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Medicine > Gastro/ GI Surg > Flashcards

Gastro/ GI Surg Flashcards

1
Q

GI causes of clubbing

A

Uncommon:

Cirrhosis (especially biliary cirrhosis)
Inflammatory bowel disease
Coeliac disease

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2
Q

Management of anal fissure

A

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

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3
Q

Management of haemorrhoids

A

Conservative

Medical: steroid/ LA ointment or suppository

Surgery

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4
Q

In what % is a cause of UGIB not found on endoscopy?

A

20%

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5
Q

2 most common causes of UGIB

A

PUD and varices

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6
Q

how much more common in UGIB compared with pr bleeding

A

x4

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7
Q

how does UGIB present?

A

haematemesis
coffee-ground vomit
melaena
haematochezia

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8
Q

What to look for on examination of UGIB?

A

Signs of shock
Hydration
Anaemia
Signs of tumours, eg lymphadenopathy

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9
Q

What clinical findings are suggestive of Boerhaave’s?

A

s/c emphysema

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10
Q

Ix for UGIB

A

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

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11
Q

Who should be considered for hospital admission for UGIB?

Name of scores

A

60 years+
witnessed fresh blood/ suspected continued bleeding
haemodynamic disturbance
liver disease or known varices

Blatchford score: first assessment
Rockall: after endoscopy

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12
Q

Mx options for oesophageal varices

A

Terlipressin
Prophylactic abx
Band ligation

if uncontrolled, consider balloon tamponade and TIPS

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13
Q

Most important factor in managing bleeding PUD

A

H.pylori eradication

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14
Q

With rectal bleeding, who to refer for flexi sig and who to refer for colonoscopy?

A

colonoscopy if suspicion of malignancy
virtual colonoscopy is NICE-approved

flexi sig for younger patients with concern about pathology other than haemorrhoids

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15
Q

Who should be referred under 2WW cancer pathway (bowel ca)?

A

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

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16
Q

Causes of acute oesophagitis

A

Immunocompromised
HSV/ CMV (ulceration more common in lower bowel)
Deliberate/ accidental swallowing corrosive substances

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17
Q

Complications of chronic oesophagitis

A

Fibrosis/ strictures
Ulcers may haemorrhage or perforate
Barrett’s oesophagus

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18
Q

What is achalasia?

How does it show on imaging?

A

Loss of coordinated peristalsis of the lower oesophagus and spasm of LOS - preventing passage of contents into stomach
Bird beak

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19
Q

Describe two types hiatus hernia

A

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

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20
Q

How does Boerhaave syndrome differ from MW tear?

A

Transmural oesophageal rupture (vs tear at gastro-oesophageal jct)

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21
Q

Medications that must be taken with sufficient water to avoid GORD

A

NSAIDs and bisphosphonates

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22
Q

What is relationship between GORD and H.pylori?

A

None

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23
Q

Who should be referred on 2WW for upper GI cancer?

A

Dysphagia

Dyspepsia + alarms
Dyspepsia (over 50) + symptoms persistent/ within last 1 year
Dyspepsia + clinical finding or risk factors

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24
Q

Pharmacological mx GORD

A

Trial 1 month PPI

consider if on drugs that slower motility/ exacerbate

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25
Q

Mechanisms contributing to/ causing hiatus hernia

A

Widening of diaphragmatic hiatus
Pulling up of stomach (oesophageal shortening)
Pushing up of stomach (intra-abdominal pressure)

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26
Q

Presentation of sliding hiatus hernia

A

Asymptomatic

Or: heartburn, reflux, difficulty swallowing

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27
Q

Presentation of para-oesophageal hernia

A

Asymptomatic

Or: chest pain, epigastric pain, fullness, nausea, potentially sx of obstruction

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28
Q

Usual surgical procedure for hiatus hernia

A 
laparoscopic fundoplication
(although PPIs preferred mx)
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29
Q

Histology of oesophageal ca (and Barrett’s)

A

Barrett’s = columnar metaplasia

SCC (esp with smoking + alcohol, Barrett’s is precursor), AC (now much-increased)

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30
Q

Causes of acute gastritis

A

Almost always: drugs (esp aspirin), alcohol

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31
Q

Name of gastritis caused by shock, severe burns, toxic substances

A

Acute erosive gastritis

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32
Q

What causes autoimmune chronic gastritis

A 
Pernicous anaemia (autoimmune gastritis + macrocytic anaemia)
Against parietal cells and IF
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33
Q

Shape of H.pylori

A

Gram neg spiral-shaped bacillus

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34
Q

Transmission of H.pylori

A

oral-oral, faecal-oral

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35
Q

What is reactive gastritis? How does it present?

A

Regurg of duodenal contents into stomach through pylorus

Dyspepsia, biliary vomiting

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36
Q

What causes reactive gastritis?

A

Irritants: NSAIDs, alcohol, biliary reflux

or when motility is compromised

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37
Q

What causes acute peptic ulcer disease?

A

Same as acute gastitis

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38
Q

Most common: gastric ulcers or duodenal?

A

Duodenal (x2-3) - clasically exacerbated by hunger

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39
Q

Peptic ulceration is rare without…

A

H.pylori (95% duodenal, 80% gastric)

or NSAID use

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40
Q

How can H.pylori be tested?

A

Urea breath test or stool antigen test

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41
Q

Eradication of H.pylori therapy

A

7-day course: PPI + 2 abx (amoxicillin or clarithromycin or metronidazole)

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42
Q

Usual mx gastric ca

A

Surgery

5 year prognosis (15%)

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43
Q

General pattern for LFTs

A

Pre-hepatic: bilirubin raised

Intrahepatic: bilirubin raised + AST/ ALT raised

Posthepatic: Bilirubin raised + ALP raised

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44
Q

Why is acute pancreatitis so dangerous?

A

Releases exocrine enzymes

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45
Q

Most common causes of acute pancreatitis?

A

Gallbladder disease (blocked bile duct causing back pressure in pancreatic duct)

Excess alcohol

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46
Q

Classic presentation of acute pancreatitis

A

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

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47
Q

Best test for acute pancreatitis

A

Lipase

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48
Q

Ix acute pancreatitis

A

Bloods: FBC, U&Es, LFTs, lipase, glucose, CRP, calcium
(in chronic pancreatitis - lipase often normal)

Imaging: plain erect AXR

Consider USS for gallstones

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49
Q

Scoring systems for acute pancreatitis

A

Glasgow Prognostic Score

Ranson’s score (similar, involves criteria on admission)

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50
Q

Mx acute pancreatitis

A

Fluids + pain relief (pethidine or buprenorphine/ +/- IV benzos)

(IV abx if significant necrosis - mx in ITU/ HDU)

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51
Q

Why is morphine relatively contraindicated in acute pancreatitis?

A

Possible spasm of sphincter of Oddi

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52
Q

Abdominal complications of acute pancreatitis

A

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

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53
Q

Presentation of chronic pancreatitis

A 
Epigastric pain radiating into the back (can be severe: may need opiates)
N&V
Decreased appetite
Exocrine dysfunction
Endocrine dysfunction
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54
Q

What is Courvoisier’s sign?

A

palpable bladder + painless jaundice
usually pancreatic ca
(only in about 25%)

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55
Q

How might pain be treated in palliative care of pancreatic ca?

A

Coeliac plexus block

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56
Q

Tumour marker for pancreatic ca

A

CA19-9

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57
Q

What is hydrogen test for?

A

Bacterial overgrowth in gut

58
Q

Dermatological manifestation of coeliac

A

Dermatitis herpetiformis

59
Q

Who should be screened for coeliac

A

unexplained neuro sx, metabolic bone disorder…lots of others

60
Q

Types of diarrhoea

A

Osmotic
Secretory
Rapid transit

61
Q

Most common source of bacterial food poisoning in UK

A

Campylobacter

62
Q

Hepatic complication related to UC

A

Primary sclerosing cholangitis (5%)

63
Q

Transmission of C.difficile?

A

Faeco-oral

Spores on surfaces

64
Q

Appearance of C.diff

A

Gram-positive rods

REPORTABLE

65
Q

How long after abx therapy does C.diff usually present?

A

5-10 days

sometimes no abx exposure

66
Q

Rovsing’s sign

A

Touch L, pain in R

67
Q

Initial ix for IBD

A

FBC, U&Es, LFTs, CRP, stool culture + microscopy, faecal calprotectin

For UC: also iron studies, B12 and folate

68
Q

Initial ix for IBS

A

FBC, CRP, coeliac screen, CA-125, faecal calprotectin

69
Q

Why do hernias become irreducible?

A

Hernia enlarges. Fibrous adhesions form.

70
Q

Types of inguinal hernia

A

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

71
Q

Presentation of femoral hernia

A

Bump lateral and inferior to pubic tubercle

All should be repaired electively, as soon as possible

72
Q

Define ileus

A

Non-mechanical intestinal obstruction

73
Q

Causes of small bowel obstruction

A

Adhesions (75%), strangulated hernia, malignancy (usually caecal), volvulus

74
Q

Causes of large bowel obstruction

A

Colorectal malignancy, tumours often advanced

75
Q

Initial ix intestinal obstruction

A

FBC, U&Es, group + cross-match

erect AXR

76
Q

Proper name for small bowel ischaemia

A

Mesenteric ischaemia (vs ischaemic colitis) - more acute

77
Q

Causes of bowel ischaemia

A

arterial throboembolism, non-occlusive ischaemia (hypoperfusion, vasospasm), venous thrombosis

78
Q

Where are diverticula most commonly found?

A

Sigmoid and descending colon

but can be anywhere in GI tract

79
Q

Main histology of colorectal ca

A

adenocarcinomas

80
Q

Causes and signs of prehepatic jaundice

A

Haemolysis
Ineffective erythropoiesis
Gilbert’s

Increased unconjugated billi in serum. None in urine: insoluble

81
Q

Causes and signs of hepatic (mixed) jaundice

A 
Hepatitis
Cirrhosis
Autoimmune disease
Weil's disease (bacterial infection spread from rat urine)
Wilson's

Increased clotting time
Increased ALT and AST - hepatocellular damage

82
Q

Causes and signs of post-hepatic jaundice

A 
Pancreatitis
Primary billiary cirrhosis
Gallstones
Drugs
Ca obstructing bile duct

Dark urine, pale stools, itching

Gamma-GT and AP increase (damage to biliary tree)

83
Q

Antibodies is primary biliary cirrhosis

A

antii-mitochondrial antibodies

84
Q

Why are those with Crohn’s susceptible to gallstones?

A

Malabsorption of bile salts from the terminal ileum - can’t deal with cholesterol

85
Q

Innervation of gallbladder

A

T5-9

86
Q

Charcot’s triad

A

Ascending cholangitis:

upper RUQ pain - fever (usually with rigors) - jaundice

87
Q

Bacteria in ascending cholangitis

A

gut bugs: e coli, klebsiella etc

88
Q

Why is gallstone ileus a misnomer?

A

ileus characterised by cessation of normal peristalsis - if a gallstone obstructs the bowel there is vigorous peristalsis in attempt to remove it

89
Q

Ix for ascending cholangitis

A 
FBC 
U&Es
LFTs
Blood cultures
amylase

USS

90
Q

Range of alcoholic liver disease

What is equivalent for NAFLD?

A

Fatty liver
Alcoholic hepatitis
Alcoholic cirrhosis

NAFLD
NASH (non-alcoholic steatohepatitis)
cirrhosis

91
Q

Mx auto-immune hepatitis

A

Pred and immunosuppress given indefinitely

transplantation if ineffective

92
Q

Most common cause of hepatitis worldwide?

A

Hep B

93
Q

Transmission of hep B

A

Sexual
Vertical
Blood-to-blood (inc transfusion)

94
Q

Hepatitis D only present in whom?

A

Those with hep B

95
Q

Inheritance pattern of Wilson’s disease

A

autosomal recessive

96
Q

Ix Wilson’s

A

low serum caeruloplasmin

97
Q

3 classes of liver failure

A

Fulminant hepatic failure (within 8 wks)
Late-onset hepatic failure (under 6 months)
Chronic decompensated hepatic failure (6 months+)

98
Q

Pre-hepatic causes of portal HTN

A

Portal vein thrombosis
AV fistula
Increased splenic bloodflow

99
Q

Hepatic causes of portal HTN

A

Cirrhosis

100
Q

Post-hepatic causes HTN

A

Budd-Chiari (hepatic vein obstruction)

101
Q

How does portal HTN led to pancytopenia?

A

Splenomegaly/ hypersplenism

102
Q

Should someone with hepatic encephalopathy reduce protein intake?

A

nah

103
Q

Role of neomycin in hepatic encephalopathy

A

Reduces nitrogen-producing bacteria

104
Q

What is bile duct cancer called?

A

cholangiocarcinoma

105
Q

A focal lesion in liver of someone with cirrhosis is highly likely to be what?

A

HCC

106
Q

Jaundice + pain suggests…

A

Gallstones

107
Q

Specific ix for autoimmune hepatitis

A

Immunoglobulins
IgG if acute
IgM if chronic

108
Q

Infective causes of hepatomegaly

A 
Viral hep
EBV
CMV
Malaria
Helminths
109
Q

Congestive/ vascular causes of hepatomegaly

A

RVF/ CCF
Constrictive pericarditis
Budd-Chiari synrome

110
Q

Autoimmune causes of hepatomegaly

A

autoimmune liver disease!

111
Q

Haematological causes of hepatomegaly

A 
thalasseaemia
SCD
other haemolytic anaemia
myeloma
leukaemia
112
Q

Tumours and infiltrative causes of hepatomegaly

A

all!

113
Q

Metabolic causes of hepatomegaly

A

haemochromatosis
Wilson’s
porphyria
NAFLD

114
Q

Toxic-related causes of hepatomegaly

A

alcoholic liver disease

drug-induced hepatitis

115
Q

Low WCC in liver disease suggests

A

viral hep

116
Q

What do ALT and AST show?

A

hepatocellular damage

ALT more specific for liver, AST is also skeletal/ cardiac

117
Q

What does ALP show?

A

From bile ducts - cholestasis

also bone

118
Q

Steps for presenting AXR

11 steps + finish

A
  1. Pt details/ indication/ presenting complaint
  2. Projection (usually AP)
  3. Technical adequacy: should show whole abdomen, hemidiaphragms to pubis symphysis
  4. Obvious abnormalities
  5. 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
  6. Pneumoperitoneum?
  7. Liver, gallbladder, spleen
  8. Urinary tract
  9. Major vasculature
  10. Skeleton
  11. Iatrogenic abnormalities

END: Request previous imaging, suggest ddx and ix

119
Q

Only indications for AXR

A

acute abdo ?obstruction

acute exacerbation IBD/ similar ?megacolon

120
Q

Causes of pneumperitoneum

A

perf
recent laparotomy
intra-abdo infection with gas-forming bug

121
Q

What analgesia is given for gastroscopy?

A 
LA spray (back of throat) or lozenge
sedative
122
Q

Practical steps in explaining gastroscopy

A

Lie on side
mouth guard
filled with air (might make you belch!)
takes ~10 mins but expect to be in hosp about 2 hours

123
Q

What preparation is needed for gastroscopy?

A

no food 4-6 hours, sips water

Someone to take home, if sedative

124
Q

What is MRCP?

A

uses MRI to produce images of liver, gallbladder, bile ducts, pancreas
with contrast

125
Q

What is ERCP?

A

Endoscope + x-rays to look at bile duct and pancreatic duct

can remove gallstones, take biopsies

126
Q

Who is invited to bowel screening?

A

55+ (some areas - one-off flexi sig)

60-74 home FOB test every 2 years

75+ call to opt-in

127
Q

How far does flexi sig go? Colonoscopy?

A

Splenic flexure, ileo-caecal valve

128
Q

What happens during CT colonoscopy?

A

Usually contrast swallowed

tube in bum to fill a little with gas

129
Q

What is an ileo-anal pouch?

A

new rectum following colectomy to store poop

130
Q

where does colostomy sit/ ileostomy

A

c: LIF - flush with skin
i: RIF - spout

131
Q

how to remove surgical drains?

A

2 cm per day, slowly allowing to heal

may cause discomfort, may need analgesia

132
Q

What causes reactive bleeding?

A

Bleeding within 24h op

Pt usually hypotensive and relatively vasoconstricted. When BP rises, bleeding can occur

133
Q

what is dumping syndrome

A

complication of gastrectomy
fullness (even after eating small amounts cramps, pain, N&V, severe diarrhoea, autonomic
quickly dumps into small intestine

134
Q

dysphagia: OGD or barium swallow?

A

OGD if solids only

barium if liquids too

135
Q

what gives a corkscrew oesophagus appearance on barium swallow?

A

diffuse oesophageal spasm

136
Q

What is mirizzi syndrome?

A

Gallstones become impacted - obstructive jaundice ensues

137
Q

what is pellagra? sx?

A

Dermatitis, diarrhoea, dementia/delusions, leading to death

niacin (b3) deficiency

138
Q

when should alginates be given?

A

2 hours after meds so not to cause absorption problems

139
Q

examples of dopamine-receptor anti-emitics. when are these best?
when should not be given?

A

metoclopramide, domperidone
pro-kinetic
risk of EPSE (kids, young adults). not in perf or GI obstruction

140
Q

examples of histamine-receptor anti-emitics. when are these best?
when should not be given?

A

cyclizine, promethazine
N&V, esp vertigo/ motion sickness
anticholinergic side-effects so no BPH, also hepatic encephalopathy

141
Q

examples serotonin-receptor anti-emetics. when best?

A

ondansetron, best following chemo/ GA

causes prlonged QT

Medicine (30 decks)

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