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
Symptoms of IBS?
Lower abdo pain spasms, belly button or lower Bloating commonly associated Altered bowel habit
26
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
27
Treatment for IBS?
* *1st** * *Loperamide** = antimotility for diarrhoea * *Laxatives** for constipation - avoid lactulose * *Antispasmodics** = hyoscine butylbromide ``` 2nd = tricyclic antidepressants 3rd = SSRI ```
28
What is Inflammatory Bowel Disease?
chronic relapsing inflammatory disorder, primarily affecting gastrointestinal tract
29
Differentials of IBS?
Coeliac disease, IBD Colorectal cancer in women who are over 45 / post menopausal: ovarian cancer
30
Management IBD?
prophylactic low molecular weight heparin = prevent DVT & PE IV steroids = hydrocortisone
31
Complications of IBD?
anterior uveitis - painful red eyes, blurry vision enteropathic arthritis
32
What is ulcerative colitis?
a type of IBD autoimmune = p-ANCA positive! continuous inflammation of the colonic mucosa
33
Present - ulcerative colitis?
**diarrhoea - bloody, frequent bowel movements** **LUQ Pain!** can present with clubbing & aphthous ulcers, erythema nodusum & amyloidosis
34
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
35
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
36
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
37
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**
38
Surgical tx for UC?
if not responding to any tx colectomy (colon removed) // panproctocolectomy
39
3 types of ulcerative colitis by region affected?
40
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**
41
Key presentations of Crohn's disease?
young, 20's, positive fam history mouth ulcers right iliac fossa pain mucus and watery diarrhoea
42
General extra intestinal symptoms for IBD?
**erythema nodosum** - leg rash **mouth ulcers & psoriasis** = crohn's **episcleritis, uveitis** **arthritis / ankyspon**
43
How might you investigate Crohn's?
endoscopy + biopsy faecal calprotectin (inflam marker) / faecal occult blood test
44
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**
45
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**
46
Mechanism of anti-TNF antibodies in Crohn's disease?
= infliximab, adalimumab = reduce disease activity by **countering neutrophil accumulation, granuloma formation**, and **activating complement**
47
How might you maintain remission in Crohn's disease?
1st = **Azathioprine** 2nd = **Methotrexate** (+ folic acid)
48
Methotrexate: mechanism of action?
inhibit dihydrofolate reductase = converts folic acid → FH4 **= prevent cellular replication** ## Footnote **antiinflammatory & immunosuppression effects against ILs & cytokines**
49
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
50
Crohn's associations
changes in NOD-2 gene!!
51
Criteria for assessing severity in IBD?
Truelove & Witt's criteria
52
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)
53
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
54
Types of diarrhoea and what they signify
floating = fat (coeliac?) watery = infection blood = inflammation or cancer!
55
What investigations would you order for diarrhoea?
bloods - culture and CRP Stool - culture and test for blood
56
General treatment for diarrhoea?
Fluid + electrolyte placement antibiotics = vancomysin barrier nursing = side room with gloves and apron antimotility agents + antiemetics
57
How might you investigate colon cancer?
GOLD = endoscopy with biopsy faecal occult blood screen CT, barium enema tumour markers = monitor progress
58
How might you treat colon cancer?
resection mets could travel up
59
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
60
Causes of ischaemic colitis?
atherosclerosis of superior or inferior mesenteric artery (most common) thrombosis or emboli decreased cardiac output & arrhythmias
61
How might ischaemic colitis present?
LLQ pain bloody diarrhoea
62
How might you investigate ischaemic colitis?
GOLD = colonoscopy + biopsy CT / MRI angiography
63
How might you treat ischaemic colitis?
fluid replacement antibiotics surgery for gangrene or perforation
64
What is gastritis?
Inflammation of the lining of the stomach causes an UGIB
65
Causes of gastritis?
Mucosal ischaemia helicobacter pylori urease + protease aspirin or NSAIDs induced autoimmune gastritis
66
Risk factors for gastritis?
diabetes travel + alcohol + older NSAIDs + aspirin stress + autoimmune
67
Presentation for gastritis?
epigastric pain (top middle) diarrhoea - sudden, 3x per 24 hours indigestion, vomiting, nausea dever and malaise dehydration
68
Investigations for gastritis?
GOLD = endoscopy H pylori tests: pylori stool antigen OR urea breath test Faecal occult blood, CRP
69
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!!
70
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
71
Histopathology results for peptic ulcer disease?
Abrupt lesions with normal adjacent mucosa Villous abnormalities Brunners gland hypertrophy - reduces the acidity of duodenum
72
Causes of peptic / duodenal ulcers?
Prolonged NSAID or aspirin use H pylori infection = urease + protease Zollinger Ellison syndrome = gastrinoma
73
How might you differentiate between a peptic / duodenal ulcer?
DUODENAL gets BETTER with eating gastric gets worse when eating
74
Investigation for peptic ulcer?
1st line + gold standard = endoscopy with biopsy
75
Investigations for duodenal ulcers?
1st line (test for H pylori) urea breath test or faecal antigen test = 2 weeks without PPI, 4 weeks without antibiotics
76
Symptoms of ulcers?
epigastric pain (differential = gastritis) eating related pain weight change bloating vomiting and nausea
77
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
78
Differentiate between the location and arteries affected by each ulcer?
Gastric ulcer = left gastric artery = lesser curve of stomach Duodenal = gastroduodenal artery = posterior wall
79
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
80
If a gastric ulcer is healed post treatment following scope?
low dose PPI preventative persistent symptoms = low dose PPI PPI not tolerated = H2 antagonist
81
If a gastric ulcer is _not_ healed post treatment?
suspect malignancy try another h pylori regime PPI for 4 more weeks
82
Cause of gastric cancer
Mutation in CDH1 = 80% smoked foods, pickles h pylori pernicious anaemia
83
Symptoms of gastric carcinoma?
Haematemesis melaena = black / dark red stool from bleeding dysphagia jaundice = mets!
84
Investigations for gastric carcinoma?
Gastroscopy with biopsy CT / MRI Laparoscopic exploration
85
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
86
What is GORD?
Gastro-oesophageal reflux disease (GORD) reflux of stomach contents into the oesophagus
87
Pathology of GORD?
**Inappropriate lower oesophageal sphincter relaxation** Acid = inflammation → scarring → esophageal stenosis damage to lining = risk of neoplasia
88
Risk factors for GORD?
Meds - CCB, antidepressants, glucocorticoids, antihista, benzodiazepines hiatal hernia, scleroderma, zollinger-ellison
89
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
90
What is scleroderma?
= **hardening of the skin** most patients also have **systemic sclerosis** = autoimmune inflam connective tissue disease
91
Symptoms of GORD
WORSE when lying flat dysphagia, dyspepsia chronic cough, nocturnal asthma
92
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
93
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
94
Complications of GORD?
**Barrett's esophagus** **erosive oesophagitis / stricture** esophageal adenocarcinoma laryngitis or asthma = acid moving into larynx cardiopulmonary issues perforation / bleed
95
What is dyspepsia?
Indigestion!
96
Causes of Dyspepsia?
excess: meals, acid prolonged NSAIDs obesity, smoking, alcohol pregnancy cancer
97
Non- red flag symptoms of dyspepsia?
Heartburn bloating acid taste reflux when lying down
98
What are some red flag symptoms of dyspepsia?
unexplained weight loss anaemia dysphagia persistent vomiting bleeding upper abdo mass
99
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
100
How should you treat dyspepsia with red flags?
Endoscopy!
101
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
102
Risk factors & cause of Barrett's oesophagus?
white male, smoking alcohol, obesity and GORD cause = GORD
103
Change in cell type & name of the process from GORD → Barrett's?
Squamous → metaplasia (goblet cells) → dysplastic (precancer) → neoplastic (cancer) stratified squamous to columnar!!
104
Barrett's oesophagus - symptoms & investigations?
dyspepsia, dysphagia chest pain rare endoscopy with biopsy
105
Barrett's oesophagus - treatment
Non-dysplastic = PPI + surveillance Low grade dysplasia = radiotherapy with mucosal resection High grade dysplasia = radiotherapy with esophagectomy
106
Oesophageal carcinoma - risk factors?
Risk = GORD, Barrett's, Alcohol, smoking, male, hiatal hernia
107
Oesophageal carcinoma - symptoms?
Dysphagia to solids then liquids Odynophagia = painful swallowing hoarse voice, hiccups, paroxysmal cough GI bleed, reflux typical cancer symptoms
108
Oesophageal carcinoma - investigations?
GOLD = endoscopy with biopsy Barium swallow test CT / MRI / PET for staging
109
Oesophageal carcinoma - treatments?
fit + mets = chemo + operate unfit + mets = palliative care, stents help
110
What is achalasia?
Damage to the oesophageal nerves → lower eso sphincter fails to relax dysphagia to solids and liquids
111
Symptoms of achalasia?
dysphagia regurgitation change in posture to help swallowing pain in the chest
112
Investigations for achalasia?
Endoscopy Barium swallow - will show birds beak shape (curved narrowing)
113
Treatment for Achalasia?
GOLD = surgery = pneumatic dilatation cut valve / botox to relax valve / meds to relax valve
114
What are esophageal varices?
abnormal, dilated veins that occur at the lower end of the oesophagus usually due to chronic liver disease & portal hypertension
115
Symptoms of oesophageal varices
haematemesis & maelena
116
Investigations for oesophageal varices?
Endoscopy
117
Treatment for oesophageal varices
small = watch & wait m to L = non-selective beta blocker + band ligation if acute bleed follow acute GI bleed protocol!
118
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
119
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
120
Mallory Weiss tear - risk factors?
alcohol, chronic cough, bulimia gastroenteritis weight lifting hyperemesis gravidarum
121
Mallory Weiss tear - symptoms?
haematemesis after vomiting maelena - dark sticky faeces with digested blood hypovolaemic shock
122
Treatment for Mallory Weiss tear?
resus + antiemetic + PPI most heal in 24 hours as they're minor
123
Summary - major causes of upper GI bleeds?
Peptic / duodenal ulcers - 50% Gastritis = 20% Oesophageal varices = 10% Mallory Weiss tear = 5-10% classic = haematemesis & melaena
124
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
125
What is pancreatitis?
Inflammation of the pancreas acute - from autodigestion by **_trypsin_**, released by pancreatic acinar cells
126
Causes of pancreatitis?
I GET SMASHED idiopathic gallstones, ethanol, trauma steroids, mums/malignancy, autoimmune, scorpion stings, hypercalcaemia/hyperlipidemia, ERCP, drugs - NSAIDs + diuretics + steroids
127
Most common causes of pancreatitis (3)?
Gallstones - women, older Alcohol - men, younger Post-ERCP
128
Pathology for alcohol caused pancreatitis?
**low fluid + low bicarbonate + increase of zymogen secretion** = thick pancreatic juices causing increase in pressure → **_release of trypsin & autodigestion_**
129
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
130
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
131
Investigations for acute pancreatitis?
GOLD = ERCP (only if no obstruction!!) 1st line = LDH + amylase (3x) urine or serum! + lipase (more sens)
132
Criteria to assess severity of pancreatitis?
Glasgow score determines mild, moderate or severe
133
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
134
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
135
Acute pancreatitis - treatment?
Analgesia / fluids / bowel rest Shock = catheter, ABC Infection = antibiotics, oedematous = drain Stones = ERCP
136
Causes of chronic pancreatitis (4)?
Inflammation - fibrosis - cirrhosis acute to chronic repeated alcohol abuse cystic fibrosis
137
Symptoms of chronic pancreatitis?
can be asymptomatic if epigastric pain - discrete attacks earlier, persistent later pancreatic insufficiency = triad!! = **steatorrhea** + **pancreatic diabetes** + **calcifications**
138
Investigations for chronic pancreatitis?
Abdo XR & CT = calcifications ERCP / MRCP = HOLD CRP HbA1c = diabetes screen do _not_ check amylase & lipase! (normal or anything)
139
Treatment for chronic pancreatitis?
**Abstinence + Analgesia** Obstruction = **ERCP stent** **Pancreatic enzyme replacement** **Surgery** - for pseudocysts, abscesses, severe obstruct / pain etc
140
Pancreatic cancer - risk factors?
Chronic pancreatitis smoking, caffeine alcohol diabetes aspirin
141
Symptoms of pancreatic cancer?
Painless jaundice (head) Body and tail symptom = epigastric radiating to the bad, relieved by sitting forward acute pancreatitis weight loss
142
Investigations for pancreatic cancer?
Biopsy ultrasound / CT
143
Cause of appendicitis?
Main cause = **_obstruction_** **faecolith** (poo) / **food** / **lymphoid** **hyperplasia** **Infection and vaccines** → stimulate follicle growth (e.g. pinworm)
144
Pathology for appendicitis?
Blockage → compression → ischaemia & necrosis Infection → pus formation → WBC + → cells die → wall rupture
145
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**
146
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)
147
Complications for appendicitis?
Rupture = bacteria → peritoneum = **peritonitis** → rebound tender & abdo guarding = muscle tense when apply P **Periappendiceal abscess** = most common **Subphrenic abscess**
148
Investigations for appendicitis?
CT / US MRI if pregnant (pregnant test before!) Bloods = WBC + CRP + ESR raised
149
Treatment for appendicitis?
Appendectomy - laparoscopic, occasionally open antibiotics drain abscess
150
What are hernias?
When a body organ within the wall passes out of the cavity wall
151
Causes of hernias?
Muscle weakness Body strain = chronic cough, constipation, weight lifting age pregnancy
152
Classify the hernias and their treatment?
**Reducible** = can push back = no tx **Irreducible** = cannot push back = tx with surgery
153
Types of hernia?
Obstructed = bowel out of abdomen Strangulation = out of wall, wall compromises blood supply
154
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!**
155
Investigations for a hiatal hernia?
Barium swallow test → X ray gastroscopy
156
Complications & tx of hiatus hernia?
gastric volvulus = twist on itself, bleeding surgery
157
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
158
What are inguinal hernias?
Intestines & peritoneum push through and forms a bulge more common in men!!
159
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!!
160
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!!
161
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)
162
What is an anal fissure?
tear in the anal sphincter usually from hard stool
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Symptoms of an anal fissue?
blood on wiping - red, light & streaky often constipated, itchy bum, pain during defecation
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Treatment for anal fissures?
1st line = stool softeners
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What is a perianal abscess?
Infection in anal gland
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Risk factors for perianal abscess?
Immunosuppression, IBD, IBM
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Symptoms of a perianal abscess?
**Pus in stool** **constant anal pain** **fever or chills** Nothing on physical examination!!
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Treatment for perianal abscess?
Surgical removal & drain abscess → antibiotics might not work on something that's walled off
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What is a fistula?
Abnormal connection from one place to another
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How is a fistula formed?
crypts inside colon → something stuck → infection → forms abscess → bigger = connection from inside colon to outside → fistula
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Symptoms of a fistula?
Blood in stools, pus = infection WILL be able to see from outside!!
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Treatment for a fistula?
Drain infection, remove tract
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If the hair in natal cleft irritates the skin, cyst is called?
Pliondial cyst | (abscess as it might make one)
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How might you treat a pliondial cyst?
Asymptomatic watch and wait Symptomatic = incision and drainage + analgesic
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What are hemorrhoids?
Buldgy veins in anus which prolapse out of it
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Risk factors for haemorrhoids?
constipation increased abdominal pressure
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Symptoms of haemorrhoids?
Bulging pain in anus, itchiness, bleeding (bright red on wiping)
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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
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How might you investigate & treat a haemorrhoid?
Investigate - Anoscopy Stool softeners & rubber band ligation
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What is pseudomembranous colitis?
= not a real infection, usually by **antibiotic abuse** or **c diff**
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Symptoms & treatment of pseudomembranous colitis?
watery diarrhoea (mind dehydration!) fever tx = stop antibiotics
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Risk factors for a C Difficile infection?
Antibiotic use, C starting PPI Old, comorbidity Long hospital stays
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C diff infections - antibiotic causes?
clindamycin co-amoxiclav [cephalosporins] ciprofloxacin [classes are - cephalosporin, fluoroquinolone, ampicillin / amoxicillin]
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Investigations for a suspected C. Difficile infection?
GOLD = stool sample severity = FBC & serum creatinine
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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
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H pylori - type of bacteria?
Gram negative bacili with flagella produces urease → ammonia which damages gastric mucosa
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H pylori triggered diseases?
Gastritis Peptic ulcer gastric cancer H pylori + low gastric acid duodenal ulcer H pylori + high gastric acid
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Symptoms of H pylori infection?
Aches or burning pain worse when empty stomach! Bloating, weight loss and nausea
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How would you investigate an H pylori infection
Urea breath test Pylori stool antigen test [1st line duodenal ulcer!] Endoscopy Blood test
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How would you treat an H pylori infection?
Clarithromycin + Amoxicillin + PPI (omeprazole)
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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
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PPI Indications of use?
1st tine tx & prev - peptic ulcer disease symptomatic relief - GORD & dyspepsia eradication of H pylori
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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
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Indications for H2 antagonists?
= ranitidine 2nd tx prev - peptic ulcer disease (1st = PPI ) 2nd tx - GORD & dyspepsia (PPI 1st & if more severe)
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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
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What is a schistosomiasis? (aka bilharzia**)**
Infection caused by a parasitic worm living in fresh water of tropical regions
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Symptoms and tx of schistosomiasis?
fever, itchy red and raised rash cough, diarrhoea muscle and joint pain, tummy pain self eliminating, but tx **Praziquantel**
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If it's just diarrhoea and water sports then?
Shigella (esp if travel to Spain) (symptom = infective gastroenteritis / dysentry)
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Chest virus with diarrhoea in a child is likely caused by?
Rotavirus
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General diarrhoea in an elderly person?
Norovirus
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If watery diarrhoea and neurological signs?
Guillan-Barre
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Causing organism if someone has diarrhoea and has had - ingested raw chicken - been near dirty water - drank unpasteurised milk - had shellfish
Campylobacter jejuni
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Causing organism if someone has diarrhoea and has had -uncooked poultry, dairy, eggs, meat, reptiles, seafood
Salmonella (spp. or enteritidis!)
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Causing organism if someone has diarrhoea and has had ground beef & salads?
E coli
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If rapid dementia and ingested ‘cooked’ beef?
Cruetzfeldt-Jakob disease | (umbrella including mad cow disease)