Gastro for long case Flashcards

1
Q

Smoking related complications

A

IHD

Peripheral vascular disease

Berger’s disease of the peripheries

Carcinoma of lung, head and neck, bladder, oesophagous, colon, renal

Osteoporosis in women

Erectile dysfunction in men

Peptic ulcers

Polycythemia

?Tobacco-alcohol amylopia

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2
Q

Side effects of chronic alcoholism

A

Cognitive impairment

Wernike’s encephalopathy

Poor personal hygiene

Obesity/malnutrition

Midline cerebellar ataxia

Dilated cardiomyopathy

Recurrent pneumonia, TB

Pancreatitis

Cirrhosis, hepatitis

Parotid gland swelling

Carcinoma of the head, neck and esophagous

AF

Dupuytren’s contractures

Poor dentition

Easy bruising

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3
Q

History for chronic alcoholism

A

Type of alcohol, duration, amount, frequency

Family and coping

CAGE - C-wanting/told to cut down, A-others annoyed by intake, G- guilt, E - morning eye opener

Smoker, IVDU, marijuana

Depression, previous suicide attempts, current suicidal ideation

Occupational stressors

Criminal history - loss of driver’s licence, dangerous activity drinking

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4
Q

Chronic liver disease history

A

Mode of acquisition -History of Hep B/C, sexual activity, alcohol IVDU

Previous haematemesis and malaena

Prior scopes, ?HCC

Hypogonadism - lack of libido

Swelling of abdomen and ankles

History of haemachromatosis or autoimmune hepatitis

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5
Q

Chronic liver disease exam

A

Cognitive screen for encephalopathy

Asterixis

Wasting, jaundice, faetor hepaticus

Spider naevi, gynaecomastia

Terry’s nails, Duputren’s contracture, leukonychia

Testicular atrophy

Hyperreflexia (encephalopathy)

Portopulmonary hypertension w/ RHF

Fevers and peritonitis

Oligouria and dehydration

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6
Q

Alcohol examination

A

Signs of alcohol withdrawal - tremor, tachycardia, anxiety

GI examination ?cirrhosis ?pancreatitis

AF and CCF

Werneke’s

Peripheral neuropathy

Lymphadenopathy (?cancer)

Respiratory exam (?pneumonia)

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7
Q

Complications of IBD

1) Local
2) Liver
3) Haematological
4) Joints
5) Skin
6) Ocular
7) Renal and bone

A

1) Ulcerative colitis - Toxic megacolon (colon diameter >6cm on AXR), perforation, massive haemorrhage, strictures, carcinoma of colon)

Crohn’s - Anorectal disease (anal fissures/fistulae, pararectal abscess, rectovaginal fistula), terminal ileal obstruction, fistula, toxic megacolon, carcinoma of small and large bowel

2) Fatty liver, primary sclerosing cholangitis, cirrhosis, carcinoma of bile duct, amyloidosis

Crohn’s - gallstones more common, PSC less common

3) Anaemia - chronic disease, iron deficiency, ileal involvement, haemolysis from sulfazalazine or microangiopathy), thromboembolism - antithrombin III deficiency, stasis, dehydration
4) Oligoarthritis (large joints), ankylosing spondylitis
5) Erythema nodosum, pyoderma gangrenosum, aphthus ulcers
6) Uveitis, conjunctivitis, episcleritis
7) Crohn’s - urate and calcium oxalate stones, pyelonephritis, hydronephrosis, amyloidosis; malabsorption from small bowel resection, subsequent osteomalacia

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8
Q

History for IBD

A

Symptoms of bloody diarrhoea, malaise, fever and weightloss

Colonic - history of fistulae, anal fissures or abscesses, toxic megacolon and resection, strictures and repairs, carcinoma of large bowel

Extracolonic manifestations - Joint pain, back pain, eye pain, RUQ pain, PHx DVT, renal stones, gallstones and colecystectomy, fractures, UTIs and renal infections

Sexual preference, anal trauma, radiation, smoking, alcohol

Meds - NSAIDs, retinoic acid, oral contraceptives

Colonoscopies, investigations, hospital admissions, surgeries

Current treatment - sulfasalazine, 5-ASA, budesonide, metronidazole, immunosuppressants (azathioprine), infliximab or adalimumab

Prior antibiotics possibility of pseudomembranous/c. diff colitis

Employment, living

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9
Q

Issues and management for IBD

A

Exclude infection - amoebiasis, Shigella/salmonella/Yersinia, Campylobacter, E. coli, 0157:H7, C diff colitis, lymphogranuloma venereum, gonorrhoea and syphilis;

Immunocompromised infection - herpes, CMV, cryptosporidium, isospora belli, TB (can mimic crohn’s disease)

Determine severity -mild (<4motions, minimal blood, afebrile), severe(>6motions, bleeding, febrile, abdominal tenderness), fulminant (>10, distension, fever, tachy); need AXR, ESR, alb, CRP, FBE

LFT, UEC for renal function, liver involvement, iron and folate levels, potassium

Colonoscopy - granulomas 25% in crohn’s disease, crypt abscess formation in UC (avoid barium enema in severe cases)

anti saccharomyces cerevisiae positive and pANCA negative (crohn’s)

IV sterioids in severe UC -/+ cyclosporin (cyclosporin is ineffective in crohn’s), may require surgery for toxic megacolon

Sulfasalazine - to reduce UC relapse rate; topical preparation for proctitis

Steroids do not reduce relapse rates

Azathioprine required for steroid sparing agent if repeated episodes (methotrexate considered only in Crohn’s, ineffective in UC)

Infliximab for refractory cases or fistula (SE: lymphoproliferative disease, TB, demyelination)

Surgery - total colectomy

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10
Q

Other causes of colitis - non IBD

A

Infections, c. diff colitis

Ischaemic colitis

Radiation

Toxic exposure - peroxideor soapsud enemas, gold induced colitis

Microscopic or collagenous colitis

Lymphocytic colitis

Diversion colitis - colonic loops excluded from faecal stream

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11
Q

Management of colorectal Ca

A

Investigations - ALP, CTCAP colonoscopy/sigmoidoscopy, transrectal ultrasound, MRI and PET

Follow up colonoscopy 1 month following stenosed carcinoma to look for synchronous tumours; 1 yearly colonoscopies following

Dukes A and B - mucosa/submucosa or muscularis- surgery

Dukes C - lymph node involvement - adjuvant chemotherapy with 5-fluorouracil and leucovorin and oxaliplatin

Dukes D - palliative surgery and/or chemotherapy

Rectal carcinoma may benefit from neo-adjuvant chemotherapy (prior to surgery)

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