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
Management of antitrypsin
Quit smoking
Augementation of plasma antitrypsin
Liver transplant if decompensated liver diseae
What presents with SOB and jaundice
Antitrypsin
Antibodies raised in AIH
ANA
SMA
SLA- soluble liver antigen
Anti liver/kidney microsomal ytpe ABs
What typically presents in younger women with jaundice, RUQ pain, polyarthralgia, glomerulonephritis and pernicious anaemia
AIH
Investigations and findings of AIH
FBC- low WCC and plts
Serology - viral neg
MRCP to rule out PSC
Liver biopsy- mononuclear infiltration
What is a cholangiocarcinoma
Cancer of bilary tree
What presents with fever, abdo pain and jaundice
Cholangiocarcinoma
Causes of cholangiocarcinoma
PSC
Biliary cysts
N-nitroso toxins
Investigations for cholangiocarcinoma
Bilirubin up
LFTs- ALP up
USS
ERCP biopsy
Causes of hepatocellular carcinoma
Viral Cirrhosis Haemochromatosis PBC Alcohol cirrhosis
Most common liver benign primary tumour
Haemangioma
6 malignant liver tumours
Hepatocellular carcinoma Cholangiocarcinoma Fibrosarcoma Leiyomyoscarcoma Hepatoblastoma Angiosarcoma CHHALF
What tumour is alpha fetoprotein also elevated in
Testicular
RFx of pancreatic cancer
High fat diet Smoking Alcohol abuse DM Chronic pancreatitis
What presents on examination with hapeatoslplenomegaly, palpable gall bladder and epigastric mass
Pacreatic cancer
Extra pancreatic signs of cancer there
Thrombophlebitis migrans
Hypercalcaemia
What presents with steatoorhoea, diarrorhoea, cramping, bloating, weight loss and nausea
Coeliac
How does UC appear histologically
Inflammatory infilitrates
Goblet cell depletion
Mucosal ulcers
Crypt abcesses
How does crohns appear histologically
Transmural non caseating granulomatous inflammation
Fissuring ulcers
Lymphoid aggregates
Neutrophil infiltrates
What is histology of IBS
Normal
What is truelove and witts criteria
Assesses severity of UC flare ups
What is used to assess UC severity
Truelove and Witts criteria
Mild
Moderate
Severe
Severe category of true love and witts
Bowel movements greater than 6/day with lots of blood
Moderate category of truelove and witts
Open bowels between 4-6 times
Moderate amounts of bloods
Mild category of truelove and witts
Open bowels less than 4 times a day with little or no blood
When do you see cobblestoning and rose thorn ulcers
Crohns- barium follow through
Moderate UC managment
Prednisolone 40mg
BD Mesalazine
Hydrocortisone topical foams
Mild UC tx
Tapering steroid dose
One mesalazine a day
If distal steroid foams
Severe UC Tx
Admitted for IV Hydrocortisone
Fluids
Rectal steroids
Difference in smoking effects UC and Crohns
UC- protective
Crohns- worse
Where are calcium and iron absorbed
Duodenum
Where is vitamin C absorbed
Proximal ileum
3 categories of abdo pain
Acute or chronic
Surgical or medical
Localised or general
What presents with epigastric that moves to RIF, anorexia and vomiting
Appendicitis
Why do urine dip appendicitis
WCC and blood in urine as appendix inflam can lead to bladder inflam
What presents with dysuria for a few days and then flank pain
UTI to Pyelonephritis
Where does pyelonephritis pain radiate
The back
In what age category does diverticulitis tend to present
over 60s
What does pain radiating to back suggest in abdo suggest (more than 1)
Pancreatitis
AAA
Pyelonephritis
What must rule out in really severe abdo pain
Ischaemic
What does pain relieved by defacating imply
IBS
What presents with pain after eating
Biliary colic
Peptic ulcer
Pancreatitis
What is cholelithiasis
Solid gall stones present in GB
What is choledocholithiasis
Solid gall stones in bile ducts
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
What is CXR useful for in abdo
Perforation
Pneumonia
What is AXR used for in gastro
Hernia
Biliary colic
Cholecystisis
What is CT abdo with contrast useful for
Perforation
Cancer
Appendicitis
Cholecystitis
What is diverticulitis
Inflammation of outpouchings of bowel lumen
What group of ppl does diverticulitis often present on right side in
Asian
RFx for diverticular disease
Low fibre diet
Western diet
Elderly
Obesity
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
How is diverticulitis classified
Hincheys classification
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
Blood finding of diverticulitis
Leukocytosis
What presents with guarding and tenderness in left lower quadrant, LIF pain, fever and constipation
Diverticulitis
How does diverticulitis present
guarding and tenderness in left lower quadrant, LIF pain, fever and constipation/diarrorhoea with blood
Abdo distension
Investigations for diverticulitis
Routine bloods
Blood culture
Sepsis 3
CTAP
Conservative management of diverticulitis
Co-amox
Probiotics
IV fluids
Surgical management of diverticulitis
Wash it out with drain
Colectomy with potential stoma or anastomosis
Lifestyle management of diverticulitis
Avoid high fibre in acute phase but after that high fibre
Most common bacteria pyelonephritis
E coli
Presentation of pyelonephritis
UTI sx Fever Rigors Constant loin pain radiating to back Myalgia
How does pyelonephritis pt appear
Restless
Severe pain
Investigations for pyelonepritis
Bloods Cultures Urine dip VBG US kidney
RFx for pyelonephritis
DM UTI Sex Stresss incontinence FB in urinary tract like catheter
Management of pyelonephritis
Sepsis 6 Morphine IV fluids Abx of gentamycin Cn be nephrostomy
Presentation of appendicitis
Central pain that goes to RIF
Vomiting
Diarrorhoea
Anorexia
3 appendicits signs
Rovsings
Psoas
Mcburneys
Rovsings sign
palpate LIF and RIF hurts
Mcburneys sign
Palpation at mcburneys sign equals pain
Investigations for appendicitis
Bloods routine
Blood cultures
US abdo
CTAP
Management of appendicitis
Abx and appendectomy
Complications of pancreatitis
Peripancreatic fluid collections Pseudocyst Necrosis Pancreatic abcess Haemorrhage
Investigations for pancreatitis
Bloods routine Lipase and amylase Erect CXR CTAP contrast Toxicology VBG US
Mx pancreatitis
Fluids lots Morphine Creon If gallstones ERCP Alcohol pabrinex Abx maybe
What is creon
Pancreatic enzyme replacement
Causes of appendicitis
Anything that blocks appendix opening leading to division of bacteria inside- faecolith, normal stool and lymphoid hyperplasia
What is faecolith
Hard mass of faeces
What is lymphoid hyperplasia
Increase in number of immune cells at lymph nodes in response to infections
Most common bacteria in appendix
Ecoli and bacteroides fragilis
What cell elevated in appendicitis
Neutrophils
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
Drugs that cause hepatocyte damage
Sodium valproate Amiodarone Rifampicin Paracetemol OD Alcohol
What happens in a bowel obstruction
Dilatation and increased presistalsis leads to secretion of large high electrolyte rich fluid into the bowel
What is called when bowel not mechanically blocked but doesnt work properly
Paralytic ielus
How can causes of BO be classified
Intraluminal
Mural
Extramural
Intraluminal causes of bowel obstruction
Gallstone ileus
Foreign body
Faecal impaction
Mural causes of bowel obstruction
Cancer
Inflammatory strictures
Diverticular structures
Meckels diverticulum
Extramural causes of bowel obstruction
Hernias
Adhesions
Volvulus
Peritoneal cancers
Difference in vomiting large vs small bowel
Vomiting early in small bowel obstruction whereas minimal or delayed in large obstruction
What does guarding and rebound tenderness in bowel obstruction suggest
Ischaemia
What is a pseudo-obstruction
Caused when no mechanical obstruction but a peristalsis abnormailty
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
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
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
What is gastrograffin
Water soluble contrast study aka fluoroscopy
What is purpose of gastrograffin
Used in SBO to see if obstruction will settle or needs further surgery
What indicates ischeamia in bowel obstruction
Fever
Colicky pain that becomes constant
Guarding and tenderness
Pain when moving
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
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
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
What is importance of stangulation recognition in bowel obstruction
May prevent bowel resection
What are complications of bowel obstructions
Ischaemia
Perforation
Peritonitis
Renal failure from dehydration
Common steroid complications
Osteoporosis Diabetes Cataracts Cushings Joint problems
What are complications of gallstones
Gallstone ileus
Mirrizis syndrome
Fistula to transcending colon
Perforation of gall bladder
What happens when gallbladder perforates
Peritonitis
Septicaemia
30% mortality
What can make a perforated gall bladder not so bad?
If bile seeps into the liver
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
What is mirrizi syndrome
Occurs when dilated cystic duct presses against common hepatic bile duct leading to obstructive jaundice- often a fistula formed
How will you tell if patient has had a fistula to transverse colon from gall bladder in history
Diarrorhoea recently
How to tell if has history of has chronic cholelithiasis
Abdo pain occasionally that eases with eating
What must always ask a female with any abdo pain
Pregnant?
Why is pregnancy with RUQ significant
Can cause cholestasis of pregnancy
Where are stones in choledocholithiasis
Common bile duct
What can cause RUQ pain with jaundice
Cholangiocarcinoma
Choledocholithiasis
Cholangitis
Pancreatits and cancer there
What must never forget with any upper abdo pain
Pneumonia or inferior MI
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
What is problem with lipase in pancreatits diagnosis
Very expensive and rarely used
Why cant just elevated ALP be used to diagnose obstructive jaundice
Could be raised from pagets or bone cancer
GGT must be raised too
Immediate imaging for RUQ pain
CXR
US of GB, common bile duct, pancreas
What can cause air under diaphragm
Recent abdo surgery
Perforated viscous such as duodenal or gastric ulcer
Where is cholecystitis pain originally
Constant epigastric due to only visceral peritoneum irritation but when spreads to parietal it becomes localised
What causes right shoulder pain
Gallbladder irritates liver capsule which irritates the diaphragm
What is the benefit of doing chole 6-12 weeks later rather than acutely
Lower conversion of lap to open abdo
Why must be NBM with cholecystitis
Prevent contraction of GB
Complications of cholecystitis
Empyema
Cholecystoduodenal fistula
Gallstone ileus
Ascending cholangitis
How will a cholecystoduodenal fistula appear on imaging
Air within Gall bladder, shouldnt be air in GB as a closed system
What are 2 types of gallstone
Bile pigment and cholesterol
Management of ascending cholangitis
Abx broad then dependant on the cultures that come back
ERCP drainage
What is bile made up of
Water Fat Bile salts Fat soluble vitamins Conjugated bilirubin
How many times a day can bile be recycled
Up to 10
How does liver disease affect PT
Can’t produce the clotthing factors for extrinsic pathway
How does obstructive CBD disease affect PT time
Vitamin K must be absorbed through fat soluble bile salts
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
Which patients are most susceptible to pigment gallstones
Those with haemolytic anaemias
Long term parenteral nutrition
Which patients are most susceptible to cholesterol stones
FFFS women
Oral contraceptive
Crohns as terminal ileum pathology means less bile reabsorbed
When do gallstones cause pancreatits
When lodged in ampulla of vater
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
Disadvantages of ERCP
Very unpleasant to undergo
Risk of bleeding, perforation of biliary tree, cholangitis and pancreatits
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
Why is ALT true measure of hepatocytes not AST
AST also produced by RBCs, cardiac tissue, kidney and brain
Main epigastric pain causes
Acute pancreatitis Perofrated peptic ulcer Gastris or duodenitis Peptic ulcer disease Biliary colic Cholecystitis MI AAA Mesenteric ischaemia
Differences of onset of epigastric pain
Very sudden- perforation
10-20 minutes- pancreatits and colic
Hours- inflammation like pneumonia and cholecystitis
What is a boorhaves perforation
Perforation of oesophagus
Crushing or tight epigastric pain
MI
Boring epigastric pain
Pancreatitis
Sharp or burning epigastric pain
Duodentitis
Gastritis
Peptic ulcers
Epigastric pain radiating to back
Pancreatitis
Ruptured AAA
Epigastric pain radiating to shoulder
Diaphragmatic irritation- cholecystitis, pneumonia, subphrenic abcess
Epigastric pain radiating to jaw, neck or arm
MI
Epigastric pain radiating to retrosternal
MI
Oesophagitis
Epigastric pain that is self limiting
Bilaiary colic
Uncomplicated peptic ulcer disease, gastritis, duodenitis
Epigastric pain made worse by exercise
Cardiac pathology
Important thing to check with nausea in epigastric pain
Before or after
Before- boorhaaves perforation
After- MI, SBO
Chronic cough with epigastric pain
GORD
Fever with epigastric pain
Acute hepatits
Pneumonia
Peritonitis
Heartburn and retrosternal pain with bad taste in mouth
GORD
Epigastric pain with change in stool
Pancreatits
Chronic biliary obstruction
How does chronic mesenteric ischaemia present
Colicky post prandial pain
Risk factors for chronic mesenteric ischaemia
Smoking
Alcohol
Diabetes
Family of heart disease
Risk factors for acute mesenteric ischaemia
AF
Recent MI
Valvular disease
Drugs predisopsing to peptic ulcers
NSAIDS
Aspirin
Bisphosphonates
Steroids- also mask signs of peritonitis
Drugs linked to pancreatitis
Sodium valproate
Thiazides
Azathioprine
Steroids
What is important part of family history in epigastric pain
Cardiovascular
How will a patient with pancreatis position themselves
In recovery position or leaning forward
Can pancreatits cause jaundice in absence of gallstones
Yes 2-3 days after due to inflammation pressing on CBD
Why would U and Es be deranged if has pancreatitis
In shock so renal hypoperfusion
Vomiting
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
Common resp complication of pancreatitis
ARDS
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
What is normally required for a CXR to show air under diaphragm
Sitting up for 10 mins
What conditions do you do a CT for in epigastric pain
Mesenteric ischaemia
Ruptured AAA if stable
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
When is CT used to diagnose pancreatitis
If biochemicl and clinical findings inconclusive
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
Management of pancreatitis
IV fluids Oxygen as required Analgesia Antiemetics and NG tube PPIs DVT prophylaxis Low fat diet
What happens to glucose in pancreatitis
Increases as damage to pancreas affects indulin release
How to prevent pancreatits recurrence
Most recover within a week
Most common causes are gallstones and alcohol
Gallstones- lap chole
Alochol-lifestyle guidance
Over the counter medication for dyspepsia
Ant acids
Stronger medications for dyspepsia
PPIs
Histamine antagonists
Why is heart burn not helped by antacids necessarily conclusive
Some dyspepsia requires much stronger meds
What does pain worse after eating, lying down or bending over indicate
GORD
What lifestyle changes can help dyspepsia
Stopping smoking
Eating less chocolate, fatty foods and caffeine
Triad for peritonitis
Motionless
Guarding on palpation
Absent bowel sounds
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
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
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
What happens in peptic ulcer penetration
Penetration through peptic wall without leakage into surrounding tissue
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
Local complications of pancreatitis
Necrosis of pancreas Abcess formation Pseudocyst Obstructive jaundice Paralytic ileus Duodenal stress ulceration Fistula formation to duodenum
Systemic complications of pancreatitis
Sepsis Shock Acute renal failure ARDS DIC Hypocalcaemia Hyperglycaemia Pancreatic encephalopathy- hypoperfusion
How can pancreatitis cause shock
Haemorrhage
Systemic inflam markers leading to vasodilation
Loss of fluid to peritoneum
How can pancreatitis cause jaundice
Choledocholithiasis
Pancreatic odema
What can compromise elastase reliabiility in pancreatic compromise
Disease of small bowel
What pancreatic pathologies can raise amylase
Pancreatitis
Pancreatic tumour
Pancreatic trauma
What intra abdominal pathologies can lead to raised amylase
Perforated peptic ulcer Acute appendicitis Acute cholecystitis Ectopic pregnancy Mesenteric ischaemia Leaking AAA
Which miscellaneous conditions can cause raised amylase
DKA
Head trauma
What conditions can lead to raised amylase due to poor clearance
Kidney failure
Macroamylasaemia
What is macroamylasaemia
Amylase bound to Ig so cant be excreted
What presents with erythematous mucosa on oesophagus on OGD
GORD
What type of tumour are GORD sufferers at risk of
Adenocarcinoma
What are 3 Hs in get smashed
Hypertriglyceridaemia
Hypercalcaemia
Hypothermia
What presents with fever, tender hepatomegaly and RUQ pain
Liver abcess
How does an abcess appear on liver
Septated hypodense mass
Which liver abcess causing pathogen can be tested for using serology
Amoebic
Hydatid
What is hydatid
A tapeworm- echinoccus granulosus
What can be sources of liver abcess
Practically aything Direct trauma Central venous catheter Appendicitis Diverticular disease UTI
What are some complications of liver abcess
Septic shock Peritonitis Lung empyema DVT Cerebral abcess
Liver abcess causing pathogens
Escherichia coli Klebsiella pneumoniae Bacteroides spp Streptococcus milleri Staphylococcus aureus Entamoeba histolytica Candida albicans Echinococcus granulosus
3 most common causes of liver abcess
E coli
Klebsiella pneumoniae
Strep milleri
Proportion of stones contents
Mixed stones- 80%
Cholesterol- 10%
Pigment- 10%
What stones are people with crohns and parenteral feeding more at risk of
Pigment as less bile salts reabsorbed to dissolve bilirubin in
Complications of portal HTN
Splenomegaly
Oesophageal varices
Haemorrhoids
Histological findings of UC
Mucosa and submucosa
Mucosal ulcers
Crypt abcesses
Coeliac disease biopsy finding
Subvillous atrophy
Crypt hyperplasia
Investigations for coeliac
Anti TTG ABs
Duodenal biopsy
IgA levels
What can be found in faeces of IBS
Faecal calprotectin
What is watershed zone
Area between IMA and SMA supply of colon that is susceptible to iscahemic damage
AXR finding acute mesenteric iscahemia
Gasless abdo
Investigation of ischeamic colitis
Colonoscopy or sigmoidoscopy
Investigations for mesenteric ischaemia
AXR
Lactic acidosis
Mesenteric angiography
What is appearacne of sigmoid volvulus AXR
Coffee bean sign
What is appearacne of caecal volvulus AXR
embryo sign
What is coffee bean sign seen in
Sigmoid volvulus
What is embryo sign seen in
Caecal volvulus
What does cough reflex suggest
Hernia isnt incarcerated
Difference between bowel sounds in functional vs mechanical bowel obstruction
Functional absent
Mechanical louder or present
What is acute urinary retention
Painful inability to void with relief only gained after drainage of bladder
What precipitates acute urinary retention
Normally discomfort, increased frequency of urinating, nocturia and dribbling over course of few days leading up to retention
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
Management of acute urinary retention
Analgesia if needed
Insertion of urethral catheter
Send urine for microscopy and culture
If in acute urinary retention what is important investigation to do after
PR exam
What is the function of PSA
To liquefy the ejaculate to enable fertilisation
What is PSA raised in
BPH
UTIs
Acute and chronic prostatitis
What investigation shouldnt be done in suspected testicular torsion
US- only do a urine dipstick
Typical presentation of oesophageal tumour
Short history of progressive dysphagia from liquid to solids
Weight loss
Typical presentation of achalasia
Long history of equal dysphagia
History for benign pepctic stricture
Long history of progressive dysphagia
Investigations for oesophageal cancer
OGD
Barium swallow
CXR
How does achalasia appear on barium swallow
Birds beak appearance
Smooth tapering distally
Oesophageal dilation proximally containing foods contents
Common oesophageal met sites
Liver
Lung
Investigations to stage oesophageal cancer
CT chest abdo pelvis
Endoscopic US
PET scan
Treatment for severe dysphagia
Stent
Risk factors for oesophageal cancer
Achalasia
Smoking
GORD
Management of pancreatitis feeding
Start oral feeding ASAP- shown to improve outcomes
Potential NG tube
How do pancreatic cysts tend to developed
Disruption of the pancreatic ducts
Common sequelae of chronic pancreatic insufficiency
DM
Malabsorption
What is best measure of pancreatic exocrine ability
Faecal elastase
What is faecal calprotectin a measure of
GI inflammation
How does external compresion dysphagia present
Slow progression from solids to liquid
Alongside chest Sx too
Investigations for achalasia
Barium swallow
OGD
Oesophageal manometry
What does oesophageal manometry do
Checks function of lower oesophageal sphincter
Gold standard test for achalasia
Oesophageal manometry
Can achalasia be painful
Yes
What types of conditions are associated with gallstones
Haemolytic
What is mucocele of the gallbladder
Occurs when hartmanns pouch is obstructed leading to mucous distension of GB
Complications of gall bladder surgery
Haemorrhage
Bile leak
Biliary tree damage
3% open surgery risk
Problem with CT pancreatitis
Doesnt show til 2 days after
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
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
Imaging for pancreatitis
eCXR- rule out perf (only 70% visible)
US- see signs of gallstone disease
MRI preferred to CT
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
Why are pancreatitis patients at great risk of VTE
Serious inflammation can trigger cascade
Fluid loss so blood thicker
Which location of pancreatic cancer can give pancreatitis
Head
Why cant you operate on patients with pancreatitis
SIRS already so another response to cut will mean go into shock
Order of investigations for pancreatic cancer
CT and tumour markers
Then ERCP to obtain biopsy and put stent in
Is diabetes a RF for pancreatic cancer
No
Most common gastric cancer
Adenocarcinoma
RFs for gastric cancer
Male H pylori Smoking Pernicious anaemia Diet with high salt and preserved foods
What is it called when large bowel loop is interposed between liver and diaphragm
Chilaiditis sign
What is chilaiditis sign
When large bowel loop is inbetween diaphragm and liver
What is chilaiditis syndrome
Normal variant whereby large bowel loop is inbetween diaphragm and liver alongside pain- if asymptomatic called chilaiditis signs
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
Presentation of chronic cholecystitis
Recurrent RUQ pain after eating
Nausea and vomiting
Bloating and flatulence
What happens to gall bladder after chronic inflammation
Becomes fibrosed and calcified- porcelain gall bladder
How is porcealin gall bladder visible
On AXR
Investigations for chronic cholecystitis
AXR
US-CT is better to delineate
What type of surgery is there a particular association of pseudo obstruction with
Orthopaedic
Patient presents post op with bowel obstruction sx
Ileus
In post op ieus why is K+ resus particularly important
Helps peristalsis continue
When patient has bowel obstruction how should they be fed
Para-enteral
What should be given before para-enteral feeding in bowel obstruction
Pabrinex as in periods of starvation there is risk of wernickes
What is pseudomembranous colitis
Inflammation of colon due to growth of C diff
Why is it important to do AXR in pseudomembranous colitis
Check gas pattern to exclude toxic megacolon or perforation
What is thumbprinting on AXR
Dilated oedematous areas of bowel
Where can c diff affect in bowel
Only colon
Management and investigations of c diff
Rehydration
Discontinue current ABx
Stool assay for toxins aswell as ELISA for them
Oral vancomycin or metronidazole
Bowel sounds in ileus
Absent
Which sex are femoral hernias more common in
Females
Which hernias are the most likely to strangulate
Femoral
Which sex are inguinal hernias more common in
Men
What are the majority of inguinal hernias
Indirect- 80%
How to differentiate between femoral and inguinal
Inguinal medial and superior to public tubercle whereas femoral inferior and lateral
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
How does carcinoma appear on contrast enema
Applecore
Most common causes of RIF mass
Crohns
Appendix abcess
Hepatomegaly
Cancer
What infective pathogns can mimic crohns in RIF
TB
Yersina
What is name when TB affects bowel and how would you confirm
Ileo caecal TB
CXR
In suspected LBO what investigations would you do
AXR
Rectal examination
How to manage sigmoid volvulus in old people
Decompression flatus tube into sigmoid
Which patients do sigmoid volvulus tend to occur in
Elderly
Psyciatric
Management of UC
IV 100mg Hydrocortisone- can give smt to protect bone too like Adcal-3
What conditions can give you toxic megacolon
UC
Crohns
Pseudomembranous colitis
What is most commonly damaged organ in trauma within abdomen
Spleen
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
What is % of perforations picked up on eCXR
70
Common causes of functional obstructions
Post operative ileus Hypokalaemia Hypomagnesia Hypercalcaemia Opiates Hypothyroidism Intra abdominal sepsis
3 most common causes of SBO
Adhesions
Hernia
Caecal cancer
Causes of SBO
Adhesions Hernia Caecal cancer Crohns Faecal impaction Bezoar
What does colour of vomit suggest about bowel obstruction
Green- proximal
Darker- distal
What is a tricobezoar
Bezoar made up of hair
What is a phytobezoar
Bezoar made up of fibre, skin etc any indigestible plant or animal material
What is main thing to determine severity of bowel obstruction
PAIN PAIN PAIN
Best way to classify bowel obstruction causes
Extra luminal
Intramural
Intra luminal
Extramural causes of SBO
Adhesions
Hernias
Diverticular abcesses
Cancers
Intramural causes of SBO
Crohns
Radiotherapy
Cancer of caecum or appendix
TB
Intraluminal causes of SBO
Bezoars
Faecal impaction
Gallstone ileus
What are signs on AXR of pneuperitoneum
Rigles sign
Falcifrom ligament sign
Football sign
What is rigles sign
Where can see white outline of bowel due to air in abdomen
How to interpret AXR systematically
ABDOX
What is amyloidosis
Deposition of proteins with abnormal shapes that stick together and cause tissue damage
What is normal path of abnormally folded proteins
Get broken down by proteases
What happens to misfolded protein breakdown in amyloidosis
There is too much breakdown and the proteases become overhwhelmed
What do abnormally folded proteins form together in amyloidosis
Insoluble beta sheets that deposit in tissues
What can amyloidosis be divided into
Systemic and local
What are the 2 types of systemic amyloidosis
AL
AA
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
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
What conditions are associated with with AA
IBD
Rheumatoid arthritis
Cancer
Which organs does systemic amyloid tend to affect
Nerves Heart Gut Kidney Spleen Liver Tongue
What organs does amyloidosis cause organ enlargement in
Liver
Spleen
Tongue
How does amyloid affect the kidneys
Deposits on podocytes affecting the glomerulus -> nephrotic syndrome
How does albumin loss lead to hyperlipidaemia
Albumin inhibits lipid synthesis
What does bruit over liver suggest
Cancer or cirrhosis
Extra luminal causes of LBO
Hernias- most common worldwide Adhesions Volvuluses Tumours invading colon Diverticular abscess
Mural causes of LBO
Carcinomas Chronic diverticular disease leading to strictures Crohns Radiation Anastamotic strictures
Intra luminal causes of LBO
Faecal impaction
Bezoars
Foreign objects up the anus
Difference between episcleritis and scleritis
Eye pain and visual disturbances seen in scleritis
What is scleritis and episcleritis
Reddening of eyes
Why are adhesions less likely to occur in large colon
Ascending and descending colon are retroperitoneal so fixed position
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
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
How do closed bowel loop obstructions present
With RIF pain following on from LBO symptoms
What presents with LBO sx and then RIF pain
Closed bowel loop
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
Bloods ordered for LBO and why
FBC- anaemia, WCC U&Es- hypokalaemia and AKI G&S LFTs Clotting Amylase Glucose
Tx for LBO
Hartmanns fluid
Analgesia
NG tube
Catheter to do fluid balance
Two regular drugs taken for Crohns
Methotrexate
Azathioprine
Drug come into hospital to take for crohns
Infliximab
What to tell patient about for upcoming coeliac duodenal biopsy
Have to maintain eating gluten
Colonoscopy term to describe crohns
Cobble stone
Colonsocopy description of UC
Lead pipe
What does leadpipe refer to in colonsocopy
UC
Steatorrhoea differentials
Coeliac
Chronic pancreatitis
HIgh fat diet
Specific drug used for UC
5-Aminosalicylic acid
Risk factors in history for coeliac
Autoimmune thyroiditis
T1DM
Pernicious anaemia
What are coeliac patients often deficient in
Vit ADEK
Consequences of coeliac patients being Vit D deficient
Have osteomalacia
How do coeliac patients end up with low calcium and phosphate
Reduced absorption of Vit D leading to osteomalacia
What are coeliac patients at increased risk of
Adenocarcinoma in small bowel
T cell lymphoma in small bowel
Osteoporosis
What can lead to increased presence of mouth ulcers
Iron deficiency
What can cause glossitis
B12
Folate
Iron deficiency
What percentage of gallstones does an US pick up
81%
What to do if uncertain of diagnosis of gallstones- next investigation?
HIDA scan or a CT
Complications of cholecystitis
Empyema
Gangrene
Perforation
Semi surgical management of cholecystitis
Percutaneous cholecystostomy
Investigations ordered for suspected cholangiocarcinoma
LFTS
CA 19-9
ERCP with brushing
What are causes of appendicits
Faecolith Impacted normal stool Tumour Lymphoid hyperplasia of peyers patches Carcinoid tumour
Who does appendicitis most commonly appear in
Male 16-25
Symptoms of appendicits
Pain that localises
N and V
Low grade fever
Anorexia
Signs on examination of appendicitis
Rebound tenderness and guarding over McBurneys point
Difference between pain in SBO and LBO
Intermittent and crampy SBO
Diffuse and constant in LBO
Where are diverticulae most likely to form
Sigmoid due to presence where food sits for the longest time
Investigations and management for appendicitis
US and if inconclusive do CT
Whisk off to surgery but beforehand give prophylactic Abx
RFx for diverticular disease
Age
Low fibre diet
NSAID use
What are diverticulae
Outpouching of intestinal mucosa
What is diverticulosis
Presence of diverticulae but asymptomatic
What is diverticular disease
Symptomatic diverticulosis
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
Complications of appendicitis
Perforation
Appendicular mass
Abcess
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
Progression of hernia description
Reducible
Incarcerated
Obstructed
Strangulated
Investigations for diverticulitis
Barium enemas
Colonoscopy
CT
Investigations for colorectal cancer
Bedside DRE Bloods FBC Haematinics CEA FOBT Colonsocopy CT to stage
Diverticular disease management
Lifestyle advice- increase fiber and hydration
Mild acute diverticulitis management
Oral Abx
Severe diverticulitis management
IV abx IV fluids Analgesia Surgery if perf or SEPSIS
Complications of diverticular disease
Diverticulitis Intra abdo abscess Perforation and peritonitis Sepsis Fistula formation to bladder LBO from stricture
Percentage of where colon cancers are
40 rectum 30 sigmoid Ascending and caecum 15 Transverse 10 Descending 5
Genetic associations of colon cancer and their percentages
Sporadic 95%
HNPCC 5%
FAP less than 1%
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
What score can be used to stratify patients presenting with haematemesis
Batchford
How do boerhaaves perforations normally present
Vomiting and lots of pain
Only sometimes with haematemesis
Imaging needed for haematemesis
OGD
eCXR
CT
What is common finding on CXR of boerhaaves perforation
Left sided pleural effusion
What is significant recent operation in terms of haematemesis
Aortic graft as can lead to aortic-enteric fistula
What does fresh blood suggest in haematemesis
Upper GI bleed
What does coffee grounds in blood suggest
Blood thats been partially digested by stomach acid
How does blood affect faeces transit time
Increases it as blood acts as a cathartic
What does recent forceful vomiting suggest about cause of haematemesis
Boerhaaves
Mallory weiss tear
What does recent dysphagia suggest about haematemesis
Oesophageal cancer or oesophagitis
Recent weight loss causing haematemesis
Cancer of stomach or oesophagus
What would suggest cirrhosis as cause of haematemesis
Easy bruising, ascites, lethargy
What would knawing epigastric pain asuggest about haematemesis
Gastric cancer
What would recent episodic dyspepsia suggest about haematemesis
GORD
Important PMH questions haematemesis
Bleeding tendency
GORD-> oesopagitis
Peptic ulcer
Liver disease
Important drugs in haematemesis history
NSAIDS- ulcer Aspirin- ulcer Steroids- ulcer Bisphosphonates- ulcer Anticoagulants- bleeding Metho trexate- liver Amiodarone- liver Beta blockers- mask shock
Social history significance haematemesis
Alcohol- liver, ulcers, gastritis
Smoking- cancer, GORD
IV drug use- cirrhosis
Tattoos- cirrhosis
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
In haematemesis why may patient not be anaemia
Proportion of whats lost, Hb will be lost in equal propportions to everything else
Raised GGT in absence of raised ALP
Alcohol abuse
What can cause a raised urea in presence of normal creatinine
Dehydration
Increased protein ingestion due to blood in GI tract
If patient has low albumin what investigation must do
Urinalysis to rule out nephrotic syndrome
How should patients awaiting endoscopy be managed
NBM
Regular obs
Fluids
If keep bleeding correct platelets or coagulopathy
What imaging can be used if endoscopy fails haematemesis
Angiography
Laparatomy
How are oesophageal varices managed surgically/endoscopically in order
Endoscopic band ligation Endoscopic sclerotherapy Balloon tamponade TIPS Portocaval shunt
What is TIPS
Transjugular intrahepatic portosystemic shunt- create shunt between portal vein and hepatic vein to reduce portal HTN
What is portocaval shunt
Surgically performed shunt between portal and heaptic vein
What is problem with portocaval shunt
Toxins from gut that would be sorted by liver go straight into systemic circulation
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
If beta blockers are contraindicated in controlling BP post oesophageal varices what is best option
Isosorbide mononitrate
How to treat encephalopathy
Low protein diet
Lactulose
Enemas
Why is lactulose beneficial in treating encephalopathy
Decreases transit time in bowel
Lowers pH making biome more hostile to ammonia producing bacteria
What does clots in haematemesis suggest
Partially digested so likely to be of peptic source
How does mallory weiss tear present
Chest pain
Vomiting blood
What non GI pathology can cause haematemesis
Epistaxis
Which causes of epistaxis can lead to haematemesis
Posterior nose bleeds from branches of sphenopalatine artery
Rfx peptic ulcer
H pylori Smoking Alcohol Blood group O Hypercalcaemia Stress physiological Aspirin NSAIDS
Why are alcohoics suscpetible to haematemesis
Varices
Prone to mallory weiss tears from vomiting
Liver damage leads to reduced pro coagulant synthesis
What is the Child pugh score for
Prognosis of liver cirrhosis
What can oesophagitis often be secondary to
GORD
Hiatus hernia
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
Who is mesenteric adenitis usually only seen in
Children
RIF pain elderly people- what is more likely to be considered
Caecal cancer
Volvulus
Mesenteric diverticulum
How will appendicitis patients often sit
With right knee flexed
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
If suspected guarding or rebound tenderness in area what is polite thing to do
Percuss the area- if parietal inflammation will still hurt
What normally precedes mesenteric adenitis
URTI
With RIF pain how is rectal bleeding revelant
May suggest bleeding caecal or meckels diverticulum
Which dermatome can epididymitis, orchitis and testicular torsion present to
T10 so bear this in mind
Signs on VBG of ischaemia or sepsis
Raised lactate
pH of less than 7.35 with low/normal CO2
Base excess
How can appendicits present on urinalysis
Proteinuria- microscopy to differentiate from UTI
When would do transvaginal US
If unsure RIF pain of appendiceal cause or gynae
How is eCXR relevant in RIF pain
Perf appendix
Meckels diverticulum
Caecal diverticulum
What is pain generally in mesenetic adenitis
More diffuse
What are symptoms of meckels diverticulitis
Identical to appendicitis
In gastroenteritis what tends to predominate
Vomitin and diarrorhoea
Which drugs can elevate amylase
Opiods
What could RIF mass be in appendicitis
Appendicular mass
Abscess
Howt to investigate RIF mass in appendicits
CT
When is only time AXR are acceptable
Suspected BO
History of IBD
Foreign body
Signs on examination of testicular torsion
Raised testicle
Scrotal erythema
Tenderness
Common associated symptom of testicular torsion
Nausea and vomiting
When examining the other testis in suspected testicular torsion what would indicate torsion
Lying horizontal- testicles lying like this increases risk of torsion
What is prehns sign
Elevating the affected testicle relieves pain in epididymitis- helps distinguish from torsion
What is the cremasteric reflex
If stroke superomedial side of thigh then should result in elevation of ipsilateral testicle
What does negative cremasteric reflex suggest
Can exclude torsion
What can be laparascopic finding of crohns
Mesenteric fat wrapped around ileum
Woman presents with RIF pain every month
Probably Mittelschmerz- middle pain
What is mittelschmerz
Pain in either IF that can rotate and is always in the middle of each menstrual cycle
What is SIRS
Systemic inflammatory response syndrome- the bodys response to a wide range of pro-inflammatory processes
How is SIRS defined
2 of Temp RR WCC HR
What is SEPSIS
SIRS caused by an infection
What is severe sepsis
Sepsis causing hypotension(SBP <90 or drop of 40 from their baseline) and end organ hypoperfusion (metabolic acidosis)
What is septic shock
Severe sespis refractory to fluids and vasopressors are needed
What is MODS
Multiple organ dysfunction syndrome- evidence of 2 or more organs failing
What is a gridiron scar
This is old method of appendectomies- perpendicular to line between umbilicus and ASIS
What is the lanz scar
New method of appendectomies- horizontal course starting just medial to ASIS
Why when doing an appendectomy does surgeon check the distal 2 feet of the ileum
Look for meckels diverticulum
Or Crohns
How does non inflamed bowel look
Lily white
What cells can be found in meckels diverticulum
Gastric and pancreatic
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
What is an interval appendicectomy
If has had conservative treatment of appendicular mass or abscess then remove it
What is link between appendicectomy and UC
Patients who have had appendicectomy are less likely to develop severe symptoms of UC and need colectomy
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
Scoring system for appendicitis
Alvarado
What is the most common anantomical position of appendix
Retrocaecal
What epigastric pain can radiate to back
Pancreatitis
Peptic ulcers
Ruptured AAA
What are 2 types of Hpylori gastritis
Antrum predominates
Pangastritis
What do you nomally get in antrum gastritis from H pylori
Duodenal ulcers and duodenal pathology
What does Hpylori pangastritis predispose to
Adenocarcinoma
MALT lymphoma
What gives you multipe ulcers in stomach
NSAIDS
If no history suspect Zollinger Ellison
What does urgency to defaecate indicate
Rectal colitis as cant store there so has to come out
Who does Behcets normally appear in
Mediterranean descent
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
How does diverticulitis pain present
Starts off general abdo and colicky but then localises to the LIF
What does acute onset LIF pain suggest
Ruptured vessel such as AAA or ovarian cyst
Perforation of cancer
How in history will describe past few months if has IBS
Abdominal discomfort and bloating
LIF pain with PR bleeding
Carcinoma
Diverticular disease
Colitis- inf or inflam
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
What drugs predisopose to pseudomembranous colitis
Abx
PPIs
If patient has peritonitis how will they present
Shallow breaths
Lying still
Any movement will hurt
Pale
What would be significant about jaundice in LIF pain
Carcinoma that has metastasised to liver
Peritonitis on examination
Tender
Rigid abdomen
Absent bowels can be a later presentation
DDx for absent bowel sounds
Functional obstruction
Peritonitis
Peritonitis in LIF pain
AAA
Complicated diverticulitis
Carcinoma perforation
LIF mass in pain
Colonic carcinoma
Diverticulitis alone but can be abscess too
What is troisiers sign
Presence of virchows node
Why is CRP so important in colitis
Predicts outcome
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
Diagnostic method of choice for acute diverticulitis
CT with contrast
What is non specific sign on AXR of acute diverticulitis
Large bowel dilatation
What are contraindicated in acute phase of diverticulitis
Barium swallow through
Endoscopy
Management of acute diverticulitis in acute phase
IV fluids if cant keep oral down Bowel rest IV fluids VTE prophylaxis Analgesia Abx
Longer term management of acute diverticulitis
Colonscopy or barium swallow to check how bad stricture is and to visualise diagnosis
High fibre diet
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
What does pelvic inflammatory disease present with
IF pain
Nausea
Fever
Discharge
What is natural history of diverticulosis
70% asymptomatic
15% acute diverticulitis developed
10% get PR bleeding
Why are colovesical fistulas more common in men in diverticular disease
Uterus sits between bladder and sigmoid in women
Difference in preceding abdo pain diverticulitis and appendicitis
Appendicitis is in midgut so T10
Diverticulitis is in hindgut so T12
Where are diverticulae least likely to develop
Rectum as complete coat of longtitudal muscles
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
What is main site copper in blood spreads to
Brain
What happens if copper is deposited in brain
Cerebrum- dementia
Basal ganglia- parkinsonism
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
How does wilson tend to present in younger people
Hepatitis then cirrhosis
How does wilson tend to present in elderly
Parkinsonism
Dementia
Investigations for wilsons
High copper
Low caeruplasmin
High urinary copper
What is velvety epithelium seen in
Barretts oesophagus
What are the 2 extra enteric manifestations of UC that arent related to disease activity
Axial spondyloarthropathy
PSC
What drug can often cause colitis
NSAIDS
How does NSAID colitis present
bloody diarrhoea, weight loss, iron deficiency anaemia and sometimes abdominal pain
Management of acute UC
IV hydrocortisone
If IV hydrocortisone doesnt work for UC flare what is next line
IV ciclosporin
Infliximab
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
What presents with recurrent peptic ulcers and diarrohoea
Zollinger elson SYNDROME
How is zollinger elison diagnosed
Very high fasting gastrin
Peptic ulcer with history of tumours in family
Zollinger elison due to MEN
What will be seen in HPC of zollinger ellison disease
Hypercalcaemia symptoms
How does recent ICU stay predispose to peptic ulcer disease
Organ failure leads to gastrin production
What does pointing sign mean in relation to peptic ulcer disease
Often the patient can localise the pain very well to an exact location
What does pointing sign suggest
Peptic ulcer
If weight loss in peptic ulcer disease history and patient is over 55 what must do
OGD 2ww
Epigastric pain that wakes you up at night
Peptic ulcer disease
First line investigations for peptic ulcer disease
Urease breath test
Stool antigen
Serology but less accurate
Bloods- FBC
Gold standard test for peptic ulcer disease
OGD
What is done in OGD of peptic ulcer disease
Visualise number of lesions
Biopsy to see if malignant or H pylori
Treat if bleeding
What can be done to peptic ulcer if bleeding in OGD
Band ligation
Adrenaline injection
Thermocoagulation
Bloods ordered for peptic ulcer disease
FBC looking for anaemia
When can first line investigation for peptic ulcer disease change
If over 55 and wt loss
If over 60 and dyspepsia
2ww OGD
If penicillin allergy what is ab instead used in H pylori peptic ulcer
Metronidazole
If non h pylori peptic ulcer what is management
4-8 weeks of PPIs
Second line management of peptic ulcer disease
H2 anatagonists- ranitidine
Where can pain radiate in duodenal ulcer disease
To back
What is pathophysiology of GORD
Reflux of gastric contents into oesophagus, pharynx or lung due to relaxation of LOS
2 main risk factors for GORD
Obesity
Hiatus hernia
Other risk factors for GORD
Smoking Alcohol NSAIDS Acidic food CCB
What are acidic foods that can affect GORD
Citrus
Mint
Coffee
Main presentation of GORD
Heart burn on eating
Bad taste in mouth- mainly acidic and occurs post eating
When is heartburn pain in GORD worse
Lying down or bending over
How can GORD present with voice affected
Laryngitis
Other symptoms of GORD
Dysphagia Halitosis Dyspepsia Early satiety Bloating
First line investigation for GORD
PPI trial
If GORD persists post PPI trial what may consider plus what would push you towards a certain investigation
OGD- barretts, erosion
Barium
Manometry- dysphagia
Lifestyle mangement of GORD
Lose weight
Avoid citrus/spicy food, coffee, alcohol, chocolate
Avoid eating late at night
Elevate head when sleeping
If GORD persists what is management
Fundoplication surgery
Risk factors for barrets oesophagus
Same as GORD
Presentation of barretts oesopahgus
Same as GORD, perhaps years of GORD
Could be dysphagia too with cancer
Diagnosis of barretts oesophagus
OGD with biopsy
Histopathology confirms
What is seen on OGD in barretts oesophagus
Velvety epithelium
Salmon coloured epithelium
Z line migrates upwards
Managmenet of barretts oesophagus
PPI with surveillance
Lifestyle same as GORD
Further management of barretts
Fundoplication
Radio/cryo abaltion
Oesophagectomy
What is main risk of barretts
Dsyplasia to adenocarcinoma
Types of hernia
Inguinal Femoral Epiastric Umbilical Incisional Spigelian
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
Hiatus hernia RFs
Obesity
Oesophageal/gastro procedures
Increased abdo pressure
Examination findings of hiatus hernia
Bowel sounds in chest
Oropharyngitis
Presentation of hiatus hernia
Symptoms of GORD
Belching
Lower dysphagia
Painless regurgitation of food
Best investigation for hiatus hernia
Barium
What is a sliding hiatus hernia
When GEJ slides above diaphragm
What is a rolling hiatus hernia
When GEJ stays in place but fundus moves into chest alongside the oesophagus
What is seen on CXR hiatus hernia
Retrocardiac air bubble
Why do OGD in hiatus hernia
To see if GORD has undergone dysplasia
Managmeent of hiatus hernia
Same as GORD- lifestyle and PPIs
Fundoplication surgery
Why do barium when GORD diagnosed
To see if cause is hiatus hernia
Complications of hiatus hernia
Volvulus
Ischaemia
Obstruction
Bleeding-> haematemesis
Most common type of gastric cancer, what are others
Adenocarcinoma
Lymphoma, leiomyosarcoma, neuroendocrine
Main risk factors for gastric cancer
Smoking
Hypylori infection
Poor diet- high salt, low fruit and veg
3 lymphadenopathy sites in gastric cancer
Virchows
Sister mary joesph- periumbilical
Irish node- left axillary
Cancer markers that are elevated in gastric cancer
Ca19-9
CEA
Diagnostic investigation for gastric cancer
OGD with biopsy
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
Risk factors for achalasia
Chagas disease Fh Autoimmunity Allgrove syndrome measles and herpes
Dysphagia to solids and liquids with jaundice
Chagas disease
Achalasia presentation
Dysphagia to liquids and solids
Retrosternal pain sometimes
Regurgitiation of food
Weight loss
First line investigation for achalasia
OGD and biopsy
Definitive test for achalasia
High resolution manometry
What is beak sign seen in
Achalasia on barium swallow
What is CXR finding of achalasia
Absence of gastric bubble
Dilated oesophagus
What are risk factors for mallory weiss tear
Increase in abdo pressure- vomiting, coughing, hiccups, straining
Hiatus hernia
Alcohol use
What is a mallory weiss tear
When increase in abdo pressure causes tear in oesophagus just above the LOS
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
PC of mallory weiss tear
Haematemesis
Postural hypotension
Light headedness
Investigations for mallory weiss tear
FBC- anaemia LFTs- alcoholism CXR is perforated G&S OGD
What score is used to stratify risk when vomiting blood
Rockall
Management of mallory weiss tear
ABC
PPI and antiemetics to reduce acid scretions and vomiting respectively
Endoscopy
First line mallory weiss tear management on endoscopy
Adrenaline injection
Second line mallory weiss tear investigation on endoscopy
Band ligation
Second line management of mallory weiss tear if endoscopy fails
Sengstaken blakemore tube
Last resort management of mallory weiss tear
Surgery
Presentation of boerhaves perforation
Retrosternal chest pain
SOB
Vomiting
What is pneumomediastinum seen in
Boerhaves perforation
Signs on ausculaton of boerhaves perforation
Cracking/ crunching sound over heart due to pneumomediastinum
Reduced air sounds
Surgical emphysema- crepitus around skin area
Management of boerhaves perforation
Surgery
What layer does oesophageal cancer begin in
Mucosa then enters submucosa then muscularis
Where can oesophageal cancer invade to
Lungs Aorta Recurrent laryngeal nerve Trachea Phrenic nerve
Where does oesophageal cancer spread to
3 Ls
Lung
Liver
Lymph nodes
What is most common cancer in lower oesophagus
Adenocarcinoma
What is most common cancer in upper 2/3 of oesophagus
SqCC
Risk factors for SqCC in oesophagus
Smoking
Alcohol
HPV
Risk factors for adenocarcinoma of oesophagus
GORD
Barretts oesophagus
Hiatus hernia
Obesity
What does hiccuping a lot suggest in dysphagia
Phrenic invasion of oesophageal cacner
Hiatus hernia
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
First line and diagnostic investigation for oesophageal cancer
OGD and Bx
Investigations for oesophageal cancer
OGD and Bx
CT to look for mets
PET scan
Bloods- volume depletion, hypokalaemia
Odonyphagia to solids and liquids
Chagas disease
Odonyphagia just to solids
Oesophageal cancer
What are 2 types of oesophageal spasm
Diffuse
Hypertensive
What is name of hypertensive oesophageal spasm
Nutcracker oesophagus
What causes diffuse oesophageal spasm
Often secondary to GORD and hiatus hernia
How is oesophageal spasm diagnosed
Using barium swallow
Manometry or PPI trial useful especially if cause is GORD or Hiatus hernia
Anorectal causes bleeding
Haemorrhoids
Tumour
Anal fissure
Anal fistula
Colonic causes of bleeding
Diverticular disease Angiodysplasia Ischaemic colitis UC Chess organisms Cancer Iatrogenic - anastamotic leak or endoscopy
Ileo jejunal causes of bleeding
Crohns Peptic ulceration Coeliac Small bowel tumours AV malformation
Upper GI causes of malaena
Peptic ulcer Gastritis Varices Tumour Mallory weiss tear
First range of questions to ask in history of PR bleeding
Questions about hypovolaemia- light headed, SOB and fatigue
How much blood
What unpathological source can make stool black
If on iron as malaena caused by oxidation of haem
What does blood mixed in with stool say about source of blood
Source proximal to sigmoid
What does blood streaked on stool suggest about source of blood
Anorectal or sigmoid
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
If blood occurs after passing stool what does this suggest about source
Haemorrhoids
If blood is only seen on toilet paper what does this suggest about source
Haemorrhoids or anal fissure
What is main cause of pain on defaecation leading to bleeding
Anal fissure
What presents with bleeding and abdo cramping
Any colitis
What does prolapse with PR bleeding suggest
Haemorrhoids
Prolapse
Which cancer leads to pain rectal or anal
Anal
Why is UC history relevant in PR bleeding
Likelihood of development to adenocarcinoma
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
What is relvant in PMH of PR bleeding
Liver disease
UC
Haemophilia
Important surgical history of PR bleeding
Aortic surgery
Endoscopy
Significance of examination PR bleeding
Cachexia Virchows node Palpable masses Hepatomegaly Ascites Pallor Koilonychia Pulse and BP
Rectal examination significance PR bleeding
Inspect for fissures, haemorrhoids and fistulas
Masses
Cant feel haemorrhoids unless prolapsed or thrombosed
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
Why is urea elevated if upper GI bleed
Urea a breakdown product of haemolysed RBCs
What should be bedside investigation for lower GI bleed
Proctoscopy for diverticular disease or rectal cancer could be seen
Which drgs increase the risk of diverticular disease bleeding
NSAIDS
What is problem of colonsocopy in acute bleed
Bowel must be prepped
If there is an acute massive bleed and colonoscopy needs to happen what can be done to prepare the bowel
Caecal catheter
When is mesenteric angiography or CT angio done for PR bleeding
If colonoscopy doesnt find source of blood and the bleeding continues
What is last investigation used for GI bleed
Technetium-99 labelled red blood cell scintigraphy
Lifestyle modification for haemorrhoids
Increase water intake
Avoid straining on the loo
Increase dietary fibre
Medical management of haemorrhoids
Local anaesthetic creams for soreness and itching
Steroidal creams
Laxative therapy when needed for constipation
Surgical mangement of haemorrhoids
Rubber band ligation
Injected sclerotherapy
Important bloods to order for suspected carcinoma
FBC Haematinics CEA LFTS-mets Ca- mets Other cancer markers
What is done with diverticular disease if keeps bleeding on presentation
Straight to surgery
If fail to respond to medical treatments of anal fissures what do you do
Lateral internal sphincterectomy
What is defined as a lower GI bleed
Anything below the ligament of treitz at the duodenojejunal junction
What could cause painful haemorrhoid
Thrombosed external haemorrhoid
Anal fissure
Perianal abscess
Familial conditions leading to colorectal cancer
Familial adenomatous polyposis
Hereditary non polyposis colorectal cancer
Risk factors for colorectal cancer
Increasing age Male sex Central obesity IBD Polyps Colorectal radiation FAP HNPCC Sedentary lifestyle
Why do a CT in small bowel obstruction
Determine point of tightness
How many obstructed points
Extent of the dilation
Viability of the bowel
What is massive area of gas in upper abdomen
Stomach distension from pyloric obstruction
Management of excessive vomiting
NG tube and antiemetics
What is triad of allgrove syndrome
Achalasia
Alacrima
Adrenal insufficiency
How can achalasia appear on OGD
Saliva obstructing the mucosa from chronic obstruction
How can achalasia appear on barium swallow
Poor peristalsis
Bird beak appearance
How does achalasia appear on manometry
Poor relaxation of LOS
Poor peristalsis
What does FIT stand for
Faecal immunochemical teseting
