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gastro Flashcards

1
Q

investigations for diverticular disease

A

FBC → ↑WCC, ↑CRP, microcytic anaemia
Erect CXR → exclude pneumoperitoneum caused by perforation
Barium enema → sawtooth appearance of lumen (investigation of choice)
USS → assess bowel wall thickness, rule out other differentials
CT abdomen
Colonoscopy

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2
Q

indications for end ileostomy

A

permanent: panproctocolectomy for UC or FAP
temporary: emergency bowel resection for intra-abdominal sepsis, haemorrhage

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3
Q

indications for end colostomy

A

permanent: abdominoperineal resection for cancer involving anal sphincter
temporary: Hartmann’s (diverticulitis / bowel obstruction from cancer)

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4
Q

Hartmann’s procedure definition + indications

A

proctosigmoidectomy (rectosigmoid resection) → temporary end colostomy
emergency surgery when immediate anastomosis not possible for:
• Inflammation e.g. diverticulitis
• Colorectal cancer → obstruction / perforation

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5
Q

causes of abdominal distension

A 
fat
fluid: ascites 
fetus
flatus: IBS, bowel obstruction 
faeces
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6
Q

causes of small bowel obstruction

A

adhesions
hernia
intra-abdominal masses e.g. lymphoma

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7
Q

causes of large bowel obstruction

A

colorectal cancer
volvulus
strictures e.g. from diverticular disease

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8
Q

bowel obstruction management

A

ABCDE
drip + suck (NBM + NGT decompression + IV fluids)
analgesia
definitive:
SBO → gastrograffin follow-through
laparotomy → bowel resection if: no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis

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9
Q

indications for laparotomy in bowel obstruction

A

no prev abdo surg, strangulation, perforation, complete obstruction, irreducible hernia, peritonitis

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10
Q

SMA supplies which parts of bowel?

A

distal duodenum → splenic flexure

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11
Q

IMA supplies which parts of bowel?

A

splenic flexure → rectum

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12
Q

indications for loop ileostomy

A

anterior resection (rectosigmoid resection) + anastomosis for colon cancer / Crohn’s

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13
Q

indications for loop colostomy

A

relief of Sx of obstruction (no resection)

rare

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14
Q

Kocher’s incision: where + for what surg

A

L subcostal → open cholecystectomy

R subcostal → splenectomy / distal pancreatectomy

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15
Q

McBurney’s / Gridiron incision: where + for what surg

A

RIF (2/3 between umbilicus + ASIS) → open appendicectomy

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16
Q

indications for midline laparotomy

A

emergency: Hartmann’s (obstruction, perforation, trauma), ruptured AAA
elective: colectomy, vascular bypass, AAA repair

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17
Q

Mercedes Benz incision: where + for what surg

A

subcostal margins + midline → hepatobiliary surgery: liver transplant/resection, Whipple procedure (pancreatic cancer)

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18
Q

rooftop incision: where + for what surg

A

subcostal margins (similar to mercedes benz but w/o midline) → upper GI surg: oesophagectomy, gastrectomy

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19
Q

Rutherford Morrison / hockey stick / J-shaped incision: where + for what surg

A

LIF / RIF (more commonly L) → renal transplant

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20
Q

Pfannenstiel incision: where + for what surg

A

low transverse incision → gynaecological procedures: C-sections / lower urinary tract procedures: radical cystectomy / prostatectomy

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21
Q

flank incision for what surg

A

nephrectomy: renal cell carcinoma, PKD

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22
Q

inguinal incision for what surg

A

hernia repair

vertical incision = for vascular access

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23
Q

Lanz incision: where + for what surg

A

transverse @ McBurney’s point → open appendicectomy (reduced scarring)

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24
Q

stoma complications

A

immediate: operative complications (pain, infection, bleeding)
early: high output stoma, retraction, ischaemia/necrosis, parastomal abscess
late: parastomal hernia, prolapse, obstruction (strictures / stenosis)

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25
Q

causes of ascites

A

high albumin gradient (>11g/L): cirrhosis, portal HTN, cardiac failure
low albumin gradient (<11g/L): infection (peritonitis, TB), inflammation (nephrotic syn, pancreatitis), malignancy

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26
Q

causes of hepatomegaly

A

cirrhosis

malignancy: primary / mets
congestion: cardiac failure, constrictive pericarditis
infection: hepatitis
haematological: leukaemia, lymphoma, myeloproliferative disorders (sickle cell, myelofibrosis)
infiltration: sarcoidosis, amyloidosis, haemochromatosis

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27
Q

anterior resection: definition, indications, results in?

A

rectosigmoid resection
can be low or high
for rectal cancer not involving rectal sphincter
anorectal anastomosis (if healthy rectum) / temporary loop ileostomy / end colostomy

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28
Q

abdominoperineal resection: definition, indications, results in?

A

resection of sigmoid + rectum + anal sphincter
for malignancy involving anal sphincter
permanent end colostomy

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29
Q

panproctocolectomy: definition, indications, results in?

A

resection of entire colon + rectum
for UC / FAP
permanent end ileostomy / J pouch

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30
Q

complications IBD

A

toxic megacolon
malabsorption → gallstones, vit B12 deficiency
fistula, abcesses, strictures
malignancy: colon / PSC → cholangiocarcinoma

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31
Q

extra-abdominal signs IBD

A

derm: pyoderma gangrenosum, erythema nodosum, clubbing
eye: iritis, conjunctivitis
hepato-pancreato-biliary: gallstones, PSC → cholangiocarcinoma

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32
Q

histology in UC vs Crohn’s

A

ulcerative colitis: crypt abscesses

crohn’s: non-caesating granulomas

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33
Q

definition fistula

A

abnormal connection between two epithelial surfaces

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34
Q

definition hernia

A

protrusion of viscous / part of viscous through defect of its containing cavity into an abnormal position

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35
Q

indirect vs direct inguinal hernias

A

direct (20%) via Hesselbach’s triangle (weakness in posterior wall of inguinal canal)
↑intra-abdominal pressure
indirect (80%): through deep ring and out through superficial
patent processus vaginalis
complications more common
more difficult to reduce

differentiate: occlude deep ring + ask patient to cough

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36
Q

induction of remission ulcerative colitis

A 
mild-mod:
proctitis / proctosigmoiditis: rectal 5ASA
after 4wks: + oral 5-ASA
then add oral / rectal corticosteroid 
extensive: rectal 5ASA + oral 5ASA 
severe: admission 
IV corticosteroids 
\+ ciclosporin / consider surg
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37
Q

causes chronic liver disease

A 
alcohol
non-alcoholic fatty liver disease 
infection: hepatitis 
autoimmune: hepatitis, PSC, PBC
vascular: Budd-Chiari, 
infiltrative: sarcoidosis, amyloidosis, haemochromatosis
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38
Q

causes of portal HTN

A

pre-hepatic: portal / splenic vein thrombosis
external compression (malignancy)
hepatic: cirrhosis (most common)
post-hepatic: budd-chiari, congestive heart failure, constrictive pericarditis

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39
Q

presentation portal HTN

A 
ascites 
splenomegaly
oesophageal varices (melaena, haematemesis)
caput medusae
worsening of haemorrhoids
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40
Q

management oesophageal varices

A 
ABCDE 
IV fluids 
terlipressin (reduces portal pressure)
endoscopic band ligation 
can treat portal HTN with TIPS (transjugular intrahepatic portosystemic shunt): hepatic to portal vein
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41
Q

management ascites

A

monitor weight
diuretics: spironolactone (+ furosemide if required)
fluid + salt restriction
therapeutic paracentesis (+ albumin infusion for large volume paracentesis)
TIPS (transjugular intrahepatic portosystemic shunt) for portal HTN

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42
Q

causes of splenomegaly

A

portal HTN

haem: leukaemia, lymphoma, myelofibrosis, haemolytic anaemia, sickle cell
infection: TB, malaria, HIV
inflammatory: Felty’s

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43
Q

definition + causes of massive splenomegaly

A 
reaches midline / iliac crest / > 1500g
CML
myelofibrosis 
leishmaniasis
malaria
EBV
44
Q

signs of decompensated liver disease

A

JAB:
jaundice
asterixes, ascites, altered consciousness (encephalopathy)
bruising

45
Q

causes of dysphagia

A

obstruction: cancer, mallory-weiss tear
oesphageal dysmotility: achalasia, systemic sclerosis, stroke, MND, myaesthenia gravis
other: pharyngeal pouch

46
Q

causes of tender hepatomegaly

A

hepatitis

rapid liver enlargement: budd-chiari, R heart failure

47
Q

indications for splenectomy

A

emergency: rupture / trauma → uncontrolled bleeding
elective: haem (hypersplenism): ITP, TTP, AIHA, hereditary spherocytosis
oncological: leukaemia, lymphoma

48
Q

causes of pancreatitis

A 
most common: gallstones, alcohol 
trauma
steroids
mumps
autoimmune 
scorpion bites
hypercalcaemia 
ERCP 
drugs: furosemide, thiazides, azathioprine
49
Q

scoring system for pancreatitis

A 
glasgow score (severity)
pao2 ↓
age > 55 
neuts ↑
calcium ↓
renal function: ↑urea 
enzymes: AST, ALT, LDH
albumin ↓
sugar: glucose ↑
50
Q

signs on examination pancreatitis

A 
epigastric tenderness
grey-turner's sign: flank bruising
cullen's sign: periumbilical bruising 
fox's sign: inguinal ligament bruising 
signs of hypocalcaemia: trousseau's (carpopedal spasm on BP cuff inflation) / chvostek's sign (facial nerve tap induces spasm)
51
Q

investigations pancreatitis

A

bloods: FBC, CRP, U&Es, LFTs, amylase / lipase (normal in chronic), low Ca, faecal elastase reduced in chronic
imaging: abdo USS
AXR / erect CXR to rule out other causes
CT in chronic / diagnostic uncertainty for acute
ERCP: can remove gallstones

52
Q

management acute pancreatitis

A

ABCDE
IV fluids + oxygen if low sats
analgesia
antiemetics
nutritional support: consider NGT + TPN, vitamin supplementation
treat cause: if gallstones cholecystectomy / ERCP if not fit for surgery

53
Q

complications pancreatitis

A 
acute: 
necrotising pancreatitis (high risk mortality) 
sepsis 
pseudocysts 
chronic: 
pseudocysts 
exocrine sufficiency + malabsorption 
diabetes 
pancreatic cancer
54
Q

management chronic pancreatitis

A

cons: reduce alcohol
med: analgesia, creon, insulin for diabetes
surg: ERCP (sphincterotomy, stone extraction, stricture stenting) / cholecystectomy for gallstones
lateral pancreaticojejunal drainage
resection / opening of pancreatic duct

55
Q

severity classification for diverticular disease

A

hinchley classification

  1. paracolonic abscess
  2. pelvic abscess
  3. purulent peritonitis
  4. faecal peritonitis
56
Q

diverticular disease acute management

A 
ABCDE
IV fluids 
analgesia 
oral / IV ABx if diverticulitis 
surg: 
bleeding → colonscopy + endoscopic haemostasis (adrenaline injection, cauterisation)
complications → Hartmann's
57
Q

pathophysiology behind toxic megacolon

A

non-obstructive colonic dilatation due to myenteric plexus swelling (loss of bowel tone + motility)

58
Q

gastrointestinal causes of clubbing

A

IBD
liver cirrhosis
coeliac disease
cancers: GI lymphoma, oesophageal carcinoma

59
Q

causes of spider naevi

A

liver disease (>3)
pregnancy
COCP

60
Q

prevention of oesophageal bleeding

A

propranolol

61
Q

liver cirrhosis severity score

A

child-pugh

62
Q

ulcerative colitis severity score

A

truelove + witt’s criteria:

mild: < 4 stools / day, some blood
mod: 4-6 stools / day, mod blood
severe: > 6 stools / day, systemic features (fever, high ESR, tachycardia)

63
Q

maintenance Tx for ulcerative colitis

A

following mild-mod flare: rectal 5-ASA +/- oral 5-ASA

severe flare OR > 2 flares / year: oral azathioprine / mercaptopurine

64
Q

maintenance Tx for Crohn’s

A
  1. azathioprine / mercaptopurine

2. methotrexate

65
Q

induction of remission Crohn’s

A
  1. glucocorticoids (or 5-ASA or budesonide)

2. add azathioprine / mercaptopurine / methotrexate

66
Q

features of peutz jeghers

A

autosomal dominant
pigmented freckling of lips, face, palms, soles
hamartous polyps in GIT
small bowel obstruction e.g. intususseption
increased risk of malignancy: colorectal, pancreatic, breast

67
Q

causes budd-chiari

A

hepatic venous outflow obstruction

primary: hypercoagulable states (myeloproliferative, anti-phospholipid, COCP), stenosis
secondary: external compression (malignancy, trauma, abscess, cyst)

68
Q

classification of intestinal ischaemia

A
  1. acute mesenteric ischaemia: SMA (distal duodenum → splenic flexure)
  2. chronic mesenteric ischaemia: all 3 gut arteries (SMA, IMA + coeliac trunk)
  3. ischaemic colitis: IMA (splenic flexure → rectum)
69
Q

indications for liver transplant

A 
liver failure due to: 
alcoholic / non-alcoholic liver disease 
viral hepatitis (chronic B+C) 
autoimmune hepatitis
malignancy: HCC 
drug induced: paracetamol overdose 
budd-chiari
infiltration: haemochromatosis, amyloidosis
70
Q

complications liver transplant

A

immediate: pain, infection, bleeding, acute rejection
late: vascular / biliary anastomosic problems, immunosuppression (infection, malignancy)

71
Q

types of liver transplant

A
  1. cadaveric (more common)

2. partial live donor transplantation (L / R lobe)

72
Q

complications of liver disease

A

portal HTN
hepatocellular carcinoma
hepatic encephalopathy (toxins not removed from blood e.g. ammonia)
coagulopathy

73
Q

management liver cirrhosis

A

supportive / symptomatic until liver transplant
cons: diet, reduce alcohol, avoid hepatotoxic drugs (e.g. NSAIDs), monitor for complications
med:
treat cause (e.g. protease inhibitors ± ribavirin for hep C)
treat symptoms / complications (e.g. diuretics, fluid restriction, tap for ascites)

74
Q

severity scoring for cirrhosis

A 
child-turcotte-pugh score
encephalopathy 
ascites
bilirubin
albumin
prothrombin time
75
Q

severity scoring for cirrhosis

A 
child-turcotte-pugh score
encephalopathy 
ascites
bilirubin
albumin
prothrombin time
76
Q

types of gallstones

A

cholesterol (80%)
bilirubin
mixed

77
Q

investigations gallstones

A

bloods: FBC, CRP, U+Es, LFTs
imaging: abdo USS (1st line)
ERCP if choledocholithiasis (common bile duct stone) → diagnostic + therapeutic

78
Q

management gallstones

A

asymptomatic: observation
elective cholecystectomy if: gallstones > 3cm, porcelain gallbladder, gallstone in CBD

symptomatic (cholelithiasis): elective cholecystectomy

gallstone in CBD (choledocholithiasis): 
ERCP w biliary sphincterotomy + stone extraction 
OR cholecystectomy 
other surgical options: 
extra-corporeal shockwave lithotripsy
biliary stent
papillary balloon dilatation 
laparopscopic CBD exploration
79
Q

complications gallstones

A 
ascending cholangitis
cholecystitis 
pancreatitis
sepsis 
gallstone ileus
80
Q

causes of jaundice

A

pre-hepatic: haemolysis (autoimmune, sickle cell. malaria), Gilbert’s
hepatic: viral hepatitis, alcohol, drugs (paracetamol, isoniazid, rifampicin)
post-hepatic: obstructive (gallstones, pancreatic cancer)

81
Q

PBC vs PSC

A

PBC: autoimmune damage (AMA +ve) to intrahepatic bile ducts → cholestasis
PSC: fibrosis → stenosis of bile ducts (intra + extrahepatic) → cholestasis

82
Q

complications of PBC

A

liver cirrhosis + failure
osteomalacia + osteoporosis
risk of hepatocellular carcinoma

83
Q

PBC associations

A

autoimmune conditions:
rheumatoid, systemic sclerosis, sjogren’s
thyroid disease

84
Q

complications of PSC

A

liver cirrhosis + failure

risk of cholangiocarcinoma + colorectal carcinoma

85
Q

PSC associations

A

IBD esp ulcerative colitis

HIV

86
Q

definition of achalasia

A
  1. oesophageal aperistalsis
  2. failure of relaxation of lower oesophageal sphincter
    due to loss of ganglion cells in myenteric plexus
87
Q

presentation of achalasia

A 
dysphagia (fluid + solids) 
posturing to aid swallowing 
regurgitation (+ cough + risk of aspiration pneumonia) 
retrosternal pain / pressure 
weight loss
88
Q

how does a lateral pancreaticojejunostomy work

A

jejunum divided and proximal end anastomosed to pancreas to allow drainage
jejuno-jejunostomy restores continuity of GI tract

89
Q

differentiating Sx of small + large bowel obstruction

A

SBO: early vomiting, late constipation, high-pitched tinkling bowel sounds, central more frequent abdo pain
LBO: late vomiting, early constipation, lower less frequent abdo pain, empty rectum on PR

90
Q

definitive management of volvulus

A

caecal volvulus: usually requires surgery (R hemicolectomy)

sigmoid volvulus: decompression w rigid sigmoidoscopy + rectal tube insertion

91
Q

typical presentation acute cholangitis

A 
charcot's triad: 
1. fever
2. RUQ pain (radiating to back) 
3. jaundice (+ itching, pale stools, dark urine)
raynaud's pentad: 
4. hypotension
5. confusion
92
Q

management acute cholangitis

A 
ABCDE
IV fluids + analgesia + anti-emetics 
broad-spectrum ABx
definitive: 
therapeutic ERCP after 24-48hrs (to relieve obstruction) 
other options: 
shockwave lithotripsy 
cholecystectomy
93
Q

types of hiatus hernia

A
  1. sliding: Z-line moves above diaphragm

2. rolling: fundus of stomach herniates above diaphragm w Z-line maintined below

94
Q

types of oesophageal carcinoma

A

upper 2/3: squamous cell carcinoma

lower 1/3: adenocarcinoma

95
Q

management achalasia

A

medical: CCBs, nitrates (isosorbide dinitrate)
surgical:
pneumatic (balloon) dilatation (older pts)
Heller cardiomyotomy (laparoscopic incision of LOS muscle, younger pts)
2nd line: endoscopic botox injection
last line: gastrostomy

96
Q

types of autoimmune hepatitis

A

type I: most common
anti-SMA (smooth muscle), ANA (anti-nuclear Ab)

type II: ALKM1-Ab (anti-liver/kidney microsomal type 1), younger pts w other autoimmune conditions

type III: soluble liver-kidney Ag, older pts

97
Q

complications coeliac disease

A 
dermatitis herpetiformis
malabsorption: 
folate / B12 / iron deficiency 
vitamin D deficiency → osteomalacia
malignancy: small-bowel cancer, EATL 
hyposplenism
98
Q

DDx RUQ pain

A

duodenal ulcer
hepatitis, liver abscess
gallstones, cholangitis, cholecystitis

99
Q

DDx LUQ pain

A

splenic rupture / infarct

100
Q

DDx epigastric pain

A

GORD
gastric ulcer
pancreatitis

101
Q

DDx umbilical pain

A

early appendicitis
ruptured AAA
IBD

102
Q

DDx hypochondrial pain

A

renal colic
pyelonephritis
hydronephrosis

103
Q

DDx RLQ pain

A

IBD
late appendicitis
gynae: ectopic pregnancy, ovarian cyst / torsion

104
Q

DDx LLQ pain

A

diverticulitis
IBD
faecal impaction
gynae: ectopic pregnancy, ovarian cyst / torsion

105
Q

DDx suprapubic pain

A

cystitis
UTI
urinary retention

106
Q

investigations liver cirrhosis

A

bloods: FBC, CRP, LFTs, U&Es, clotting, hepatitis serology, aFP (for HCC)

diagnostic:
fibroscan (transient elastography): best
acoustic radiation force impulse imaging
liver biopsy

monitor for complications:
USS / CT / MRI
OGD → varices

107
Q

tumour markers cholangiocarcinoma

A

CEA
Ca19-9
Ca125

med / surg (15 decks)

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