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Year 6 > Gastro > Flashcards

Gastro Flashcards

1
Q

Define achalasia

A

oesophageal motor disorder characterised by failure or incomplete relaxation of the lower oesophageal sphincter

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2
Q

What infection causes achalasia?

A

oesophageal infection with Trypanosoma cruzi
Causes myocarditis + achalasia

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3
Q

List some risk factors for achalasia

A

AI disease
Herpes/measles viruses
triple A (Allgrove) syndrome

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4
Q

List the common presenting symptoms of achalasia

A

Dysphagia to solids and liquids
Regurgitation
Heartburn
Retrosternal chest pain
Gradual weight loss

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5
Q

List some appropriate investigations for achalasia

A

1st line:
-Upper GI endoscopy
-Barium swallow
-High res oesophageal monometry

Consider:
-Chest X-ray
-Radionucleotide oesophageal emptying studies

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6
Q

What might manometry show in achalasia?

A

Elevated resting LOS pressure >45 mmHg

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7
Q

Outline the management for achalasia

A

Good surgical candidate:
-Pneumatic dilatation (air inflated balloons apply mechanical stretch to LOS to tear muscle fibres)
-Heller cardiomyotomy (cutting of muscles of LOS)
-Peroral endoscopic myotomy (relatively new)

Poor surgical candidates:
-Botulinum toxin A (injection into LOS)
-pharmacological therapy (CCBs or nitrates)
-Gastrostomy (considered in frail older patients where other measures have not worked)

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8
Q

What are some complications of achalasia?

A

Aspiration pneumonia
GORD
Oesophageal carcinoma

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9
Q

Define acute cholangitis

A

infection of the biliary tree

note: it is aka ascending cholangitis

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10
Q

List some risk factors for acute cholangitis

A

age >50 yrs
gallstones
strictures/stenosis of bile ducts
PSC
Tumours
ERCP
Parasitic infection (e.g. ascariasis)

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11
Q

List the presenting symptoms of acute cholangitis

A

Charcot’s Triad:
-RUQ pain (may refer to right shoulder)
-Fever with rigors
-Jaundice
Reynolds’ Pentad:
-Mental confusion
-Septic shock (hypotension)

Pale stools/dark urine
Puritis

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12
Q

What specific sign is associated with acute cholangitis?

A

Murphy’s sign

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13
Q

List some appropriate investigations for acute cholangitis

A

A-E approach
1. Abdo exam + obs
2. Bloods (FBC, U&Es, LFTs, CRP, ABG, cultures, clotting, amylase)
3. Transabdominal ultrasound
4. BEST 1st intervention = ERCP (if not confirmed stone/unsure then do MRCP before this)
5. Contrast CT

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14
Q

What typical pattern would LFTs show in acute cholangitis?

A

pattern of obstructive jaundice (raised ALP + GGT)

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15
Q

List some differentials for acute cholangitis

A

Acute cholecystitis
Peptic ulcer disease
Acute pancreatitis
Hepatic abscess
Acute pyelonephritis
Acute appendicitis

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16
Q

Generate a management plan for acute cholangitis

A
  1. A-E approach (if septic then carry out sepsis 6)
  2. IV Abx (given once cultures taken):
    -Piperacillin + tazobactam 4.5g IV every 8hrs
    -Cefuroxime + metronidazole
  3. Opioid analgesics
  4. If unresponsive to abx then endoscopic biliary drainage (ERCP)
  5. Consider lithotripsy
  6. Last line = choledochotomy with T-tube places or cholecystectomy
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17
Q

What scale is used to determine alcohol withdrawal?

A

Clinical Institute Withdrawal Assessment of Alcohol Scale (a score ≥10 suggests alcohol withdrawal)

Can also use Glasgow modified Alcohol Withdrawal Scale (GMAWS)

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18
Q

List the presenting symptoms of alcohol withdrawal

A

Hx of alcohol intake
Tremor
Anxiety
N+V
Sweating
Palpitations
Tachycardia
Seizures
Delirium tremens - HALLUCINATIONS

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18
Q

Define delirium tremens

A

an acute confusional state often seen as withdrawal syndrome in chronic alcoholics and caused by sudden cessation of drinking alcohol. It can be precipitated by a head injury or an acute infection causing abstinence from alcohol.

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19
Q

List some appropriate investigations for alcohol withdrawal

A
  1. Abdo + neuro exam
  2. Bloods (VBG, glucose, FBC, U&Es, LFTs, bone profile, clotting screen)

Consider:
3. Cultures
4. CT head
5. CXR
6. ECG
7. amylase (if there is abdo pain/ N+V as acute pancreatitis is a complication)
8. EEG (if seizures)

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20
Q

List some differentials for alcohol withdrawal

A

Sympathomimetic intoxication
Encephalitis
Meningitis
Trauma
Hypoglycaemia
Wernicke’s encephalopathy
Alcoholic ketoacidosis
Drug withdrawal
Psychotic disorder e.g. schizophrenia

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21
Q

Generate a management plan for alcohol withdrawal

A
  1. A-E approach
  2. Chlordiazepoxide OR Diazepam OR Lorazepam - reducing regimen (initially high dose). Oral if tolerated, if not then IV.
  3. Pabrinex (give this BEFORE glucose)
  4. Fluids
  5. Supportive care
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22
Q

What would LFTs show in alcohol withdrawal?

A

ALT: almost always elevated. The classic ratio of AST:ALT >2 is seen in about 70% of patients
GGT > 10 times upper limit of normal
Other liver enzymes also elevated

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23
Q

What can you give to alcohol withdrawal patients if they are benzodiazepine resistant?

A

propofol

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24
Q

List some complications of alcohol withdrawal

A

Over sedation
Status epilepticus

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25
Q

List some complications of acute cholangitis

A

Sepsis
Acute pancreatitis
Hepatic abscess
Inadequate biliary drainage

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26
Q

What 3 forms of liver disease can be caused by alcoholic hepatitis?

A

Alcoholic fatty liver (steatosis)
Alcoholic hepatitis
Chronic cirrhosis

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27
Q

List some histopathological features of alcoholic hepatitis

A

Centrilobular ballooning
Necrosis of hepatocytes
Neutrophil inflammation
Mallory-hyaline inclusions
Steatosis

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28
Q

Define alcoholic hepatitis

A

Inflammatory liver injury caused by chronic heavy intake of alcohol

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29
Q

List the presenting symptoms of alcoholic hepatitis

A

Right hypochondrial pain
Low grade fever
Jaundice
Malaise
N+V
Haematemesis + malaena (if GI bleed)

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30
Q

List the SIGNS of alcoholic hepatitis on examination

A

Malnourished
Hepatomegaly
Palmar erythema
Dupuytren’s contracture
Spider naevi
Gynaecomastia
Testicular atrophy

In severe cases can also get:
-Ascites
-Encephalopathy (liver flap, confusion, drowsiness)

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31
Q

Give some differentials for alcoholic hepatitis

A

HBV
HCV
Cholecystitis
Acute liver failure
AI hepatitis
Wilson’s disease

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32
Q

List some appropriate investigations for alcoholic hepatitis

A
  1. Abdo exam + obs
  2. Bloods (FBC, U&Es, LFTs, Clotting, B12/folate)
  3. Liver ultrasound

Consider:
-viral hepatitis serology
-serum iron studies
-ceruloplasmin
-AMA/ANA
-non invasive tests of liver elasticity

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33
Q

List all the elements of a typical liver screen

A

liver function tests - including gamma GT and total protein
ethanol
coagulation tests, including INR and APTT
hepatitis serology - for A, B, and C
viral screen, for CMV, EBV etc
ferritin and total iron binding capacity
alpha 1 antitrypsin
immunoglobulins and protein electrophoresis
autoantibody screen
alpha-feto protein
serum copper, ceruloplasmin, 24 hour copper

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34
Q

Generate a management plan for alcoholic hepatitis

A

Acute:
1. A-E
2. IV Pabrinex + fluids
3. Monitor and correct electrolytes + glucose
4. Diuretics (if ascites)
5. Oral lactulose/phosphate enema (if encephalopathic)
6. Alcohol abstinence + withdrawal management
7. Immunisations
8. Short term steroid therapy to reduce mortality

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35
Q

What is hepatorenal syndrome and what can be given to treat it?

A

the development of renal failure in patients secondary to advanced chronic liver disease
Key symptoms = cirrhosis + ascites + renal failure

Treatment = Glypressin and N-acetylcysteine

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36
Q

Give some complications of alcoholic hepatitis

A

Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
Esophageal varices
Peptic ulcers

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37
Q

What signs are seen on examination in anal fissures?

A

Tears in squamous lining
Sentinel piles

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38
Q

List some appropriate investigations for anal fissures

A

Usually just a clinical diagnosis
Note - do not usually do a DRE due to pain

Can perform anal manometry in patients with resistant fissures

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39
Q

Generate a management plan for anal fissures

A
  1. Conservative - high fibre diet, laxatives, hydration
  2. Medical - topical analgesic, GTN ointment, diltiazem

Can consider botulinum toxin injection for resistant fissures

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40
Q

Outline the key presenting symptoms of appendicitis

A

Central abdo pain localising to RIF
N+V
Fever
May have guarding and rebound tenderness

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41
Q

What special signs are seen in appendicitis?

A

Rovsing’s sign - palpation of LIF causes more pain in RIF
Psoas sign - pain on extending hip (pt in knees to chest position)
Obturator/Cope sign - pain on flexion + internal rotation of hip

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42
Q

List some appropriate investigations for appendicitis

A

Usually a clinical diagnosis

  1. A-E + obs
  2. Bloods (FBC, U&Es, LFTs, CRP, G&S, clotting)
  3. Pregnancy test (if appropriate)
  4. Abdo ultrasound
    [Can consider CT with contrast but usually go straight to surgery]
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43
Q

Generate a management plan for appendicitis

A
  1. NBM
  2. IV fluids (bolus if septic)
  3. Analgesia
  4. Appendicectomy (emergency if perforation) - give prophylactic abx before surgery
  5. Post op antibiotics: amoxicillin + metronidazole OR pip/taz
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44
Q

What are the 2 major forms of AI hepatitis?

A

Type 1 (classic):
-ANA
-ASMA

Type 2:
-ALKM-1
-ALC-1

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45
Q

List some risk factors for AI hepatitis

A

Female
Genetic predisposition
Immune dysregulation

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46
Q

Outline the presenting symptoms of AI hepatitis

A

May be asymptomatic with abnormal LFTs

-Fatigue
-Malaise
-Anorexia
-Abdo pain
-N+V

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47
Q

Give some differentials for AI hepatitis

A

PBC
PSC
Hepatitis B/C/D/viral
Wilson’s disease

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48
Q

List some appropriate investigations for AI hepatitis

A
  1. Abdo exam + obs
  2. Bloods (LFTs, FBC, clotting, antibody screen)
  3. Viral serology
  4. Liver biopsy
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49
Q

Generate a management plan for AI hepatitis

A
  1. High dose steroid (usually oral pred)
  2. Add Azathioprine or 6-mercaptopurine
  3. Consider liver transplant
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50
Q

Define Barrett’s oesophagus

A

A change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia.

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51
Q

List some risk factors for Barrett’s oesophagus

A

GORD
Increased age
White ethnicity
Male

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52
Q

Outline the presenting symptoms of Barrett’s oesophagus

A

GORD symptoms (heartburn, waterbrash, reflux)
Dysphagia

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53
Q

List the appropriate investigations for Barrett’s oesophagus

A

OGD + biopsy

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54
Q

Generate a management plan for Barrett’s oesophagus

A

High grade:
-Radiofrequency ablation with or without endoscopic mucosal resection + PPI
-2nd line = oesophagectomy

Low grade:
-endoscopic mucosal resection + PPI

No dysplasia:
-PPI + surveillance

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55
Q

List some differential diagnoses for Barrett’s oesophagus

A

Oesophagitis
GORD
Oesophageal adenocarcinoma
Gastritis

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56
Q

Define cholangiocarcinoma

A

primary adenocarcinoma of the biliary tree

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57
Q

List some risk factors for cholangiocarcinoma

A

Ulcerative colitis
PSC
Cholangitis

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58
Q

List the key presenting symptoms of cholangiocarcinoma

A

PAINLESS JAUNDICE
Palpable gallbladder which is not tender
Weight loss
Pruritus

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59
Q

What is Courvoisier’s Law?

A

in the presence of jaundice, a palpable gallbladder (that is non-tender) is unlikely to be due to gallstones (i.e. cancer of the pancreas or biliary tree is more likely or a distended gallbladder due to to other causes other than gallstones)

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60
Q

List some appropriate investigations for cholangiocarcinoma

A
  1. Abdo exam
  2. LFTs (high ALP + GGT + bilirubin + PTT)
  3. FBC, U&Es
  4. CA19-9, CEA, CA-125
  5. Abdo USS

Consider ERCP for biopsy or CT/MRI for staging

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61
Q

Generate a management plan for cholangiocarcinoma

A

RESECTABLE:
Partial/total excision ± chemo/immunotherapy/ radiotherapy. Consider preoperative portal vein embolisation or biliary drainage.

NON RESECTABLE:
Liver transplant or palliative therapy

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62
Q

Give some differentials for cholangiocarcinoma

A

HCC
Ampullary carcinoma
Pancreatic carcinoma
Choledocholithiasis
Cholangitis

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63
Q

Define acute cholecystitis

A

inflammation of the gallbladder

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64
Q

List some risk factors for cholecystitis

A

Gallstones
Physical inactivity
Low fibre intake
Severe illness

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65
Q

List the presenting symptoms for cholecystitis

A

RUQ pain
Palpable mass
Fever
N+V
Right shoulder pain

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66
Q

What sign is positive in cholecystitis?

A

Murphy’s sign

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67
Q

Define the terms:
Cholelithiasis
Cholecystitis
Choledocholithiasis
Cholangitis

A

Cholelithaisis - presence of gallstones in the gallbladder
Cholecystitis - cystic duct obstruction + inflammation
Choledocholithiasis - common bile duct obstruction
Cholangitis - choledocholithiasis + infection

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68
Q

List some appropriate investigations for cholecystitis

A
  1. Abdo exam
  2. Bloods (FBC, CRP, LFTs, amylase)
  3. Blood cultures
  4. Abdo USS (wall >3mm is indicative) - GOLD STANDARD
  5. CT Abdo
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69
Q

Generate a management plan for acute cholecystitis

A
  1. Admit
  2. NBM
  3. IV fluids
  4. Analgesia + anti-emetics
  5. Abx (if infection)
  6. Drainage via ERCP or laparoscopic cholecystectomy
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70
Q

Define cirrhosis

A

Irreversible liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes

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71
Q

What is seen on histology in cirrhosis?

A

bridging fibrosis + nodular regeneration

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72
Q

List some risk factors for cirrhosis

A

alcohol misuse
intravenous drug use
unprotected intercourse
obesity (NASH)
autoimmune
PBC/PSC
Inherited (Wilson’s/haemochromatosis etc.)
Vascular (e.g. Budd Chiari syndrome)

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73
Q

Outline the presenting symptoms of cirrhosis

A

Jaundice
Pruritis
Abdo pain
Haematemesis/Malaena
Signs of chronic liver disease
Constitutional symptoms

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74
Q

List some appropriate investigations for cirrhosis

A
  1. Abdo exam
  2. LFTs - can be normal
  3. FBC (usually low plts)
  4. U+Es
  5. Clotting + platelets
  6. Viral serology
  7. Liver biopsy - to confirm

Consider:
-iron studies
-ascitic tap (>250 = SBP)
-antibody screen

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75
Q

Generate a management plan for cirrhosis

A
  1. Treat the cause
  2. Adequate nutrition -enteral supplements if necessary
  3. Sodium restriction + diuretics if ascitic
  4. Liver transplant
  5. TIPSS
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76
Q

What scoring system is used to predict prognosis is chronic liver disease? What are the parameters?

A

Child-Pugh Grading
It is based on 5 factors:
○ Albumin
○ Bilirubin
○ PT
○ Ascites
○ Encephalopathy

77
Q

Define coeliac disease

A

inflammatory disease caused by intolerance to GLUTEN, causing chronic intestinal malabsorption.

78
Q

List some risk factors for coeliac disease

A

FHx
IgA def
Other AI conditions (e.g. T1DM)
Down’s syndrome

79
Q

List the presenting symptoms of coeliac disease

A

Diarrhoea
Bloating
Abdo pain
Steatorrhoea
dermatitis herpetiformis
Amenorrhoea
FTT (in kids)

80
Q

List some appropriate investigations for coeliac disease

A
  1. Abdo exam
  2. Bloods (FBC, U+Es, LFTs, albumin)
  3. Antibody serology (anti-TTG and anti-gliadin)
  4. IgA levels (look for IgA def)
  5. Small bowel endoscopy + histology (GOLD STANDARD)
81
Q

Generate a management plan for coeliac disease

A

Gluten free diet
Calcium and vitamin D supplementation
+/- iron supplementation

82
Q

What is seen on histology in coeliac disease?

A

subtotal villous atrophy and crypt hyperplasia

83
Q

What are some key complications of coeliac disease?

A

GI lymphoma
Osteoporosis/osteopaenia
Coeliac crisis (rare)

84
Q

Outline the presenting symptoms of colorectal cancer

A

Left sided:
-Change in bowel habit
-Rectal bleeding
-Tenesmus
-PR mass

Right sided:
-Abdo mass
-Anaemia sx
-FLAWS

85
Q

Give some appropriate investigations for colorectal cancer

A
  1. Abdo exam + DRE
  2. Bloods (FBC, U+Es, LFTs)
  3. Tumour markers (CEA)
  4. FIT test
  5. Colonoscopy + biopsy (GOLD STANDARD)

Consider double contrast barium enema - ‘apple core’ strictures

86
Q

Generate a management plan for colorectal cancer

A

Surgical resection +/- radiotherapy + chemotherapy

For patients unsuitable for surgery - consider immunotherapy

87
Q

Define Crohn’s disease

A

Chronic granulomatous inflammatory disease that can affect any part of the gastrointestinal tract causing transmural inflammation

88
Q

List some risk factors for Crohn’s

A

white ethnicity and Ashkenazi Jewish ancestry
age 15-40 or 50-60 years
family history of CD
cigarette smoking

89
Q

Outline the presenting symptoms of Crohn’s

A

crampy abdo pain
diarrhoea (can be bloody/steatorrhoea)
fever
malaise
weight loss
extra-intestinal manifestations (ulcers, uveitis, joint pain, erythema nodosum)

90
Q

List some appropriate investigations for Crohn’s disease

A
  1. Abdo exam + DRE
  2. Bloods (FBC, U+Es, LFTs, ESR, CRP, B12, folate, Anti TTG, ASCA)
  3. Iron studies
  4. Stool testing - MC&S + faecal calprotectin
  5. AXR
  6. Consider ileocolonoscopy
91
Q

Generate a management plan for Crohn’s disease

A

Acute exacerbation:
-Fluid resus
-IV/oral corticosteroids
-5-ASA analogues
-Analgesia
-Parenteral nutrition

Long term:
-Steroids
-Immunosuppression (azathioprine/mercaptopurine)

Consider biological therapy - TNF alpha etc.

92
Q

Define diverticulosis and diverticular disease

A

Diverticulosis: the presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel
Diverticular Disease: diverticulosis associated with complications e.g. haemorrhage, infection, fistulae

93
Q

Where are diverticulae most commonly found?

A

sigmoid and descending colon

note: they are NOT found in the rectum

94
Q

List the presenting symptoms of diverticular disease

A

Often asymptomatic
LLQ abdo pain
Fever
Rectal bleeding
Bowel changes

95
Q

List some appropriate investigations for diverticular disease

A
  1. Abdo exam + DRE
  2. Bloods (FBC, U+Es, CRP, LFTs)
  3. Barium enema (sawtooth lumen)
  4. Flexible sigmoidoscopy + colonoscopy (if suspicious of bowel ischaemia)

In emergency - CT

96
Q

Generate a management plan for diverticular disease

A
  1. Dietary and lifestyle modifications

If symptomatic:
-analgesia
-antispasmodic
-consider abx

note: if recurrent diverticulitis then consider elective surgery

97
Q

Give some differentials for diverticular disease

A

Endometriosis
Colorectal cancer
Appendicitis
Ulcerative colitis
Crohn’s disease

98
Q

What are the different types of gallstones?

A

Mixed stones - contain cholesterol, calcium bilirubin, phosphate and protein
Pure cholesterol stones
Bile pigment stones

99
Q

What are the risk factors for gallstones?

A

6 Fs
Fat
Fair
Fertile
Forty
Female
FHx

100
Q

Outline the presenting symptoms of gallstones

A

Colicky RUQ pain
Radiating to right shoulder
Worse after eating, precipitated by fatty meals

101
Q

List some appropriate investigations for gallstones

A
  1. Abdo exam
  2. Bloods (FBC, LFTs, lipase, amylase)
  3. Abdo USS (GOLD STANDARD)
102
Q

Generate a management plan for gallstones

A

Conservative = low fat diet

Symptomatic:
ERCP to remove gallstones
Then lap cholecystectomy to prevent obstructive complications

103
Q

List some risk factors for gastric cancer

A

Smoked/processed foods
Smoking
H. pylori
Pernicious anaemia
FHx

note: common in Japan

104
Q

Outline the presenting symptoms of gastric cancer

A

Early satiety
Epigastric discomfort
Haematemesis, melaena, symptoms of anaemia
Weight loss
Virchow’s node

105
Q

List some appropriate investigations for gastric cancer

A
  1. Abdo exam - lymph nodes esp
  2. Bloods - FBC, U+Es, LFTs
  3. Upper GI endoscopy + biopsy - DIAGNOSTIC

Consider CT for staging

106
Q

Generate a management plan for gastric cancer

A

Surgery - subtotal gastrectomy is preferred. Superficial cancer can be treated with endoscopic mucosal resection
Chemotherapy
Radiotherapy

107
Q

Outline the presenting symptoms of GORD

A

heartburn - usually aggravated by lying supine
acid regurgitation
waterbrash
dysphagia
bloating

108
Q

List some appropriate investigations for GORD

A

Usually a clinical diagnosis
If suspected then offer a PPI trial

109
Q

Generate a management plan for GORD

A

Conservative advice:
-small meals
-exercise
-weight loss
-stop smoking

Medical:
-PPIs
-H2 antagonists

If no good response to medical treatment then can try surgery:
-Endoscopy for dilation/stenting
-Nissen fundoplication

110
Q

Outbreak of D+V in institutions with elderly - causative organism?

111
Q

Uni student with watery diarrhoea - causative organism?

112
Q

Rapid onset diarrhoea after a meal - causative organism?

A

S aureus (toxins produced) or Bacillus cereus

113
Q

Name the CHESS organisms that cause bloody diarrhoea

A

▪ Campylobacter jejuni/ c.diff (can cause D or dysentry)
▪ Haemorrhagic E Coli O157
▪ Entamoeba histolytica
▪ Salmonella (can cause D or dysentry)
▪ Shigella

114
Q

What is the treatment for C diff gastroenteritis?

A

Isolate
Oral metronidazole 10-14 days
If refractory/pseudomembranous colitis - vancomycin

115
Q

List some common causes of a GI perforation

A

Peptic ulcers
Sigmoid diverticulum
Colorectal cancer
Appendicitis
UC
Volvulus

116
Q

What signs can be seen on an AXR in a GI perforation?

A

Rigler’s sign
Psoas sign

117
Q

Generate a management plan for GI perforation

A

Correct fluid and electrolytes
IV antibiotics (with anaerobic cover) – cefuroxime and metronidazole
Nil by mouth + NG tube inserted

Surgery - resection of perforation section (usually Hartmann’s procedure)

118
Q

What is the inheritance pattern of haemochromatosis?

A

autosomal recessive
(caused by defect in HFE gene)

119
Q

Outline the presenting symptoms of haemochromatosis

A

Fatigue
Weakness
Arthralgia
Erectile dysfunction
Heart problems/arrhythmias

LATER –> DIABETES MELLITUS + BRONZE SKIN

120
Q

List some appropriate investigations for haemochromatosis

A
  1. Obs + exam
  2. Iron studies - serum transferrin saturation, serum ferritin
  3. Bloods (FBC, CRP, LFTs)
  4. Hormones

Consider liver biopsy to confirm

121
Q

Generate a management plan for haemochromatosis

A

Lifestyle modifications - avoid iron/Vit C supplements

For severe cases - plebotomy regimen
2nd line = iron chelation therapy (deferasirox)

122
Q

Define haemorrhoids

A

disrupted and dilated veins which are located within the anal canal

123
Q

What are the different degrees of haemorrhoids?

A

1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation (extend to outside rectum when excreting) but reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced

124
Q

Outline the presenting symptoms of haemorrhoids

A

Bright red blood on toilet paper
Perianal discomfort
Anal pruritis
Tenesmus

125
Q

List the appropriate investigations for haemorrhoids

A
  1. Abdo exam + Anascopic exam + DRE
  2. FBC
  3. stool for occult haem
  4. colonoscopy - to exclude other causes of bleeding
126
Q

Generate a management plan for haemorrhoids

A

1st degree = conservative
2/3rd degree = non operative measures:
-band ligation
-sclerotherapy
4th degree = surgery
-haemorrhoidectomy

127
Q

List some appropriate investigations for hepatocellular carcinoma

A
  1. Abdo exam
  2. Bloods (FBC, ESR, LFTs, Clotting, a-fetoprotein)
  3. Viral serology
  4. Ultrasound of liver
  5. CT/MRI for staging
128
Q

What are the borders of Hesselbach’s triangle?

A

lateral border of rectus abdominis, inferior epigastric vessels, inguinal ligament

note: direct hernias pass through this

129
Q

Generate a management plan for inguinal hernias

A

If strangulated:
Surgery - mesh repair if the bowel is viable, but resection if in doubt

Large/complicated hernias:
-Laparoscopic/open mesh repair

If small then can consider watchful waiting

130
Q

Outline the presenting symptoms of a hiatus hernia

A

GORD symptoms
Painless regurgitation
Bowel sounds in chest

131
Q

Generate a management plan for hiatus hernias

A

Usually lifestyle measures

If strangulated or necrotic –> surgery
1st line Nissen fundoplication

132
Q

List some appropriate investigations for intestinal ischaemia

A
  1. Abdo exam
  2. Bloods - FBC, U+Es, LFTs, ABG, lactate, G&S, Cross-match, clotting
  3. AXR - thickening of small bowel folds. May show ‘gasless abdomen’ and thumbprinting
  4. ECG
  5. Colonoscopy + biopsy - gold standard for ischaemic colitis
  6. CT
133
Q

Generate a management plan for intestinal ischaemia

A
  1. A to E approach
  2. Resuscitation + supportive measures
  3. Empirical antibiotics (usually IV ceftriaxone)
  4. Embolectomy/arterial bypass +/- bowel resection
  5. Post op heparinisation

For vein occlusions first line is anticoagulation (usually heparin)

134
Q

Outline the presenting symptoms of intestinal ischaemia

A

Acute : sudden onset diffuse pain, shock signs and norm exam, gas less abdo on AXR (recent operations, trauma, coagulopathy etc), BS may be absent

Chronic : intermittent gut claudication, post-prandial pain, PR bleeding, Weight loss, norm abdo exam

135
Q

Outline the presenting symptoms of intestinal obstruction

A

Colicky pain (spasms are shorter in small bowel compared to large bowel)
Abdo distension
Frequent vomiting
Absolute constipation

136
Q

List some appropriate investigations for intestinal obstruction

A
  1. Abdo exam + DRE
  2. Bloods - FBC, U+Es, LFTs, clotting, G&S, X match
  3. AXR (small bowel >3, large bowel >6, caecum >9)
  4. Erect CXR
  5. CT abdo
137
Q

Generate a management plan for intestinal obstruction

A
  1. A-E approach
  2. Drip and suck method:
    -NBM + NG tube
    -IV fluids + electrolyte replacement
    -analgesia
    -catheter + fluid balance
  3. Surgery - emergency laparotomy if perforation
138
Q

List some appropriate investigations for a Mallory Weiss tear

A
  1. Bloods (FBC, U+Es, LFTs, X match, G&S)
  2. Gastroscopy
  3. CXR
139
Q

Generate a management plan for a Mallory Weiss tear

A

A-E
Resuscitation
Endoscopy with treatment (ligation/adrenaline)
Consider transfusion
Consider anti-emetic
Consider PPI

140
Q

What scoring systems can be used for nonvariceal upper GI bleeding?

A

Glasgow Blatchford
Rockall (can only be calculated after endoscopy)

141
Q

List some risk factors for non-alcoholic fatty liver disease

A

Obesity
Diabetes
Dyslipidaemia
Hypertension
Increasing age (>50)
Smoking
TPN

142
Q

List some appropriate investigations for NAFLD

A
  1. Abdo exam
  2. Bloods - LFTs, lipids, FBC, met panel
  3. Viral serology
  4. AI screen
  5. Liver ultrasound
143
Q

Generate a management plan for NAFLD

A

Conservative = controlling risk factors
Consider pioglitazone and weight loss pharmacology

In severe liver disease –> transplant

144
Q

Generate a management plan for ruptured oesophageal varices

A
  1. A-E approach - put out a major haemorrhage call
  2. Resuscitation and supportive therapy
  3. IV access
  4. Prophylactic Abx
  5. 2mg terlipressin SC QDS

Consider senstaken-blakemore tube/balloon

145
Q

What are the 2 types of oesophageal cancer?

A

Adenocarcinoma (lower 1/3)
Squamous cell carcinoma (upper 2/3)

146
Q

Outline the presenting symptoms of oesophageal cancer

A

Often asymptomatic
Progressive dysphagia
Regurgitation
Cough
Voice hoarseness
Odynophagia
FLAWS

147
Q

List some appropriate investigations for oesophageal cancer

A

OGD + biopsy
Bloods
CT thorax
PET scan

148
Q

Generate a management plan for oesophageal cancer

A

Oesophagectomy +/- chemotherapy
Consider postop nivolumab

149
Q

Outline the presenting symptoms of pancreatic cancer

A

NON-SPECIFIC
Epigastric pain - radiates to back and relieved by sitting forward
FLAWS
Jaundice + palpable gallbladder
Anorexia
Trousseau’s sign of malignancy

150
Q

List some appropriate investigations for pancreatic cancer

A

pancreatic protocol CT
abdominal ultrasound
LFTs
Consider CEA/Ca19-9

151
Q

Generate a management plan for pancreatic cancer

A

1ST LINE –
surgical resection (Whipple)

PLUS –
pancreatic enzyme replacement

CONSIDER –
preoperative biliary stenting

CONSIDER –
neoadjuvant radiotherapy or chemoradiotherapy

152
Q

Outline the causes of acute pancreatitis

A

Gallstones (MOST COMMON)
Ethanol
Trauma
Steroids
Mumps/HIV/Coxsackie
Autoimmune
Scorpion Venom
Hypercalcaemia/hyperlipidaemia/hypothermia
ERCP (examining pancreatic and bile ducts)
Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)

153
Q

What are the key presenting symptoms of pancreatitis?

A

Severe epigastric pain - better when lean forward
Radiating to the back
Relieved by sitting forward
Aggravated by movement
Associated with anorexia, nausea and vomiting

note: severe pancreatitis may also have Cullen’s and Grey-Turner’s sign present

154
Q

List some appropriate investigations for acute pancreatitis

A
  1. Abdo exam
  2. Serum lipase + amylase
  3. FBC, LFTs, U+Es
  4. CRP
  5. ABG
  6. USS biliary tree (then ERCP if confirmed gallstones)
  7. CXR (to exclude pleural effusion)
155
Q

Generate a management plan for acute pancreatitis

A
  1. Nil by mouth – stop patients eating – (no stimulus = less amylase)
  2. Urinary catheter and NG tube if vomiting – suck out all the contents so all the XS enzymes are out
  3. Fluid resuscitation
  4. Analgesia
  5. Consider empirical abx if infection

If confirmed gallstones then proceed to ERCP
Necrotising pancreatitis requires surgery

156
Q

What scales are used to determine the severity of pancreatitis?

A

Modified Glasgow Score (combined with CRP (> 210 mg/L)
APACHE-II Score

157
Q

List the criteria for the modified Glasgow score

A

PaO2 < 7.9
Age > 55
Neutrophilia (WCC > 15 x 109/L)
Calcium < 2mmol
Renal function (urea > 16 mmol)
Enzymes (LDH > 600 U/L or AST > 200 U/L)
Albumin < 32 g/L
Sugar (glucose) > 10 mmol

158
Q

What is the triad of chronic pancreatitis?

A

Steatorrhoea
DM
Epigastric pain

159
Q

List some appropriate investigations for chronic pancreatitis

A
  1. Bloods (incl. amylase/lipase)
  2. USS
  3. MRCP (or ERCP)
  4. CT
  5. Faecal elastase (tests pancratic exocrine function)
160
Q

Generate a management plan for chronic pancreatitis

A
  1. Interventions for alcohol + smoking cessation
  2. Oral pancreatic enzyme replacement + PPI
  3. Analgesia

If medical therapy doesn’t work then consider surgery:
-modified Puestow procedure
-Whipple

161
Q

List some common causes of peptic ulcer disease and gastritis

A

Alcohol
H. Pylori
NSAIDs
Bisphosphonates
Smoking

162
Q

List the appropriate investigations for peptic ulcer disease/gastritis

A
  1. Abdo exam
  2. Bloods - FBC, U+Es, LFTs, clotting, amylase
  3. H pylori breath test/stool antigen test
  4. Stool occult blood test
  5. Serum gastrin - zollinger Ellison syndrome

If any red flags –> Upper GI endoscopy + biopsy (if ulcer present then another endoscopy in 6-8 wks to confirm resolution)

163
Q

Generate a management plan for peptic ulcer disease

A

A-E approach
Fluid resus +/- transfusion
Endoscopy - (coagulation, injection sclerotherapy etc.)
Treat underlying cause

164
Q

What is the treatment for H. pylori?

A

Triple therapy for 1-2 weeks
Usually a combination of 2 antibiotics + PPI (high dose) (e.g. clarithromycin 500mg + amoxicillin 1g/metronidazole 400mg + omeprazole) - taken twice daily

165
Q

List some risk factors for perineal abscesses/fistulae

A

IBD
Diabetes mellitus
Malignancy
Diverticulitis

166
Q

Generate a management plan for perineal abscesses/fistulae

A
  1. Examination
  2. Surgical drainage
  3. Fistulotomy (if appropriate)
167
Q

List some appropriate investigations for suspected peritonitis

A
  1. Abdo exam
  2. Obs
  3. Bloods (FBC, U+Es, LFTs, amylase, CRP, clotting, G&S, X match, CULTURES)
  4. ABG
  5. Pregnancy test (if appropriate)
  6. Erect CXR
  7. AXR
  8. If ascites then ascitic tap and cell count
168
Q

What is the ascitic tap cut off for SBP?

A

> 250 neutrophils/mm3

169
Q

How do you treat SBP?

A

Quinolone antibiotics
OR
Cefuroxime + Metronidazole

170
Q

What is a pilonidal sinus?

A

Obstruction of natal cleft hair follicles ~6cm above the anus

171
Q

List some appropriate investigations for a pilonidal sinus

A

None needed
Clinical diagnosis

172
Q

Generate a management plan for a pilonidal sinus

A

Hair removal + hygiene advice

Without abscess: sinus excision or primary off-midline closure (on either side of natal cleft)
With abscess: drainage + incision

173
Q

When is portal hypertension considered clinically significant?

A

Clinically significant portal hypertension is defined as a hepatic venous pressure gradient > 10 mm Hg (NORMAL is < 5mmHg)

174
Q

List some causes of portal hypertension

A

Cirrhosis
Thrombosis
Chronic hepatitis
Granulomata
Myeloproliferative disease
Post hepatic causes e.g. Budd chiari or RHF

175
Q

List some appropriate investigations for portal hypertension

A
  1. Abdo exam
  2. Bloods (LFTs, U+Es, Clotting (esp. PT), FBC, glucose)
  3. Imaging - Abdo USS, Doppler USS, endoscopy (to check for varices)
  4. Measure hepatic venous pressure gradient
176
Q

Generate a management plan for portal hypertension

A
  1. A-E approach
  2. Immediate treatment: terlipressin and prophylactic antibiotics
  3. Fluid resuscitation
  4. Endoscopy is done within 12h to diagnose and treat using band ligation or injection sclerotherapy
  5. If insufficient: TIPS [shunt placed between the hepatic portal vein and the hepatic vein to ease congestion in the portal vein]

Consider: Liver transplant
Consider: Beta blockers (e.g. carvedilol) used for prophylaxis of variceal bleed

177
Q

Define PBC

A

A chronic inflammatory liver disease involving progressive destruction of intrahepatic bile ducts (smaller bile ducts that drain liver), leading to cholestasis, and, ultimately, cirrhosis

178
Q

List some appropriate investigations for PBC

A
  1. Bloods (LFTs, FBC, U+Es, clotting, TFTs)
  2. Antimitochondrial antibodies
  3. Ultrasound

Consider MRCP

179
Q

Generate a management plan for PBC

A
  1. Ursodeoxycholic acid (exogenous bile salts) to help improve the flow of bile
  2. Cholestyramine for the puritis (must be given at least 2 hours after ursodeoxycholic acid)

Liver transplant in severe cases

180
Q

Define PSC

A

A chronic cholestatic liver disease characterised by progressive inflammatory fibrosis and obliteration of intrahepatic and extrahepatic bile ducts

181
Q

List some appropriate investigations for PSC

A
  1. Abdo exam
  2. Bloods (LFTs, U+Es, FBC, clotting)
  3. Serology (pANCA present in 70% cases_
  4. ERCP (beaded appearance)

Consider liver biopsy

182
Q

Generate a management plan for PSC

A

1st line - observation + lifestyle changes
DEXA scans at yearly intervals

Consider ursodeoxycholic acid + pruritis relief

If strictures - interventional procedure via ERCP

End stage liver disease - liver transplantation

183
Q

What is the difference between a type 1 and type 2 rectal prolapse?

A

Type 1 rectal prolapse occurs when only the rectal mucosa protrudes through the anus and type 2 occurs when all layers of the rectum protrude through the anus, creating a mass which has palpable, concentric muscular rings

184
Q

Outline the presenting symptoms of ulcerative colitis

A

Bloody/mucous diarrhoea
Tenesmus + urgency
Crampy abdo pain
Weight loss
Fever
Extra GI manifestations (e.g. uveitis, scleritis, erythema nodosum, pyoderma gangrenosum)

185
Q

List some appropriate investigations for ulcerative colitis

A
  1. Abdo exam + obs
  2. Stool (culture, faecal calprotectin)
  3. Bloods (FBC, U+Es, LFTs, CRP, pANCA)
  4. AXR
  5. Flexible sigmoidoscopy/colonoscopy (loss of haustra)
  6. Barium enema (lead pipe)
186
Q

What criteria are used to determine the severity of ulcerative colitis?

A

Truelove and Witts (>6 stools = severe)

187
Q

Generate a management plan for ulcerative colitis

A

Acute exaceration/severe UC:
A-E approach
IV fluids
IV steroids (+AdCal for bone protection)
2nd line = ciclosporin
Bowel rest
Parenteral feeding (if necessary)

Management of UC in remission
1st line: Rectal (topical) 5-ASA derivatives (e.g. mesalazine, olsalazine, sulphasalazine)
2nd line: rectal corticosteroids (hydrocortisone) or oral mesalazine
3rd line: oral corticosteroids (+/- oral tacrolimus (immunosuppressive)

Surgical management:
- Proctocolectomy with ileostomy
- Ileo-anal pouch formation
NOTE - TOXIC MEGACOLON IS AN ABSOLUTE C/I FOR SURGERY

188
Q

List some appropriate investigations for Wilson’s disease

A

LFTs
24-hour urinary copper
slit-lamp examination
serum ceruloplasmin (will be low <180mg/dL)

189
Q

Generate a management plan for Wilson’s disease

A

If very bad liver failure –> transplant

Mild failure = oral chelation therapy + zinc + dietary restriction of copper

Year 6 (2 decks)

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