Gastro Flashcards
1
Q
Define achalasia
A
oesophageal motor disorder characterised by failure or incomplete relaxation of the lower oesophageal sphincter
2
Q
What infection causes achalasia?
A
oesophageal infection with Trypanosoma cruzi
Causes myocarditis + achalasia
3
Q
List some risk factors for achalasia
A
AI disease
Herpes/measles viruses
triple A (Allgrove) syndrome
4
Q
List the common presenting symptoms of achalasia
A
Dysphagia to solids and liquids
Regurgitation
Heartburn
Retrosternal chest pain
Gradual weight loss
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
6
Q
What might manometry show in achalasia?
A
Elevated resting LOS pressure >45 mmHg
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)
8
Q
What are some complications of achalasia?
A
Aspiration pneumonia
GORD
Oesophageal carcinoma
9
Q
Define acute cholangitis
A
infection of the biliary tree
note: it is aka ascending cholangitis
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)
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
12
Q
What specific sign is associated with acute cholangitis?
A
Murphy’s sign
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
14
Q
What typical pattern would LFTs show in acute cholangitis?
A
pattern of obstructive jaundice (raised ALP + GGT)
15
Q
List some differentials for acute cholangitis
A
Acute cholecystitis
Peptic ulcer disease
Acute pancreatitis
Hepatic abscess
Acute pyelonephritis
Acute appendicitis
16
Q
Generate a management plan for acute cholangitis
A
- A-E approach (if septic then carry out sepsis 6)
- IV Abx (given once cultures taken):
-Piperacillin + tazobactam 4.5g IV every 8hrs
-Cefuroxime + metronidazole - Opioid analgesics
- If unresponsive to abx then endoscopic biliary drainage (ERCP)
- Consider lithotripsy
- Last line = choledochotomy with T-tube places or cholecystectomy
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)
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
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.
19
Q
List some appropriate investigations for alcohol withdrawal
A
- Abdo + neuro exam
- 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)
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
21
Q
Generate a management plan for alcohol withdrawal
A
- A-E approach
- Chlordiazepoxide OR Diazepam OR Lorazepam - reducing regimen (initially high dose). Oral if tolerated, if not then IV.
- Pabrinex (give this BEFORE glucose)
- Fluids
- Supportive care
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
23
Q
What can you give to alcohol withdrawal patients if they are benzodiazepine resistant?
A
propofol
24
List some complications of alcohol withdrawal
Over sedation
Status epilepticus
25
List some complications of acute cholangitis
Sepsis
Acute pancreatitis
Hepatic abscess
Inadequate biliary drainage
26
What 3 forms of liver disease can be caused by alcoholic hepatitis?
Alcoholic fatty liver (steatosis)
Alcoholic hepatitis
Chronic cirrhosis
27
List some histopathological features of alcoholic hepatitis
Centrilobular ballooning
Necrosis of hepatocytes
Neutrophil inflammation
Mallory-hyaline inclusions
Steatosis
28
Define alcoholic hepatitis
Inflammatory liver injury caused by chronic heavy intake of alcohol
29
List the presenting symptoms of alcoholic hepatitis
Right hypochondrial pain
Low grade fever
Jaundice
Malaise
N+V
Haematemesis + malaena (if GI bleed)
30
List the SIGNS of alcoholic hepatitis on examination
Malnourished
Hepatomegaly
Palmar erythema
Dupuytren's contracture
Spider naevi
Gynaecomastia
Testicular atrophy
In severe cases can also get:
-Ascites
-Encephalopathy (liver flap, confusion, drowsiness)
31
Give some differentials for alcoholic hepatitis
HBV
HCV
Cholecystitis
Acute liver failure
AI hepatitis
Wilson's disease
32
List some appropriate investigations for alcoholic hepatitis
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
33
List all the elements of a typical liver screen
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
34
Generate a management plan for alcoholic hepatitis
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
35
What is hepatorenal syndrome and what can be given to treat it?
the development of renal failure in patients secondary to advanced chronic liver disease
Key symptoms = cirrhosis + ascites + renal failure
Treatment = Glypressin and N-acetylcysteine
36
Give some complications of alcoholic hepatitis
Acute liver decompensation
Hepatorenal syndrome
Cirrhosis
Esophageal varices
Peptic ulcers
37
What signs are seen on examination in anal fissures?
Tears in squamous lining
Sentinel piles
38
List some appropriate investigations for anal fissures
Usually just a clinical diagnosis
Note - do not usually do a DRE due to pain
Can perform anal manometry in patients with resistant fissures
39
Generate a management plan for anal fissures
1. Conservative - high fibre diet, laxatives, hydration
2. Medical - topical analgesic, GTN ointment, diltiazem
Can consider botulinum toxin injection for resistant fissures
40
Outline the key presenting symptoms of appendicitis
Central abdo pain localising to RIF
N+V
Fever
May have guarding and rebound tenderness
41
What special signs are seen in appendicitis?
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
42
List some appropriate investigations for appendicitis
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]
43
Generate a management plan for appendicitis
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
44
What are the 2 major forms of AI hepatitis?
Type 1 (classic):
-ANA
-ASMA
Type 2:
-ALKM-1
-ALC-1
45
List some risk factors for AI hepatitis
Female
Genetic predisposition
Immune dysregulation
46
Outline the presenting symptoms of AI hepatitis
May be asymptomatic with abnormal LFTs
-Fatigue
-Malaise
-Anorexia
-Abdo pain
-N+V
47
Give some differentials for AI hepatitis
PBC
PSC
Hepatitis B/C/D/viral
Wilson's disease
48
List some appropriate investigations for AI hepatitis
1. Abdo exam + obs
2. Bloods (LFTs, FBC, clotting, antibody screen)
3. Viral serology
4. Liver biopsy
49
Generate a management plan for AI hepatitis
1. High dose steroid (usually oral pred)
2. Add Azathioprine or 6-mercaptopurine
3. Consider liver transplant
50
Define Barrett's oesophagus
A change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia.
51
List some risk factors for Barrett's oesophagus
GORD
Increased age
White ethnicity
Male
52
Outline the presenting symptoms of Barrett's oesophagus
GORD symptoms (heartburn, waterbrash, reflux)
Dysphagia
53
List the appropriate investigations for Barrett's oesophagus
OGD + biopsy
54
Generate a management plan for Barrett's oesophagus
High grade:
-Radiofrequency ablation with or without endoscopic mucosal resection + PPI
-2nd line = oesophagectomy
Low grade:
-endoscopic mucosal resection + PPI
No dysplasia:
-PPI + surveillance
55
List some differential diagnoses for Barrett's oesophagus
Oesophagitis
GORD
Oesophageal adenocarcinoma
Gastritis
56
Define cholangiocarcinoma
primary adenocarcinoma of the biliary tree
57
List some risk factors for cholangiocarcinoma
Ulcerative colitis
PSC
Cholangitis
58
List the key presenting symptoms of cholangiocarcinoma
PAINLESS JAUNDICE
Palpable gallbladder which is not tender
Weight loss
Pruritus
59
What is Courvoisier's Law?
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)
60
List some appropriate investigations for cholangiocarcinoma
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
61
Generate a management plan for cholangiocarcinoma
RESECTABLE:
Partial/total excision ± chemo/immunotherapy/ radiotherapy. Consider preoperative portal vein embolisation or biliary drainage.
NON RESECTABLE:
Liver transplant or palliative therapy
62
Give some differentials for cholangiocarcinoma
HCC
Ampullary carcinoma
Pancreatic carcinoma
Choledocholithiasis
Cholangitis
63
Define acute cholecystitis
inflammation of the gallbladder
64
List some risk factors for cholecystitis
Gallstones
Physical inactivity
Low fibre intake
Severe illness
65
List the presenting symptoms for cholecystitis
RUQ pain
Palpable mass
Fever
N+V
Right shoulder pain
66
What sign is positive in cholecystitis?
Murphy's sign
67
Define the terms:
Cholelithiasis
Cholecystitis
Choledocholithiasis
Cholangitis
Cholelithaisis - presence of gallstones in the gallbladder
Cholecystitis - cystic duct obstruction + inflammation
Choledocholithiasis - common bile duct obstruction
Cholangitis - choledocholithiasis + infection
68
List some appropriate investigations for cholecystitis
1. Abdo exam
2. Bloods (FBC, CRP, LFTs, amylase)
3. Blood cultures
4. Abdo USS (wall >3mm is indicative) - GOLD STANDARD
5. CT Abdo
69
Generate a management plan for acute cholecystitis
1. Admit
2. NBM
3. IV fluids
4. Analgesia + anti-emetics
5. Abx (if infection)
6. Drainage via ERCP or laparoscopic cholecystectomy
70
Define cirrhosis
Irreversible liver damage with replacement of normal liver architecture with diffuse fibrosis and nodules of regenerating hepatocytes
71
What is seen on histology in cirrhosis?
bridging fibrosis + nodular regeneration
72
List some risk factors for cirrhosis
alcohol misuse
intravenous drug use
unprotected intercourse
obesity (NASH)
autoimmune
PBC/PSC
Inherited (Wilson's/haemochromatosis etc.)
Vascular (e.g. Budd Chiari syndrome)
73
Outline the presenting symptoms of cirrhosis
Jaundice
Pruritis
Abdo pain
Haematemesis/Malaena
Signs of chronic liver disease
Constitutional symptoms
74
List some appropriate investigations for cirrhosis
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
75
Generate a management plan for cirrhosis
1. Treat the cause
2. Adequate nutrition -enteral supplements if necessary
3. Sodium restriction + diuretics if ascitic
4. Liver transplant
5. TIPSS
76
What scoring system is used to predict prognosis is chronic liver disease? What are the parameters?
Child-Pugh Grading
It is based on 5 factors:
○ Albumin
○ Bilirubin
○ PT
○ Ascites
○ Encephalopathy
77
Define coeliac disease
inflammatory disease caused by intolerance to GLUTEN, causing chronic intestinal malabsorption.
78
List some risk factors for coeliac disease
FHx
IgA def
Other AI conditions (e.g. T1DM)
Down's syndrome
79
List the presenting symptoms of coeliac disease
Diarrhoea
Bloating
Abdo pain
Steatorrhoea
dermatitis herpetiformis
Amenorrhoea
FTT (in kids)
80
List some appropriate investigations for coeliac disease
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
Generate a management plan for coeliac disease
Gluten free diet
Calcium and vitamin D supplementation
+/- iron supplementation
82
What is seen on histology in coeliac disease?
subtotal villous atrophy and crypt hyperplasia
83
What are some key complications of coeliac disease?
GI lymphoma
Osteoporosis/osteopaenia
Coeliac crisis (rare)
84
Outline the presenting symptoms of colorectal cancer
Left sided:
-Change in bowel habit
-Rectal bleeding
-Tenesmus
-PR mass
Right sided:
-Abdo mass
-Anaemia sx
-FLAWS
85
Give some appropriate investigations for colorectal cancer
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
Generate a management plan for colorectal cancer
Surgical resection +/- radiotherapy + chemotherapy
For patients unsuitable for surgery - consider immunotherapy
87
Define Crohn's disease
Chronic granulomatous inflammatory disease that can affect any part of the gastrointestinal tract causing transmural inflammation
88
List some risk factors for Crohn's
white ethnicity and Ashkenazi Jewish ancestry
age 15-40 or 50-60 years
family history of CD
cigarette smoking
89
Outline the presenting symptoms of Crohn's
crampy abdo pain
diarrhoea (can be bloody/steatorrhoea)
fever
malaise
weight loss
extra-intestinal manifestations (ulcers, uveitis, joint pain, erythema nodosum)
90
List some appropriate investigations for Crohn's disease
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
Generate a management plan for Crohn's disease
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
Define diverticulosis and diverticular disease
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
Where are diverticulae most commonly found?
sigmoid and descending colon
note: they are NOT found in the rectum
94
List the presenting symptoms of diverticular disease
Often asymptomatic
LLQ abdo pain
Fever
Rectal bleeding
Bowel changes
95
List some appropriate investigations for diverticular disease
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
Generate a management plan for diverticular disease
1. Dietary and lifestyle modifications
If symptomatic:
-analgesia
-antispasmodic
-consider abx
note: if recurrent diverticulitis then consider elective surgery
97
Give some differentials for diverticular disease
Endometriosis
Colorectal cancer
Appendicitis
Ulcerative colitis
Crohn's disease
98
What are the different types of gallstones?
Mixed stones - contain cholesterol, calcium bilirubin, phosphate and protein
Pure cholesterol stones
Bile pigment stones
99
What are the risk factors for gallstones?
6 Fs
Fat
Fair
Fertile
Forty
Female
FHx
100
Outline the presenting symptoms of gallstones
Colicky RUQ pain
Radiating to right shoulder
Worse after eating, precipitated by fatty meals
101
List some appropriate investigations for gallstones
1. Abdo exam
2. Bloods (FBC, LFTs, lipase, amylase)
3. Abdo USS (GOLD STANDARD)
102
Generate a management plan for gallstones
Conservative = low fat diet
Symptomatic:
ERCP to remove gallstones
Then lap cholecystectomy to prevent obstructive complications
103
List some risk factors for gastric cancer
Smoked/processed foods
Smoking
H. pylori
Pernicious anaemia
FHx
note: common in Japan
104
Outline the presenting symptoms of gastric cancer
Early satiety
Epigastric discomfort
Haematemesis, melaena, symptoms of anaemia
Weight loss
Virchow's node
105
List some appropriate investigations for gastric cancer
1. Abdo exam - lymph nodes esp
2. Bloods - FBC, U+Es, LFTs
3. Upper GI endoscopy + biopsy - DIAGNOSTIC
Consider CT for staging
106
Generate a management plan for gastric cancer
Surgery - subtotal gastrectomy is preferred. Superficial cancer can be treated with endoscopic mucosal resection
Chemotherapy
Radiotherapy
107
Outline the presenting symptoms of GORD
heartburn - usually aggravated by lying supine
acid regurgitation
waterbrash
dysphagia
bloating
108
List some appropriate investigations for GORD
Usually a clinical diagnosis
If suspected then offer a PPI trial
109
Generate a management plan for GORD
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
Outbreak of D+V in institutions with elderly - causative organism?
Norovirus
111
Uni student with watery diarrhoea - causative organism?
C. jejuni
112
Rapid onset diarrhoea after a meal - causative organism?
S aureus (toxins produced) or Bacillus cereus
113
Name the CHESS organisms that cause bloody diarrhoea
▪ Campylobacter jejuni/ c.diff (can cause D or dysentry)
▪ Haemorrhagic E Coli O157
▪ Entamoeba histolytica
▪ Salmonella (can cause D or dysentry)
▪ Shigella
114
What is the treatment for C diff gastroenteritis?
Isolate
Oral metronidazole 10-14 days
If refractory/pseudomembranous colitis - vancomycin
115
List some common causes of a GI perforation
Peptic ulcers
Sigmoid diverticulum
Colorectal cancer
Appendicitis
UC
Volvulus
116
What signs can be seen on an AXR in a GI perforation?
Rigler's sign
Psoas sign
117
Generate a management plan for GI perforation
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
What is the inheritance pattern of haemochromatosis?
autosomal recessive
(caused by defect in HFE gene)
119
Outline the presenting symptoms of haemochromatosis
Fatigue
Weakness
Arthralgia
Erectile dysfunction
Heart problems/arrhythmias
LATER --> DIABETES MELLITUS + BRONZE SKIN
120
List some appropriate investigations for haemochromatosis
1. Obs + exam
2. Iron studies - serum transferrin saturation, serum ferritin
3. Bloods (FBC, CRP, LFTs)
4. Hormones
Consider liver biopsy to confirm
121
Generate a management plan for haemochromatosis
Lifestyle modifications - avoid iron/Vit C supplements
For severe cases - plebotomy regimen
2nd line = iron chelation therapy (deferasirox)
122
Define haemorrhoids
disrupted and dilated veins which are located within the anal canal
123
What are the different degrees of haemorrhoids?
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
Outline the presenting symptoms of haemorrhoids
Bright red blood on toilet paper
Perianal discomfort
Anal pruritis
Tenesmus
125
List the appropriate investigations for haemorrhoids
1. Abdo exam + Anascopic exam + DRE
2. FBC
3. stool for occult haem
4. colonoscopy - to exclude other causes of bleeding
126
Generate a management plan for haemorrhoids
1st degree = conservative
2/3rd degree = non operative measures:
-band ligation
-sclerotherapy
4th degree = surgery
-haemorrhoidectomy
127
List some appropriate investigations for hepatocellular carcinoma
1. Abdo exam
2. Bloods (FBC, ESR, LFTs, Clotting, a-fetoprotein)
3. Viral serology
4. Ultrasound of liver
5. CT/MRI for staging
128
What are the borders of Hesselbach's triangle?
lateral border of rectus abdominis, inferior epigastric vessels, inguinal ligament
note: direct hernias pass through this
129
Generate a management plan for inguinal hernias
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
Outline the presenting symptoms of a hiatus hernia
GORD symptoms
Painless regurgitation
Bowel sounds in chest
131
Generate a management plan for hiatus hernias
Usually lifestyle measures
If strangulated or necrotic --> surgery
1st line Nissen fundoplication
132
List some appropriate investigations for intestinal ischaemia
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
Generate a management plan for intestinal ischaemia
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
Outline the presenting symptoms of intestinal ischaemia
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
Outline the presenting symptoms of intestinal obstruction
Colicky pain (spasms are shorter in small bowel compared to large bowel)
Abdo distension
Frequent vomiting
Absolute constipation
136
List some appropriate investigations for intestinal obstruction
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
Generate a management plan for intestinal obstruction
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
List some appropriate investigations for a Mallory Weiss tear
1. Bloods (FBC, U+Es, LFTs, X match, G&S)
2. Gastroscopy
3. CXR
139
Generate a management plan for a Mallory Weiss tear
A-E
Resuscitation
Endoscopy with treatment (ligation/adrenaline)
Consider transfusion
Consider anti-emetic
Consider PPI
140
What scoring systems can be used for nonvariceal upper GI bleeding?
Glasgow Blatchford
Rockall (can only be calculated after endoscopy)
141
List some risk factors for non-alcoholic fatty liver disease
Obesity
Diabetes
Dyslipidaemia
Hypertension
Increasing age (>50)
Smoking
TPN
142
List some appropriate investigations for NAFLD
1. Abdo exam
2. Bloods - LFTs, lipids, FBC, met panel
3. Viral serology
4. AI screen
5. Liver ultrasound
143
Generate a management plan for NAFLD
Conservative = controlling risk factors
Consider pioglitazone and weight loss pharmacology
In severe liver disease --> transplant
144
Generate a management plan for ruptured oesophageal varices
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
What are the 2 types of oesophageal cancer?
Adenocarcinoma (lower 1/3)
Squamous cell carcinoma (upper 2/3)
146
Outline the presenting symptoms of oesophageal cancer
Often asymptomatic
Progressive dysphagia
Regurgitation
Cough
Voice hoarseness
Odynophagia
FLAWS
147
List some appropriate investigations for oesophageal cancer
OGD + biopsy
Bloods
CT thorax
PET scan
148
Generate a management plan for oesophageal cancer
Oesophagectomy +/- chemotherapy
Consider postop nivolumab
149
Outline the presenting symptoms of pancreatic cancer
NON-SPECIFIC
Epigastric pain - radiates to back and relieved by sitting forward
FLAWS
Jaundice + palpable gallbladder
Anorexia
Trousseau's sign of malignancy
150
List some appropriate investigations for pancreatic cancer
pancreatic protocol CT
abdominal ultrasound
LFTs
Consider CEA/Ca19-9
151
Generate a management plan for pancreatic cancer
1ST LINE –
surgical resection (Whipple)
PLUS –
pancreatic enzyme replacement
CONSIDER –
preoperative biliary stenting
CONSIDER –
neoadjuvant radiotherapy or chemoradiotherapy
152
Outline the causes of acute pancreatitis
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
What are the key presenting symptoms of pancreatitis?
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
List some appropriate investigations for acute pancreatitis
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
Generate a management plan for acute pancreatitis
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
What scales are used to determine the severity of pancreatitis?
Modified Glasgow Score (combined with CRP (> 210 mg/L)
APACHE-II Score
157
List the criteria for the modified Glasgow score
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
What is the triad of chronic pancreatitis?
Steatorrhoea
DM
Epigastric pain
159
List some appropriate investigations for chronic pancreatitis
1. Bloods (incl. amylase/lipase)
2. USS
3. MRCP (or ERCP)
4. CT
5. Faecal elastase (tests pancratic exocrine function)
160
Generate a management plan for chronic pancreatitis
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
List some common causes of peptic ulcer disease and gastritis
Alcohol
H. Pylori
NSAIDs
Bisphosphonates
Smoking
162
List the appropriate investigations for peptic ulcer disease/gastritis
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
Generate a management plan for peptic ulcer disease
A-E approach
Fluid resus +/- transfusion
Endoscopy - (coagulation, injection sclerotherapy etc.)
Treat underlying cause
164
What is the treatment for H. pylori?
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
List some risk factors for perineal abscesses/fistulae
IBD
Diabetes mellitus
Malignancy
Diverticulitis
166
Generate a management plan for perineal abscesses/fistulae
1. Examination
2. Surgical drainage
3. Fistulotomy (if appropriate)
167
List some appropriate investigations for suspected peritonitis
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
What is the ascitic tap cut off for SBP?
> 250 neutrophils/mm3
169
How do you treat SBP?
Quinolone antibiotics
OR
Cefuroxime + Metronidazole
170
What is a pilonidal sinus?
Obstruction of natal cleft hair follicles ~6cm above the anus
171
List some appropriate investigations for a pilonidal sinus
None needed
Clinical diagnosis
172
Generate a management plan for a pilonidal sinus
Hair removal + hygiene advice
Without abscess: sinus excision or primary off-midline closure (on either side of natal cleft)
With abscess: drainage + incision
173
When is portal hypertension considered clinically significant?
Clinically significant portal hypertension is defined as a hepatic venous pressure gradient > 10 mm Hg (NORMAL is < 5mmHg)
174
List some causes of portal hypertension
Cirrhosis
Thrombosis
Chronic hepatitis
Granulomata
Myeloproliferative disease
Post hepatic causes e.g. Budd chiari or RHF
175
List some appropriate investigations for portal hypertension
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
Generate a management plan for portal hypertension
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
Define PBC
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
List some appropriate investigations for PBC
1. Bloods (LFTs, FBC, U+Es, clotting, TFTs)
2. Antimitochondrial antibodies
3. Ultrasound
Consider MRCP
179
Generate a management plan for PBC
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
Define PSC
A chronic cholestatic liver disease characterised by progressive inflammatory fibrosis and obliteration of intrahepatic and extrahepatic bile ducts
181
List some appropriate investigations for PSC
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
Generate a management plan for PSC
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
What is the difference between a type 1 and type 2 rectal prolapse?
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
Outline the presenting symptoms of ulcerative colitis
Bloody/mucous diarrhoea
Tenesmus + urgency
Crampy abdo pain
Weight loss
Fever
Extra GI manifestations (e.g. uveitis, scleritis, erythema nodosum, pyoderma gangrenosum)
185
List some appropriate investigations for ulcerative colitis
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
What criteria are used to determine the severity of ulcerative colitis?
Truelove and Witts (>6 stools = severe)
187
Generate a management plan for ulcerative colitis
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
List some appropriate investigations for Wilson's disease
LFTs
24-hour urinary copper
slit-lamp examination
serum ceruloplasmin (will be low <180mg/dL)
189
Generate a management plan for Wilson's disease
If very bad liver failure --> transplant
Mild failure = oral chelation therapy + zinc + dietary restriction of copper
