

Acute pancreatitis - treatment?

A

Analgesia / fluids / bowel rest

Shock = catheter, ABC

Infection = antibiotics, oedematous = drain

Stones = ERCP

136
Q

Causes of chronic pancreatitis (4)?

A

Inflammation - fibrosis - cirrhosis

acute to chronic

repeated alcohol abuse

cystic fibrosis

137
Q

Symptoms of chronic pancreatitis?

A

can be asymptomatic

if epigastric pain - discrete attacks earlier, persistent later

pancreatic insufficiency = triad!!
= steatorrhea + pancreatic diabetes + calcifications

138
Q

Investigations for chronic pancreatitis?

A

Abdo XR & CT = calcifications

ERCP / MRCP = HOLD

CRP

HbA1c = diabetes screen

do not check amylase & lipase! (normal or anything)

139
Q

Treatment for chronic pancreatitis?

A

Abstinence + Analgesia

Obstruction = ERCP stent

Pancreatic enzyme replacement

Surgery - for pseudocysts, abscesses, severe obstruct / pain etc

140
Q

Pancreatic cancer - risk factors?

A

Chronic pancreatitis

smoking, caffeine

alcohol diabetes

aspirin

141
Q

Symptoms of pancreatic cancer?

A

Painless jaundice (head)

Body and tail symptom
= epigastric radiating to the bad, relieved by sitting forward

acute pancreatitis

weight loss

142
Q

Investigations for pancreatic cancer?

A

Biopsy

ultrasound / CT

143
Q

Cause of appendicitis?

A

Main cause = obstruction
faecolith (poo) / food / lymphoid hyperplasia

Infection and vaccines → stimulate follicle growth (e.g. pinworm)

144
Q

Pathology for appendicitis?

A

Blockage → compression → ischaemia & necrosis

Infection → pus formation → WBC + → cells die → wall rupture

145
Q

Symptoms of appendicitis?

A

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

146
Q

Signs for appendicitis (3)?

A

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)

147
Q

Complications for appendicitis?

A

Rupture = bacteria → peritoneum = peritonitis
→ rebound tender & abdo guarding
= muscle tense when apply P

Periappendiceal abscess = most common

Subphrenic abscess

148
Q

Investigations for appendicitis?

A

CT / US

MRI if pregnant
(pregnant test before!)

Bloods = WBC + CRP + ESR raised

149
Q

Treatment for appendicitis?

A

Appendectomy - laparoscopic, occasionally open

antibiotics

drain abscess

150
Q

What are hernias?

A

When a body organ within the wall passes out of the cavity wall

151
Q

Causes of hernias?

A

Muscle weakness

Body strain
= chronic cough, constipation, weight lifting

age

pregnancy

152
Q

Classify the hernias and their treatment?

A

Reducible = can push back = no tx

Irreducible = cannot push back = tx
with surgery

153
Q

Types of hernia?

A

Obstructed = bowel out of abdomen

Strangulation = out of wall, wall compromises blood supply

154
Q

What is a hiatal hernia and classify it?

A

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!

155
Q

Investigations for a hiatal hernia?

A

Barium swallow test → X ray

gastroscopy

156
Q

Complications & tx of hiatus hernia?

A

gastric volvulus = twist on itself, bleeding

surgery

157
Q

Differentiate between the locations of an inguinal hernia and a femoral hernia?

A

Inguinal hernia = superior and medial to pubic tubercle (UPCLOSE)

Femoral hernia = inferior and lateral to pubic tubercle

158
Q

What are inguinal hernias?

A

Intestines & peritoneum push through and forms a bulge

more common in men!!

159
Q

Differentiate between direct & indirect inguinal hernias?

A

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!!

160
Q

Differentiate between direct & indirect inguinal hernias?

A

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!!

161
Q

What are femoral hernias?

A

more common in females

below and lateral to pubic turbercle

often irreducible & strangulates

often with a cough impulse!!
(without = thrombophlebitis of a saphena varix)

162
Q

What is an anal fissure?

A

tear in the anal sphincter

usually from hard stool

163
Q

Symptoms of an anal fissue?

A

blood on wiping - red, light & streaky

often constipated, itchy bum, pain during defecation

164
Q

Treatment for anal fissures?

A

1st line = stool softeners

165
Q

What is a perianal abscess?

A

Infection in anal gland

166
Q

Risk factors for perianal abscess?

A

Immunosuppression, IBD, IBM

167
Q

Symptoms of a perianal abscess?

A

Pus in stool

constant anal pain

fever or chills

Nothing on physical examination!!

168
Q

Treatment for perianal abscess?

A

Surgical removal & drain abscess

→ antibiotics might not work on something that’s walled off

169
Q

What is a fistula?

A

Abnormal connection from one place to another

170
Q

How is a fistula formed?

A

crypts inside colon → something stuck → infection → forms abscess → bigger = connection from inside colon to outside → fistula

171
Q

Symptoms of a fistula?

A

Blood in stools, pus = infection

WILL be able to see from outside!!

172
Q

Treatment for a fistula?

A

Drain infection, remove tract

173
Q

If the hair in natal cleft irritates the skin, cyst is called?

A

Pliondial cyst

(abscess as it might make one)

174
Q

How might you treat a pliondial cyst?

A

Asymptomatic watch and wait

Symptomatic = incision and drainage + analgesic

175
Q

What are hemorrhoids?

A

Buldgy veins in anus which prolapse out of it

176
Q

Risk factors for haemorrhoids?

A

constipation

increased abdominal pressure

177
Q

Symptoms of haemorrhoids?

A

Bulging pain in anus, itchiness, bleeding (bright red on wiping)

178
Q

Differentiate between internal & external haemorrhoids?

A

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

179
Q

How might you investigate & treat a haemorrhoid?

A

Investigate - Anoscopy

Stool softeners & rubber band ligation

180
Q

What is pseudomembranous colitis?

A

= not a real infection, usually by antibiotic abuse or c diff

181
Q

Symptoms & treatment of pseudomembranous colitis?

A

watery diarrhoea (mind dehydration!)

fever

tx = stop antibiotics

182
Q

Risk factors for a C Difficile infection?

A

Antibiotic use, C starting

PPI

Old, comorbidity

Long hospital stays

183
Q

C diff infections - antibiotic causes?

A

clindamycin co-amoxiclav [cephalosporins] ciprofloxacin

[classes are - cephalosporin, fluoroquinolone, ampicillin / amoxicillin]

184
Q

Investigations for a suspected C. Difficile infection?

A

GOLD = stool sample

severity = FBC & serum creatinine

185
Q

Treatment for C Diff infections?

A

1st = oral vancomycin

2nd = oral fidaxomicin

if not = up dose vanco, add oral metronidazole

if 2 or more = consider faecal microbiota transplant

186
Q

H pylori - type of bacteria?

A

Gram negative bacili with flagella

produces urease → ammonia which damages gastric mucosa

187
Q

H pylori triggered diseases?

A

Gastritis

Peptic ulcer

gastric cancer
H pylori + low gastric acid

duodenal ulcer
H pylori + high gastric acid

188
Q

Symptoms of H pylori infection?

A

Aches or burning pain

worse when empty stomach!

Bloating, weight loss and nausea

189
Q

How would you investigate an H pylori infection

A

Urea breath test

Pylori stool antigen test
[1st line duodenal ulcer!]

Endoscopy

Blood test

190
Q

How would you treat an H pylori infection?

A

Clarithromycin + Amoxicillin + PPI (omeprazole)

191
Q

PPI selection indicators?

A

NOT omeprazole if with clopidrogrel
(- activation of latter, CYP450)
= lansoprazole, pantoprazole

SE Gi disturbances, headache, + risk fracture, prolonged = hypomagnesium = tetany & ventricular arrhy

192
Q

PPI Indications of use?

A

1st tine tx & prev - peptic ulcer disease

symptomatic relief - GORD & dyspepsia

eradication of H pylori

193
Q

Mechanism of action. PPI\s

A

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

194
Q

Indications for H2 antagonists?

A

= ranitidine

2nd tx prev - peptic ulcer disease
(1st = PPI )

2nd tx - GORD & dyspepsia
(PPI 1st & if more severe)

195
Q

Mechanism of action, H2 antagonists?

A

= 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

196
Q

What is a schistosomiasis?
(aka bilharzia)

A

Infection caused by a parasitic worm living in fresh water of tropical regions

197
Q

Symptoms and tx of schistosomiasis?

A

fever, itchy red and raised rash

cough, diarrhoea

muscle and joint pain, tummy pain

self eliminating, but tx Praziquantel

198
Q

If it’s just diarrhoea and water sports then?

A

Shigella

(esp if travel to Spain)
(symptom = infective gastroenteritis / dysentry)

199
Q

Chest virus with diarrhoea in a child is likely caused by?

A

Rotavirus

200
Q

General diarrhoea in an elderly person?

A

Norovirus

201
Q

If watery diarrhoea and neurological signs?

A

Guillan-Barre

202
Q

Causing organism if someone has diarrhoea and has had

  • ingested raw chicken
  • been near dirty water
  • drank unpasteurised milk
  • had shellfish
A

Campylobacter jejuni

203
Q

Causing organism if someone has diarrhoea and has had

-uncooked poultry, dairy, eggs, meat, reptiles, seafood

A

Salmonella (spp. or enteritidis!)

204
Q

Causing organism if someone has diarrhoea and has had ground beef & salads?

A

E coli

205
Q

If rapid dementia and ingested ‘cooked’ beef?

A

Cruetzfeldt-Jakob disease

(umbrella including mad cow disease)

Phase 2A (12 decks)

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