Gastro/ GI Surg Flashcards
GI causes of clubbing
Uncommon:
Cirrhosis (especially biliary cirrhosis)
Inflammatory bowel disease
Coeliac disease
Management of anal fissure
Conservative: high fibre diet/ lactulose to allow to heal
Medical: steroid/LA suppositories before opening bowels - GTN ointment to relieve anal muscle spasm pain
Surgical
Management of haemorrhoids
Conservative
Medical: steroid/ LA ointment or suppository
Surgery
In what % is a cause of UGIB not found on endoscopy?
20%
2 most common causes of UGIB
PUD and varices
how much more common in UGIB compared with pr bleeding
x4
how does UGIB present?
haematemesis
coffee-ground vomit
melaena
haematochezia
What to look for on examination of UGIB?
Signs of shock
Hydration
Anaemia
Signs of tumours, eg lymphadenopathy
What clinical findings are suggestive of Boerhaave’s?
s/c emphysema
Ix for UGIB
Endoscopy:
immediately after resus if severe acute
everyone else within 24h
FBC (seially every 4-6h to check Hb trend)
Cross-match (usually 4-6 units)
Coagulation profile
LFTs
U&Es
Ca: detect hyperparathyroidism and monitor effects of blood transfusion
Gastrin: rule out gastrinoma
CXR: identify aspiration pneumonia, pleural effusion, perforated oesophagus
Erect + supine AXR: perforated viscus and ileus
Consider other imaging
Who should be considered for hospital admission for UGIB?
Name of scores
60 years+
witnessed fresh blood/ suspected continued bleeding
haemodynamic disturbance
liver disease or known varices
Blatchford score: first assessment
Rockall: after endoscopy
Mx options for oesophageal varices
Terlipressin
Prophylactic abx
Band ligation
if uncontrolled, consider balloon tamponade and TIPS
Most important factor in managing bleeding PUD
H.pylori eradication
With rectal bleeding, who to refer for flexi sig and who to refer for colonoscopy?
colonoscopy if suspicion of malignancy
virtual colonoscopy is NICE-approved
flexi sig for younger patients with concern about pathology other than haemorrhoids
Who should be referred under 2WW cancer pathway (bowel ca)?
Age 40+ with unexplained weight loss and abdo pain
Age 50+ with unexplained rectal bleeding
Age 60+ with iron-deficiency anaemia or change in bowel habit
Causes of acute oesophagitis
Immunocompromised
HSV/ CMV (ulceration more common in lower bowel)
Deliberate/ accidental swallowing corrosive substances
Complications of chronic oesophagitis
Fibrosis/ strictures
Ulcers may haemorrhage or perforate
Barrett’s oesophagus
What is achalasia?
How does it show on imaging?
Loss of coordinated peristalsis of the lower oesophagus and spasm of LOS - preventing passage of contents into stomach
Bird beak
Describe two types hiatus hernia
Sliding: gastro-oesophageal jct slides through hiatus and sits above diaphragm (more common)
Rolling (para-oesophageal): part of fundus rolls up next to oesophagus - usually requires surgical correction to avoid strangulation
How does Boerhaave syndrome differ from MW tear?
Transmural oesophageal rupture (vs tear at gastro-oesophageal jct)
Medications that must be taken with sufficient water to avoid GORD
NSAIDs and bisphosphonates
What is relationship between GORD and H.pylori?
None
Who should be referred on 2WW for upper GI cancer?
Dysphagia
Dyspepsia + alarms
Dyspepsia (over 50) + symptoms persistent/ within last 1 year
Dyspepsia + clinical finding or risk factors
Pharmacological mx GORD
Trial 1 month PPI
consider if on drugs that slower motility/ exacerbate
Mechanisms contributing to/ causing hiatus hernia
Widening of diaphragmatic hiatus
Pulling up of stomach (oesophageal shortening)
Pushing up of stomach (intra-abdominal pressure)
Presentation of sliding hiatus hernia
Asymptomatic
Or: heartburn, reflux, difficulty swallowing
Presentation of para-oesophageal hernia
Asymptomatic
Or: chest pain, epigastric pain, fullness, nausea, potentially sx of obstruction
Usual surgical procedure for hiatus hernia
laparoscopic fundoplication (although PPIs preferred mx)
Histology of oesophageal ca (and Barrett’s)
Barrett’s = columnar metaplasia
SCC (esp with smoking + alcohol, Barrett’s is precursor), AC (now much-increased)
Causes of acute gastritis
Almost always: drugs (esp aspirin), alcohol
Name of gastritis caused by shock, severe burns, toxic substances
Acute erosive gastritis
What causes autoimmune chronic gastritis
Pernicous anaemia (autoimmune gastritis + macrocytic anaemia) Against parietal cells and IF
Shape of H.pylori
Gram neg spiral-shaped bacillus
Transmission of H.pylori
oral-oral, faecal-oral
What is reactive gastritis? How does it present?
Regurg of duodenal contents into stomach through pylorus
Dyspepsia, biliary vomiting
What causes reactive gastritis?
Irritants: NSAIDs, alcohol, biliary reflux
or when motility is compromised
What causes acute peptic ulcer disease?
Same as acute gastitis
Most common: gastric ulcers or duodenal?
Duodenal (x2-3) - clasically exacerbated by hunger
Peptic ulceration is rare without…
H.pylori (95% duodenal, 80% gastric)
or NSAID use
How can H.pylori be tested?
Urea breath test or stool antigen test
Eradication of H.pylori therapy
7-day course: PPI + 2 abx (amoxicillin or clarithromycin or metronidazole)
Usual mx gastric ca
Surgery
5 year prognosis (15%)
General pattern for LFTs
Pre-hepatic: bilirubin raised
Intrahepatic: bilirubin raised + AST/ ALT raised
Posthepatic: Bilirubin raised + ALP raised
Why is acute pancreatitis so dangerous?
Releases exocrine enzymes
Most common causes of acute pancreatitis?
Gallbladder disease (blocked bile duct causing back pressure in pancreatic duct)
Excess alcohol
Classic presentation of acute pancreatitis
Severe upper abdo pain: sudden onset with vomiting
Sometimes more L-sided, sometimes encircles abdo. Often penetrates to the back.
Dehydrated
Maybe jaundice (esp common bile duct obstruction) Maybe Cullen's/ Grey Turner's
Hypoxia is characteristic
Pain steadily decreases over 72h
Best test for acute pancreatitis
Lipase
Ix acute pancreatitis
Bloods: FBC, U&Es, LFTs, lipase, glucose, CRP, calcium
(in chronic pancreatitis - lipase often normal)
Imaging: plain erect AXR
Consider USS for gallstones
Scoring systems for acute pancreatitis
Glasgow Prognostic Score
Ranson’s score (similar, involves criteria on admission)
Mx acute pancreatitis
Fluids + pain relief (pethidine or buprenorphine/ +/- IV benzos)
(IV abx if significant necrosis - mx in ITU/ HDU)
Why is morphine relatively contraindicated in acute pancreatitis?
Possible spasm of sphincter of Oddi
Abdominal complications of acute pancreatitis
Pancreatic necrosis (raising CRP)
Acute fluid collections (usually spontaneously resolve)
Pancreatic abscess (needs surgical drainage)
Pseudo-cyst (pancreatic juice in a wall of fibrous/ granulation tissue): can rupture/ haemorrhage
Presentation of chronic pancreatitis
Epigastric pain radiating into the back (can be severe: may need opiates) N&V Decreased appetite Exocrine dysfunction Endocrine dysfunction
What is Courvoisier’s sign?
palpable bladder + painless jaundice
usually pancreatic ca
(only in about 25%)
How might pain be treated in palliative care of pancreatic ca?
Coeliac plexus block
Tumour marker for pancreatic ca
CA19-9
What is hydrogen test for?
Bacterial overgrowth in gut
Dermatological manifestation of coeliac
Dermatitis herpetiformis
Who should be screened for coeliac
unexplained neuro sx, metabolic bone disorder…lots of others
Types of diarrhoea
Osmotic
Secretory
Rapid transit
Most common source of bacterial food poisoning in UK
Campylobacter
Hepatic complication related to UC
Primary sclerosing cholangitis (5%)
Transmission of C.difficile?
Faeco-oral
Spores on surfaces
Appearance of C.diff
Gram-positive rods
REPORTABLE
How long after abx therapy does C.diff usually present?
5-10 days
sometimes no abx exposure
Rovsing’s sign
Touch L, pain in R
Initial ix for IBD
FBC, U&Es, LFTs, CRP, stool culture + microscopy, faecal calprotectin
For UC: also iron studies, B12 and folate
Initial ix for IBS
FBC, CRP, coeliac screen, CA-125, faecal calprotectin
Why do hernias become irreducible?
Hernia enlarges. Fibrous adhesions form.
Types of inguinal hernia
INDIRECT: 80% - protrusion through internal inguinal ring (usually failure of inguinal canal to close properly) - runs LATERALLY to inferior epigastric vessels
DIRECT: hernia protrudes directly through weakness in posterior wall of inguinal canal - more common in elderly, v rare in kids - runs MEDIALLY to inferior epigastric vessels
Presentation of femoral hernia
Bump lateral and inferior to pubic tubercle
All should be repaired electively, as soon as possible
Define ileus
Non-mechanical intestinal obstruction
Causes of small bowel obstruction
Adhesions (75%), strangulated hernia, malignancy (usually caecal), volvulus
Causes of large bowel obstruction
Colorectal malignancy, tumours often advanced
Initial ix intestinal obstruction
FBC, U&Es, group + cross-match
erect AXR
Proper name for small bowel ischaemia
Mesenteric ischaemia (vs ischaemic colitis) - more acute
Causes of bowel ischaemia
arterial throboembolism, non-occlusive ischaemia (hypoperfusion, vasospasm), venous thrombosis
Where are diverticula most commonly found?
Sigmoid and descending colon
but can be anywhere in GI tract
Main histology of colorectal ca
adenocarcinomas
Causes and signs of prehepatic jaundice
Haemolysis
Ineffective erythropoiesis
Gilbert’s
Increased unconjugated billi in serum. None in urine: insoluble
Causes and signs of hepatic (mixed) jaundice
Hepatitis Cirrhosis Autoimmune disease Weil's disease (bacterial infection spread from rat urine) Wilson's
Increased clotting time
Increased ALT and AST - hepatocellular damage
Causes and signs of post-hepatic jaundice
Pancreatitis Primary billiary cirrhosis Gallstones Drugs Ca obstructing bile duct
Dark urine, pale stools, itching
Gamma-GT and AP increase (damage to biliary tree)
Antibodies is primary biliary cirrhosis
antii-mitochondrial antibodies
Why are those with Crohn’s susceptible to gallstones?
Malabsorption of bile salts from the terminal ileum - can’t deal with cholesterol
Innervation of gallbladder
T5-9
Charcot’s triad
Ascending cholangitis:
upper RUQ pain - fever (usually with rigors) - jaundice
Bacteria in ascending cholangitis
gut bugs: e coli, klebsiella etc
Why is gallstone ileus a misnomer?
ileus characterised by cessation of normal peristalsis - if a gallstone obstructs the bowel there is vigorous peristalsis in attempt to remove it
Ix for ascending cholangitis
FBC U&Es LFTs Blood cultures amylase
USS
Range of alcoholic liver disease
What is equivalent for NAFLD?
Fatty liver
Alcoholic hepatitis
Alcoholic cirrhosis
NAFLD
NASH (non-alcoholic steatohepatitis)
cirrhosis
Mx auto-immune hepatitis
Pred and immunosuppress given indefinitely
transplantation if ineffective
Most common cause of hepatitis worldwide?
Hep B
Transmission of hep B
Sexual
Vertical
Blood-to-blood (inc transfusion)
Hepatitis D only present in whom?
Those with hep B
Inheritance pattern of Wilson’s disease
autosomal recessive
Ix Wilson’s
low serum caeruloplasmin
3 classes of liver failure
Fulminant hepatic failure (within 8 wks)
Late-onset hepatic failure (under 6 months)
Chronic decompensated hepatic failure (6 months+)
Pre-hepatic causes of portal HTN
Portal vein thrombosis
AV fistula
Increased splenic bloodflow
Hepatic causes of portal HTN
Cirrhosis
Post-hepatic causes HTN
Budd-Chiari (hepatic vein obstruction)
How does portal HTN led to pancytopenia?
Splenomegaly/ hypersplenism
Should someone with hepatic encephalopathy reduce protein intake?
nah
Role of neomycin in hepatic encephalopathy
Reduces nitrogen-producing bacteria
What is bile duct cancer called?
cholangiocarcinoma
A focal lesion in liver of someone with cirrhosis is highly likely to be what?
HCC
Jaundice + pain suggests…
Gallstones
Specific ix for autoimmune hepatitis
Immunoglobulins
IgG if acute
IgM if chronic
Infective causes of hepatomegaly
Viral hep EBV CMV Malaria Helminths
Congestive/ vascular causes of hepatomegaly
RVF/ CCF
Constrictive pericarditis
Budd-Chiari synrome
Autoimmune causes of hepatomegaly
autoimmune liver disease!
Haematological causes of hepatomegaly
thalasseaemia SCD other haemolytic anaemia myeloma leukaemia
Tumours and infiltrative causes of hepatomegaly
all!
Metabolic causes of hepatomegaly
haemochromatosis
Wilson’s
porphyria
NAFLD
Toxic-related causes of hepatomegaly
alcoholic liver disease
drug-induced hepatitis
Low WCC in liver disease suggests
viral hep
What do ALT and AST show?
hepatocellular damage
ALT more specific for liver, AST is also skeletal/ cardiac
What does ALP show?
From bile ducts - cholestasis
also bone
Steps for presenting AXR
11 steps + finish
- Pt details/ indication/ presenting complaint
- Projection (usually AP)
- Technical adequacy: should show whole abdomen, hemidiaphragms to pubis symphysis
- Obvious abnormalities
- BOWEL
Large (has partial haustra): start at rectum
a) bowel diameter (~6 cm, except caecum)
b) bowel wall thickness
Small bowel (has full width valvulae conniventes)
a) bowel diameter (~3 cm)
b) bowel wall thickness - Pneumoperitoneum?
- Liver, gallbladder, spleen
- Urinary tract
- Major vasculature
- Skeleton
- Iatrogenic abnormalities
END: Request previous imaging, suggest ddx and ix
Only indications for AXR
acute abdo ?obstruction
acute exacerbation IBD/ similar ?megacolon
Causes of pneumperitoneum
perf
recent laparotomy
intra-abdo infection with gas-forming bug
What analgesia is given for gastroscopy?
LA spray (back of throat) or lozenge sedative
Practical steps in explaining gastroscopy
Lie on side
mouth guard
filled with air (might make you belch!)
takes ~10 mins but expect to be in hosp about 2 hours
What preparation is needed for gastroscopy?
no food 4-6 hours, sips water
Someone to take home, if sedative
What is MRCP?
uses MRI to produce images of liver, gallbladder, bile ducts, pancreas
with contrast
What is ERCP?
Endoscope + x-rays to look at bile duct and pancreatic duct
can remove gallstones, take biopsies
Who is invited to bowel screening?
55+ (some areas - one-off flexi sig)
60-74 home FOB test every 2 years
75+ call to opt-in
How far does flexi sig go? Colonoscopy?
Splenic flexure, ileo-caecal valve
What happens during CT colonoscopy?
Usually contrast swallowed
tube in bum to fill a little with gas
What is an ileo-anal pouch?
new rectum following colectomy to store poop
where does colostomy sit/ ileostomy
c: LIF - flush with skin
i: RIF - spout
how to remove surgical drains?
2 cm per day, slowly allowing to heal
may cause discomfort, may need analgesia
What causes reactive bleeding?
Bleeding within 24h op
Pt usually hypotensive and relatively vasoconstricted. When BP rises, bleeding can occur
what is dumping syndrome
complication of gastrectomy
fullness (even after eating small amounts cramps, pain, N&V, severe diarrhoea, autonomic
quickly dumps into small intestine
dysphagia: OGD or barium swallow?
OGD if solids only
barium if liquids too
what gives a corkscrew oesophagus appearance on barium swallow?
diffuse oesophageal spasm
What is mirizzi syndrome?
Gallstones become impacted - obstructive jaundice ensues
what is pellagra? sx?
Dermatitis, diarrhoea, dementia/delusions, leading to death
niacin (b3) deficiency
when should alginates be given?
2 hours after meds so not to cause absorption problems
examples of dopamine-receptor anti-emitics. when are these best?
when should not be given?
metoclopramide, domperidone
pro-kinetic
risk of EPSE (kids, young adults). not in perf or GI obstruction
examples of histamine-receptor anti-emitics. when are these best?
when should not be given?
cyclizine, promethazine
N&V, esp vertigo/ motion sickness
anticholinergic side-effects so no BPH, also hepatic encephalopathy
examples serotonin-receptor anti-emetics. when best?
ondansetron, best following chemo/ GA
causes prlonged QT
