Gastro Flashcards

Question

What is the management for appendicitis?

Answer 1

**Surgical emergency > Immediate hospital admission** **GAME:** - G (group and save) - A (abx – IV amoxicillin or ceftriaxone with metronidazole) - M (MRSA screen) - E (do not eat or drink – NBM) - +IV fluids **Appendicectomy** - (Laparoscopic preferred in uncomplicated appendicitis)

Answer 2

Invagination of one portion of bowel into the lumen of the adjacent bowel

Answer 3

Mesenteric constriction > venous obstruction > engorgement and oedema > bleeding from bowel mucosa > perforation > peritonitis and gut necrosis

Answer 4

Usually 6-18m Rarely <3m More common in boys

Answer 5

Most commonly ileum into caecum through ileocecal valve (ilio-colic)

Answer 6

- Idiopathic - Post-gastroenteritis (enlarged Peyer’s patches) - Associated with CF, adenovirus, HSP, FAP, lymphoma

Answer 7

- Paroxysmal abdominal colic pain (child will draw knees up into a ball) - Non-bilious > bilious vomiting (as intussusception becomes more established) - Red-currant jelly PR bleeding (late sign due to necrosis)

Answer 8

Sausage-shaped mass in RUQ Abdominal distension

Answer 9

**1st line = Abdominal USS:** - Target like mass / donut sign **2nd line = AXR:** If perforation/obstruction suspected - Less air in RUQ and large bowel - Thickened wall (oedema) - Poorly defined liver edge - Dilated small bowel loops **Contrast enema:** Not if unstable - Meniscus sign; coiled spring sign - Most specific and sensitive diagnostic test

Answer 10

**EMERGENCY, ABCDE approach** - Drip and suck (NBM + NGT to decompress bowel, IV fluids) - Broad spectrum abx (clindamycin + gentamycin OR tazocin OR cefoxitin + vancomycin) **1st line:** *(no peritonitis, perforation or hypovolaemic shock)* - Rectal air insufflation / contrast enema (with fluoroscopy guidance) under radiological control **2nd line:** *(if fails / peritonitis)* - Surgical reduction

Answer 11

**Congenital diverticulum of the ileum along the antimesenteric border.** It is a remnant of the omphalomesenteric duct and contains ectopic ileal, gastric or pancreatic mucosa

Answer 12

Occurs in 2% of population Is 2 feet from ileocecal valve Is 2 inches long Between 1-2yrs

Answer 13

- Usually asx - Intermittent painless massive PR bleeding (bright / dark red) - RIF abdominal pain mimicking appendicitis - Lethargy, pallor, FTT (anaemia) - May show bilious vomiting, dehydration, constipation - May be present in addition to intussusception, volvulus, or diverticulitis

Answer 14

**Bloods:** - FBC (low Hb/Hct, leukocytosis) **Meckel’s scan (technetium-99m scan):** - Increased uptake by gastric mucosa **CT/USS of abdomen:** - Will allow diagnosis of complications e.g. intussusception, obstruction, diverticulitis *Consider:* **Mesenteric arteriography** - May be used in more severe cases e.g. if transfusion required

Answer 15

**Asymptomatic:** - Incidental imaging finding = no treatment required - Detected during another surgery = prophylactic excision **Symptomatic:** - Surgery (ileal resection and primary anastomosis) - +/- blood transfusion if bleeding / haemodynamically unstable

Answer 16

Can develop an ulcer in the ileum

Answer 17

Failure of normal rotation of the small intestine around the superior mesenteric artery (SMA) during embryological development, predisposing to intestinal obstruction, volvulus, and ischaemia

Answer 18

**Asx and present at any age with volvulus** OR **Present in first few days of life with obstruction +/- compromised blood supply** - BILIOUS VOMITING - Abdominal pain - Peritonism - Abdominal distension - Scaphoid abdomen (concave abdomen) - Tinkling bowel sounds

Answer 19

**Bilious vomiting in neonate is malrotation until proven otherwise**

Answer 20

**UGI contrast scan:** *Diagnostic standard test* - Malrotation = right-sided duodenum - Volvulus = cork-screw appearance **AXR:** *Done in ED* - Distended stomach/duodenum, gasless abdominal field **Bloods:** - FBC, ABG

Answer 21

**If signs of vascular compromise = SURGICAL EMERGENCY** - Drip and suck - IV broad spectrum abx (cefazolin) - Ladd Procedure

Answer 22

Altered GI mobility and abnormal sensation +/- psychosocial stress and anxiety effect

Answer 23

FHx Sx may be preceded by GI infection

Answer 24

- Abdominal pain (often worse before/relieved by defecation) - Explosive loose or mucus stools - Bloating - Tenesmus - Constipation

Answer 25

FBC, ESR/CRP Coeliac disease screen (TTG antibodies)

Answer 26

**Supportive:** - Reassurance of absence of organic disease - Encourage patient to identify sources of stress or anxiety in their lifestyle and any foods that may aggravate symptoms - Recommend adequate fluid intake **Psychological:** - CBT

Answer 27

Inflammation of the GI tract secondary to infection by an enteropathogen

Answer 28

- ROTAVIRUS - Campylobacter jejuni - Shigella / Salmonella - Cholera / E. coli - Protozoan - Adenovirus

Answer 29

- Vomiting - Diarrhoea (sudden change to loose-stools) - Fever - Abdominal pain - Anorexia - Dehydration +/- shock (increased risk if <6m, >2 vomits in 24hrs, >5 diarrhoeal stools in 24hrs, cannot tolerate extra fluids, malnourished)

Answer 30

**Bloods:** FBC, U&Es, LFTs **Stool:** MC&S (if this reveals a causative organism, seek specialist advice regarding abx treatment) **AXR** (can exclude other causes)

Answer 31

**Shocked/haemodynamically compromised:** - Resuscitation fluids **CANNOT meet fluid requirements enterally + clinical signs of dehydration:** - Replacement fluids **CANNOT meet fluid requirements enterally + NO clinical signs of dehydration:** - Maintenance fluids **CAN meet fluid requirements enterally:** - Encourage oral intake / NG feeding - Do not give sugary / carbonated drinks **Safety net:** - D usually 5-7d, most stop within 2w - V usually 1-2d, most stop within 3d - Advice on preventing spread and follow-up - Do not give anti-diarrhoeals to <5yrs

Answer 32

Form of IBD, commonly affecting the terminal ileum and proximal colon, but may be seen anywhere from mouth to anus

Answer 33

Inflammation occurs in all layers (transmural inflammation), down to the serosa (why pts are prone to strictures, fistulas, and adhesions)

Answer 34

- Abdominal pain - RLQ (most common sx in children) - Diarrhoea (most common sx in adults) > may be bloody in Crohn’s colitis - Weight loss, lethargy, growth failure, delayed puberty - Perianal disease > skin tags or ulcers - Uveitis - Arthralgia - Erythema nodosum

Answer 35

Typically presents in late adolescence or early adulthood

Answer 36

**Bloods** = raised inflammatory markers, low B12 + vit D **Faecal calprotectin** = raised **Colonoscopy and biopsy** = non-caseating epithelioid cell granulomata, discontinuous/patchy inflammation with skip lesions **Histology** = inflammation in all layers from mucosa to serosa, goblet cells, granulomas **Small bowel enema** = strictures (Kantor’s string sign), proximal bowel dilation, ‘rose thorn’ ulcers, fistulae

Answer 37

**Conservative:** - Education on features and flare ups - Support - www.crohnsandcolitis.org.uk - Stop smoking - Careful with NSAIDs and COCP (increased risk of relapse) **Inducing remission:** *1st line = Exclusive Enteral Nutrition (EEN)* (effective in 85-100% of patients) - Whole protein modular diet (excessively liquid) for 6-8w - May need NGT if child struggles to drink that much - (Products easily digested, replaces WL) *2nd line = CS e.g. prednisolone* **Maintaining remission:** - 1st line = mercaptopurine or azathioprine *(cannot be given with TPMT mutation, cannot have live vaccines, must have pneumococcal and influenza vaccines)* - 2nd line = Methotrexate (immunosuppressant) if fail to respond to azathiprine - Also - CS e.g. Budesonide, biologic therapies e.g. infliximab **Surgery:** - For complications (obstruction, fistula, abscess, severe localised disease unresponsive to treatment)

Answer 38

- Small bowel cancer - Colorectal cancer - Osteoporosis - Abscess formation - Fistulas

Answer 39

Form of IBD. Inflammation always starts at the rectum, never spreads beyond ileocecal valve and is continuous

Answer 40

- Bloody diarrhoea - Abdominal pain – particularly LLQ - Urgency, tenesmus - Weight loss, growth failure - Erythema nodosum - Arthritis

Answer 41

- PSC - Enteropathic arthritis - Toxic megacolon - Haemorrhage - Perforation - Bowel cancer

Answer 42

- **Mild** = <4 stools/d, small amount of blood - **Moderate** = 4-6 stools/d, varying amounts of blood, no systemic upset - **Severe** = >6 blood stools/d, features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Answer 43

**1. Paediatric CD Activity Index (PCDAI) 2. Paediatric UC Activity Index (PUCAI) 3. Truelove and Witts score** - Severe = >65 points - Mild-Moderate = 10-64 points

Answer 44

**Bloods:** - FBC *(anaemia, leukocytosis)* - CRP/ESR - CMP (including LFTs) **Stool sample:** - Test for c. Dif / other infective pathogens - Faecal calprotectin *(raised)* **Abdominal X-Ray:** - Dilated loops with air-fluid level secondary to ileus - Free air = perforation - Toxic megacolon = transverse colon dilated to ≥6cm in diameter **Flexible sigmoidoscopy / Colonoscopy & Biopsy:** - Continuous colitis extending from rectum proximally - Superficial inflammation (not beyond submucosa) - Loss of vascular marking - Diffuse erythema - Ulceration and psuedopolyps - Crypt abscesses - Depletion of goblet cells and mucin **Barium enema:** - Loss of haustrations - Superficial ulceration, 'pseudopolyps' - Long standing disease = colon is narrow and short (drainpipe colon)

Answer 45

**Inducing remission:** *(Topical > oral if no improvement after 4w)* - 1st line: Topical/Oral aminosalicylates e.g. mesalazine - 2nd line: Topical/Oral CS e.g. pred, beclomethasone - 3rd line (steroid resistant): Oral tacrolimus - 4th line: Biological agents e.g. infliximab - 5th line (resistant disease): Surgery (colectomy with ileostomy or ileojejunal pouch) **Maintaining remission:** - ASA (topical, topical + oral, oral) **Education / Support:** - Regular screening for bowel cancer after 10yrs of dx - Crohn’s and Colitis UK

Answer 46

**EMERGENCY** > Treated in hospital with MDT approach - 1st line = IV corticosteroids - 2nd line = IV ciclosporin (CS contraindicated or ineffective) - 3rd line = Surgery

Answer 47

Chronic, non-specific diarrhoea. Most common cause of loose stools in preschool kids

Answer 48

- Varying consistency stools (well-formed to explosive and loose) - Stools often contain undigested food / vegetables - Child is well and thriving, normal examination

Answer 49

Lab ix usually negative Dietary ix may reveal high intake of apple juice

Answer 50

1. Increased fibre and fat in diet (whole milk, yogurts, cheeses) 2. Avoid fruit juice / squash / milk 3. Reassurance

Answer 51

Decrease in the frequency of bowel movements, characterised by the passing of hardened stools that may be large and associated with straining and pain

Answer 52

- **1st week of life** = 4 per day - **1yr** = 2 per day - **4yrs** = between 3 per day and 3 per week

Answer 53

- Inadequate fluid intake - Reduced dietary fibre - Toilet training issues - Drugs - Psychosocial issues - FHx - Pain - Fever

Answer 54

- <3 stools per week - Hard, large stool - 'Rabbit droppings' stool - Overflow soiling in children >1yr

Answer 55

- Hx of severe constipation, overflow soiling, faecal mass palpable = faecal impaction - Failure to pass meconium within 24hrs of life / gross abdominal distension = Hirschsprung’s disease - Abnormal LL neurology / deformity = Lumbosacral pathology - Sacral dimple above natal cleft or on spine = Spina bifida occulta - Perianal bruising or multiple fissures = sexual abuse - Perianal fistulae, abscesses, fissures = Crohn’s

Answer 56

Faltering growth, developmental delay, concerns about wellbeing = systemic condition (Coeliac, hypothyroidism, CF)

Answer 57

**Red flags present** = urgent referral to specialist, tx not initiated in primary care **Amber flags present** = referral arranged, tx can be initiated in primary care **Advise:** - Underlying causes have been excluded - Behavioural interventions (scheduled toileting, bowel habit diary, reward system) - Diet and lifestyle adjustments (adequate fluid intake) - Offer sources of info and support **Disimpaction Therapy:** - Movicol Paediatric Plain, escalating dose for 2w *If unsuccessful after 2wks, add:* - Stimulant laxative e.g. senna - Followed by maintenance therapy until normal bowel patterns reestablished **Maintenance Therapy:** - First-line: Movicol Paediatric Plain - Add stimulant laxative if no response / not tolerated - Add another laxative such as lactulose or docusate if stools are hard - Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually **If medical evacuation not possible:** - Enemas - Manual evacuation under anaesthetic

Answer 58

AKA congenital aganglionic megacolon - Missing myenteric plexus and submucous plexus - Results in functional bowel obstruction *(Cluster of nerves missing, leads to blocked colon, causes it to enlarge)*

Answer 59

- More common in males - Down’s Syndrome

Answer 60

**Neonatal:** - Failure/delay to pass meconium - Acute intestinal obstruction = abdominal distension, poor feeding, bilious vomiting - Severe life-threatening enterocolitis (C. diff) **Infantile:** - Constipation - Abdominal distension - Intermittent abdominal pain and fever (during episodes of retained faeces) - Failure to thrive

Answer 61

PR exam reveals sudden explosive passage of liquid/foul stools

Answer 62

**1. AXR** - Dilated bowel **2. Contrast (barium) enema** - Most valuable INITIAL screening diagnostic test - Dilated distal segment and narrowed, aganglionic proximal segment **3. Suction full thickness rectal biopsy** - GOLD STANDARD for definitive diagnosis - Absence of ganglion cells, large ACh+ve nerve trunks

Answer 63

**Initial:** - Rectal washouts / bowel irrigation - Neonates = broad spectrum IV abx, NGT decompression **Surgical:** - Anorectal pull-through procedure

Answer 64

- Constipation - IBD - Sexual abuse / traumatic injury

Answer 65

- Pain/crying with bowel movements - Bright red blood on stool / nappy - Fever, rashes, WL, diarrhoea

Answer 66

**Conservative:** - Increase dietary fibre - Increase fluid intake - Manage pain (simple analgesia) - Anal hygiene - Advise against stool holding **Medical (can be considered):** - Topical GTN or diltiazem - Stool softeners e.g. polythene glycol or lactulose - Botox **Surgical:** - Open lateral internal sphincterotomy

Answer 67

- Asx in most cases - May experience perianal itching, particularly at night - Girls may have vulval sx

Answer 68

Infestation occurs after swallowing eggs that are present in the environment

Answer 69

Dx made by applying Sellotape to perianal area and sending it to the lab for microscopy to see the eggs Most pts tx empirically

Answer 70

**Children <6m = Hygiene measures alone (6w)** - Hand washing - Cut fingernails regularly (avoid biting nails, scratching around anus) - Shower each morning - Change bed linen and nightwear daily for several days after tx - Thoroughly dust and vacuum **Children >6m = Single dose anti-helminth e.g. mebendazole to ENTIRE household** - Dose repeated in 2w if infection persists - Rigorous hygiene for 2w

Answer 71

Inability to metabolise the carbohydrate lactose due to lactase deficiency

Answer 72

**Congenital** = autosomal recessive condition **Primary** = natural non-persistence of lactase enzyme after early childhood **Secondary** = damage to the intestinal brush border following gastroenteritis, Crohn’s, Coeliac

Answer 73

- Loose stools (frothy and explosive) - Bloating with lactose ingestion - Cramping abdominal pain - Flatus **Congenital:** Infantile diarrhoea, FTT **Primary:** GI sx increase with age due to progressive loss of lactase **Secondary:** Preceding infective episode of diarrhoea

Answer 74

**Clinical diagnosis** - Hydrogen Breath Test = earlier rise in exhaled H2 following CHO ingestion - Stools = acidic and contain undigested sugar - FBC = rule out secondary disease (anaemia, increased WCC)

Answer 75

> > Dietician referral **Congenital:** - Avoid milk and dairy products - Provide Ca and vit D supplements **Primary:** - Experiment with diet > find lactose tolerance - Potential foods > high-fat dairy (lower lactose), hard cheeses, milk substitutes **Secondary:** - Cut out dairy and allow gut time to heal (4-6w) - Ca and vit D supplements - Digestive enzymes can be taken in a capsule before eating lactose until gut heals

Answer 76

Autoimmunity to gliadin (in gluten, wheat, barley, rye) > shorter villi and flat mucosa

Answer 77

**> > Presents 8-24m after introduction of wheat-foods** - Sx of malabsorption (diarrhoea, steatorrhoea, FTT, WL, abdominal distension/bloating) - Malnutrition (wasted buttocks, distended abdomen) - Anaemia - Fatigue, irritability - Can be asx - Dermatitis herpetiformis > itchy blisters on elbows, knees, face and buttocks

Answer 78

**Serological testing:** - IgA anti-tissue transglutaminase antibodies (anti-tTG) - most sensitive - IgA anti-endomysial cell antibodies (anti-EMA) **Bloods:** - FBC, iron studies, vit B12/D/folate **Endoscopy & biopsy:** *(Confirmation of dx)* - Subtotal villous atrophy - Crypt hyperplasia - Intra-epithelial lymphocytes (IELs) - Very young children = no histopathological confirmation **If dx unclear in <2yrs** = gluten challenge to confirm at 6-7yrs

Answer 79

**Remove all products containing wheat, rye and barley FOR LIFE** **+ MDT approach** - Dietician, child psychologist, school involvement, GP, paediatric gastroenterologist **+ Dietician referral** - Regular checks of height, weight, and BMI - Review sx - Review adherence to diet - Consider blood tests **+ Support = Coeliac UK** - Explain importance of sticking to diet (non-adherence > micronutrient deficiency > osteoporosis, EATL, hyposplenism)

Answer 80

Mesenteric lymph node inflammation associated with systemic illness and abdominal sx

Answer 81

**Often follows recent viral infection** - URT viruses most common cause - Can follow UTI

Answer 82

- Abdominal pain > central or RIF - Nausea - Diarrhoea - Decreased appetite - Infectious picture = fever, lymphadenopathy

Answer 83

- **Laparoscopy:** Large mesenteric lymph nodes (w normal appendix) = definitive - **Bloods:** FBC, U&Es - **USS of RIF:** May confirm dx

Answer 84

- Simple analgesia (sx resolve in few days, max 2w) - Safety net for increased pain, deterioration etc

Answer 85

- Male - Premature - Connective tissue disorders

Answer 86

- Scrotal sac enlarged, contains palpable loops of bowel, fluid (doesn’t always transilluminate) +/- pain - Swelling or bulge may be intermittent > can appear on crying / straining

Answer 87

- Tender, firm mass - Vomiting - Unable to pass stool - Poor feeding - Erythematous/discoloured skin overlying

Answer 88

**Clinical dx** - Determine type of hernia > examine supine and standing

Answer 89

**Urgent surgical correction = elective herniorrhaphy** - <6w = within 2d - <6m = within 2w - <6y = within 2m

Answer 90

- Afro-Caribbean - Down’s Syndrome - Mucopolysaccharide diseases

Answer 91

**Common in newborns and often resolve by 12m** - <1y = watch and wait - >1y = surgical repair (large/symptomatic = 2-3yrs, small/asx = 4-5yrs)

Answer 92

Wet, moist, leaks fluid

Answer 93

Tx with salt

Answer 94

Congenital defect in the anterior abdominal wall just lateral to the umbilical cord. (Abdominal contents outside body, without peritoneal covering)

Answer 95

- Vaginal delivery may be attempted - Newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours

Answer 96

The abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac / peritoneal covering

Answer 97

Chromosomal abnormalities in 15% (Patau’s, Edwards, Down’s, Turner’s)

Answer 98

- Caesarean section is indicated to reduce the risk of sac rupture - A staged closure should be started immediately, finishing at 6-12m

Answer 99

Soiling of underwear with stool in children who are past the stage of toilet training (>4yrs)

Answer 100

Usually due to constipation overflow

Answer 101

Enquire about psych stressors, change in medications, food intolerances etc