Gastro Flashcards
Aetiology of gastroenteritis
Bacterial or viral infection of intestines. Bacteria include Ecoli, campylobacter and salmonella. Viral includes norovirus and rotaviruses
Risk factors for gastroenteritis
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
Define gastroenteritis
Inflammation of small intestine and stomach
Define infective colitis
Inflammation of colon
Epidemiology of gastroenteritis
Worldwide massive fatality problem but in UK just uncomfortable and 20% of people will have it in a year.
Problem for children too
Presenting symptoms of gastroenteritis and infective colitis
Diarrorhoea
Vomiting and nausea
Loss of appetite
Abdominal pain
Gastroenteritis and infective colitis on examination
Tender pain across abdomen on palpation
Appropriate investigations for gastroenteritis and infective colitis
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
Management ideas for gastroenteritis and infective colitis
Treat dehydration with fluid and possible fluid resucitation
Replace electrolytes
How to classify jaundice
Pre hepatic
Hepatic
Post hepatic
First thing need to do when find out someone has high bilirubin
Work out if uncon or con
Investigation for differentiating whether bilirubin uncon or con
Van den bergh
What elevated enzyme indicate post hepatic jaundice
Alkaline phosphate
What investigation would you do in healthy person with elevated bilirubin
Fasting bilirubin
Presentation of Gilberts syndrome
Very healthy but jaundiced upon stress
What is inheritance of gilberts
Recessive
Which tests are best representative of liver function
Livers make clotting factors (PT) and albumin. Bilirubin is used as well
Whst liver function test gets elevated acutely
PT
How long does it take for albumin to dop off
Ages
Rule of thumb based on what to do with patient with liver disease acutely
If PT rises by a second every bloods then call liver unit however if not they are fine to stay where are
Pre hepatic causes of jaundice
Gilberts
Haemolysis
Post hepatic causes of jaundice
Gallstones
Pancreatic cancer
Which enzymes are particularly elevated in heaptic jaundice
AST
ALT
All suggest hepatocyte damage
What would exclude post hepatic as a cause of jaundice in blood
Marginal ALP
What are 3 causes of hepatits
Viral
Autoimmune
Alcoholic
How long after Hep A consumption do you start seeing it in faeces
2-5 weeks
How long after Hep A infection do you get Jaundice
4 weeks
What are 2 fates of Hep A infection
Cure or death cery common in poverished nations
How is Hep A spread
Faeco oral
If you get Hep A can you get it again
No- after 12 weeks IgG very high
How is Hep B transmitted
IV- transfusions or sharing needles
How to tell if someone has had Hep B infection
Anti- HBe antibodies as wel as Anti- HBs
How to tell if someone has had Hep B vaccine
Anti-HBs antibodies only as these are all that is given in vaccine
Histologically what does fatty liver look like
Areas of white
How to tell if hepatocytes damaged histologically
Mallorys hyaline
Defining alcoholic hepatitis histological features
Liver cell damage Fibrosis Inflammation Megamitochondria Fatty liver
DDx for alcoholic hepatitis histologically
NASH- non-alocholic steato-hepatitis
What can cause NASH
Insulin resistance/ high BMI
What is treatment for alcoholic hepatitis
Stop alcohol
Nutrition
Thiamine
Occasionally steroids
What is caused by thiamine deficiency
Beri beri
Signs of chronic stable liver disease O/E
Spider naevi
Palmar erythema
Gynaecomastia
Duputyrens contractures
What is caput medusa
Umbilical vein distended
What does caput medusa suggest
Portal hypertension
What will you find alongside caput medusa on examination
Splenomegaly as umbilical vein drains into splenic vein
3 signs of portal HTN
Splenomegaly
Caput medusa
Ascites
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
What causes a liver flap
Liver failure
What are problems of liver failure
Failed synthetic function
Failed clotting factor and albumin- bleeding and hypoalbuminaemia
Failed bilirubin clearance
Failed ammonia clearance- encephalopathy
Sign on examination of encephalopathy
liver flap
How does liver appear when cirrhosed
Fibrosis
Hepatocyte nodules
Shunting of blood
Whole liver involved- pale
Causes of cirrhosis
Fatty liver disease Viral hepatitis Haemochromatosis Wilsons disease Primary biliary cholangitis Primary sclerosing cholangitis
What is haemochromatosis
Iron overload
What is wilsons disease
Copper overload
4 sites of porto-systemic anastamoses
Oesophageal varices
Rectal varices
Umblical vein
Spleno-renal shunt
What do scratch marks suggest
Obstruction of bile ducts as bile salts go in to skin
What is special about primary hepatocellular carcinoma
Still make bile
Signs on examination of pancreatic cancer
Palpable gall bladder
Scratch marks
Jaundice
Pain on palpation
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
What endocrine condition can affect liver
Thyroid- in particular hyper which can present with jaundice and elevated transaminases
What would exclude thyroid issues from liver diagnosis
Would occur alongside other severe signs of thyrotoxicosis or alongside HF
Who must you consider AI hepatits in most commonly
young women
How to remove haemochromatosis from liver ddx
Wouldn’t present with extremely high LEs
Only occurs in elderly normally
Does non alcoholic fatty liver disease present with jaundice
Not normally
Anitbodies tested for in AIH
anitnuclear AB
Smooth muscle AB
Investigations for hepatitis
US
Viral serology
Protein and globulin elevated
Liver biopsy
What is used to diagnose AIH conclusively
Liver biopsy
Treatment for AIH
High dose steroids with subsequent Azathioprine- doses and use of azathioprine depends on severity
How long is treatment for AIH
At least 2 years after bloods normalise then would also want to do liver biopsy before discontinuing meds
What is LFT indicator of Primary biliary cirrhosis
Raised ALP as post hepatic
Typical presentation of PBC
Lethargy
Puritus
How are most PBC cases picked up
Incidental notice of elevated ALP
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
RFx for PBC
Female
Aged 54-60
Smoking
Autoimmune condition
Investigations for PBC
US Liver biopsy showing granulomas Serum lipids Blood clotting profile Serology hep Anti-nuclear and anti-mitochondrial ABs
Lipid profile in PBC
Elevated
What antibodies are normally positive in PBC
Anti-nuclear and anti-mitochondrial
When is liver biopsy contraindicated
Platelets under 100
INR over 1.3
Confused state
Extensive ascites
What is treatment PBC
Cholecystyramine
Ursodeoxycholic acid
Fat soluble vitmain prophylaxis
Liver transplant
What is given to alleviate puritus
Cholestyramine
Important thing to remember when taking cholestyramine
Must be taken at least 2 hours apart from ursodeoxycholic acid
Typical presentation of haemochromatosis
Arthralgia
Fatigue
Deranged liver function
Development of diabetes
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
Findings of blood results haemochromatosis
Serum ferritin up
Serum iron up
Total iron binding capacity down
Transferrin saturation
Pathophysiology of haemochromatosis
Genetic condition leading to dysregulation of iron absorption and macrophage release of iron
Complications of haemochromatosis
Increased skin deposition Diabetes- pancreatic failure and can be insulin resistance Cardiomyopathy Hepatic cirrhosis Hypogonadism Pituitary dysfunction Chondralcinosis and arthropathy
What are complications of haemochromatosis due to
Deposition of iron
RFx for haemochromatosis
White
Male
Middle aged
Fx
Main treatment for haemochromatosis
Regular venesection
Refer to diabetes
What is inheritance of haemochromatosis
Autosomal recessive
Sx of malignant hepatic liver disease
Tender hepatomegaly
Jaundice
Weight loss
How would liver abcess typically present
Septic
What is raised in most hepatocellular carcinomas
Alpha-fetoprotein
When is MRCP indicated
Biliary tree dilated
What is used as imaging for liver cancers
Abdo CT
Treatment for para-aortic node involvement liver cancer
Chemotherapy
Sex most likely to find hepatocellular carcinoma
Male
How often do people with cirrhosis get abdo CT for liver malignancy
6 months
When elderly person presents anaemic what is most likely cause
IDA
How does iron deficiency anaemia present
SOB
Fatigue
Abdo pain potentially pointing to cause
When anaemia without obvious cause what investigations are necessary
Gastroscopy and colonoscopy
Coeliacs disease serology
What are majority of duodenal ulcers caused by
H.pylori
NSAIDS
Non invasive ways to diagnose H pylori
Urea breath test
Stool for HP antigen
Invasive ways to diagnose H pylori
CLO test
What is involved in campylobacter like organism test
Biopsy
Difference in diagnosis between gastric and duodenal ulcers
Gastric more likely to do biopsy as only 70% chance its down to that
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
Presentation of peptic stricture
Progressice dysphagia from solids to liquids
Risk factor for peptic stricture
GORD
First line investigation for peptic stricture
OGD and biopsy
Treatment for benign peptic stricture
Balloon dilatation
Underlying GORD then PPI
Most common complication of balloon dilatation
Oesophageal perforation
How would oesophageal perforation present
Mediastinits so SOB and chest pain
Investigation for suspected oesophageal perforation
CT scan with oral contrast
Important blood markers of liver disease status
Plt function
Glucose
What can happen to glucose in liver disease
Hypo
Also marker of liver synthetic function
In major suspected variceal bleeds what prophylactic management would be given
Abx
Management of variceal bleed
Refer to endoscopy
Fluid resus with blood transfusion
Abx
IV vasopressin analogue
Immediate intervention for variceal bleed
Band ligatation
Long term management of variceal bleed
Non cardioselective beta blocker
What do you look for in hands abdo exam
Asterixis Bruising Clubbing Duptyrens contracture Erythema Leukonychia
What to look for in chest abdo exam
Gyanecomastia
Hair loss
Excoriation marks
Spider naevi
What does right subcostal scar indicate
Biliary surgery
What would a midline laparotomy incision
GI or major vascular surgery
4 causes of hepatomegaly
Cancer
Cirrhosis
Cardiac/vascular
Infiltration
Causes of liver diseases
Alcohol Autoimmune Drugs Viral Biliary disease
Causes of splenomegaly
Portal hypertension
Haematological
Infection
Inflammatory
Cardiac causes of hepatomegaly
Congestive heart failure
Constrictive pericarditis
Budd chiari
Differences in nature of abdo pain
Constant or colicky
What does constant abdo pain suggest
Inflammation
What does colicky pain suggest
Obstruction- this could be for
DDx for stomach and their RFx
Peptic ulcer- NSAIDS GORD- antacids Gastritis- retrosternal, ETOH Maligancy Ruptured AA
What to do with DDx for a certain region
Think whats above, below, right and left
Acute pancreatitis presentation
Epigastric pain
Blood of acute pancreatitis
High amylase
Chronic pancreatitis presentation
Pain
Weight loss
Loss of endocrine and exocrine function
Blood of chronic pancreatitis
Normal amylase
Differentials for RUQ pain
Gall bladder - cholecystisis - cholangitis - gallstones Liver - hepatits - abcess
How can appendicitis present with RUQ pain
When appendix is retrocaecal- very common in pregnant women
DDx of RIF pain
GI Appendicitis Mesenteric adenitis Colitis Malignancy Gynaecological Ovarian cyst, torsion Ectopic pregnancy
Causes of diffuse abdo pain
Obstruction Infection- peritonitis, gastroenteritis Inflammation- IBD Ischaemia- mesenteric ischaemia Medical causes- DKA, addisons, hypercalcaemia, porphyria, hypercalcaemia
What is elevated in any diffuse abdo case
Amylase
What is a risk factor for bowel obstruction
Recent abdo surgeries
What is responsible for dark urine and pale stool
Stercobilinogen
Acute GI bleed management
ABC IV access and fluid G and S X-match blood OGD
What vessels are affected in variceal bleed
Splanchnic
Investigation for acute abdomen
FBC U and Es LFTs CRP Clotting G and S
What to look for general inspection abdo
Pallor and jaundice
What does leukonychia look like
White line on nails very advanced
What does leukonychia indicate
Hypoalbuminaemia
When do you get gum hpertrophy
On ciclosporine after renal transplant
How to determine if spider naevi is actually spider naevi
Press on it and it will fill from the middle
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
What does a mercedes benz scar indicate
Liver transplant
What does a small scar at mcburneys point indicate
Apendectomy
What would a hockey stick scar from iliac to hypogastric region indicate
Renal translpant
What would scar in suprapubic region indicate
Gynaecological surgery
What would diagonal more horizontal scar indicate
Nephrectomy
What would inguinal scar indicate
Hernia surgery
Important thing to remember when palpating kidney
Not lateral have to feel medially
Infiltrative causes of hepatomegaly
Fatty infiltration (obese), hemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative disease
Haematological causes of splenomegaly
Lymphoma
Leukaemias
Haemolytic anaemia
Inflammatory causes of splenomegaly
Sarcoid
Infective causes of splenomegaly
Malaria
RB
IE
EBV
DDx need to know for gastro
Abdominal pain
- Abdominal distension
- Change of bowel habit
o Infection
o Inflammation
o Malignancy
- GI bleed
- Jaundice
- Ascites
5 fs for cause of abdo distension
Fat Fluid Foetus Flatus Faeces
If upper GI bleed how does stool appear
Malaena
If lower GI bleed how does stool appear
Bright red
3 categories for cause of change in bowel habits
Infection
Inflammation
Cancer
How does pain for ruptured AAA present
Epigastric radiating to back
What to ask about for acute pancreatitis
Hx of gallstone
Test for chronic pancreatitis
Stool elastase- low
DDx of suprapubic pain
Cystitis
Urinary retention
DDx of LIF pain
GI - Diverticulitis - colitis -maligancy Gynaecological - ovarian cyst rupture, twist,bleed - ectopic pregnancy
Why do you get hyperpigmentation under bra strap
Addisons- increased pressure there leads to pigmentation
How does mesenteric ischaemia present
Pain on eating
Central pain
Difference between ischaemic colitis and mesenteric ischaemia
Mesenteric ischaemia is from blockage of large arteries and ischaemic colitis from blockage of small vessels
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
What is spontaneous bacterial peritonitis
Translocation of bacteria into ascites
Signs of decompensated liver cirrhosis
Liver asterixis Encephalopathy Ascotes Bleeding coagulopathy Increased INR Reduced albumin Jaundice
What must give straight away if liver patient presents with confusion
Ciprofloxacin to reverse encephalopathy
Signs on examination of ascites
Shifting dullness
Peripheral liver signs such as A-E in hands
Presentation of obstructed bowel
Colicky pain
Nausea and vomiting
Constipation
Bowel sounds on examination of obstruction
High pitched tinkles
Risk factor for bowel obstruction
Recent surgery
What to check for in examination if suspect bowel obstruction
Irreducible femoral hernia
Causes of SBO
Adhesions from surgery
Hernias
Causes of LBO
Cancer
Diverticular structure
Volvulus
What are classifications of ascites
Exudate and transudate
Causes of transudate ascites
HF
Cirrhosis
Nephrotic syndrome
Causes of transudate ascites
HF
Cirrhosis
Causes of exudate ascites
Malignancy
Infection
Vascular
Nephrotic syndrome
Infective causes of exudate ascites
TB
Pyogenic
Vascular causes of transudate ascites
Budd chiari syndrome
Portal vein thrombosis
What is Budd chiari syndrome
Occlusion of hepatic vein
Triad of Sx Budd chiari syndrome
Hepatomegaly
Ascites
Abdo pain
Calculation for whether ascites is exudate or transudate
SAAG
What is SAAG
Serum albumin to ascites gradient
What is SAAG calculation
Serum albumin- ascites albumin
What does SAAG of over 11g/L suggest
Transudate
What does SAAG of over 11g/L suggest
Transudate
Where is unconjugated bilirubin converted to conjugated bilirubin
The liver
What would pale appearance in jaundice suggest
Haemolytic anaemia
Which types of jaundice cause pale stool
Post hepatic
Which types of jaundice cause dark urine
Hepatic and post hepatic
What gives stool its brown appearance
Stercobilin
How does hepatic jaundice cause dark urine
Hepatocytes damaged so conjugated bilirubin leaks into blood
What is name of thrombophlebitis associated with malignancy
Trousseaus sign
Common malignancy associated with trousseasus sign
Pancreatic
What is thrombophlebitis
Clots forming in legs of veins
What is marker of pancreatic cancer
CA19 9
Categories for bloody diarrorhoea causes
Infective
Inflammatory
Ischaemic
Malignancy
Ischaemic cause of bloody diarrorhoea
Ischaemic colitis
Bacteria that cause inefctive colitis
Campylobacter Haemorrhagic E Coli Entamoeba histolytica Salmonella Shigella
In which patients do you see ischaemic colitis
Elderly
In which patients do you see inflammatory colitis
Young and with Extra- Gi manifestations
In alcoholic hepatits what transaminase is higher
AST
Extra GI complications of inflammatory colitis
Uveitis
Arthritis
Erythema nodosum
Questions to ask about in hepatitis history
Transfusions
Sexuality
Medications
In what condition do you get nocturnal diarrorhoea
IBS
What is x ray sign of IBD
Thumb printing
Thick haustral fold
What is a featureless bowel a sign of
UC
What investigation do you have to do in acute IBD exacerbation
Abdo x ray
What is potential risk of IBD exacerbation
Toxic megacolon which could rupture
How does toxic megacolon look in x ray
Dilation of bowels more than 6cm
How will a toxic megacolon patient present
Fever
Hypotension
Tachycardic
Systemically very unwell
How does faecal loading appear on x ray
Bowels full of opacity indicative of spurious diarrorhoea
Management of acute abdo
NBM IV access Fluids Analgesia Anti emetics Abx Monitor vitals FBC CXR CT
Abx given for acute abdo
Cephalosporin for gram pos and neg
Metronidazole for anaerobes
Management of acute GI bleed
ABC IV access Fluids G and S, X match blood OGD
What is given for variceal bleed
Abx- Tazocin
Terlipressin
Investigations jaundice
FBC, LFTs, CRP
Abdo USS fasting
Investigations dysphagia
OGD, biopsy
Investigations PR bleed
Colonoscopy, Wt loss
Management of Ascites
Ascitic tap- micro, biochemistry, cytology
Diuretics- spironolactone, furosemide
Sodium restriction
Monitor weight
Therapeutic paracentesis alongside IV albumin
Management of encephalopathy
Lactulose
Phosphate enemas
Treat infection
Exclude a bleed
What must be avoided when treating encephalopathy
Sedation
Why must you exclude a bleed in encephalopathy
Blood would provide bacteria with large source of protein to feast on and produce more ammonia
Features of post op care wound infection
Erythematous
Discharge
What would be features of an anastomotic leak post surgery
Diffuse tenderness
Guarding and rigidity
Hyoptensive/tachycardic
In post op care what could be Sx of a pelvic abcess
Sweating
Fever
Pain
Mucus diarrorhoea
When are post op pelvic abcesses common
Appendectomy
Presentation of perianal fissure
Tender anus with red swelling
Tx for perianal fissure
Incision and drainage
Presentation of anal fissure
Rectal pain
Stool coated in blood
Tx anal fissure
Diet advice for more fluids and fibre
GTN cream
How does IBS present
Recurrent abdo pain and bloating
Alternating constipation and diarrorhoea
Improves with defecation
Change in frequency and form
What must you ask about to exclude other DDx for IBS
Nocturnal diarrorhoea Anaemia PR bleeding Wt loss Exclude coeliac
Treatment for IBS
Diet and lifestyle changes
Laxatives
Anti-diarrorhoeals
Anti-spasmodics
What drugs can be given for abdo pain
Anti-spasmodics
What is dyspepsia
Indigestion
What do you request with microcytic anaemia of gastro cause
Haemitinics
Coeliac screen
Top and tail depending on Sx
Red flags in abdo history to ask about
Weight loss
Change in bowel habits
Fatigue
4 complications of portal HTN
Ascites
SBP
Encephalopathy
Variceal bleed
What are name of circular folds that go all the way around bowel
Valvulae conniventes
Small bowel folds
Valvulae conniventes
Signs in blood of alcohol abuse
GGT
Macrocytosis
What must never discount in patients
Alcohol withdrawal
Signs on examination of alchol abuse
Brusing
Signs of alcohol withdrawal
Anxiety and restlessness Tremor Sweating Headache Nausea Tachycardia and palpitations
Severe Sx of alcohol withdrawal
Hallucinations
Seizures
Delirium
Types of hallucinations in alcohol withdrawal
Tactile
Visual
Managment of alcohol withdrawal
IV thiamine supplements
Oral benzodiazepine
What can precipitate wernickes encephalopathy
Glucose infusion
Why is IV pabrinex given slowly
Reduce risk of anaphylaxis
What is pabrinex
Vitamin B and C supplements
What is wernickes encephalopathy
Acute neurological condition caused by thiamine deficiency
Triad of wernickes encephalopathy
Confusion
Ataxia
Oculomotor dysfunction- nystagmus, conjugate gaze dysfunction,
What is progression of wernickes encephalopathy
Korsakoffs psychosis
Investigations for autoimmune hepatitis
Serum Ig
Smooth muscle and ANA Abs
Liver biopsy
Proportions of where pancreatic cancers arise
60% head
25% body
15% tail
First scan for pancreatic cancer needed
Abdo CT for diagnosis and also staging
Chronic pancreatitis presentation
Epigastric pain “boring through to back”
Diarrorhoea- statorrhoea
Diabetes diagnosis
Abdo x ray finding chronic pancreatitis
Calcification in pancreatic region- pathognomic
Further imaging for chronic pancreatitis
CT
MRCP
Not ERCP as invasive and complication risk
Complications of pancreatitis
Diabetes Malabsorption Pancreatic insufficiency Carcinoma Opiate addiction Pseudocyst formation
How does coeliac disease typically present
Weight loss Diarrorhoea Cramping Iron deficiency anaemia Malaise Osteoporosis
Can UC and crohns cause weight loss
UC no
Crohns yes
Differentiating between crohns and coeliac on blood
Folate deficiency in coeliac
How to diagnose coeliac
TTG serology IgA
Alpha gliadin ab
Anti endomysial ab
Duodenal biopsy needed to confirm
What is treatment for coeliac
Gluten free diet
How to tell if coeliac is being controlled well
Redo TTG AB
What will happen if you touch a spider naevi
Will blanch and go pale
Where is distribution of spider naevi
Can only be found in distribution of SVC
What does having spider naevi suggest
Stable chronic liver disease
What do campbell de morgan spots suggest
Pathology unknown
Who do you see campbell de morgan spots in
A lot of people over 40 and is unpathological
On average which enzyme does Hep C tend to elevate more
ALT
What is a perianal fissure
A tear in the rectum or anus
How does perianal fissure present
Pain on defaecation
Red and tender swelling around anus
Stools of inflammatory colitis
Mucous
Blood
What is rovsings sign
Press on left iliac fossa and will hurt- suggestive of appendicitis
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
What is biliary colic
Gallstone in biliary tree
Signs on examination of biliary colic
Tender RUQ and epigastrium
Investigations for biliary colic
Urine dip
CXR
Amylase/LFTs/Clotting
USS
Findings of investigations for biliary colic
Normal bloods
USS show thin GB walls with stone
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
Sepsis 6
Give fluids Oxygen Abx Urine output Blood cultures Lactate
Diagnosis criteria for acute pancreatitis
Amylase 3x higher than normal
Clinical history consistent
CT to exclude other DDx
Aetiology of pancreatitis
Gallstones Ethanol Trauma Steroids Mumps, cocksackie, COVID Autoimmune Scorpion Hyperlipidaemia ERCP Drug
Commonest causes of acute pancreatitis UK
Gallstones
Ethanol
Idiopathic
Scoring for acute pancreatitis pnemonic
Pancreas
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
Separate poor prognostic markers of acute pancreatitis
Obesity
CRP over 150
Complications of gallstones categories
Within gall bladder
Within biliary tree
Outside biliary tree
Complications of gallstones in gall bladder
Bilairy colic
Acute cholecystisis
Empyema
Complications of gallstones in bilairy tree
Obstructive jaundice
Ascending cholangitis
Complications of gallstones outside of biliary tree
Pancreatitis
Gallstone ileus
What is guarding
When palpating the patients organs they tense their muscles to protect organs
Standard investigations must do every time in gastro
ECXR
Routine bloods
Urine dip
Pregnancy test women
How do you get shoulder tip pain after abdo surgery
Pressure in abdo can irritate diaphragm and phrenic nerves so get refferred pain
Common lung complication of surgery
Atelectasis
Bilairy colic risk factors
4 Fs Female Fat Forty Fair- pregnancy
Sx of biliary colic
Dull pain RUQ or epigastrium
Can radiate to right shoulder
Nausea and vomiting
Sweating
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
Complication of biliary colic
Acute cholecystisis if remains in the cystic duct for a while
Sx of acute cholecystisis
RUQ pain Nausea Vomiting Sweating Fever
What is acute cholecystisis
Gall bladder inflammation of rapid onset
Sx of acute cholecystisis
Epigastric pain that can radiate to RUQ and become dull. Here can also radiate to shoulder
Nausea and vomiting
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
What bacteria can be involved in cholecystisis
E coli
Clostridium
Enterococci
Bacteroides fragilis
How can cholecystisis lead to peritonitis
Bacteria invade through wall of GB to peritoneum causing inflammation
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
Positive murphys sign
Acute cholecystisis
Complication of acute cholecystisis
Peritonitis
Gangrenous cell death
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
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
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
What is sonographic murphys sign
When do ultrasound and press on gall bladder get pain and so murphys sign
US findings in cholecystisis
Stones
GB wall thickening
Sludge
GB distension
Further imaging of acute cholecystitis
HIDA scan
ERCP
MRCP
What is a HIDA scan
cholescintigraphy
Treatment for cholecystitis
IV fluids
Pain managment
Abx
Cholecystectomy
Cholecystitis Rfx
Gall stones Low fibre Parenteral feeding Diabetes Immobility
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
What normally obstructs common bile duct in ascending cholangitis
Chiledocholithiasis
Cancer nearby
Laporoscopic tear
Bacteria that normally colonise in ascending cholangitis
E coli
Klebsellia
Entercoccus
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
Ascending cholangitis Sx
RUQ pain
Fever
Jaundice
Can be septic shock
What is charcots triad
Triad of symptoms seen in ascending cholangitis
Fever
RUQ pain
Jaundice
What is reynolds pentad
5 Sx characterising spetic cholangitis
Charcots triad
Confusion
Low BP/tachycardia
Investigations for cholangitis
Bloods for signs of jaundice, shock and infection
ERCP
Treatment for ascending cholangitis
Manage symptoms with rehydration and Abx
Remove obstruction ERCP and shockwave lithotripsy
Can add stent
Cholecystectomy
What is primary scleorsing cholangitis
Fibrosing of intra hepatic and extra hepatic bile ducts
How do PSC bile ducts appear
Beaded where are areas of dilation and constriction
How does PSC appear histologically
Rings of fibrosis around ducts called onion ring fibrosis
What is PSC associated with
UC
Crohns
What is beleived to be aetiology of PSC
T cell autoimmune where is genetic and environmental factors at play
Genetic associations of PSC
HLA-B8
HLA-DR3
HLA-DRw52a
Serum findings of PSC
Raised IgM
Increased p-ANCA Abs
ALP and GGT raised
Conjugated bilirubin raised
Urine findings of PSC
Raised bilirubin
Reduced urobilinogen
How does PSC lead to portal HTN
Thickened fibrosis can obstruct portal veins
Signs on examination of PSC
Dark urine
Hepato-splenomegaly
Jaundice
Typical presentation of PSC
40-50 year old man with IBD Pruritus Jaundice RUQ pain Weight loss Fever
Investigation for PSC
LFTs Serum IgM and pANCA USS Biopsy ERCP and MRCP
Complications of PSC
Cirrhosis
Cholangiocarcinoma
Treatment of PSC
Advanced immunosuppressant dont reallu work
Liver transplant
What must always think about with IBD in liver symptoms
PSC
How can causes of dysphagia be classified
Obstructive
Oesophageal immobility
Other
Obstructive causes of dysphagia
Oesophageal carcinoma Peptic stricture Oesophageal web/ring Gastric carcinoma Pharyngeal carcinoma Extrinsic pressure
Oesophageal mobility disorders
Achalasia Systemic sclerosis Stroke MG MND
Other causes of dysphagia
Oesophagitis
Pharyngeal pouch
Oesophageal candidiasis
What can be an extrinsic pressure on oesophagus causing dysphagia
Lung cancer
Retrosternal goitre
What is achalasia
Condition affecting lower oesophageal sphincter where it doesnt open- aetiology unknown
What are oesophageal webs
Protrusions of mucosa into oesophagus that looks like webs
What are more common, duodenal or gastric ulcers
Duodenal 4x more likely
What is characteristic of duodenal ulcer pain
Eased after eating meals or drinking milk
Worse in morning
What is characteristic of gastric ulcers
Worse after eating
Can you get weight loss with gastric or duodenal ulcers
Both but more likely in gastric ulcers
What is retrosternal pain
Pain behind sternum
Sx of GORD
Dry cough
Retrosternal pain worse on lying flat or after meals
When is GORD eased
Antacids- hours after eating
When is gastritis worse
On eating
What does worse epigastric pain in morning suggest
Duodenal ulcer
What does epigastric pain eased on eating or drinking milk suggest
Duodenal ulcer
What does pain worse on eating meals indicate
Gastric ulcers
Gastritis
Pancreatitis
GORD
What is the treatment for an ulcer caused by H pylori
PPI such as omeprazole and 2 antibiotics normally amoxicillin and clarithomycin
What Abx are given to ulcer patients who are allergic to pencillin
Clarithomycin and metronidazole
Most common cause of duodenal ulcers
H pylori
What is a hiatus hernia
When part of your stomach moves through diaphragm into chest area
Best way to diagnose a hiatus hernia
Barium meal
Patient presents with history of heartburn on eating but isnt eased by antacids
Hiatus hernia
How can hiatus hernia present
heartburn on eating but isnt eased by antacids
What can heartburn be on eating
GORD
Hiatus hernia
What is change seen in barretts oesophagus
Lower third of oesophagus metaplasia squamous to columnar epithelium
What is metaplasia in barretts oesophagus described as
Pre-melignant as very high chance of adenocarcinoma
When do Sx of gastroenteritis tend to present
A few hours after eating meal
What is management of gastroenteritis mostof the time
Usually self limiting so would discharge with hydration advice and anti emettics
When would you admit patient with gastroenteritis
In severe dehydration where confusion and hypotension would give fluids
When do you normally only give Abx in gastroenteritis
When bacteria has been isolated
Most appropriate investigation for person with unexplained diarrorhoea
Stool culture
Patient comes in with gastroenteritis sx what do you do
FBC, LFTs, clotting and U and Es
Stool cultures
Maybe CXR and abdo film
What bacteria cause bloody diarrorhoea
Campylobacter
Salmonella
Ecoli
Shigella
Aetiology of budd chiari
Obstruction of hepatic vein outflow
50% unknown
Of known 75% hepatic vein thrombous
25%compresssion on vein
Most sensitive test for gallstones
US
MRI and CT all less sensitive only pick up 10% on CT
ERCP too invasive
What drugs can cause cholestasis
Penicillins Erythomycin Chlorpromazine Oestrogens Clavulanic acid
Gastro conditions causing clubbing
IBD Cirrhosis PBC Coeliacs Achalasia
What presents with malaena, haematemesis and epigstric pain
Upper GI bleed
Causes of duodenal ulcers
H pylori
NSAIDs
Alcohol
Chronic corticosteroid abuse
What are types of laxatives
Osmotic
Stimulant
How do osmotic laxatives work
Retain fluid within the bowel
Examples of osmotic laxatives
Lactulose
Magnesium salts
What are used when rapid bowel excavation needed
Phosphate enemas
Sodium or magnesium salts
Examples of stimulant laxatives
Senna
Docusate sodium
All with bisacodyl
What laxatives are contraindicated in bowel obstruction
Stimulant
When shouldnt you use stimulant laxatives
Bowel obstruction
Long term use
Problem of stimulant laxative use long term
Hypokalaemia
Atonic colon
Types of stimulant laxatives
Rectal
Bulking agents
Example of rectal stimulant
Glycerin suppositories
When are bulking agent laxatives contraindicated
Dysphagia
Faecal impaction
Bowel obstruction
Causes of upper GI bleeds
Peptic ulcers Mallory weiss tears Oesophagitis Gastric erosions Varices Drugs Upper GI malignancy
Drugs that can cause upper GI bleeds
NSAIDS
Anticoagulants
Steroids
Causes of portal hypertension categories
Pre hepatic
Hepatic
Post-hepatic
Pre-hepatic causes of portal HTN
Portal vein thrombosis
Splenic vein thrombosis
Hepatic causes of portal HTN
Cirrhosis
Shitosomiasis
Myeloproliferative disease
Post hepatic causes of portal HTN
RHF
Constrictive pericarditis
Budd chiari
Drugs that can cause cirrhosis
Methotrexate
Amiodarone
Methyldopa
Genetic causes of cirrhosis
Haemochromatosis
Wilsons disease
How is cirrhosis often picked up
Just on examination seeing signs of liver disease
What does koilonychia suggest
IDA
Complications of cirrhosis
Portal HTN Encephalopathy Hypoglycaemia Hypoalbuminaemia Coagulopathy Risk of carcinoma
What is given for pruritus
Colestyramine
What is treatment for HCV induced cirrhosis
Interferon Alpha
What is PBC
Granulomatous condition leading to inflammation and damage of interlobar ducts
What does PBC lead to
Cirrhosis
Portal HTN
Cholestasis
What would present with jaundice, xanthomata, xanthelasma, skin pigmentation and hepato-splenomegaly
PBC
Inheritance of wilsons
Autosomal recessive
Pathophysiology of wilsons
Disorder of chromosome 13 leading to mutation in copper ATP ase resulting in copper accumulation in liver and CNS
What are kayser fischer rings pathognomic for
Wilsons disease
What are kayser fischer rings
Copper deposits found in eye
Investigations for wilsons disease
Liver biopsy
Blood
Urine copper- high
Genetic testing
What presents with low plasma copper and caeruloplasmin
Wilsons
What is mutation in haemochromatosis
HFE
What condition presents with slate grey skin in late progression
Haemochromatosis
What leads to bronze diabetes
Haemochromatosis from iron deposits in pancreas
What presents with positive ANA, SMA and ANCA Abs
PSC
What are ANCA Abs
Anti neutrophil cytoplasmic antibodies
What presents with jaundice, pruritus, tiredness and abdo pain
PSC
Categories of causes of acites
Venous HTN Hypoalbuminaemia Malgnant disease Infections Others (pseudocyst, Meigs-only women)
Portal HTN causes of ascites
HF Cirrhosis Budd chiari Portal vein thrombosis Constrictive pericarditis
Causes of hypoalbuminaemia
Nephrotic syndrome
Diet
Infections leading to ascites
TB
Other causes of ascites
Myxoedema
Ovarian disease
Pancreatic disease
Inheritance of antitrypsin deficiency
Autosomal recessive
What can cause emphysema, chronic liver disease, wegners granulomatosis, gallstones and pancreatits,
Anti trypsin
Investigations of antitrypsin
Serum antitrypsin
DNA analysis
Genetic phenotyping
