gastro DPD Flashcards
40 year old mother of 5 complains of abdo pain after eating fish and chips. What is the likely diagnosis?
Gallstones – immediate pain post-fatty meal.
n.b. here there is no inflammation/infection as there is no fever, jaundice (cholecystitis or cholangitis).
RFs for gallstones: overweight, Caucasians, female, fertile, ~40years)
40 year old man drinks a bottle of vodka every night is known to have chronic liver disease, developed severe abdo pain with extreme tenderness. Examination revealed a rigid abdomen. What is the likely diagnosis?
Acute pancreatitis -
leakage of pancreatic enzymes into peritoneum causes rigidity and peritonitis
DDx: peptic ulcer disease is also common in alcoholics. PUD will not present with fever.
Pneumonia can also cause upper abdo pain but look for other resp abnormalities.
Diagnostic confirmatory blood investigation for acute pancreatitis
Serum amylase
n.b. some places use lipase
Causes of splenomegaly
Portal HTN Haematological CCF Infection (TB, malaria, schistosomiasis, infective endocarditis) Inflammation
70yr old breathless man O/E has splenomegaly. He drinks heavily and had an anterior MI previously
Think about causes of splenomegaly.
Here the most likely DDx = portal HTN secondary to liver cirrhosis
35 year old male IVDU with a 3 day history of jaundice, flu-like symptoms and nausea. O/E: he is cachectic and jaundiced, with smooth, tender hepatomegaly.
- Hepatitis C
- HIV
These are likely in IV drug abusers
DDx: alcoholic hepatitis, paracetamol overdose (=acute liver failure), Gilbert’s syndrome
Gilbert’s syndrome definition
When is it worse?
What drug makes it better?
Asymptomatic hyperbilirubinaemia
Worse on starving
Better with phenobarbital
Needs no specific treatment.
Porto-systemic anastomoses
Oesophageal varices
Rectal varices
Umbilical vein recanalising
Spleno-renal shunt
Features of portal HTN
ascites
splenomegaly
caput medusae
(encephalopathy, SBP, variceal bleed)
A 65 year old man had a triple AAA repair 2 days ago. He has now got diffuse abdominal pain with HR 120 and RR 30. DDx is a surgical leak. What are blood tests likely to show
High amylase
Decompensated liver disease results in
Jaundice
Encephalopathy
Ascites
50 year old man with painless jaundice and palpable gallbladder presents. He has weight loss, dark urine and pale stools. This is pancreatic cancer, blood tests are likely to show elevated levels of…?
Ca19-9
ALP
Causes of bloody diarrhoea
Infection - infective colitis (CHESS pathogens) Inflammation - IBD colitis Ischaemia Malignancy Diverticulitis
Ascites Rx
take an ascitic tap to exclude SBP
Diuretics (spironolactone ±furosemide) Dietary Na+ restriction Fluid restrict hypoNa+ pts Monitor weight daily Therapeutic paracentesis (with IV human albumin)
Albumin gradient equation =
serum albumin - ascites albumin
> 11g/L - high gradient i.e. transudate
<11g/L - low gradient i.e. exudate
Encephalopathy Rx
Lactulose
Phosphate enemas
Treat infections
Exclude GI bleeds
Avoid sedation
Presentations of the following post-op complications:
- Wound infection
- Anastomotic leak
- Pelvic abscess e.g. post-appendicetomy
- Wound infection -> erythematous, discharge
- Anastomotic leak -> diffuse abdo tenderness, guarding, rigidity, hypotensive, tachy
- Pelvic abscess -> fever, pain, sweats, mucous, diarrhoea
Peri-anal abscess = tender red swelling. its treatment…
incision and drainage
Anal fissure = pain on defaecation. Stool is coated with blood. its treatment…
Advice re diet and fibre
GTN cream
IBS - recurrent abdo pain with bloating. Improves with defaecation. Change in frequency/form of stool. No FLAWS or nocturnal symptoms. Important to exclude Coeliac. Rx:
Diet and lifestyle modification Symptomatic treatment: abdo pain - anti-spasmodics prokinetic agents - metoclopramide constipation - laxatives anti-diarrhoeas low dose TCAs - lowers visceral awareness
Patient presents with dyspepsia and weight loss. What is the most important investigation?
OGD gastroscopy
Superior mesenteric artery supplies
Small intestine and R colon
Inferior mesenteric artery supplies
L colon
Causes of diffuse abdominal pain
Obstruction Infection (peritonitis, gastroenteritis) Inflammation (IBD) Ischaemia (mesenteric) Metabolic causes (DKA, addison's, hyperCa2+, porphyria, lead poisoning)
Acute abdomen investigations
Bloods: FBC, U+Es, LFTS, CRP, clotting, group and save, cross match
Erect CXR
CT
Acute abdomen management
NBM IV fluids Analgesia Antibiotics Anti-emetics Monitor vitals + UO
acute GI bleed: similar ABC approach. Ix HAVE to include group+save, cross-match and OGD!!!! Variceal bleeds give terlipressin + b-blockers too.
van den Bergh test
Direct reaction results vs indirect reaction results mean…
Direct reaction = conjugated BR
Indirect reaction = unconjugated BR
Gilbert’s syndrome mode of inheritance
Autosomal recessive
n.b. 50% of population are carriers
Alcoholic hepatitis:
Defining histological features
± Associated features
Hepatocyte damage
Inflammation (neutrophils)
Fibrosis
±Fatty change
±Megamitochondria
Caput medusae cause
Visible vein on anterior abdominal wall. Occurs because of pressure in umbilical vein - a sign of severe portal hypertension.
Liver failure is a failure of….
Synthetic function
Clotting factor and albumin
Clearance of bilirubin
Clearance of ammonia (= encephalopathy)
Pruritis in liver disease is due to
Bile salts
A 50 year old man presents with a 2hr Hx sudden onset of severe epigastric pain that is now generalised. O/E: pyrexic 37.8oC, rigid abdomen and absent bowel sounds. WCC is raised at 18.09/l. Serum amylase is raised at 450IU/L. AXR shows opacities in R hypochondrium and gas under the diaphragm. What is the likely diagnosis?
Perforated peptic ulcer
A 67 year old man presents to his GP complaining of lethargy + weight loss. Rectal examination revealed a palpable irregular mass in the rectum. What is the likely cause of this patient having anaemia?
Chronic blood loss
An 82 year old female presents with a large lump which appears at the anus after defecation, & spontaneously on coughing. The lump is uncomfortable & the patient has tenesmus. She also has incontinence + has noticed mucus PR. What is the likely diagnosis?
Rectal prolapse
A 20 year old male presents with painful defecation which persists for 30mins afterwards. The stool is smeared with blood, + he has noticed recent constipation. What is the likely diagnosis?
Anal fissure
A 50 year old female presents with a purulent discharge from the anal region + has recurrent episodes of pain, which is intense + throbbing. O/E pruritis ani. What is the likely diagnosis?
Abscess
40 male presents with PR bleeding & a palpable lump from anus, with associated mucus discharge. There is blood splashed around lavatory pan. What is the likely diagnosis?
Haemorrhoids
Ways to diagnosis H.pylori
Breath test
Serology (IgG antibody against H.pylori)
Stool antigen test
Commonest causes of small bowel obstruction
Adhesions (post-op, surgery)
Hernias
Commonest causes of large bowel obstruction
Malignancy
Volvulus
Ulcerative colitis presents with abdo pain and jaundice - likely diagnosis is….
Always consider primary sclerosing cholangitis.
LFTs may be slightly raised/normal. ALP will be the most raised but even still it can be normal.
E.coli (0157:H7 toxin) is a common cause of
HUS
Oesophageal varices Rx
- terlipressin
- propranolol
- surgery - rubber band ligation, sclerotherapy, balloon therapy
C diff Rx
ciprofloxacin + metronidazole or vancomycin
Triple AAA of 5.2cm on USS, what is the next investigation step?
3 month USS follow-up
Causes of onycholysis
Trauma
Thyrotoxicosis
Psoriasis
Fungal infection
