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Year 3 Conditions > Gastro > Flashcards

Gastro Flashcards

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1
Q

Aetiology of gastroenteritis

A

Bacterial or viral infection of intestines. Bacteria include Ecoli, campylobacter and salmonella. Viral includes norovirus and rotaviruses

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2
Q

Risk factors for gastroenteritis

A 
Eating undercooked meat
Regularly eat certain foods like mayo and eggs
Seasonal depending on any outbreaks
Travel history
Immunocompromised
Recent antibiotics
Cases in clusters such as cruise ship
People with electrolyte imbalances, glycaemic issues and renal failure suffer serious complications
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3
Q

Define gastroenteritis

A

Inflammation of small intestine and stomach

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4
Q

Define infective colitis

A

Inflammation of colon

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5
Q

Epidemiology of gastroenteritis

A

Worldwide massive fatality problem but in UK just uncomfortable and 20% of people will have it in a year.
Problem for children too

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6
Q

Presenting symptoms of gastroenteritis and infective colitis

A

Diarrorhoea
Vomiting and nausea
Loss of appetite
Abdominal pain

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7
Q

Gastroenteritis and infective colitis on examination

A

Tender pain across abdomen on palpation

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8
Q

Appropriate investigations for gastroenteritis and infective colitis

A

Full blood count
- significant deviations
- anaemia could indicate a chronic diarrorhoea
- raised Hb could show severe dehydration
- platelets could measure severity of repsonse as acute response
- also WBCs
U and Es
- see elctrolyte imbalances so what needs replacing and indicates volume depletion
- urea and creatinine probs elevated
Collect stool for cultures and microscopy

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9
Q

Management ideas for gastroenteritis and infective colitis

A

Treat dehydration with fluid and possible fluid resucitation

Replace electrolytes

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10
Q

How to classify jaundice

A

Pre hepatic
Hepatic
Post hepatic

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11
Q

First thing need to do when find out someone has high bilirubin

A

Work out if uncon or con

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12
Q

Investigation for differentiating whether bilirubin uncon or con

A

Van den bergh

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13
Q

What elevated enzyme indicate post hepatic jaundice

A

Alkaline phosphate

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14
Q

What investigation would you do in healthy person with elevated bilirubin

A

Fasting bilirubin

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15
Q

Presentation of Gilberts syndrome

A

Very healthy but jaundiced upon stress

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16
Q

What is inheritance of gilberts

A

Recessive

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17
Q

Which tests are best representative of liver function

A

Livers make clotting factors (PT) and albumin. Bilirubin is used as well

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18
Q

Whst liver function test gets elevated acutely

A

PT

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19
Q

How long does it take for albumin to dop off

A

Ages

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20
Q

Rule of thumb based on what to do with patient with liver disease acutely

A

If PT rises by a second every bloods then call liver unit however if not they are fine to stay where are

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21
Q

Pre hepatic causes of jaundice

A

Gilberts

Haemolysis

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22
Q

Post hepatic causes of jaundice

A

Gallstones

Pancreatic cancer

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23
Q

Which enzymes are particularly elevated in heaptic jaundice

A

AST
ALT
All suggest hepatocyte damage

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24
Q

What would exclude post hepatic as a cause of jaundice in blood

A

Marginal ALP

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25
What are 3 causes of hepatits
Viral Autoimmune Alcoholic
26
How long after Hep A consumption do you start seeing it in faeces
2-5 weeks
27
How long after Hep A infection do you get Jaundice
4 weeks
28
What are 2 fates of Hep A infection
Cure or death cery common in poverished nations
29
How is Hep A spread
Faeco oral
30
If you get Hep A can you get it again
No- after 12 weeks IgG very high
31
How is Hep B transmitted
IV- transfusions or sharing needles
32
How to tell if someone has had Hep B infection
Anti- HBe antibodies as wel as Anti- HBs
33
How to tell if someone has had Hep B vaccine
Anti-HBs antibodies only as these are all that is given in vaccine
34
Histologically what does fatty liver look like
Areas of white
35
How to tell if hepatocytes damaged histologically
Mallorys hyaline
36
Defining alcoholic hepatitis histological features
``` Liver cell damage Fibrosis Inflammation Megamitochondria Fatty liver ```
37
DDx for alcoholic hepatitis histologically
NASH- non-alocholic steato-hepatitis
38
What can cause NASH
Insulin resistance/ high BMI
39
What is treatment for alcoholic hepatitis
Stop alcohol Nutrition Thiamine Occasionally steroids
40
What is caused by thiamine deficiency
Beri beri
41
Signs of chronic stable liver disease O/E
Spider naevi Palmar erythema Gynaecomastia Duputyrens contractures
42
What is caput medusa
Umbilical vein distended
43
What does caput medusa suggest
Portal hypertension
44
What will you find alongside caput medusa on examination
Splenomegaly as umbilical vein drains into splenic vein
45
3 signs of portal HTN
Splenomegaly Caput medusa Ascites
46
What do you do if patient with portal HTN comes to A n E vomiting blood
Put NG tube down with balloon to compress veins
47
What causes a liver flap
Liver failure
48
What are problems of liver failure
Failed synthetic function Failed clotting factor and albumin- bleeding and hypoalbuminaemia Failed bilirubin clearance Failed ammonia clearance- encephalopathy
49
Sign on examination of encephalopathy
liver flap
50
How does liver appear when cirrhosed
Fibrosis Hepatocyte nodules Shunting of blood Whole liver involved- pale
51
Causes of cirrhosis
``` Fatty liver disease Viral hepatitis Haemochromatosis Wilsons disease Primary biliary cholangitis Primary sclerosing cholangitis ```
52
What is haemochromatosis
Iron overload
53
What is wilsons disease
Copper overload
54
4 sites of porto-systemic anastamoses
Oesophageal varices Rectal varices Umblical vein Spleno-renal shunt
55
What do scratch marks suggest
Obstruction of bile ducts as bile salts go in to skin
56
What is special about primary hepatocellular carcinoma
Still make bile
57
Signs on examination of pancreatic cancer
Palpable gall bladder Scratch marks Jaundice Pain on palpation
58
What is courvoisiers law
If the gall bladder is palpable the cause is unlikely to be stones as stones cause it to be small and fibrosed
59
What endocrine condition can affect liver
Thyroid- in particular hyper which can present with jaundice and elevated transaminases
60
What would exclude thyroid issues from liver diagnosis
Would occur alongside other severe signs of thyrotoxicosis or alongside HF
61
Who must you consider AI hepatits in most commonly
young women
62
How to remove haemochromatosis from liver ddx
Wouldn't present with extremely high LEs | Only occurs in elderly normally
63
Does non alcoholic fatty liver disease present with jaundice
Not normally
64
Anitbodies tested for in AIH
anitnuclear AB | Smooth muscle AB
65
Investigations for hepatitis
US Viral serology Protein and globulin elevated Liver biopsy
66
What is used to diagnose AIH conclusively
Liver biopsy
67
Treatment for AIH
High dose steroids with subsequent Azathioprine- doses and use of azathioprine depends on severity
68
How long is treatment for AIH
At least 2 years after bloods normalise then would also want to do liver biopsy before discontinuing meds
69
What is LFT indicator of Primary biliary cirrhosis
Raised ALP as post hepatic
70
Typical presentation of PBC
Lethargy | Puritus
71
How are most PBC cases picked up
Incidental notice of elevated ALP
72
Pathophysiology PBC
Aetiology unknown but there is slow gradual inflammation of the interlobular ducts within liver that eventually leads to loss of ducts, cirrhosis or fibrosis of liver and cholecystitis
73
RFx for PBC
Female Aged 54-60 Smoking Autoimmune condition
74
Investigations for PBC
``` US Liver biopsy showing granulomas Serum lipids Blood clotting profile Serology hep Anti-nuclear and anti-mitochondrial ABs ```
75
Lipid profile in PBC
Elevated
76
What antibodies are normally positive in PBC
Anti-nuclear and anti-mitochondrial
77
When is liver biopsy contraindicated
Platelets under 100 INR over 1.3 Confused state Extensive ascites
78
What is treatment PBC
Cholecystyramine Ursodeoxycholic acid Fat soluble vitmain prophylaxis Liver transplant
79
What is given to alleviate puritus
Cholestyramine
80
Important thing to remember when taking cholestyramine
Must be taken at least 2 hours apart from ursodeoxycholic acid
81
Typical presentation of haemochromatosis
Arthralgia Fatigue Deranged liver function Development of diabetes
82
Investigations for haemochromatosis
``` Serum ferritin Transferrrin saturation Total iron binding capacity Serum iron US to rule out any other lesion Liver biopsy Check function of ```
83
Findings of blood results haemochromatosis
Serum ferritin up Serum iron up Total iron binding capacity down Transferrin saturation
84
Pathophysiology of haemochromatosis
Genetic condition leading to dysregulation of iron absorption and macrophage release of iron
85
Complications of haemochromatosis
``` Increased skin deposition Diabetes- pancreatic failure and can be insulin resistance Cardiomyopathy Hepatic cirrhosis Hypogonadism Pituitary dysfunction Chondralcinosis and arthropathy ```
86
What are complications of haemochromatosis due to
Deposition of iron
87
RFx for haemochromatosis
White Male Middle aged Fx
88
Main treatment for haemochromatosis
Regular venesection | Refer to diabetes
89
What is inheritance of haemochromatosis
Autosomal recessive
90
Sx of malignant hepatic liver disease
Tender hepatomegaly Jaundice Weight loss
91
How would liver abcess typically present
Septic
92
What is raised in most hepatocellular carcinomas
Alpha-fetoprotein
93
When is MRCP indicated
Biliary tree dilated
94
What is used as imaging for liver cancers
Abdo CT
95
Treatment for para-aortic node involvement liver cancer
Chemotherapy
96
Sex most likely to find hepatocellular carcinoma
Male
97
How often do people with cirrhosis get abdo CT for liver malignancy
6 months
98
When elderly person presents anaemic what is most likely cause
IDA
99
How does iron deficiency anaemia present
SOB Fatigue Abdo pain potentially pointing to cause
100
When anaemia without obvious cause what investigations are necessary
Gastroscopy and colonoscopy | Coeliacs disease serology
101
What are majority of duodenal ulcers caused by
H.pylori | NSAIDS
102
Non invasive ways to diagnose H pylori
Urea breath test | Stool for HP antigen
103
Invasive ways to diagnose H pylori
CLO test
104
What is involved in campylobacter like organism test
Biopsy
105
Difference in diagnosis between gastric and duodenal ulcers
Gastric more likely to do biopsy as only 70% chance its down to that
106
Important thing to remember when inserting NG tube
Must confirm is actually in the right position Either by obtaining aspirate from tube or CXR If in gastric contents then pH will be from 1 to 5.5
107
Presentation of peptic stricture
Progressice dysphagia from solids to liquids
108
Risk factor for peptic stricture
GORD
109
First line investigation for peptic stricture
OGD and biopsy
110
Treatment for benign peptic stricture
Balloon dilatation | Underlying GORD then PPI
111
Most common complication of balloon dilatation
Oesophageal perforation
112
How would oesophageal perforation present
Mediastinits so SOB and chest pain
113
Investigation for suspected oesophageal perforation
CT scan with oral contrast
114
Important blood markers of liver disease status
Plt function | Glucose
115
What can happen to glucose in liver disease
Hypo | Also marker of liver synthetic function
116
In major suspected variceal bleeds what prophylactic management would be given
Abx
117
Management of variceal bleed
Refer to endoscopy Fluid resus with blood transfusion Abx IV vasopressin analogue
118
Immediate intervention for variceal bleed
Band ligatation
119
Long term management of variceal bleed
Non cardioselective beta blocker
120
What do you look for in hands abdo exam
``` Asterixis Bruising Clubbing Duptyrens contracture Erythema Leukonychia ```
121
What to look for in chest abdo exam
Gyanecomastia Hair loss Excoriation marks Spider naevi
122
What does right subcostal scar indicate
Biliary surgery
123
What would a midline laparotomy incision
GI or major vascular surgery
124
4 causes of hepatomegaly
Cancer Cirrhosis Cardiac/vascular Infiltration
125
Causes of liver diseases
``` Alcohol Autoimmune Drugs Viral Biliary disease ```
126
Causes of splenomegaly
Portal hypertension Haematological Infection Inflammatory
127
Cardiac causes of hepatomegaly
Congestive heart failure Constrictive pericarditis Budd chiari
128
Differences in nature of abdo pain
Constant or colicky
129
What does constant abdo pain suggest
Inflammation
130
What does colicky pain suggest
Obstruction- this could be for
131
DDx for stomach and their RFx
``` Peptic ulcer- NSAIDS GORD- antacids Gastritis- retrosternal, ETOH Maligancy Ruptured AA ```
132
What to do with DDx for a certain region
Think whats above, below, right and left
133
Acute pancreatitis presentation
Epigastric pain
134
Blood of acute pancreatitis
High amylase
135
Chronic pancreatitis presentation
Pain Weight loss Loss of endocrine and exocrine function
136
Blood of chronic pancreatitis
Normal amylase
137
Differentials for RUQ pain
``` Gall bladder - cholecystisis - cholangitis - gallstones Liver - hepatits - abcess ```
138
How can appendicitis present with RUQ pain
When appendix is retrocaecal- very common in pregnant women
139
DDx of RIF pain
``` GI Appendicitis Mesenteric adenitis Colitis Malignancy Gynaecological Ovarian cyst, torsion Ectopic pregnancy ```
140
Causes of diffuse abdo pain
``` Obstruction Infection- peritonitis, gastroenteritis Inflammation- IBD Ischaemia- mesenteric ischaemia Medical causes- DKA, addisons, hypercalcaemia, porphyria, hypercalcaemia ```
141
What is elevated in any diffuse abdo case
Amylase
142
What is a risk factor for bowel obstruction
Recent abdo surgeries
143
What is responsible for dark urine and pale stool
Stercobilinogen
144
Acute GI bleed management
``` ABC IV access and fluid G and S X-match blood OGD ```
145
What vessels are affected in variceal bleed
Splanchnic
146
Investigation for acute abdomen
``` FBC U and Es LFTs CRP Clotting G and S ```
147
What to look for general inspection abdo
Pallor and jaundice
148
What does leukonychia look like
White line on nails very advanced
149
What does leukonychia indicate
Hypoalbuminaemia
150
When do you get gum hpertrophy
On ciclosporine after renal transplant
151
How to determine if spider naevi is actually spider naevi
Press on it and it will fill from the middle
152
How to determine if caput medusa is actually one
Put two fingers on it and spread them to empty it, flow will be towards the legs
153
What does a mercedes benz scar indicate
Liver transplant
154
What does a small scar at mcburneys point indicate
Apendectomy
155
What would a hockey stick scar from iliac to hypogastric region indicate
Renal translpant
156
What would scar in suprapubic region indicate
Gynaecological surgery
157
What would diagonal more horizontal scar indicate
Nephrectomy
158
What would inguinal scar indicate
Hernia surgery
159
Important thing to remember when palpating kidney
Not lateral have to feel medially
160
Infiltrative causes of hepatomegaly
Fatty infiltration (obese), hemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative disease
161
Haematological causes of splenomegaly
Lymphoma Leukaemias Haemolytic anaemia
162
Inflammatory causes of splenomegaly
Sarcoid
163
Infective causes of splenomegaly
Malaria RB IE EBV
164
DDx need to know for gastro
Abdominal pain - Abdominal distension - Change of bowel habit o Infection o Inflammation o Malignancy - GI bleed - Jaundice - Ascites
165
5 fs for cause of abdo distension
``` Fat Fluid Foetus Flatus Faeces ```
166
If upper GI bleed how does stool appear
Malaena
167
If lower GI bleed how does stool appear
Bright red
168
3 categories for cause of change in bowel habits
Infection Inflammation Cancer
169
How does pain for ruptured AAA present
Epigastric radiating to back
170
What to ask about for acute pancreatitis
Hx of gallstone
171
Test for chronic pancreatitis
Stool elastase- low
172
DDx of suprapubic pain
Cystitis | Urinary retention
173
DDx of LIF pain
``` GI - Diverticulitis - colitis -maligancy Gynaecological - ovarian cyst rupture, twist,bleed - ectopic pregnancy ```
174
Why do you get hyperpigmentation under bra strap
Addisons- increased pressure there leads to pigmentation
175
How does mesenteric ischaemia present
Pain on eating | Central pain
176
Difference between ischaemic colitis and mesenteric ischaemia
Mesenteric ischaemia is from blockage of large arteries and ischaemic colitis from blockage of small vessels
177
What test would you use to determine if spontaneous baterial peritonitis
``` Take ascetic fluid sample - microbiology and WCC - biochemistry for protein - cytology Neutrophils will be over 250cells/mm3 ```
178
What is spontaneous bacterial peritonitis
Translocation of bacteria into ascites
179
Signs of decompensated liver cirrhosis
``` Liver asterixis Encephalopathy Ascotes Bleeding coagulopathy Increased INR Reduced albumin Jaundice ```
180
What must give straight away if liver patient presents with confusion
Ciprofloxacin to reverse encephalopathy
181
Signs on examination of ascites
Shifting dullness | Peripheral liver signs such as A-E in hands
182
Presentation of obstructed bowel
Colicky pain Nausea and vomiting Constipation
183
Bowel sounds on examination of obstruction
High pitched tinkles
184
Risk factor for bowel obstruction
Recent surgery
185
What to check for in examination if suspect bowel obstruction
Irreducible femoral hernia
186
Causes of SBO
Adhesions from surgery | Hernias
187
Causes of LBO
Cancer Diverticular structure Volvulus
188
What are classifications of ascites
Exudate and transudate
189
Causes of transudate ascites
HF Cirrhosis Nephrotic syndrome
190
Causes of transudate ascites
HF | Cirrhosis
191
Causes of exudate ascites
Malignancy Infection Vascular Nephrotic syndrome
192
Infective causes of exudate ascites
TB | Pyogenic
193
Vascular causes of transudate ascites
Budd chiari syndrome | Portal vein thrombosis
194
What is Budd chiari syndrome
Occlusion of hepatic vein
195
Triad of Sx Budd chiari syndrome
Hepatomegaly Ascites Abdo pain
196
Calculation for whether ascites is exudate or transudate
SAAG
197
What is SAAG
Serum albumin to ascites gradient
198
What is SAAG calculation
Serum albumin- ascites albumin
199
What does SAAG of over 11g/L suggest
Transudate
200
What does SAAG of over 11g/L suggest
Transudate
201
Where is unconjugated bilirubin converted to conjugated bilirubin
The liver
202
What would pale appearance in jaundice suggest
Haemolytic anaemia
203
Which types of jaundice cause pale stool
Post hepatic
204
Which types of jaundice cause dark urine
Hepatic and post hepatic
205
What gives stool its brown appearance
Stercobilin
206
How does hepatic jaundice cause dark urine
Hepatocytes damaged so conjugated bilirubin leaks into blood
207
What is name of thrombophlebitis associated with malignancy
Trousseaus sign
208
Common malignancy associated with trousseasus sign
Pancreatic
209
What is thrombophlebitis
Clots forming in legs of veins
210
What is marker of pancreatic cancer
CA19 9
211
Categories for bloody diarrorhoea causes
Infective Inflammatory Ischaemic Malignancy
212
Ischaemic cause of bloody diarrorhoea
Ischaemic colitis
213
Bacteria that cause inefctive colitis
``` Campylobacter Haemorrhagic E Coli Entamoeba histolytica Salmonella Shigella ```
214
In which patients do you see ischaemic colitis
Elderly
215
In which patients do you see inflammatory colitis
Young and with Extra- Gi manifestations
216
In alcoholic hepatits what transaminase is higher
AST
217
Extra GI complications of inflammatory colitis
Uveitis Arthritis Erythema nodosum
218
Questions to ask about in hepatitis history
Transfusions Sexuality Medications
219
In what condition do you get nocturnal diarrorhoea
IBS
220
What is x ray sign of IBD
Thumb printing | Thick haustral fold
221
What is a featureless bowel a sign of
UC
222
What investigation do you have to do in acute IBD exacerbation
Abdo x ray
223
What is potential risk of IBD exacerbation
Toxic megacolon which could rupture
224
How does toxic megacolon look in x ray
Dilation of bowels more than 6cm
225
How will a toxic megacolon patient present
Fever Hypotension Tachycardic Systemically very unwell
226
How does faecal loading appear on x ray
Bowels full of opacity indicative of spurious diarrorhoea
227
Management of acute abdo
``` NBM IV access Fluids Analgesia Anti emetics Abx Monitor vitals FBC CXR CT ```
228
Abx given for acute abdo
Cephalosporin for gram pos and neg | Metronidazole for anaerobes
229
Management of acute GI bleed
``` ABC IV access Fluids G and S, X match blood OGD ```
230
What is given for variceal bleed
Abx- Tazocin | Terlipressin
231
Investigations jaundice
FBC, LFTs, CRP | Abdo USS fasting
232
Investigations dysphagia
OGD, biopsy
233
Investigations PR bleed
Colonoscopy, Wt loss
234
Management of Ascites
Ascitic tap- micro, biochemistry, cytology Diuretics- spironolactone, furosemide Sodium restriction Monitor weight Therapeutic paracentesis alongside IV albumin
235
Management of encephalopathy
Lactulose Phosphate enemas Treat infection Exclude a bleed
236
What must be avoided when treating encephalopathy
Sedation
237
Why must you exclude a bleed in encephalopathy
Blood would provide bacteria with large source of protein to feast on and produce more ammonia
238
Features of post op care wound infection
Erythematous | Discharge
239
What would be features of an anastomotic leak post surgery
Diffuse tenderness Guarding and rigidity Hyoptensive/tachycardic
240
In post op care what could be Sx of a pelvic abcess
Sweating Fever Pain Mucus diarrorhoea
241
When are post op pelvic abcesses common
Appendectomy
242
Presentation of perianal fissure
Tender anus with red swelling
243
Tx for perianal fissure
Incision and drainage
244
Presentation of anal fissure
Rectal pain | Stool coated in blood
245
Tx anal fissure
Diet advice for more fluids and fibre | GTN cream
246
How does IBS present
Recurrent abdo pain and bloating Alternating constipation and diarrorhoea Improves with defecation Change in frequency and form
247
What must you ask about to exclude other DDx for IBS
``` Nocturnal diarrorhoea Anaemia PR bleeding Wt loss Exclude coeliac ```
248
Treatment for IBS
Diet and lifestyle changes Laxatives Anti-diarrorhoeals Anti-spasmodics
249
What drugs can be given for abdo pain
Anti-spasmodics
250
What is dyspepsia
Indigestion
251
What do you request with microcytic anaemia of gastro cause
Haemitinics Coeliac screen Top and tail depending on Sx
252
Red flags in abdo history to ask about
Weight loss Change in bowel habits Fatigue
253
4 complications of portal HTN
Ascites SBP Encephalopathy Variceal bleed
254
What are name of circular folds that go all the way around bowel
Valvulae conniventes
255
Small bowel folds
Valvulae conniventes
256
Signs in blood of alcohol abuse
GGT | Macrocytosis
257
What must never discount in patients
Alcohol withdrawal
258
Signs on examination of alchol abuse
Brusing
259
Signs of alcohol withdrawal
``` Anxiety and restlessness Tremor Sweating Headache Nausea Tachycardia and palpitations ```
260
Severe Sx of alcohol withdrawal
Hallucinations Seizures Delirium
261
Types of hallucinations in alcohol withdrawal
Tactile | Visual
262
Managment of alcohol withdrawal
IV thiamine supplements | Oral benzodiazepine
263
What can precipitate wernickes encephalopathy
Glucose infusion
264
Why is IV pabrinex given slowly
Reduce risk of anaphylaxis
265
What is pabrinex
Vitamin B and C supplements
266
What is wernickes encephalopathy
Acute neurological condition caused by thiamine deficiency
267
Triad of wernickes encephalopathy
Confusion Ataxia Oculomotor dysfunction- nystagmus, conjugate gaze dysfunction,
268
What is progression of wernickes encephalopathy
Korsakoffs psychosis
269
Investigations for autoimmune hepatitis
Serum Ig Smooth muscle and ANA Abs Liver biopsy
270
Proportions of where pancreatic cancers arise
60% head 25% body 15% tail
271
First scan for pancreatic cancer needed
Abdo CT for diagnosis and also staging
272
Chronic pancreatitis presentation
Epigastric pain "boring through to back" Diarrorhoea- statorrhoea Diabetes diagnosis
273
Abdo x ray finding chronic pancreatitis
Calcification in pancreatic region- pathognomic
274
Further imaging for chronic pancreatitis
CT MRCP Not ERCP as invasive and complication risk
275
Complications of pancreatitis
``` Diabetes Malabsorption Pancreatic insufficiency Carcinoma Opiate addiction Pseudocyst formation ```
276
How does coeliac disease typically present
``` Weight loss Diarrorhoea Cramping Iron deficiency anaemia Malaise Osteoporosis ```
277
Can UC and crohns cause weight loss
UC no | Crohns yes
278
Differentiating between crohns and coeliac on blood
Folate deficiency in coeliac
279
How to diagnose coeliac
TTG serology IgA Alpha gliadin ab Anti endomysial ab Duodenal biopsy needed to confirm
280
What is treatment for coeliac
Gluten free diet
281
How to tell if coeliac is being controlled well
Redo TTG AB
282
What will happen if you touch a spider naevi
Will blanch and go pale
283
Where is distribution of spider naevi
Can only be found in distribution of SVC
284
What does having spider naevi suggest
Stable chronic liver disease
285
What do campbell de morgan spots suggest
Pathology unknown
286
Who do you see campbell de morgan spots in
A lot of people over 40 and is unpathological
287
On average which enzyme does Hep C tend to elevate more
ALT
288
What is a perianal fissure
A tear in the rectum or anus
289
How does perianal fissure present
Pain on defaecation | Red and tender swelling around anus
290
Stools of inflammatory colitis
Mucous | Blood
291
What is rovsings sign
Press on left iliac fossa and will hurt- suggestive of appendicitis
292
Cope obturator and psoas sign
Patient lies flat and slightly roles on to left side- flexes knee at 90 degrees and then extends the knee and externally rotates. Pain suggests appendicitis
293
What is biliary colic
Gallstone in biliary tree
294
Signs on examination of biliary colic
Tender RUQ and epigastrium
295
Investigations for biliary colic
Urine dip CXR Amylase/LFTs/Clotting USS
296
Findings of investigations for biliary colic
Normal bloods | USS show thin GB walls with stone
297
Management of biliary colic
Symptom relief Can go home on low fat diet but told to watch out for jaundice and fever If recurrent then cholecystectomy
298
Sepsis 6
``` Give fluids Oxygen Abx Urine output Blood cultures Lactate ```
299
Diagnosis criteria for acute pancreatitis
Amylase 3x higher than normal Clinical history consistent CT to exclude other DDx
300
Aetiology of pancreatitis
``` Gallstones Ethanol Trauma Steroids Mumps, cocksackie, COVID Autoimmune Scorpion Hyperlipidaemia ERCP Drug ```
301
Commonest causes of acute pancreatitis UK
Gallstones Ethanol Idiopathic
302
Scoring for acute pancreatitis pnemonic
Pancreas
303
Scoring for pancreatitis
``` Pa O2 under 8 Age over 55 Neutrophils over 15 Calcium under 2 Raised urea over 16 Ekevated enzymes such as LDH Albumin under 32 Sugar over 10 ```
304
Separate poor prognostic markers of acute pancreatitis
Obesity | CRP over 150
305
Complications of gallstones categories
Within gall bladder Within biliary tree Outside biliary tree
306
Complications of gallstones in gall bladder
Bilairy colic Acute cholecystisis Empyema
307
Complications of gallstones in bilairy tree
Obstructive jaundice | Ascending cholangitis
308
Complications of gallstones outside of biliary tree
Pancreatitis | Gallstone ileus
309
What is guarding
When palpating the patients organs they tense their muscles to protect organs
310
Standard investigations must do every time in gastro
ECXR Routine bloods Urine dip Pregnancy test women
311
How do you get shoulder tip pain after abdo surgery
Pressure in abdo can irritate diaphragm and phrenic nerves so get refferred pain
312
Common lung complication of surgery
Atelectasis
313
Bilairy colic risk factors
``` 4 Fs Female Fat Forty Fair- pregnancy ```
314
Sx of biliary colic
Dull pain RUQ or epigastrium Can radiate to right shoulder Nausea and vomiting Sweating
315
Onset of biliary colic pain
Very sudden then reaches plateau before subsiding when gets dislodged Normally starts hours after a meal and can be at night
316
Complication of biliary colic
Acute cholecystisis if remains in the cystic duct for a while
317
Sx of acute cholecystisis
``` RUQ pain Nausea Vomiting Sweating Fever ```
318
What is acute cholecystisis
Gall bladder inflammation of rapid onset
319
Sx of acute cholecystisis
Epigastric pain that can radiate to RUQ and become dull. Here can also radiate to shoulder Nausea and vomiting
320
Pathophysiology of acute cholecystisis
Normally caused by a gallstone. Contraction to release stone to no avail causes inflammation and increased pressure. Is release of mucous and inflammatory enzymes into GB and bacterial growth
321
What bacteria can be involved in cholecystisis
E coli Clostridium Enterococci Bacteroides fragilis
322
How can cholecystisis lead to peritonitis
Bacteria invade through wall of GB to peritoneum causing inflammation
323
Murphys test
Ask patient to take deep breath in and hold hand under costal margin. When breath in and inflammed gall bladder comes into contact with hand they will cease inspiration and be in a lot of pain
324
Positive murphys sign
Acute cholecystisis
325
Complication of acute cholecystisis
Peritonitis | Gangrenous cell death
326
2 fates of gall stones if lodged in cystic duct
Stone gets dislodged | Stone doesnt get removed and gall bladder continues to inflame and cause pressure
327
Danger when stone doesnt get dislodge and cholecystisis continues
Gall bladder gets so big it compresses arteries supplying GB so ischaemia and gangrene. If severe enough will rupture and lead to sepsis
328
What happens if gallstone lodged in common bile duct
Back up of bile all the way up the tree into the liver causing conjugated bili to seep into blood - jaundice
329
What is sonographic murphys sign
When do ultrasound and press on gall bladder get pain and so murphys sign
330
US findings in cholecystisis
Stones GB wall thickening Sludge GB distension
331
Further imaging of acute cholecystitis
HIDA scan ERCP MRCP
332
What is a HIDA scan
cholescintigraphy
333
Treatment for cholecystitis
IV fluids Pain managment Abx Cholecystectomy
334
Cholecystitis Rfx
``` Gall stones Low fibre Parenteral feeding Diabetes Immobility ```
335
What is ascending cholangitis
Bacteria from gut can ascend up the bile duct causing inflammation. Normally bacteria cant make it up the common bile duct due to pancreatic juices and bile so normally occurs when obstruction
336
What normally obstructs common bile duct in ascending cholangitis
Chiledocholithiasis Cancer nearby Laporoscopic tear
337
Bacteria that normally colonise in ascending cholangitis
E coli Klebsellia Entercoccus
338
How can you become septic from ascending cholangitis
Pressure is so great in blockage that spaces can open in walls of bile ducts allowing bacteria through
339
Ascending cholangitis Sx
RUQ pain Fever Jaundice Can be septic shock
340
What is charcots triad
Triad of symptoms seen in ascending cholangitis Fever RUQ pain Jaundice
341
What is reynolds pentad
5 Sx characterising spetic cholangitis Charcots triad Confusion Low BP/tachycardia
342
Investigations for cholangitis
Bloods for signs of jaundice, shock and infection | ERCP
343
Treatment for ascending cholangitis
Manage symptoms with rehydration and Abx Remove obstruction ERCP and shockwave lithotripsy Can add stent Cholecystectomy
344
What is primary scleorsing cholangitis
Fibrosing of intra hepatic and extra hepatic bile ducts
345
How do PSC bile ducts appear
Beaded where are areas of dilation and constriction
346
How does PSC appear histologically
Rings of fibrosis around ducts called onion ring fibrosis
347
What is PSC associated with
UC | Crohns
348
What is beleived to be aetiology of PSC
T cell autoimmune where is genetic and environmental factors at play
349
Genetic associations of PSC
HLA-B8 HLA-DR3 HLA-DRw52a
350
Serum findings of PSC
Raised IgM Increased p-ANCA Abs ALP and GGT raised Conjugated bilirubin raised
351
Urine findings of PSC
Raised bilirubin | Reduced urobilinogen
352
How does PSC lead to portal HTN
Thickened fibrosis can obstruct portal veins
353
Signs on examination of PSC
Dark urine Hepato-splenomegaly Jaundice
354
Typical presentation of PSC
``` 40-50 year old man with IBD Pruritus Jaundice RUQ pain Weight loss Fever ```
355
Investigation for PSC
``` LFTs Serum IgM and pANCA USS Biopsy ERCP and MRCP ```
356
Complications of PSC
Cirrhosis | Cholangiocarcinoma
357
Treatment of PSC
Advanced immunosuppressant dont reallu work | Liver transplant
358
What must always think about with IBD in liver symptoms
PSC
359
How can causes of dysphagia be classified
Obstructive Oesophageal immobility Other
360
Obstructive causes of dysphagia
``` Oesophageal carcinoma Peptic stricture Oesophageal web/ring Gastric carcinoma Pharyngeal carcinoma Extrinsic pressure ```
361
Oesophageal mobility disorders
``` Achalasia Systemic sclerosis Stroke MG MND ```
362
Other causes of dysphagia
Oesophagitis Pharyngeal pouch Oesophageal candidiasis
363
What can be an extrinsic pressure on oesophagus causing dysphagia
Lung cancer | Retrosternal goitre
364
What is achalasia
Condition affecting lower oesophageal sphincter where it doesnt open- aetiology unknown
365
What are oesophageal webs
Protrusions of mucosa into oesophagus that looks like webs
366
What are more common, duodenal or gastric ulcers
Duodenal 4x more likely
367
What is characteristic of duodenal ulcer pain
Eased after eating meals or drinking milk | Worse in morning
368
What is characteristic of gastric ulcers
Worse after eating
369
Can you get weight loss with gastric or duodenal ulcers
Both but more likely in gastric ulcers
370
What is retrosternal pain
Pain behind sternum
371
Sx of GORD
Dry cough | Retrosternal pain worse on lying flat or after meals
372
When is GORD eased
Antacids- hours after eating
373
When is gastritis worse
On eating
374
What does worse epigastric pain in morning suggest
Duodenal ulcer
375
What does epigastric pain eased on eating or drinking milk suggest
Duodenal ulcer
376
What does pain worse on eating meals indicate
Gastric ulcers Gastritis Pancreatitis GORD
377
What is the treatment for an ulcer caused by H pylori
PPI such as omeprazole and 2 antibiotics normally amoxicillin and clarithomycin
378
What Abx are given to ulcer patients who are allergic to pencillin
Clarithomycin and metronidazole
379
Most common cause of duodenal ulcers
H pylori
380
What is a hiatus hernia
When part of your stomach moves through diaphragm into chest area
381
Best way to diagnose a hiatus hernia
Barium meal
382
Patient presents with history of heartburn on eating but isnt eased by antacids
Hiatus hernia
383
How can hiatus hernia present
heartburn on eating but isnt eased by antacids
384
What can heartburn be on eating
GORD | Hiatus hernia
385
What is change seen in barretts oesophagus
Lower third of oesophagus metaplasia squamous to columnar epithelium
386
What is metaplasia in barretts oesophagus described as
Pre-melignant as very high chance of adenocarcinoma
387
When do Sx of gastroenteritis tend to present
A few hours after eating meal
388
What is management of gastroenteritis mostof the time
Usually self limiting so would discharge with hydration advice and anti emettics
389
When would you admit patient with gastroenteritis
In severe dehydration where confusion and hypotension would give fluids
390
When do you normally only give Abx in gastroenteritis
When bacteria has been isolated
391
Most appropriate investigation for person with unexplained diarrorhoea
Stool culture
392
Patient comes in with gastroenteritis sx what do you do
FBC, LFTs, clotting and U and Es Stool cultures Maybe CXR and abdo film
393
What bacteria cause bloody diarrorhoea
Campylobacter Salmonella Ecoli Shigella
394
Aetiology of budd chiari
Obstruction of hepatic vein outflow 50% unknown Of known 75% hepatic vein thrombous 25%compresssion on vein
395
Most sensitive test for gallstones
US MRI and CT all less sensitive only pick up 10% on CT ERCP too invasive
396
What drugs can cause cholestasis
``` Penicillins Erythomycin Chlorpromazine Oestrogens Clavulanic acid ```
397
Gastro conditions causing clubbing
``` IBD Cirrhosis PBC Coeliacs Achalasia ```
398
What presents with malaena, haematemesis and epigstric pain
Upper GI bleed
399
Causes of duodenal ulcers
H pylori NSAIDs Alcohol Chronic corticosteroid abuse
400
What are types of laxatives
Osmotic | Stimulant
401
How do osmotic laxatives work
Retain fluid within the bowel
402
Examples of osmotic laxatives
Lactulose | Magnesium salts
403
What are used when rapid bowel excavation needed
Phosphate enemas | Sodium or magnesium salts
404
Examples of stimulant laxatives
Senna Docusate sodium All with bisacodyl
405
What laxatives are contraindicated in bowel obstruction
Stimulant
406
When shouldnt you use stimulant laxatives
Bowel obstruction | Long term use
407
Problem of stimulant laxative use long term
Hypokalaemia | Atonic colon
408
Types of stimulant laxatives
Rectal | Bulking agents
409
Example of rectal stimulant
Glycerin suppositories
410
When are bulking agent laxatives contraindicated
Dysphagia Faecal impaction Bowel obstruction
411
Causes of upper GI bleeds
``` Peptic ulcers Mallory weiss tears Oesophagitis Gastric erosions Varices Drugs Upper GI malignancy ```
412
Drugs that can cause upper GI bleeds
NSAIDS Anticoagulants Steroids
413
Causes of portal hypertension categories
Pre hepatic Hepatic Post-hepatic
414
Pre-hepatic causes of portal HTN
Portal vein thrombosis | Splenic vein thrombosis
415
Hepatic causes of portal HTN
Cirrhosis Shitosomiasis Myeloproliferative disease
416
Post hepatic causes of portal HTN
RHF Constrictive pericarditis Budd chiari
417
Drugs that can cause cirrhosis
Methotrexate Amiodarone Methyldopa
418
Genetic causes of cirrhosis
Haemochromatosis | Wilsons disease
419
How is cirrhosis often picked up
Just on examination seeing signs of liver disease
420
What does koilonychia suggest
IDA
421
Complications of cirrhosis
``` Portal HTN Encephalopathy Hypoglycaemia Hypoalbuminaemia Coagulopathy Risk of carcinoma ```
422
What is given for pruritus
Colestyramine
423
What is treatment for HCV induced cirrhosis
Interferon Alpha
424
What is PBC
Granulomatous condition leading to inflammation and damage of interlobar ducts
425
What does PBC lead to
Cirrhosis Portal HTN Cholestasis
426
What would present with jaundice, xanthomata, xanthelasma, skin pigmentation and hepato-splenomegaly
PBC
427
Inheritance of wilsons
Autosomal recessive
428
Pathophysiology of wilsons
Disorder of chromosome 13 leading to mutation in copper ATP ase resulting in copper accumulation in liver and CNS
429
What are kayser fischer rings pathognomic for
Wilsons disease
430
What are kayser fischer rings
Copper deposits found in eye
431
Investigations for wilsons disease
Liver biopsy Blood Urine copper- high Genetic testing
432
What presents with low plasma copper and caeruloplasmin
Wilsons
433
What is mutation in haemochromatosis
HFE
434
What condition presents with slate grey skin in late progression
Haemochromatosis
435
What leads to bronze diabetes
Haemochromatosis from iron deposits in pancreas
436
What presents with positive ANA, SMA and ANCA Abs
PSC
437
What are ANCA Abs
Anti neutrophil cytoplasmic antibodies
438
What presents with jaundice, pruritus, tiredness and abdo pain
PSC
439
Categories of causes of acites
``` Venous HTN Hypoalbuminaemia Malgnant disease Infections Others (pseudocyst, Meigs-only women) ```
440
Portal HTN causes of ascites
``` HF Cirrhosis Budd chiari Portal vein thrombosis Constrictive pericarditis ```
441
Causes of hypoalbuminaemia
Nephrotic syndrome | Diet
442
Infections leading to ascites
TB
443
Other causes of ascites
Myxoedema Ovarian disease Pancreatic disease
444
Inheritance of antitrypsin deficiency
Autosomal recessive
445
What can cause emphysema, chronic liver disease, wegners granulomatosis, gallstones and pancreatits,
Anti trypsin
446
Investigations of antitrypsin
Serum antitrypsin DNA analysis Genetic phenotyping
447
Management of antitrypsin
Quit smoking Augementation of plasma antitrypsin Liver transplant if decompensated liver diseae
448
What presents with SOB and jaundice
Antitrypsin
449
Antibodies raised in AIH
ANA SMA SLA- soluble liver antigen Anti liver/kidney microsomal ytpe ABs
450
What typically presents in younger women with jaundice, RUQ pain, polyarthralgia, glomerulonephritis and pernicious anaemia
AIH
451
Investigations and findings of AIH
FBC- low WCC and plts Serology - viral neg MRCP to rule out PSC Liver biopsy- mononuclear infiltration
452
What is a cholangiocarcinoma
Cancer of bilary tree
453
What presents with fever, abdo pain and jaundice
Cholangiocarcinoma
454
Causes of cholangiocarcinoma
PSC Biliary cysts N-nitroso toxins
455
Investigations for cholangiocarcinoma
Bilirubin up LFTs- ALP up USS ERCP biopsy
456
Causes of hepatocellular carcinoma
``` Viral Cirrhosis Haemochromatosis PBC Alcohol cirrhosis ```
457
Most common liver benign primary tumour
Haemangioma
458
6 malignant liver tumours
``` Hepatocellular carcinoma Cholangiocarcinoma Fibrosarcoma Leiyomyoscarcoma Hepatoblastoma Angiosarcoma CHHALF ```
459
What tumour is alpha fetoprotein also elevated in
Testicular
460
RFx of pancreatic cancer
``` High fat diet Smoking Alcohol abuse DM Chronic pancreatitis ```
461
What presents on examination with hapeatoslplenomegaly, palpable gall bladder and epigastric mass
Pacreatic cancer
462
Extra pancreatic signs of cancer there
Thrombophlebitis migrans | Hypercalcaemia
463
What presents with steatoorhoea, diarrorhoea, cramping, bloating, weight loss and nausea
Coeliac
464
How does UC appear histologically
Inflammatory infilitrates Goblet cell depletion Mucosal ulcers Crypt abcesses
465
How does crohns appear histologically
Transmural non caseating granulomatous inflammation Fissuring ulcers Lymphoid aggregates Neutrophil infiltrates
466
What is histology of IBS
Normal
467
What is truelove and witts criteria
Assesses severity of UC flare ups
468
What is used to assess UC severity
Truelove and Witts criteria Mild Moderate Severe
469
Severe category of true love and witts
Bowel movements greater than 6/day with lots of blood
470
Moderate category of truelove and witts
Open bowels between 4-6 times | Moderate amounts of bloods
471
Mild category of truelove and witts
Open bowels less than 4 times a day with little or no blood
472
When do you see cobblestoning and rose thorn ulcers
Crohns- barium follow through
473
Moderate UC managment
Prednisolone 40mg BD Mesalazine Hydrocortisone topical foams
474
Mild UC tx
Tapering steroid dose One mesalazine a day If distal steroid foams
475
Severe UC Tx
Admitted for IV Hydrocortisone Fluids Rectal steroids
476
Difference in smoking effects UC and Crohns
UC- protective | Crohns- worse
477
Where are calcium and iron absorbed
Duodenum
478
Where is vitamin C absorbed
Proximal ileum
479
3 categories of abdo pain
Acute or chronic Surgical or medical Localised or general
480
What presents with epigastric that moves to RIF, anorexia and vomiting
Appendicitis
481
Why do urine dip appendicitis
WCC and blood in urine as appendix inflam can lead to bladder inflam
482
What presents with dysuria for a few days and then flank pain
UTI to Pyelonephritis
483
Where does pyelonephritis pain radiate
The back
484
In what age category does diverticulitis tend to present
over 60s
485
What does pain radiating to back suggest in abdo suggest (more than 1)
Pancreatitis AAA Pyelonephritis
486
What must rule out in really severe abdo pain
Ischaemic
487
What does pain relieved by defacating imply
IBS
488
What presents with pain after eating
Biliary colic Peptic ulcer Pancreatitis
489
What is cholelithiasis
Solid gall stones present in GB
490
What is choledocholithiasis
Solid gall stones in bile ducts
491
Gastro investigations needed
``` Urine dip Bloods- TFTs, LFTs, FBC,U and Es, CRP, glucose and VBG lactate CXR AXR CT abdo with contrast USS abdomen ```
492
What is CXR useful for in abdo
Perforation | Pneumonia
493
What is AXR used for in gastro
Hernia Biliary colic Cholecystisis
494
What is CT abdo with contrast useful for
Perforation Cancer Appendicitis Cholecystitis
495
What is diverticulitis
Inflammation of outpouchings of bowel lumen
496
What group of ppl does diverticulitis often present on right side in
Asian
497
RFx for diverticular disease
Low fibre diet Western diet Elderly Obesity
498
Patholphysiology of diverticular disease
Low fibre diet increases transit time of faeces resulting in increased pressure intraluminally thus predisposes to diverticulitis. Is both genetic and environmental indications
499
How is diverticulitis classified
Hincheys classification
500
Hincheys classification of diverticulitis
I- small confined pericolic abcess II-large paracolic abcess often extending into pelvis III- perforated diverticulitis where peri-diverticular abcess has perforated leading to purulent peritonitis IV- perforated diverticulitis where is free perforation with faecal peritonitis
501
Blood finding of diverticulitis
Leukocytosis
502
What presents with guarding and tenderness in left lower quadrant, LIF pain, fever and constipation
Diverticulitis
503
How does diverticulitis present
guarding and tenderness in left lower quadrant, LIF pain, fever and constipation/diarrorhoea with blood Abdo distension
504
Investigations for diverticulitis
Routine bloods Blood culture Sepsis 3 CTAP
505
Conservative management of diverticulitis
Co-amox Probiotics IV fluids
506
Surgical management of diverticulitis
Wash it out with drain | Colectomy with potential stoma or anastomosis
507
Lifestyle management of diverticulitis
Avoid high fibre in acute phase but after that high fibre
508
Most common bacteria pyelonephritis
E coli
509
Presentation of pyelonephritis
``` UTI sx Fever Rigors Constant loin pain radiating to back Myalgia ```
510
How does pyelonephritis pt appear
Restless | Severe pain
511
Investigations for pyelonepritis
``` Bloods Cultures Urine dip VBG US kidney ```
512
RFx for pyelonephritis
``` DM UTI Sex Stresss incontinence FB in urinary tract like catheter ```
513
Management of pyelonephritis
``` Sepsis 6 Morphine IV fluids Abx of gentamycin Cn be nephrostomy ```
514
Presentation of appendicitis
Central pain that goes to RIF Vomiting Diarrorhoea Anorexia
515
3 appendicits signs
Rovsings Psoas Mcburneys
516
Rovsings sign
palpate LIF and RIF hurts
517
Mcburneys sign
Palpation at mcburneys sign equals pain
518
Investigations for appendicitis
Bloods routine Blood cultures US abdo CTAP
519
Management of appendicitis
Abx and appendectomy
520
Complications of pancreatitis
``` Peripancreatic fluid collections Pseudocyst Necrosis Pancreatic abcess Haemorrhage ```
521
Investigations for pancreatitis
``` Bloods routine Lipase and amylase Erect CXR CTAP contrast Toxicology VBG US ```
522
Mx pancreatitis
``` Fluids lots Morphine Creon If gallstones ERCP Alcohol pabrinex Abx maybe ```
523
What is creon
Pancreatic enzyme replacement
524
Causes of appendicitis
Anything that blocks appendix opening leading to division of bacteria inside- faecolith, normal stool and lymphoid hyperplasia
525
What is faecolith
Hard mass of faeces
526
What is lymphoid hyperplasia
Increase in number of immune cells at lymph nodes in response to infections
527
Most common bacteria in appendix
Ecoli and bacteroides fragilis
528
What cell elevated in appendicitis
Neutrophils
529
What are main complications of appendicitis
Arterieoles get thrombosed leading to infarction through which perforation occurs. Bacteria leak out leading to peritonitis and septic shock
530
Drugs that cause hepatocyte damage
``` Sodium valproate Amiodarone Rifampicin Paracetemol OD Alcohol ```
531
What happens in a bowel obstruction
Dilatation and increased presistalsis leads to secretion of large high electrolyte rich fluid into the bowel
532
What is called when bowel not mechanically blocked but doesnt work properly
Paralytic ielus
533
How can causes of BO be classified
Intraluminal Mural Extramural
534
Intraluminal causes of bowel obstruction
Gallstone ileus Foreign body Faecal impaction
535
Mural causes of bowel obstruction
Cancer Inflammatory strictures Diverticular structures Meckels diverticulum
536
Extramural causes of bowel obstruction
Hernias Adhesions Volvulus Peritoneal cancers
537
Difference in vomiting large vs small bowel
Vomiting early in small bowel obstruction whereas minimal or delayed in large obstruction
538
What does guarding and rebound tenderness in bowel obstruction suggest
Ischaemia
539
What is a pseudo-obstruction
Caused when no mechanical obstruction but a peristalsis abnormailty
540
Investigations for bowel obstruction
``` FBC CRP U and Es- bowel obstructions leads to secretion of electrolye fluid and also vomiting LFTs G and S VBG- check lactate for ischaemia Fluid balance CT CXR- air in perforation ```
541
Why are CTs preferred to AXR in bowel obstruction
More sensitive Distinguish between mechanical obstruction and pseudo-obstruction Give exact location to help with operative planning Presence of mets if cancer
542
Imaging findings SBO vs LBO
SBO Over 3cm Central location Valvulae connitentes present across the bowel LBO Over 6cm Peripheral location Haustral lines that go halfway across the bowel
543
What is gastrograffin
Water soluble contrast study aka fluoroscopy
544
What is purpose of gastrograffin
Used in SBO to see if obstruction will settle or needs further surgery
545
What indicates ischeamia in bowel obstruction
Fever Colicky pain that becomes constant Guarding and tenderness Pain when moving
546
Management of bowel obstruction
``` Drip and suck Often fluid depleted so IVF fluid resus needed plus catheter NG tube NBM Analgesia and anti-emetics Treat conse ```
547
Management of adhesional bowel obstruction
Conservatively at first (if no evidence of complications) | If not resolved within 24 hrs do fluoroscopy over 6 hours and if that not resolved take to theatre
548
When is surgery done on obstructions
Not resolved after 48 hrs of conservative management Suspicion ischaemia or closed bowel loop Requires surgical resection such as tumour or strangulated hernia
549
What is importance of stangulation recognition in bowel obstruction
May prevent bowel resection
550
What are complications of bowel obstructions
Ischaemia Perforation Peritonitis Renal failure from dehydration
551
Common steroid complications
``` Osteoporosis Diabetes Cataracts Cushings Joint problems ```
552
What are complications of gallstones
Gallstone ileus Mirrizis syndrome Fistula to transcending colon Perforation of gall bladder
553
What happens when gallbladder perforates
Peritonitis Septicaemia 30% mortality
554
What can make a perforated gall bladder not so bad?
If bile seeps into the liver
555
What happens in a gallstone ileus
Fistula formed between cystic duct and duodenum through which gall bladder passes. Stone goes all the way down to the ileo caecal valve where causes small bowel obstruction
556
What is mirrizi syndrome
Occurs when dilated cystic duct presses against common hepatic bile duct leading to obstructive jaundice- often a fistula formed
557
How will you tell if patient has had a fistula to transverse colon from gall bladder in history
Diarrorhoea recently
558
How to tell if has history of has chronic cholelithiasis
Abdo pain occasionally that eases with eating
559
What must always ask a female with any abdo pain
Pregnant?
560
Why is pregnancy with RUQ significant
Can cause cholestasis of pregnancy
561
Where are stones in choledocholithiasis
Common bile duct
562
What can cause RUQ pain with jaundice
Cholangiocarcinoma Choledocholithiasis Cholangitis Pancreatits and cancer there
563
What must never forget with any upper abdo pain
Pneumonia or inferior MI
564
What is problem with using amylase for pancreatitis diagnosis
Small window when elevated- can be too early or late or from chronic pancreatitis Also in any diffuse abdo pain it will be elevated for example bowel obstruction, mesenteric ischaemia
565
What is problem with lipase in pancreatits diagnosis
Very expensive and rarely used
566
Why cant just elevated ALP be used to diagnose obstructive jaundice
Could be raised from pagets or bone cancer | GGT must be raised too
567
Immediate imaging for RUQ pain
CXR | US of GB, common bile duct, pancreas
568
What can cause air under diaphragm
Recent abdo surgery | Perforated viscous such as duodenal or gastric ulcer
569
Where is cholecystitis pain originally
Constant epigastric due to only visceral peritoneum irritation but when spreads to parietal it becomes localised
570
What causes right shoulder pain
Gallbladder irritates liver capsule which irritates the diaphragm
571
What is the benefit of doing chole 6-12 weeks later rather than acutely
Lower conversion of lap to open abdo
572
Why must be NBM with cholecystitis
Prevent contraction of GB
573
Complications of cholecystitis
Empyema Cholecystoduodenal fistula Gallstone ileus Ascending cholangitis
574
How will a cholecystoduodenal fistula appear on imaging
Air within Gall bladder, shouldnt be air in GB as a closed system
575
What are 2 types of gallstone
Bile pigment and cholesterol
576
Management of ascending cholangitis
Abx broad then dependant on the cultures that come back | ERCP drainage
577
What is bile made up of
``` Water Fat Bile salts Fat soluble vitamins Conjugated bilirubin ```
578
How many times a day can bile be recycled
Up to 10
579
How does liver disease affect PT
Can't produce the clotthing factors for extrinsic pathway
580
How does obstructive CBD disease affect PT time
Vitamin K must be absorbed through fat soluble bile salts
581
Why does parenteral vit k only help PT with CBD disease but not liver disease
In liver disease there is enough vit K just the synthetic function is impaired
582
Which patients are most susceptible to pigment gallstones
Those with haemolytic anaemias | Long term parenteral nutrition
583
Which patients are most susceptible to cholesterol stones
FFFS women Oral contraceptive Crohns as terminal ileum pathology means less bile reabsorbed
584
When do gallstones cause pancreatits
When lodged in ampulla of vater
585
How does courvoisiers law work
If the jaundice is caused by a stone in CBD likely that the GB will only fibrose and shrivel up but if due to a tumour then will just be a back up of bile into the bladder thus dilating it. If was inflammed too then likely other organs would try to move around it to protect it
586
Disadvantages of ERCP
Very unpleasant to undergo | Risk of bleeding, perforation of biliary tree, cholangitis and pancreatits
587
What is risk of pancreatitis in ERCP and mortality rate from this
1-3% | Mortality rate from this pancreatis 20% which very high for pancreatitis
588
Why is ALT true measure of hepatocytes not AST
AST also produced by RBCs, cardiac tissue, kidney and brain
589
Main epigastric pain causes
``` Acute pancreatitis Perofrated peptic ulcer Gastris or duodenitis Peptic ulcer disease Biliary colic Cholecystitis MI AAA Mesenteric ischaemia ```
590
Differences of onset of epigastric pain
Very sudden- perforation 10-20 minutes- pancreatits and colic Hours- inflammation like pneumonia and cholecystitis
591
What is a boorhaves perforation
Perforation of oesophagus
592
Crushing or tight epigastric pain
MI
593
Boring epigastric pain
Pancreatitis
594
Sharp or burning epigastric pain
Duodentitis Gastritis Peptic ulcers
595
Epigastric pain radiating to back
Pancreatitis | Ruptured AAA
596
Epigastric pain radiating to shoulder
Diaphragmatic irritation- cholecystitis, pneumonia, subphrenic abcess
597
Epigastric pain radiating to jaw, neck or arm
MI
598
Epigastric pain radiating to retrosternal
MI | Oesophagitis
599
Epigastric pain that is self limiting
Bilaiary colic | Uncomplicated peptic ulcer disease, gastritis, duodenitis
600
Epigastric pain made worse by exercise
Cardiac pathology
601
Important thing to check with nausea in epigastric pain
Before or after Before- boorhaaves perforation After- MI, SBO
602
Chronic cough with epigastric pain
GORD
603
Fever with epigastric pain
Acute hepatits Pneumonia Peritonitis
604
Heartburn and retrosternal pain with bad taste in mouth
GORD
605
Epigastric pain with change in stool
Pancreatits | Chronic biliary obstruction
606
How does chronic mesenteric ischaemia present
Colicky post prandial pain
607
Risk factors for chronic mesenteric ischaemia
Smoking Alcohol Diabetes Family of heart disease
608
Risk factors for acute mesenteric ischaemia
AF Recent MI Valvular disease
609
Drugs predisopsing to peptic ulcers
NSAIDS Aspirin Bisphosphonates Steroids- also mask signs of peritonitis
610
Drugs linked to pancreatitis
Sodium valproate Thiazides Azathioprine Steroids
611
What is important part of family history in epigastric pain
Cardiovascular
612
How will a patient with pancreatis position themselves
In recovery position or leaning forward
613
Can pancreatits cause jaundice in absence of gallstones
Yes 2-3 days after due to inflammation pressing on CBD
614
Why would U and Es be deranged if has pancreatitis
In shock so renal hypoperfusion | Vomiting
615
How is calcium associated to pancreatitis
Hypercalcaemia can cause it | Calcium a marker as pancreatic auto digestion leads to lipid release which binds to calcium
616
Common resp complication of pancreatitis
ARDS
617
Why does pancreatitis lead to acidosis
Same with any inflammatory response | Leads to vasodilation so systemic hypoperfusion- so anaerobic respiration leading to lactic acid production
618
What is normally required for a CXR to show air under diaphragm
Sitting up for 10 mins
619
What conditions do you do a CT for in epigastric pain
Mesenteric ischaemia | Ruptured AAA if stable
620
When is Glasgow score used for pancreatitis
Must be done within 48 hours | Determines where to treat the patient- is 3 or greater then ICU
621
When is CT used to diagnose pancreatitis
If biochemicl and clinical findings inconclusive
622
ABC assessment of pancreatitis
Breating- severe cases develop ARDS so monitor sats and effort of breating Circulation- intravascular volume may drop due to ascites, ileus and mainly vasodilation
623
Management of pancreatitis
``` IV fluids Oxygen as required Analgesia Antiemetics and NG tube PPIs DVT prophylaxis Low fat diet ```
624
What happens to glucose in pancreatitis
Increases as damage to pancreas affects indulin release
625
How to prevent pancreatits recurrence
Most recover within a week Most common causes are gallstones and alcohol Gallstones- lap chole Alochol-lifestyle guidance
626
Over the counter medication for dyspepsia
Ant acids
627
Stronger medications for dyspepsia
PPIs | Histamine antagonists
628
Why is heart burn not helped by antacids necessarily conclusive
Some dyspepsia requires much stronger meds
629
What does pain worse after eating, lying down or bending over indicate
GORD
630
What lifestyle changes can help dyspepsia
Stopping smoking | Eating less chocolate, fatty foods and caffeine
631
Triad for peritonitis
Motionless Guarding on palpation Absent bowel sounds
632
What is the cause of 30% of dyspepsia investigations
Non ulcer dyspepsia | Diagnosed after all investigations come up clear, patient must be reassured that no sinister signs
633
What are red flag indicators for urgent endoscopy with dyspepsia presentation
``` Weight loss Progressive dysphagia IDA Epigastric mass Over 55 and rapid onset recently Chronic GI bleed Persistent vomiting ```
634
What are 5 main complications of peptic ulcer
``` Haemorrhage- particularly severe on patients with anti-coagulation Perforation- NSAIDS users more at risk Malignancy Scarring Penetration ```
635
What happens in peptic ulcer penetration
Penetration through peptic wall without leakage into surrounding tissue
636
What does patient with peptic ulcer disease whos symptoms change to no relationship between meals and pain plus not relieved by antacids suggest
That the ulcer has penetrated the wall without leakage into surrounding tissue
637
Local complications of pancreatitis
``` Necrosis of pancreas Abcess formation Pseudocyst Obstructive jaundice Paralytic ileus Duodenal stress ulceration Fistula formation to duodenum ```
638
Systemic complications of pancreatitis
``` Sepsis Shock Acute renal failure ARDS DIC Hypocalcaemia Hyperglycaemia Pancreatic encephalopathy- hypoperfusion ```
639
How can pancreatitis cause shock
Haemorrhage Systemic inflam markers leading to vasodilation Loss of fluid to peritoneum
640
How can pancreatitis cause jaundice
Choledocholithiasis | Pancreatic odema
641
What can compromise elastase reliabiility in pancreatic compromise
Disease of small bowel
642
What pancreatic pathologies can raise amylase
Pancreatitis Pancreatic tumour Pancreatic trauma
643
What intra abdominal pathologies can lead to raised amylase
``` Perforated peptic ulcer Acute appendicitis Acute cholecystitis Ectopic pregnancy Mesenteric ischaemia Leaking AAA ```
644
Which miscellaneous conditions can cause raised amylase
DKA | Head trauma
645
What conditions can lead to raised amylase due to poor clearance
Kidney failure | Macroamylasaemia
646
What is macroamylasaemia
Amylase bound to Ig so cant be excreted
647
What presents with erythematous mucosa on oesophagus on OGD
GORD
648
What type of tumour are GORD sufferers at risk of
Adenocarcinoma
649
What are 3 Hs in get smashed
Hypertriglyceridaemia Hypercalcaemia Hypothermia
650
What presents with fever, tender hepatomegaly and RUQ pain
Liver abcess
651
How does an abcess appear on liver
Septated hypodense mass
652
Which liver abcess causing pathogen can be tested for using serology
Amoebic | Hydatid
653
What is hydatid
A tapeworm- echinoccus granulosus
654
What can be sources of liver abcess
``` Practically aything Direct trauma Central venous catheter Appendicitis Diverticular disease UTI ```
655
What are some complications of liver abcess
``` Septic shock Peritonitis Lung empyema DVT Cerebral abcess ```
656
Liver abcess causing pathogens
``` Escherichia coli Klebsiella pneumoniae Bacteroides spp Streptococcus milleri Staphylococcus aureus Entamoeba histolytica Candida albicans Echinococcus granulosus ```
657
3 most common causes of liver abcess
E coli Klebsiella pneumoniae Strep milleri
658
Proportion of stones contents
Mixed stones- 80% Cholesterol- 10% Pigment- 10%
659
What stones are people with crohns and parenteral feeding more at risk of
Pigment as less bile salts reabsorbed to dissolve bilirubin in
660
Complications of portal HTN
Splenomegaly Oesophageal varices Haemorrhoids
661
Histological findings of UC
Mucosa and submucosa Mucosal ulcers Crypt abcesses
662
Coeliac disease biopsy finding
Subvillous atrophy | Crypt hyperplasia
663
Investigations for coeliac
Anti TTG ABs Duodenal biopsy IgA levels
664
What can be found in faeces of IBS
Faecal calprotectin
665
What is watershed zone
Area between IMA and SMA supply of colon that is susceptible to iscahemic damage
666
AXR finding acute mesenteric iscahemia
Gasless abdo
667
Investigation of ischeamic colitis
Colonoscopy or sigmoidoscopy
668
Investigations for mesenteric ischaemia
AXR Lactic acidosis Mesenteric angiography
669
What is appearacne of sigmoid volvulus AXR
Coffee bean sign
670
What is appearacne of caecal volvulus AXR
embryo sign
671
What is coffee bean sign seen in
Sigmoid volvulus
672
What is embryo sign seen in
Caecal volvulus
673
What does cough reflex suggest
Hernia isnt incarcerated
674
Difference between bowel sounds in functional vs mechanical bowel obstruction
Functional absent | Mechanical louder or present
675
What is acute urinary retention
Painful inability to void with relief only gained after drainage of bladder
676
What precipitates acute urinary retention
Normally discomfort, increased frequency of urinating, nocturia and dribbling over course of few days leading up to retention
677
How should acute urinary retention be investigated
Ward portable bladder scanner if diagnosis isnt certain after history and examination- will show distended bladder if done
678
Management of acute urinary retention
Analgesia if needed Insertion of urethral catheter Send urine for microscopy and culture
679
If in acute urinary retention what is important investigation to do after
PR exam
680
What is the function of PSA
To liquefy the ejaculate to enable fertilisation
681
What is PSA raised in
BPH UTIs Acute and chronic prostatitis
682
What investigation shouldnt be done in suspected testicular torsion
US- only do a urine dipstick
683
Typical presentation of oesophageal tumour
Short history of progressive dysphagia from liquid to solids | Weight loss
684
Typical presentation of achalasia
Long history of equal dysphagia
685
History for benign pepctic stricture
Long history of progressive dysphagia
686
Investigations for oesophageal cancer
OGD Barium swallow CXR
687
How does achalasia appear on barium swallow
Birds beak appearance Smooth tapering distally Oesophageal dilation proximally containing foods contents
688
Common oesophageal met sites
Liver | Lung
689
Investigations to stage oesophageal cancer
CT chest abdo pelvis Endoscopic US PET scan
690
Treatment for severe dysphagia
Stent
691
Risk factors for oesophageal cancer
Achalasia Smoking GORD
692
Management of pancreatitis feeding
Start oral feeding ASAP- shown to improve outcomes | Potential NG tube
693
How do pancreatic cysts tend to developed
Disruption of the pancreatic ducts
694
Common sequelae of chronic pancreatic insufficiency
DM | Malabsorption
695
What is best measure of pancreatic exocrine ability
Faecal elastase
696
What is faecal calprotectin a measure of
GI inflammation
697
How does external compresion dysphagia present
Slow progression from solids to liquid | Alongside chest Sx too
698
Investigations for achalasia
Barium swallow OGD Oesophageal manometry
699
What does oesophageal manometry do
Checks function of lower oesophageal sphincter
700
Gold standard test for achalasia
Oesophageal manometry
701
Can achalasia be painful
Yes
702
What types of conditions are associated with gallstones
Haemolytic
703
What is mucocele of the gallbladder
Occurs when hartmanns pouch is obstructed leading to mucous distension of GB
704
Complications of gall bladder surgery
Haemorrhage Bile leak Biliary tree damage 3% open surgery risk
705
Problem with CT pancreatitis
Doesnt show til 2 days after
706
Patient with pancreatitis presents a few weeks later with abdo pain, vomiting and palpable mass
Pseudocyst- can grow so big to point they are palpable and can put pressure on stomach causing vomiting
707
Bloods ordered pancreatitis
``` FBC U&Es- deranged due to fluid loss Calcium LFTs Amylase LDH- part of glasgow system Lipid profile- is a cause Clotting- important for DIC monitoring ```
708
Imaging for pancreatitis
eCXR- rule out perf (only 70% visible) US- see signs of gallstone disease MRI preferred to CT
709
Mr Khwajas management of pancreatitis
IV fluids lots- fluid losses into lesser sac and bowel from ileus Analgesia- helps breathing High flow oxygen VTE- prohylaxis
710
Why are pancreatitis patients at great risk of VTE
Serious inflammation can trigger cascade | Fluid loss so blood thicker
711
Which location of pancreatic cancer can give pancreatitis
Head
712
Why cant you operate on patients with pancreatitis
SIRS already so another response to cut will mean go into shock
713
Order of investigations for pancreatic cancer
CT and tumour markers | Then ERCP to obtain biopsy and put stent in
714
Is diabetes a RF for pancreatic cancer
No
715
Most common gastric cancer
Adenocarcinoma
716
RFs for gastric cancer
``` Male H pylori Smoking Pernicious anaemia Diet with high salt and preserved foods ```
717
What is it called when large bowel loop is interposed between liver and diaphragm
Chilaiditis sign
718
What is chilaiditis sign
When large bowel loop is inbetween diaphragm and liver
719
What is chilaiditis syndrome
Normal variant whereby large bowel loop is inbetween diaphragm and liver alongside pain- if asymptomatic called chilaiditis signs
720
Pathophysiology of chronic cholecystitis
Can be caused from reccurent inflam from gallstone being lodged in cystic duct and falling out Can be irritation from stones themselves within the gall bladder
721
Presentation of chronic cholecystitis
Recurrent RUQ pain after eating Nausea and vomiting Bloating and flatulence
722
What happens to gall bladder after chronic inflammation
Becomes fibrosed and calcified- porcelain gall bladder
723
How is porcealin gall bladder visible
On AXR
724
Investigations for chronic cholecystitis
AXR | US-CT is better to delineate
725
What type of surgery is there a particular association of pseudo obstruction with
Orthopaedic
726
Patient presents post op with bowel obstruction sx
Ileus
727
In post op ieus why is K+ resus particularly important
Helps peristalsis continue
728
When patient has bowel obstruction how should they be fed
Para-enteral
729
What should be given before para-enteral feeding in bowel obstruction
Pabrinex as in periods of starvation there is risk of wernickes
730
What is pseudomembranous colitis
Inflammation of colon due to growth of C diff
731
Why is it important to do AXR in pseudomembranous colitis
Check gas pattern to exclude toxic megacolon or perforation
732
What is thumbprinting on AXR
Dilated oedematous areas of bowel
733
Where can c diff affect in bowel
Only colon
734
Management and investigations of c diff
Rehydration Discontinue current ABx Stool assay for toxins aswell as ELISA for them Oral vancomycin or metronidazole
735
Bowel sounds in ileus
Absent
736
Which sex are femoral hernias more common in
Females
737
Which hernias are the most likely to strangulate
Femoral
738
Which sex are inguinal hernias more common in
Men
739
What are the majority of inguinal hernias
Indirect- 80%
740
How to differentiate between femoral and inguinal
Inguinal medial and superior to public tubercle whereas femoral inferior and lateral
741
How to differentiate between indirect and direct hernias
Attempt to reduce it and then press over mid point of inguinal ligament or the deep ring and ask patient to cough. If direct will still pop out
742
How does carcinoma appear on contrast enema
Applecore
743
Most common causes of RIF mass
Crohns Appendix abcess Hepatomegaly Cancer
744
What infective pathogns can mimic crohns in RIF
TB | Yersina
745
What is name when TB affects bowel and how would you confirm
Ileo caecal TB | CXR
746
In suspected LBO what investigations would you do
AXR | Rectal examination
747
How to manage sigmoid volvulus in old people
Decompression flatus tube into sigmoid
748
Which patients do sigmoid volvulus tend to occur in
Elderly | Psyciatric
749
Management of UC
IV 100mg Hydrocortisone- can give smt to protect bone too like Adcal-3
750
What conditions can give you toxic megacolon
UC Crohns Pseudomembranous colitis
751
What is most commonly damaged organ in trauma within abdomen
Spleen
752
Post splenectomy what important measures must be taken
``` Pneumococcal vaccination Meningococcal vaccination Haemophilis influenzae vaccination Be careful about travelling to countries with malaria Long term Penicillin ```
753
What is % of perforations picked up on eCXR
70
754
Common causes of functional obstructions
``` Post operative ileus Hypokalaemia Hypomagnesia Hypercalcaemia Opiates Hypothyroidism Intra abdominal sepsis ```
755
3 most common causes of SBO
Adhesions Hernia Caecal cancer
756
Causes of SBO
``` Adhesions Hernia Caecal cancer Crohns Faecal impaction Bezoar ```
757
What does colour of vomit suggest about bowel obstruction
Green- proximal | Darker- distal
758
What is a tricobezoar
Bezoar made up of hair
759
What is a phytobezoar
Bezoar made up of fibre, skin etc any indigestible plant or animal material
760
What is main thing to determine severity of bowel obstruction
PAIN PAIN PAIN
761
Best way to classify bowel obstruction causes
Extra luminal Intramural Intra luminal
762
Extramural causes of SBO
Adhesions Hernias Diverticular abcesses Cancers
763
Intramural causes of SBO
Crohns Radiotherapy Cancer of caecum or appendix TB
764
Intraluminal causes of SBO
Bezoars Faecal impaction Gallstone ileus
765
What are signs on AXR of pneuperitoneum
Rigles sign Falcifrom ligament sign Football sign
766
What is rigles sign
Where can see white outline of bowel due to air in abdomen
767
How to interpret AXR systematically
ABDOX
768
What is amyloidosis
Deposition of proteins with abnormal shapes that stick together and cause tissue damage
769
What is normal path of abnormally folded proteins
Get broken down by proteases
770
What happens to misfolded protein breakdown in amyloidosis
There is too much breakdown and the proteases become overhwhelmed
771
What do abnormally folded proteins form together in amyloidosis
Insoluble beta sheets that deposit in tissues
772
What can amyloidosis be divided into
Systemic and local
773
What are the 2 types of systemic amyloidosis
AL | AA
774
What is AL
Amyloid light chain- occurs in myeloma when due to mass production of ABs lots of light chains get produced in the process and these are too many for proteases to manage
775
What is AA
Amyloid of serum amyloid A- serum amyloid A is an acute phase protein that if inflammation persists for too long the proteases cant cope with its production
776
What conditions are associated with with AA
IBD Rheumatoid arthritis Cancer
777
Which organs does systemic amyloid tend to affect
``` Nerves Heart Gut Kidney Spleen Liver Tongue ```
778
What organs does amyloidosis cause organ enlargement in
Liver Spleen Tongue
779
How does amyloid affect the kidneys
Deposits on podocytes affecting the glomerulus -> nephrotic syndrome
780
How does albumin loss lead to hyperlipidaemia
Albumin inhibits lipid synthesis
781
What does bruit over liver suggest
Cancer or cirrhosis
782
Extra luminal causes of LBO
``` Hernias- most common worldwide Adhesions Volvuluses Tumours invading colon Diverticular abscess ```
783
Mural causes of LBO
``` Carcinomas Chronic diverticular disease leading to strictures Crohns Radiation Anastamotic strictures ```
784
Intra luminal causes of LBO
Faecal impaction Bezoars Foreign objects up the anus
785
Difference between episcleritis and scleritis
Eye pain and visual disturbances seen in scleritis
786
What is scleritis and episcleritis
Reddening of eyes
787
Why are adhesions less likely to occur in large colon
Ascending and descending colon are retroperitoneal so fixed position
788
How does sigmoid cancer present
Could either be asymptomatic or could present having progressed through to complications Sx include PR bleeding, change in bowel habits and overflow diarrorhoea
789
What happens in closed loop bowel obstruction
Bowel gets obstructed distally then faeces backs all the way back up into a competent ileo-caecal valve
790
How do closed bowel loop obstructions present
With RIF pain following on from LBO symptoms
791
What presents with LBO sx and then RIF pain
Closed bowel loop
792
Why do you get RIF pain in closed bowel loop
The caecum is narrowest part of the LB so most likely area for faeces to collect in
793
Bloods ordered for LBO and why
``` FBC- anaemia, WCC U&Es- hypokalaemia and AKI G&S LFTs Clotting Amylase Glucose ```
794
Tx for LBO
Hartmanns fluid Analgesia NG tube Catheter to do fluid balance
795
Two regular drugs taken for Crohns
Methotrexate | Azathioprine
796
Drug come into hospital to take for crohns
Infliximab
797
What to tell patient about for upcoming coeliac duodenal biopsy
Have to maintain eating gluten
798
Colonoscopy term to describe crohns
Cobble stone
799
Colonsocopy description of UC
Lead pipe
800
What does leadpipe refer to in colonsocopy
UC
801
Steatorrhoea differentials
Coeliac Chronic pancreatitis HIgh fat diet
802
Specific drug used for UC
5-Aminosalicylic acid
803
Risk factors in history for coeliac
Autoimmune thyroiditis T1DM Pernicious anaemia
804
What are coeliac patients often deficient in
Vit ADEK
805
Consequences of coeliac patients being Vit D deficient
Have osteomalacia
806
How do coeliac patients end up with low calcium and phosphate
Reduced absorption of Vit D leading to osteomalacia
807
What are coeliac patients at increased risk of
Adenocarcinoma in small bowel T cell lymphoma in small bowel Osteoporosis
808
What can lead to increased presence of mouth ulcers
Iron deficiency
809
What can cause glossitis
B12 Folate Iron deficiency
810
What percentage of gallstones does an US pick up
81%
811
What to do if uncertain of diagnosis of gallstones- next investigation?
HIDA scan or a CT
812
Complications of cholecystitis
Empyema Gangrene Perforation
813
Semi surgical management of cholecystitis
Percutaneous cholecystostomy
814
Investigations ordered for suspected cholangiocarcinoma
LFTS CA 19-9 ERCP with brushing
815
What are causes of appendicits
``` Faecolith Impacted normal stool Tumour Lymphoid hyperplasia of peyers patches Carcinoid tumour ```
816
Who does appendicitis most commonly appear in
Male 16-25
817
Symptoms of appendicits
Pain that localises N and V Low grade fever Anorexia
818
Signs on examination of appendicitis
Rebound tenderness and guarding over McBurneys point
819
Difference between pain in SBO and LBO
Intermittent and crampy SBO | Diffuse and constant in LBO
820
Where are diverticulae most likely to form
Sigmoid due to presence where food sits for the longest time
821
Investigations and management for appendicitis
US and if inconclusive do CT | Whisk off to surgery but beforehand give prophylactic Abx
822
RFx for diverticular disease
Age Low fibre diet NSAID use
823
What are diverticulae
Outpouching of intestinal mucosa
824
What is diverticulosis
Presence of diverticulae but asymptomatic
825
What is diverticular disease
Symptomatic diverticulosis
826
What is an appendicular mass
Occurs in acute appendicitis when the caecum, omentum and other small bowel loops wrap around the appendix forming an appendicular mass
827
Complications of appendicitis
Perforation Appendicular mass Abcess
828
Difference in symptoms between diverticular disease and diverticulitis
``` Intermittent LIF pain Altered bowel habits PR bleeding In both Then pain constant in inflam alongside fever and N and V Will be rigidity and rebound tenderness ```
829
Progression of hernia description
Reducible Incarcerated Obstructed Strangulated
830
Investigations for diverticulitis
Barium enemas Colonoscopy CT
831
Investigations for colorectal cancer
``` Bedside DRE Bloods FBC Haematinics CEA FOBT Colonsocopy CT to stage ```
832
Diverticular disease management
Lifestyle advice- increase fiber and hydration
833
Mild acute diverticulitis management
Oral Abx
834
Severe diverticulitis management
``` IV abx IV fluids Analgesia Surgery if perf or SEPSIS ```
835
Complications of diverticular disease
``` Diverticulitis Intra abdo abscess Perforation and peritonitis Sepsis Fistula formation to bladder LBO from stricture ```
836
Percentage of where colon cancers are
``` 40 rectum 30 sigmoid Ascending and caecum 15 Transverse 10 Descending 5 ```
837
Genetic associations of colon cancer and their percentages
Sporadic 95% HNPCC 5% FAP less than 1%
838
Differentials for haematemesis
``` Oesophagitis/gastritis/duodenitis Peptic ulcer Oesophageal varices Mallory weiss tear Cancer of oesophagus or stomach AV malformations Boerhaaves perforation Trauma Aorto-enteric fistula ```
839
What score can be used to stratify patients presenting with haematemesis
Batchford
840
How do boerhaaves perforations normally present
Vomiting and lots of pain | Only sometimes with haematemesis
841
Imaging needed for haematemesis
OGD eCXR CT
842
What is common finding on CXR of boerhaaves perforation
Left sided pleural effusion
843
What is significant recent operation in terms of haematemesis
Aortic graft as can lead to aortic-enteric fistula
844
What does fresh blood suggest in haematemesis
Upper GI bleed
845
What does coffee grounds in blood suggest
Blood thats been partially digested by stomach acid
846
How does blood affect faeces transit time
Increases it as blood acts as a cathartic
847
What does recent forceful vomiting suggest about cause of haematemesis
Boerhaaves | Mallory weiss tear
848
What does recent dysphagia suggest about haematemesis
Oesophageal cancer or oesophagitis
849
Recent weight loss causing haematemesis
Cancer of stomach or oesophagus
850
What would suggest cirrhosis as cause of haematemesis
Easy bruising, ascites, lethargy
851
What would knawing epigastric pain asuggest about haematemesis
Gastric cancer
852
What would recent episodic dyspepsia suggest about haematemesis
GORD
853
Important PMH questions haematemesis
Bleeding tendency GORD-> oesopagitis Peptic ulcer Liver disease
854
Important drugs in haematemesis history
``` NSAIDS- ulcer Aspirin- ulcer Steroids- ulcer Bisphosphonates- ulcer Anticoagulants- bleeding Metho trexate- liver Amiodarone- liver Beta blockers- mask shock ```
855
Social history significance haematemesis
Alcohol- liver, ulcers, gastritis Smoking- cancer, GORD IV drug use- cirrhosis Tattoos- cirrhosis
856
Examination what looking for haematemesis
``` Tattoos, track marks- liver Purpura- thrombocytopenia from ITP, liver etc Thoraco abdo scar- AAA repair Hepatomegaly- liver Splenomegaly- portal HTN Epigastric tenderness- peptic ulcer disease or gastritis Haemorrhoids- portal HTN Malaena- upper GI bleed ```
857
In haematemesis why may patient not be anaemia
Proportion of whats lost, Hb will be lost in equal propportions to everything else
858
Raised GGT in absence of raised ALP
Alcohol abuse
859
What can cause a raised urea in presence of normal creatinine
Dehydration | Increased protein ingestion due to blood in GI tract
860
If patient has low albumin what investigation must do
Urinalysis to rule out nephrotic syndrome
861
How should patients awaiting endoscopy be managed
NBM Regular obs Fluids If keep bleeding correct platelets or coagulopathy
862
What imaging can be used if endoscopy fails haematemesis
Angiography | Laparatomy
863
How are oesophageal varices managed surgically/endoscopically in order
``` Endoscopic band ligation Endoscopic sclerotherapy Balloon tamponade TIPS Portocaval shunt ```
864
What is TIPS
Transjugular intrahepatic portosystemic shunt- create shunt between portal vein and hepatic vein to reduce portal HTN
865
What is portocaval shunt
Surgically performed shunt between portal and heaptic vein
866
What is problem with portocaval shunt
Toxins from gut that would be sorted by liver go straight into systemic circulation
867
Long term management of portal HTN
Quit smoking alcohol Control BP Abx for a week as strong chance of sepsis Treat encephalopathy with lactulose and enemas
868
If beta blockers are contraindicated in controlling BP post oesophageal varices what is best option
Isosorbide mononitrate
869
How to treat encephalopathy
Low protein diet Lactulose Enemas
870
Why is lactulose beneficial in treating encephalopathy
Decreases transit time in bowel | Lowers pH making biome more hostile to ammonia producing bacteria
871
What does clots in haematemesis suggest
Partially digested so likely to be of peptic source
872
How does mallory weiss tear present
Chest pain | Vomiting blood
873
What non GI pathology can cause haematemesis
Epistaxis
874
Which causes of epistaxis can lead to haematemesis
Posterior nose bleeds from branches of sphenopalatine artery
875
Rfx peptic ulcer
``` H pylori Smoking Alcohol Blood group O Hypercalcaemia Stress physiological Aspirin NSAIDS ```
876
Why are alcohoics suscpetible to haematemesis
Varices Prone to mallory weiss tears from vomiting Liver damage leads to reduced pro coagulant synthesis
877
What is the Child pugh score for
Prognosis of liver cirrhosis
878
What can oesophagitis often be secondary to
GORD | Hiatus hernia
879
Diagnoses for RIF pain
``` Bowel - gastroenteritis - crohns - SBO - constipation - volvulus Appendix - appendicitis - mesenteric adenitis Kidney - pyelonephritis - UTC Genitalia - ectopic - fibroids - twisted or bleeding ovarian cancer - torsion -epididymitis ```
880
Who is mesenteric adenitis usually only seen in
Children
881
RIF pain elderly people- what is more likely to be considered
Caecal cancer Volvulus Mesenteric diverticulum
882
How will appendicitis patients often sit
With right knee flexed
883
If patient is in pain when doing an abdo exam what can ask patient to do
Breath in deeply and then puff out abdomen- if peritonism then will make very minimal movements Then ask patient to cough- if parietal inflammation will breath very shallow and will place hands over area that hurts
884
If suspected guarding or rebound tenderness in area what is polite thing to do
Percuss the area- if parietal inflammation will still hurt
885
What normally precedes mesenteric adenitis
URTI
886
With RIF pain how is rectal bleeding revelant
May suggest bleeding caecal or meckels diverticulum
887
Which dermatome can epididymitis, orchitis and testicular torsion present to
T10 so bear this in mind
888
Signs on VBG of ischaemia or sepsis
Raised lactate pH of less than 7.35 with low/normal CO2 Base excess
889
How can appendicits present on urinalysis
Proteinuria- microscopy to differentiate from UTI
890
When would do transvaginal US
If unsure RIF pain of appendiceal cause or gynae
891
How is eCXR relevant in RIF pain
Perf appendix Meckels diverticulum Caecal diverticulum
892
What is pain generally in mesenetic adenitis
More diffuse
893
What are symptoms of meckels diverticulitis
Identical to appendicitis
894
In gastroenteritis what tends to predominate
Vomitin and diarrorhoea
895
Which drugs can elevate amylase
Opiods
896
What could RIF mass be in appendicitis
Appendicular mass | Abscess
897
Howt to investigate RIF mass in appendicits
CT
898
When is only time AXR are acceptable
Suspected BO History of IBD Foreign body
899
Signs on examination of testicular torsion
Raised testicle Scrotal erythema Tenderness
900
Common associated symptom of testicular torsion
Nausea and vomiting
901
When examining the other testis in suspected testicular torsion what would indicate torsion
Lying horizontal- testicles lying like this increases risk of torsion
902
What is prehns sign
Elevating the affected testicle relieves pain in epididymitis- helps distinguish from torsion
903
What is the cremasteric reflex
If stroke superomedial side of thigh then should result in elevation of ipsilateral testicle
904
What does negative cremasteric reflex suggest
Can exclude torsion
905
What can be laparascopic finding of crohns
Mesenteric fat wrapped around ileum
906
Woman presents with RIF pain every month
Probably Mittelschmerz- middle pain
907
What is mittelschmerz
Pain in either IF that can rotate and is always in the middle of each menstrual cycle
908
What is SIRS
Systemic inflammatory response syndrome- the bodys response to a wide range of pro-inflammatory processes
909
How is SIRS defined
``` 2 of Temp RR WCC HR ```
910
What is SEPSIS
SIRS caused by an infection
911
What is severe sepsis
Sepsis causing hypotension(SBP <90 or drop of 40 from their baseline) and end organ hypoperfusion (metabolic acidosis)
912
What is septic shock
Severe sespis refractory to fluids and vasopressors are needed
913
What is MODS
Multiple organ dysfunction syndrome- evidence of 2 or more organs failing
914
What is a gridiron scar
This is old method of appendectomies- perpendicular to line between umbilicus and ASIS
915
What is the lanz scar
New method of appendectomies- horizontal course starting just medial to ASIS
916
Why when doing an appendectomy does surgeon check the distal 2 feet of the ileum
Look for meckels diverticulum | Or Crohns
917
How does non inflamed bowel look
Lily white
918
What cells can be found in meckels diverticulum
Gastric and pancreatic
919
Why in surgery would surgeon do appendectomy regardless of inflamed appendix or not
To guide surgeons in future as will see scar and assume has had out
920
What is an interval appendicectomy
If has had conservative treatment of appendicular mass or abscess then remove it
921
What is link between appendicectomy and UC
Patients who have had appendicectomy are less likely to develop severe symptoms of UC and need colectomy
922
What is relationship between crohns and appendicectomy
Patients whove had operation at greater risk of developing crohns symptoms but probably because appendicitis symptoms were first presentation of crohns
923
Scoring system for appendicitis
Alvarado
924
What is the most common anantomical position of appendix
Retrocaecal
925
What epigastric pain can radiate to back
Pancreatitis Peptic ulcers Ruptured AAA
926
What are 2 types of Hpylori gastritis
Antrum predominates | Pangastritis
927
What do you nomally get in antrum gastritis from H pylori
Duodenal ulcers and duodenal pathology
928
What does Hpylori pangastritis predispose to
Adenocarcinoma | MALT lymphoma
929
What gives you multipe ulcers in stomach
NSAIDS | If no history suspect Zollinger Ellison
930
What does urgency to defaecate indicate
Rectal colitis as cant store there so has to come out
931
Who does Behcets normally appear in
Mediterranean descent
932
Differentials for LIF by organ
``` Bowel - IBD - cancer - diverticular - pseudomembranous colitis Renal - stone - pyelonephritis - UTI Gynae - mittelschmerz - cyst - ectopic - ovarian tumour complications - fibroids - torsion Aorta - ruptured AAA ```
933
How does diverticulitis pain present
Starts off general abdo and colicky but then localises to the LIF
934
What does acute onset LIF pain suggest
Ruptured vessel such as AAA or ovarian cyst | Perforation of cancer
935
How in history will describe past few months if has IBS
Abdominal discomfort and bloating
936
LIF pain with PR bleeding
Carcinoma Diverticular disease Colitis- inf or inflam
937
What is most important medication to ask about in all abdo presentations
Steroids as can mask signs of infection and inflammation making the patient seem more well that they actually are
938
What drugs predisopose to pseudomembranous colitis
Abx | PPIs
939
If patient has peritonitis how will they present
Shallow breaths Lying still Any movement will hurt Pale
940
What would be significant about jaundice in LIF pain
Carcinoma that has metastasised to liver
941
Peritonitis on examination
Tender Rigid abdomen Absent bowels can be a later presentation
942
DDx for absent bowel sounds
Functional obstruction | Peritonitis
943
Peritonitis in LIF pain
AAA Complicated diverticulitis Carcinoma perforation
944
LIF mass in pain
Colonic carcinoma | Diverticulitis alone but can be abscess too
945
What is troisiers sign
Presence of virchows node
946
Why is CRP so important in colitis
Predicts outcome
947
Why are U&Es so important in any abdo presentation
Baseline elctrolytes to see if need fluids/resus Going to surgery so K+ very important Kidney function as depends if use contrast Diarrorhoea and vomiting will often lead to AKI
948
Diagnostic method of choice for acute diverticulitis
CT with contrast
949
What is non specific sign on AXR of acute diverticulitis
Large bowel dilatation
950
What are contraindicated in acute phase of diverticulitis
Barium swallow through | Endoscopy
951
Management of acute diverticulitis in acute phase
``` IV fluids if cant keep oral down Bowel rest IV fluids VTE prophylaxis Analgesia Abx ```
952
Longer term management of acute diverticulitis
Colonscopy or barium swallow to check how bad stricture is and to visualise diagnosis High fibre diet
953
What is indication for bowel resection in acute diverticulitis
If has had two proven episodes of acute diverticulitis- each time increases chance wont respond to medical intervention
954
What does pelvic inflammatory disease present with
IF pain Nausea Fever Discharge
955
What is natural history of diverticulosis
70% asymptomatic 15% acute diverticulitis developed 10% get PR bleeding
956
Why are colovesical fistulas more common in men in diverticular disease
Uterus sits between bladder and sigmoid in women
957
Difference in preceding abdo pain diverticulitis and appendicitis
Appendicitis is in midgut so T10 | Diverticulitis is in hindgut so T12
958
Where are diverticulae least likely to develop
Rectum as complete coat of longtitudal muscles
959
Pathophysiology of wilsons
Autosomal deficit in protein that binds copper to caeruplasmin and vesicles. In wilsons it doesnt bind to either so is released into liver where binds to H2O2 forming free radicals damaging liver and also in blood
960
What is main site copper in blood spreads to
Brain
961
What happens if copper is deposited in brain
Cerebrum- dementia | Basal ganglia- parkinsonism
962
``` What happens when copper spreads to Brain Eye Blood Kidney ```
Brain- dementia and parkinsonism Kidney- renal falure as PCT damage Blood- haemolytic anaemia Eye- rings
963
How does wilson tend to present in younger people
Hepatitis then cirrhosis
964
How does wilson tend to present in elderly
Parkinsonism | Dementia
965
Investigations for wilsons
High copper Low caeruplasmin High urinary copper
966
What is velvety epithelium seen in
Barretts oesophagus
967
What are the 2 extra enteric manifestations of UC that arent related to disease activity
Axial spondyloarthropathy | PSC
968
What drug can often cause colitis
NSAIDS
969
How does NSAID colitis present
bloody diarrhoea, weight loss, iron deficiency anaemia and sometimes abdominal pain
970
Management of acute UC
IV hydrocortisone
971
If IV hydrocortisone doesnt work for UC flare what is next line
IV ciclosporin | Infliximab
972
What is gastritis compared to peptic ulcer disease
Gastritis is histological inflammation of the stomach mucosa | Peptic ulcer is where inflammation penetrates through to submucosa of greater than 5mm
973
What presents with recurrent peptic ulcers and diarrohoea
Zollinger elson SYNDROME
974
How is zollinger elison diagnosed
Very high fasting gastrin
975
Peptic ulcer with history of tumours in family
Zollinger elison due to MEN
976
What will be seen in HPC of zollinger ellison disease
Hypercalcaemia symptoms
977
How does recent ICU stay predispose to peptic ulcer disease
Organ failure leads to gastrin production
978
What does pointing sign mean in relation to peptic ulcer disease
Often the patient can localise the pain very well to an exact location
979
What does pointing sign suggest
Peptic ulcer
980
If weight loss in peptic ulcer disease history and patient is over 55 what must do
OGD 2ww
981
Epigastric pain that wakes you up at night
Peptic ulcer disease
982
First line investigations for peptic ulcer disease
Urease breath test Stool antigen Serology but less accurate Bloods- FBC
983
Gold standard test for peptic ulcer disease
OGD
984
What is done in OGD of peptic ulcer disease
Visualise number of lesions Biopsy to see if malignant or H pylori Treat if bleeding
985
What can be done to peptic ulcer if bleeding in OGD
Band ligation Adrenaline injection Thermocoagulation
986
Bloods ordered for peptic ulcer disease
FBC looking for anaemia
987
When can first line investigation for peptic ulcer disease change
If over 55 and wt loss If over 60 and dyspepsia 2ww OGD
988
If penicillin allergy what is ab instead used in H pylori peptic ulcer
Metronidazole
989
If non h pylori peptic ulcer what is management
4-8 weeks of PPIs
990
Second line management of peptic ulcer disease
H2 anatagonists- ranitidine
991
Where can pain radiate in duodenal ulcer disease
To back
992
What is pathophysiology of GORD
Reflux of gastric contents into oesophagus, pharynx or lung due to relaxation of LOS
993
2 main risk factors for GORD
Obesity | Hiatus hernia
994
Other risk factors for GORD
``` Smoking Alcohol NSAIDS Acidic food CCB ```
995
What are acidic foods that can affect GORD
Citrus Mint Coffee
996
Main presentation of GORD
Heart burn on eating | Bad taste in mouth- mainly acidic and occurs post eating
997
When is heartburn pain in GORD worse
Lying down or bending over
998
How can GORD present with voice affected
Laryngitis
999
Other symptoms of GORD
``` Dysphagia Halitosis Dyspepsia Early satiety Bloating ```
1000
First line investigation for GORD
PPI trial
1001
If GORD persists post PPI trial what may consider plus what would push you towards a certain investigation
OGD- barretts, erosion Barium Manometry- dysphagia
1002
Lifestyle mangement of GORD
Lose weight Avoid citrus/spicy food, coffee, alcohol, chocolate Avoid eating late at night Elevate head when sleeping
1003
If GORD persists what is management
Fundoplication surgery
1004
Risk factors for barrets oesophagus
Same as GORD
1005
Presentation of barretts oesopahgus
Same as GORD, perhaps years of GORD | Could be dysphagia too with cancer
1006
Diagnosis of barretts oesophagus
OGD with biopsy | Histopathology confirms
1007
What is seen on OGD in barretts oesophagus
Velvety epithelium Salmon coloured epithelium Z line migrates upwards
1008
Managmenet of barretts oesophagus
PPI with surveillance | Lifestyle same as GORD
1009
Further management of barretts
Fundoplication Radio/cryo abaltion Oesophagectomy
1010
What is main risk of barretts
Dsyplasia to adenocarcinoma
1011
Types of hernia
``` Inguinal Femoral Epiastric Umbilical Incisional Spigelian ```
1012
What are 4 types of hiatus hernia
1- sliding 2- rolling 3- mixed sliding and rolling 4- giant hernia of stomach and one other structure passing through hiatus
1013
Hiatus hernia RFs
Obesity Oesophageal/gastro procedures Increased abdo pressure
1014
Examination findings of hiatus hernia
Bowel sounds in chest | Oropharyngitis
1015
Presentation of hiatus hernia
Symptoms of GORD Belching Lower dysphagia Painless regurgitation of food
1016
Best investigation for hiatus hernia
Barium
1017
What is a sliding hiatus hernia
When GEJ slides above diaphragm
1018
What is a rolling hiatus hernia
When GEJ stays in place but fundus moves into chest alongside the oesophagus
1019
What is seen on CXR hiatus hernia
Retrocardiac air bubble
1020
Why do OGD in hiatus hernia
To see if GORD has undergone dysplasia
1021
Managmeent of hiatus hernia
Same as GORD- lifestyle and PPIs | Fundoplication surgery
1022
Why do barium when GORD diagnosed
To see if cause is hiatus hernia
1023
Complications of hiatus hernia
Volvulus Ischaemia Obstruction Bleeding-> haematemesis
1024
Most common type of gastric cancer, what are others
Adenocarcinoma | Lymphoma, leiomyosarcoma, neuroendocrine
1025
Main risk factors for gastric cancer
Smoking Hypylori infection Poor diet- high salt, low fruit and veg
1026
3 lymphadenopathy sites in gastric cancer
Virchows Sister mary joesph- periumbilical Irish node- left axillary
1027
Cancer markers that are elevated in gastric cancer
Ca19-9 | CEA
1028
Diagnostic investigation for gastric cancer
OGD with biopsy
1029
Pathophysiology of achalasia
Noramlly the aubach plexus releases inhibitory NO which relaxes the LOS, now there is autoimmune damage of this plexus causing constriction of LOS and loss of peristalsis
1030
Risk factors for achalasia
``` Chagas disease Fh Autoimmunity Allgrove syndrome measles and herpes ```
1031
Dysphagia to solids and liquids with jaundice
Chagas disease
1032
Achalasia presentation
Dysphagia to liquids and solids Retrosternal pain sometimes Regurgitiation of food Weight loss
1033
First line investigation for achalasia
OGD and biopsy
1034
Definitive test for achalasia
High resolution manometry
1035
What is beak sign seen in
Achalasia on barium swallow
1036
What is CXR finding of achalasia
Absence of gastric bubble | Dilated oesophagus
1037
What are risk factors for mallory weiss tear
Increase in abdo pressure- vomiting, coughing, hiccups, straining Hiatus hernia Alcohol use
1038
What is a mallory weiss tear
When increase in abdo pressure causes tear in oesophagus just above the LOS
1039
Examples of what increases abdo pressure to cause a mall weiss tear
Vomiting- alcoholism, gastroenteritis, hyperemis gavidarum Coughing- COPD, whooping cough, lung ca Straining from constipation
1040
PC of mallory weiss tear
Haematemesis Postural hypotension Light headedness
1041
Investigations for mallory weiss tear
``` FBC- anaemia LFTs- alcoholism CXR is perforated G&S OGD ```
1042
What score is used to stratify risk when vomiting blood
Rockall
1043
Management of mallory weiss tear
ABC PPI and antiemetics to reduce acid scretions and vomiting respectively Endoscopy
1044
First line mallory weiss tear management on endoscopy
Adrenaline injection
1045
Second line mallory weiss tear investigation on endoscopy
Band ligation
1046
Second line management of mallory weiss tear if endoscopy fails
Sengstaken blakemore tube
1047
Last resort management of mallory weiss tear
Surgery
1048
Presentation of boerhaves perforation
Retrosternal chest pain SOB Vomiting
1049
What is pneumomediastinum seen in
Boerhaves perforation
1050
Signs on ausculaton of boerhaves perforation
Cracking/ crunching sound over heart due to pneumomediastinum Reduced air sounds Surgical emphysema- crepitus around skin area
1051
Management of boerhaves perforation
Surgery
1052
What layer does oesophageal cancer begin in
Mucosa then enters submucosa then muscularis
1053
Where can oesophageal cancer invade to
``` Lungs Aorta Recurrent laryngeal nerve Trachea Phrenic nerve ```
1054
Where does oesophageal cancer spread to
3 Ls Lung Liver Lymph nodes
1055
What is most common cancer in lower oesophagus
Adenocarcinoma
1056
What is most common cancer in upper 2/3 of oesophagus
SqCC
1057
Risk factors for SqCC in oesophagus
Smoking Alcohol HPV
1058
Risk factors for adenocarcinoma of oesophagus
GORD Barretts oesophagus Hiatus hernia Obesity
1059
What does hiccuping a lot suggest in dysphagia
Phrenic invasion of oesophageal cacner | Hiatus hernia
1060
Presentation of oesophageal cancer
``` Dysphagia to solids then liquids Odonyphagia Hiccuping if phrenic involvement Weight loss GORD sx if adenocarcinoma Hoarse voice if recurrent laryngeal nerve involvement ```
1061
First line and diagnostic investigation for oesophageal cancer
OGD and Bx
1062
Investigations for oesophageal cancer
OGD and Bx CT to look for mets PET scan Bloods- volume depletion, hypokalaemia
1063
Odonyphagia to solids and liquids
Chagas disease
1064
Odonyphagia just to solids
Oesophageal cancer
1065
What are 2 types of oesophageal spasm
Diffuse | Hypertensive
1066
What is name of hypertensive oesophageal spasm
Nutcracker oesophagus
1067
What causes diffuse oesophageal spasm
Often secondary to GORD and hiatus hernia
1068
How is oesophageal spasm diagnosed
Using barium swallow | Manometry or PPI trial useful especially if cause is GORD or Hiatus hernia
1069
Anorectal causes bleeding
Haemorrhoids Tumour Anal fissure Anal fistula
1070
Colonic causes of bleeding
``` Diverticular disease Angiodysplasia Ischaemic colitis UC Chess organisms Cancer Iatrogenic - anastamotic leak or endoscopy ```
1071
Ileo jejunal causes of bleeding
``` Crohns Peptic ulceration Coeliac Small bowel tumours AV malformation ```
1072
Upper GI causes of malaena
``` Peptic ulcer Gastritis Varices Tumour Mallory weiss tear ```
1073
First range of questions to ask in history of PR bleeding
Questions about hypovolaemia- light headed, SOB and fatigue | How much blood
1074
What unpathological source can make stool black
If on iron as malaena caused by oxidation of haem
1075
What does blood mixed in with stool say about source of blood
Source proximal to sigmoid
1076
What does blood streaked on stool suggest about source of blood
Anorectal or sigmoid
1077
What does passing just blood suggest about source of blood
Suggest blood was enough to create defaecation stimulus to dilate rectum- either angiodysplasia, diverticular disease, IBD or a fast growing cancer
1078
If blood occurs after passing stool what does this suggest about source
Haemorrhoids
1079
If blood is only seen on toilet paper what does this suggest about source
Haemorrhoids or anal fissure
1080
What is main cause of pain on defaecation leading to bleeding
Anal fissure
1081
What presents with bleeding and abdo cramping
Any colitis
1082
What does prolapse with PR bleeding suggest
Haemorrhoids | Prolapse
1083
Which cancer leads to pain rectal or anal
Anal
1084
Why is UC history relevant in PR bleeding
Likelihood of development to adenocarcinoma
1085
Important drugs relevance in PR bleeding
Warfarin etc Aspirin, bisphosophonates, steroids, NSAIDS peptic ulcers Antibiotics and PPIs leading to C.diff Beta blockers may mask signs of shock from hypovolaemia
1086
What is relvant in PMH of PR bleeding
Liver disease UC Haemophilia
1087
Important surgical history of PR bleeding
Aortic surgery | Endoscopy
1088
Significance of examination PR bleeding
``` Cachexia Virchows node Palpable masses Hepatomegaly Ascites Pallor Koilonychia Pulse and BP ```
1089
Rectal examination significance PR bleeding
Inspect for fissures, haemorrhoids and fistulas Masses Cant feel haemorrhoids unless prolapsed or thrombosed
1090
What to look for in bloods of PR bleeding
FBC- anaemic, low platelets, WCC indicating cause Clotting- bleeding tendancy Group and save- blood replacement or if goes to theatre Urea- indicative of upper GI bleed if elevated
1091
Why is urea elevated if upper GI bleed
Urea a breakdown product of haemolysed RBCs
1092
What should be bedside investigation for lower GI bleed
Proctoscopy for diverticular disease or rectal cancer could be seen
1093
Which drgs increase the risk of diverticular disease bleeding
NSAIDS
1094
What is problem of colonsocopy in acute bleed
Bowel must be prepped
1095
If there is an acute massive bleed and colonoscopy needs to happen what can be done to prepare the bowel
Caecal catheter
1096
When is mesenteric angiography or CT angio done for PR bleeding
If colonoscopy doesnt find source of blood and the bleeding continues
1097
What is last investigation used for GI bleed
Technetium-99 labelled red blood cell scintigraphy
1098
Lifestyle modification for haemorrhoids
Increase water intake Avoid straining on the loo Increase dietary fibre
1099
Medical management of haemorrhoids
Local anaesthetic creams for soreness and itching Steroidal creams Laxative therapy when needed for constipation
1100
Surgical mangement of haemorrhoids
Rubber band ligation | Injected sclerotherapy
1101
Important bloods to order for suspected carcinoma
``` FBC Haematinics CEA LFTS-mets Ca- mets Other cancer markers ```
1102
What is done with diverticular disease if keeps bleeding on presentation
Straight to surgery
1103
If fail to respond to medical treatments of anal fissures what do you do
Lateral internal sphincterectomy
1104
What is defined as a lower GI bleed
Anything below the ligament of treitz at the duodenojejunal junction
1105
What could cause painful haemorrhoid
Thrombosed external haemorrhoid Anal fissure Perianal abscess
1106
Familial conditions leading to colorectal cancer
Familial adenomatous polyposis | Hereditary non polyposis colorectal cancer
1107
Risk factors for colorectal cancer
``` Increasing age Male sex Central obesity IBD Polyps Colorectal radiation FAP HNPCC Sedentary lifestyle ```
1108
Why do a CT in small bowel obstruction
Determine point of tightness How many obstructed points Extent of the dilation Viability of the bowel
1109
What is massive area of gas in upper abdomen
Stomach distension from pyloric obstruction
1110
Management of excessive vomiting
NG tube and antiemetics
1111
What is triad of allgrove syndrome
Achalasia Alacrima Adrenal insufficiency
1112
How can achalasia appear on OGD
Saliva obstructing the mucosa from chronic obstruction
1113
How can achalasia appear on barium swallow
Poor peristalsis | Bird beak appearance
1114
How does achalasia appear on manometry
Poor relaxation of LOS | Poor peristalsis
1115
What does FIT stand for
Faecal immunochemical teseting

Year 3 Conditions (33 decks)

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