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Finals > Gastro/Hep > Flashcards

Gastro/Hep Flashcards

1
Q

What peptide component is coeliac immune response against?

A
  • gliadin in gluten
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2
Q

What genetic component is coeliac

A

HLA- DQ2

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3
Q

sx coeliac

A
  • triggered by eating gluten
  • bloating, cramping, abdo pain
  • N+V
  • diarrhoea, steatorrhea, constipation
  • flatulence
  • malabs- OP, anaemia, faltering growth, wt loss, mouth ulcers
  • *****Neuro:
  • ataxia
  • peripheral neuropathy
  • epilepsy
  • dementia
  • encephalopathy
  • chorea
  • GBS- like syndrome
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4
Q

what is dermatitis herpetiformis- sx , cause

A

NOT herpetic infection of eczema

  • clustering blisters, resembling herpes simplex
  • flat patches, thickened plaques, blistering, petechiae
  • often symmetrical
  • immune response triggered by gliadin
  • depositiion of immunoglobulin A (IgA) in the skin,
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5
Q

ix coeliac

A

Autoantibody test

  • eat gluten diet for 6-8 weeks
  • total Ig A
  • tranglutaminase
  • deamidated gliadin peptide antibodies
  • anti-endomysial antibody!!!!
  • gluten free diet trial
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6
Q

tx coeliac

A
  • lifelong gluten free diet- wheat, spelt, rye, barley, bread, pasta, cerelas, beer, cakes, cookies, pastries
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7
Q

histology of coeliac

A
  • crypt hyperplasia
  • itraepithelial WBC
  • villous atorphy
  • reduced duodenal folds
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8
Q

tx dermatitis herpetiformis

A

topical dapsone

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9
Q

genetic causes of colorectal cancers

A
  • sporadic
  • adenomatous polyposis coli mutation (tumour supressor) (polyp–> K-RAS and p53 mutation–> malignancy)
  • Hereditary Nonpolyposis Colorectal Cancer
  • mutations in DNA repair genes
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10
Q

stages of colorectal cancer

A

TNM
1- in situ, not passed mucosa
2. beyond mucosa, into muscle

    • invasion of whole colonic/rectal wall
    • may reach nearby organs
    • no lymph node involvement
  2. spread to lymph nodes
  3. metastatic to distant organs (liver, lungs)
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11
Q

sx of colorectal cancer

A
  • haematochezia
  • changes in frequency, consistency of bowel movements
  • anaemia
  • unexplained wt loss
  • N+V
  • fatigue
  • abdo pain
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12
Q

sx of cancer in ascending colon

A

Ascending

  • no obstruction as wider lumen and exophytic growth
  • faces are liquid in this part of the bowel
  • darker stool- blood is mixed in with the stool
  • poorer prognosis, later presentation

PC

  • anaemia
  • palpable mass
  • perforation- sepsis, peritonitis, abscess
  • obstruction unlikely
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13
Q

sx of cancer in descending colon

A
  • constipation
  • ribbon stools- thin
  • blood- bright, in or out of stool
  • DRE- tumour mass
  • tenesmus- incomplete emptying
  • intussusception

tumours are endophytic- ring around wall, into lumen, and the stool is more solid, and the lumen is thinner here- so obstruction is more likely to occur

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14
Q

ix ?colorectal cancer

A
  • FBC- anaemia
  • LFT, UE, clotting lover- common mets sites
  • FIT test
  • *- CA199- elevated in bowel, pancreas, oesophageal, hepatocellular
  • **- CEA tumour marker- infections, IBD, cirrhosis, chronic smoking, cancer, for monitoring disease only, no diagnosis
  • colonoscopy with biopsy

if pt doesnt want colonoscopy

  • barium enema (apple core sign
  • CT colonography
  • CT for staging
  • *- strep gallolyticus- assoc cancer
  • if emergency (perf, obstruction)- AXR, CT
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15
Q

management of colorectal cancer

A
  • resection
  • lymph node resection
  • mets resection
  • pre and post op CT

Emergency presentation
- resection and colostomy with delayed anastomosis ie hartmann’s

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16
Q

NICE 2ww for ?colorectal cancer

A
  • > 40 unexplained wt loss AND abdo pain
  • > 50 unexplained wt loss and rectal bleeding
  • > 60 with unexplained anaemia OR changed bowel habits
  • occult blood in stool

Consider in

  • rectal or abdo mass
  • > 50 with rectal bleeding AND abdo pain/changed bowel habits/wt loss/ iron anaemia
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17
Q

who is offered a FIT test

A

> 50 with one of

  • abdo pain
  • wt loss
  • changed bowel habits
  • Fe anaemia

> 60 with any kind of anaemia

screening- 60-74yo every 2 years
>75yo can request

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18
Q

what are hemicolectomies

A
  • whole + top of ascending (R)

- whole and top of descending (L) bowel is resected

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19
Q

what is a high anterior resection

A
  • sigmoid colon resected +- upper rectum
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20
Q

what is a low anterior resection

A
  • rectum/part of rectum is removed and colon is joined to remaining rectum
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21
Q

what is a abdominoperianal resection

A
  • anus, rectum and sigmoid colon is removed (will need permanent end colostomy bag)
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22
Q

What is a loop ileostomy/colostomy

A
  • colonostomy bag is put in bowel before the site of an anastomosis (from bowel resection op)
  • loop= bowel doesnt end at the bag
  • to prevent stool from passing over the wound, allows healing
  • stoma RIF= ileostomy
  • stoma LIF= colostomy
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23
Q

what is a hartmanns procedure

A
  • sigmoid resected
  • no anastomosis put in
  • end colostomy created– bowel feeds into bag, no tjoining to rectum
  • can be reversed and anatsomosed with remaining rectum at a later date
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24
Q

what is a permanent end colostomy/ileostomy

A
  • no colon or rectum left to anastomose to
  • done after full colectomy (ileostomy)
  • done after abominoperineal resection (colostomy)
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25
Q

What is the screening for colorectal cancer

A
  • 55yo- one off sigmoidoscopy
  • 60-74- FIT every 2 years
  • positive FIT- colonoscopy
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26
Q

describe the anatomy of the biliary tree

A

left hepatic and right hepatic ducts

  • combine into common hepatic
  • the cystic duct comes from the gall bladder and joins the common hepatic duct
  • the duct is now named the common bile duct
  • the pancreatic duct combined with the common bile duct
  • this duct drains into the duodenum at the ampulla of vater
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27
Q

what does the pancreas produce

A

Pancreatic juice ;)

  • alkalanie bicarbonate
  • anzymes- trypsin, lipase, amylase- digestion of protein, fat, and CHO respectively

Bile

  • bile salts- colic acid, chenodeochycholic acid- fat digestion (faaty acids and glycerol) and fat soluble vits
  • phospholipids
  • cholesterol
  • proteins
  • bilirubin- waste
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28
Q

how is GB emptying stimulated

A
  • duodenum fills with food

- produces Cholecystokinin (CCK) in response to fatty foods

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29
Q

describe the bilirubin ccyle

A
  • red cell destruction (spleen), heme protein catabolism and bone marrow erythropoeisis–> unconjugated bilirubin
    Liver takes this up and either:
  • converts it into urobilinogen and release back into BS, excreted by kidneys
  • conjugates it and released it into bile, stored in GB and excreted into gut via biliary tree
  • conjugated bilirubin now in small intestine
  • converted by bacterial proteases into urobilinogen
  • urobininogen excrete either in faeces (sterobilin), in urine (urobilin) or reabsorbed into portal vein and back into circulation
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30
Q

what types of gallstones are there

A

Cholesterol-

  • most common
  • large
  • radiolucent

Pigment

  • Black bile pigments from Hb, small, radiolucent –>RF- haemolysis (sickle cell, spherocytosis, thalassaemia)
  • Brown pigment- stasis and infection in biliary system (E.coli, klebsiella)

Ca bilirubinate and Ca carbonate 0 radiopaque

Mixed stones- 10% radiopaque

Overall, only 20% of stones are raiopaque

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31
Q

sx of biliary stones

A

Biliary colic

  • sudden pain in epigastric/RUQ region
  • radiates around to back in interscapular region
  • theroretically- pain flactuates, in reality, it doesnt tend to
  • persists for 15mins-1d
  • N+V

Cholecystitis sx

  • RUQ pain radiates to shoulder (diaphragm- phrenic)
  • Murphy’s sign
  • Local peritonism
  • GB mass, distemntion
  • N+V
  • flatulence
  • fat intolerance (vomiting

Obstructive jaundice- if stone in common cystic bile duct

  • Jaundice
  • puritis
  • dark urine
  • pale stools

Pancreatitis- epigastric/umbilical pain, radiates to shoulder, diarrhoea

Cholangitis- Carchot’s triad

  • RUQ pain
  • Fever
  • Jaundice
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32
Q

why do the sx of obstructive jaundice occur

A
  • pruritis (more circulating unconjugated bilirubin)
  • dark urine (more unconjugated bile converted into urobilinogen rather than conjgated for GB excretion)
  • pale stools (less conjugated bilirubin excreted from GB into gut)
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33
Q

What is Murphy;s sign

A
  • pt has ‘catch breath’ on palpation of just below the costal margin on RUQ mid-clavicular line
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34
Q

ix ?GB stone

A
  • 1st- USS- thickened GB wall= cholecystitis, plus stone visualisation, 95% sensitive
  • XR, ECG, Urinanalysis to exclude angina, MI, kidney issues
  • WCC, LFTs, UE< amylase
    If ?chronic cholecystitis - MRCP- purely diagnostic, ERCP- diagnostic and therapeutic
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35
Q

tx GB stone

A
  • if asx and found incidentally- none
  • paracetemol, NSAID, IM diclofenac, IM opioid- morphine
  • dont give ursodeocycholic acid- no evidence for effectiveness for pruritis in gallstones
  • NMB
  • co-amox
  • IV fluid
  • laparoscopic cholcystectomy
  • ERCP if in ducts
  • bile acid dissolution
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36
Q

what is cholecystitis

A
  • GB inflammation
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37
Q

causes of cholecystitis

A
  • gallstones- particularly acute onset (stuck in neck/cystic duct)
  • trauma
  • infection (coliforms- E.coli, klebsiella, enterobacter)
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38
Q

sx and signs acute cholecystitis

A

sx

  • Constant RUQ pain- radiates to shoulder
  • Anorexia, N+V

Signs

  • Murphy;s
  • local peritonism
  • GB mass
  • Gallstone sx if this is causing (obstructive jaundice, biliary colic, cholangitis (charcot’s triad) )
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39
Q

sx chronic cholecystitis

A
  • flatulence
  • nausea
  • fat intolerance (vomiting)
  • distension
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40
Q

ix for ?cholecystitis

A
  • FBC- WCC raised, LFT, CRP, amylase
  • USS- thickened GB wall, pericholecystic fluid/air in GB or wall
  • hydroxy iminodiacetic acid cholescintigraphy scan and procedure- blocked cystic duct (otherwise called hepatobiliary scan or hepatobiliary scintigraphy)
  • CT IV contracst if USS unsuccessful and high suspicion
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41
Q

tx cholecystitis

A
  • IV fluids
  • Co-amox (covers coliforms if infection)- IV then oral
  • analgesia
  • cholecystectomy
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42
Q

What is acute cholangitis/ascending cholangitis

A
  • inflammation of biliary tree
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43
Q

causes of acute cholangitis

A
  • infective, usually due to bile stasis (stones) or bacteria from duodenum
  • ERCP
  • tumours- pancreas, cholangiocarcinoma
  • bile duct stricture, stenosis
  • cyst/diverticulum of the CBD
  • AIDS
  • parasitic infection- roundworm, liver fluke
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44
Q

sx, signs of cholangitis

A

Charcot’s

  • jaundice
  • Abdo (RUQ) pain
  • fever
  • pruritis
  • acholic stool (putty coloured)
  • fatigue
  • confusion

signs

  • septic shock
  • hypotension
  • peritonism
  • hx of stone, CBD stones, recent cholecystectomy, ERCP, HIV/AIDs
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45
Q

ix for ?cholangitis

A
  • FBC- WCC, ESR, CRP, lFT, UE< blood cultures, Amylase
  • abdo USS
  • AXR
  • contrast enhanced dynamic CT
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46
Q

management of cholangitis

A
  • fluids
  • coamox
  • endoscopic biliary drainage to tx obstruction
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47
Q

what is primary sclerosing cholangitis

A

inflammation and fibrosis of the intraheptic and extrahepatic bile ducts

  • biliary strictures
  • cirrhosis
  • secondary if as a result of infection, thrombosis, iatrogenic or trauma
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48
Q

sx/signs of primary sclerosing cholangitis

A
  • asx
  • jaundice
  • pruritis
  • RUQ pain
  • wt loss, fevers, sweats
  • hepatosplenomegaly

complications

  • biliary obstruction (strictures)
  • bacterial cholangitis
  • cirrhosis- ascites, encephalopathy, raised serum albumin, bilirubin level, PTT
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49
Q

what condition is primary sclerosing cholangitis associated with

A

IBD

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50
Q

ix ?primary sclerosing cholangitis

A
  • MRI
  • Abnormal LFTs, bilirubin, albumin, PTT
  • USS- not diagnostic
  • ERCP or transhepatic cholangiography
  • liver biopsy for staging
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51
Q

management of primary sclerosing cholangitis

A
  • no cure
  • tx of pruritis due to jaundice- cholestyramine, rifampicin, naltrexone, sertraline
  • fat-soluble vit supplements- ABEK
  • avoid alcohol
  • balloon dilatation, stents for sctrictures
  • surgical drainage
  • transplant
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52
Q

What is primary biliary cholangitis (primary biliary cirrhosis)

A
  • destruction of small interlobular bile ducts, causing intrahepatic cholestasis, leading to scarring, cirrhosis
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53
Q

phases of primary biliary cholangitis

A
  • preclinical
  • asx
  • sx
  • liver insufficiency
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54
Q

sx/signs primary biliary cholangitis

A
  • asx- incidental (most)
  • fatigue- v. common
  • pruritis
  • RUQ pain/discomfort
  • jaundice, dark urine, pale stools

signs

  • hepatomegaly , spleno in later disease
  • hyperpigmentation
  • Xanthelasma- yellow deposits of choletserol under the skin
  • signs of liver disease if advanced
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55
Q

what conditions of coincides with primary biliary cholangitis

A

Sjogrens
hypothyroid
renal tubular necrosis

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56
Q

Ix primary biliary cholangitis

A

LFT

  • ALP- raised (cholestasis)
  • bilirubin normal, but increases with disease progression
  • IgM raised
  • Lipids and cholesterol rasied
  • AMA autoatnibodies!!!!!!
  • USS abdo
  • cholangiography (XR)- to exclude primary sclerosing
  • liver biopsy
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57
Q

tx primary biliary cholangitis

A

Fatigue- modafinil, rituximab

Pruritis
- 1st- ursodeoxycholic acid
cholestyramine, rfiampicin, sertraline, naltrexone
- sedating antihistamine- cyroheptadine, promethazine, chlorphenamine
- plasmsapheresis if severe

  • steroids, azathioprine, ciclosporin, methtrexate
  • avoid osestrogens- promote cholestasis
  • pregnant- ursodeoxycholic acid
  • liver transplant
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58
Q

Differences in primary sclerosing and primary biliary cholangitis

A

Sclerosing

  • affects all bile ducts
  • IBD
  • MRI
  • No medical tx
  • increased risk of colorectal cancer and cholangiocarcinoma

Biliary

  • middle age onset
  • affects bile ducts in liver only
  • AMA autoantibodies
  • medical tx slows progression
  • no increased risk of hepatocellular carcinoma, hypothyroid, renal tubular acidosis
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59
Q

RFs for gastric cancer

A
  • Male (oestrogen is protective)
  • H.pylori
  • EBV
  • AIDs
  • smoking
  • alcohol, processed meat, salt, pickled veg, low fruit/veg/aspirin/mediterranean diet
  • obesity
  • GORD
  • iodine deficincy
  • CDH mutaiton
  • diabetes
  • chronic gastitis/atophic gastritis
  • diabetes
  • pernicious anaemia
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60
Q

sx gastric cancer

A

VAGUE

  • GORD, indigestion
  • early satiety
  • dyspepsia- burning, not responsive to PPI
  • dysphagia
  • N+V, anorexia, wt loss
  • vomiting fresh blood
  • Black stool
  • change in bowel habits
  • anaemia sx

signs

  • epigastric mass
  • troisier sign- palpable L clav node (Virchow)- sign of abdo malignancy mets
  • acanthosis nigrans
  • hepatosplenomegaly, ascites, jaundice (mets)
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61
Q

ix for ?gastric cancer

A
  • rapid urease tes (CLO test)- campylobacter-like organism test- for H.pylori, biopsy during endoscopy
  • upper GI endoscopy with biopsy
  • HER2/neu protein expression (monocloncal antibody tx)
  • CT chest-abdo-pelvis
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62
Q

2ww gastric cancer

A
  • new onset dysphagia

- aged >55yp with wt loss, upper abdo pain, reflux or dyspepsia

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63
Q

cancer cell type in gastric cancer

A
  • gastric adenocarcinoma - most common
  • MALT lymphoma
  • carcinoid and stromal are rare
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64
Q

tx gastric cancer

A
  • surgery- total /subtotal gastrectomy
  • chemo, RT
  • resection if confined to mucosa
  • If HER2 positive- HER2 inhibitors- tyrosine kinase inhibis (herceptin)
  • pallitation
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65
Q

sx of gastritis

A
  • syspepsia/epigastric discomfort- gnawing/burning
  • N+V
  • loss of appetite
  • severe emesis
  • acute abod pain
  • fever
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66
Q

common causes of gastritis

A
  • H.pylori
  • NSAIDs
  • alochol
  • prev gastric surgery
  • stress
  • autoimmune
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67
Q

urgent endoscopy indications

A
  • GI bleeding
  • ealry satiety
  • unexplained wt loss >10%
  • progressive dysphagia
  • odynophagia- painful swallowing
  • persistent vomiting
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68
Q

ix for ?gastritis

A 
H.pylori urea bretah test
H.pylori faecal antigen test
- FBC
- endoscopu 
- histology
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69
Q

tx for H.pylori

A
  • PPI and 2 antibacterials– amoxicillin and either clarithro or metro, 14 days

use clarithro and metronidazole with PPI if pen allergic (no amox)

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70
Q

tx gastritis

A
  • tx H.pylori
  • PPIs- omezoprazole, lansoprazole
  • acid blockers- histamine H2 blockers- famotidine, cimetidine, nizatidine
  • antacids- aluminium or magnesium carbonate
  • antacids with alginates- sodium alginates
  • stress management
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71
Q

ix for GI bleed

A
  • routines
  • VBG
  • Endoscopy
  • erect CXR- if perfed peptic ulcer, will be air visible under diaphragm (pneumoperitoneum)
  • CT abdo with IV contrast- if endoscopy is unremarkable /too unwell for endoscopy
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72
Q

what scoring system is used for a GI bleed

A
  • Glasgow-Blacthford score
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73
Q

Management of GI bleed due to peptic ulcer

A
  • 2x wide bore cannulas
  • ABCDE

Peptic ulcer

  • injections of adrenaline
  • Cauterisisaiton

High dose PPI +- H.pylori eradication

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74
Q

management of GI blee d (non variceal)

A
  • clips +- adrenaline
  • thermal coagulation with adrenaline
  • fibrin or thrombin with adrenaline
  • PPIs
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75
Q

management of variceal bleed

A
  • terlipressin
  • **- prophylactic IV ceftriaxone
  • *- gastric- N-butyl-2-cyanoacrylate injection
  • transjugular intraheptic portosystemic shunts
  • Oesophageal- band ligation, TIPS
  • **- Sengstaken-Blakemore (SB)tube
  • LT- beta blocker— propanolol
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76
Q

hwo to differentiate location of GI bleed

A

Melena

  • black
  • upper GI bleed

Jelly

  • small intestine
  • Intussesception/Meckels

Haematochezia

  • darker red, bright
  • colon
  • intussusception

Rectorrhagia

  • rectum
  • very fresh, bright
  • intussesception

however, if haemodynamically unstable with a large, fresh rectal bleed- shoul dbe considered as upper GI bleed until disproven

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77
Q

Upper PR bleed ddx

A
  • peptic ulcers
  • gastritis.oesophagitis
  • varices
  • malignancy
  • mallory weiss
  • trauma
  • infections
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78
Q

intestinal and colon ddx PR bleed

A
  • polyps, cancer
  • diverticular disease, Meckels
  • intussusecption
  • IBD
  • trauma/foreign bodies
  • *- ischaemic colitis
  • infection- infective colitis
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79
Q

ddx PR bleed rectum/anus

A
  • haemorrhoids
  • cancer
  • anal fissures
  • radiation proctitis
  • IBD
  • trauma
  • foreign bodies
  • infections
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80
Q

ix PR bleed

A
  • ***- Oakland scoring
  • ABCDE
  • G&S
  • urgent CT angiogram if unstable- to locate precise location , also good for isc colitis
  • if stable- flexible sigmoidoscopy/full colonoscopy (to exclude L colonic malignancy
  • upper GI endoscopy
  • colonoscopy
  • MRI
  • stool cultures if ?infective
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81
Q

management of PR bleed

A
  • most resolve spontaneously
  • ABCDE- resus, 2x wide bore, packed RBs if Hb <70
  • if young, stable, bleeding stops and have low oakland score- see as OP
  • endoscopic haemostasis- adrenaline injection thermal, clips/band ligation
  • *- arterial embolisation
  • surgery if all else fails or if meckles keeps bleeding
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82
Q

what is meckles diverticulum, sx, tx

A
  • outpouching of lower part of small intestine
  • present at birth, remnant of umbilical cord

sx- large PR- brick coloured/jelly, usually painless, may be pain in children, may obstruct (severe pain)

tx- surgical correction

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83
Q

what is Crohn’s

A
  • anywhere mouth to anus
  • ulcers are deep into bowel wall (tranmural), fissuring, granulomas
  • cobblestone, patchy appearance
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84
Q

genetic mutation in crohns

A

NOD2, CARD15

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85
Q

what is UC

A
  • colon and rectum only
  • continuous inflammation of the wall
  • mucosa and submucosal only
  • T cell destruction of the wall
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86
Q

sx Crohns

A
  • diarrhoea
  • haemarochezia
  • mucous
  • abdo pain - most common RIF as ileum and or colon is most common site
  • wt loss, systemic illness
  • malnutrition sx (anaemia)
  • obstruction
  • oral/anal ulcers
  • abnormalities of eyes, liver, skin, arthritis
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87
Q

tx crohns

A
  • stop smoking

Monotherapy - to induce remission
1. pred/methylpred/hydrocortisone
consider aminosalicylate (mesalazine/sulfalazine) in first flare in 12 month period if steroids CIed

    • add to above
      - azathioprine, mercaptopurine
  2. add to 1. instead of 2. if >=2 flares per year
    methotrexate

severe flare
- infliximab

maint remission

  • azathioprines
  • mercaptopurine
  • methotrexate

Diarrhoea management

  1. antimotlity - loperamide
    - codeine
    - colestyramine

surgery

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88
Q

sx UC

A
  • severe, frequent diarrhoea +- blood
  • systemic illness
  • pain LIF
  • flare- tachy, fever, malaise, tender distended abdo
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89
Q

tx UC

A

Acute- mild-mod

  • diarrhoea- loperamide, codein
  • constipation- macrogol
    1. aminosalicylates- sulfalazine/mesalazine- enema and/or PO depending on if in descending colon
      1. corticosteroids
      2. added to steroids - tacrolimus/ciclosporin

Acute- severe

  • infliximab, adalimumab
  • IV hydrocortisone/methylpred
  • *- IV ciclosporin
Maintenance
- NOT steroids
- rectal sulfalazine +- oral preps
maint in >2 episodes 1 year/remission not maint by above:
- oral azathioprine, mercaptopurine 
- methotrexate

surgery- curative

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90
Q

IBS sx

A
  • bloating
  • mucus in stool
  • pain that imprves after bowel moevement/ flatulence
  • ‘disorders of defacation’- diarrhoe, contipation with straining, incomplete evacuation
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91
Q

tx IBS

A
  • stress and anxiety management
  • FODMAP diet
  • limit fresh fruit, solubl efibre (isphagula husk)
  • increase fluid intake
  • avoid artifical sweetener
  • probiotics
  • regular exercise
  • regular meals
Constipation- 
- fibre
- bulk forming- ispaghula husk
- stimulant- bisacodyl, senna
- softeners- docusate
- osmotic- Macrogol- do not use lactulose- increases bloating!!!!
- severe-- linaclotide
Diarrhoea- loperamide (antimotility)
Spasms
1. buscopan, mebeverine 
2. low dose TCA
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92
Q

causes of infective gastroenteritis

A
  • viral- norovirus, rotavirus, adenovirus
  • bacterial- campylorbacter, E.coli O157, salmonella, shigella, S.areus, C.diff, yersinia
  • parasites- cryptosporidium, giardia, entamoeba
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93
Q

what organisms cause bloody diarrhoea

A
  • *- shigella
  • E.coli
  • salmonella
  • campylobacter
  • *- yersinia
  • entamoeba histolytica
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94
Q

ix gastroenteritis

A
  • stool if blood, immunocomprimised, recent travel to outside of western europe North america, AU and NZ, diarrhoea not improved within 7 days
  • CT/MRI if bowel distended
  • DRE
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95
Q

when to admit a pt with diarrhoea ?gastroenteritis

A
  • persistent vomiting
  • shock/severe dehydration
  • recent foreign travel
  • old age
  • poor support at home
  • high fever
  • bloody diarrhoea
  • abdo pain/tender
  • faecal incontinence
  • diarrhoea >7d
  • co-extsing medical conditions
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96
Q

tx of diarrhoea ?gastroenteritis

A 
Bacterial- tx if severe
- campylobacter- clarithro 
- salmonella (non-typhoid)- cipro
- shigella- cipro
- typhoid (salmonella typhi)- cefotaxime and tets sensitivity 
C.diff- metrnidazole or vanc
  • oral rehydraiotn therpay
  • fluid- little and often
  • solid foods- let appetitie guide, liquidised–> mashed–> soft
  • do not give loperamide /other anti-motility drugs if infective
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97
Q

what antibiotics predispose pts of C.diff

A
  • ampicillin
  • amox, co-amox
  • cepahlosporins- ceftriaxone, cefuroxime, cephalexin
  • clindamycin
  • quinolones- cipro, ofloxacin, levofloxacin
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98
Q

signs and sx of c.diff

A
  • 5-20days following abx
  • watery diarrhoea +- blood staining
  • abdo cramps
  • fever, rigors
  • risk of sepsis
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99
Q

ix ?c.diff

A
  • FBC- WCC
  • UE
  • hypoalbuminaemia- protein losing enteropathy
  • stool sample
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100
Q

Management of c.diff

A
  • notifable
  • crrect fluid and electrlytes
  • avoid loperamide
  • cease abx if still on it

ORAL (1st ep)

  1. vanc
  2. fidaxomicin

ORAL (furtehr episdies)
1. fidaxomicin

Severe
- oral vanc with IV metronidazole

  • probiotics
  • IV iG
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101
Q

sx H.pylori

A
  • dyspepsiea (aching, burning, worse when hungry)
  • no red flags- wt loss, dysphagia, early satiety
  • loss of appetite
  • diarrhoea, loose stools
  • frequent burping, bloating
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102
Q

what can cause false negative on urea 13C breath test

A
  • PPI within 2w

abx within 4w

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103
Q

What is barrett’s oesophagus

A
  • normal stratified squamous epithelium replaced with simple collumnar (glandular)
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104
Q

red flags of upper GI malignancy

A
  • wt loss
  • dysphagia (progressive)
  • early satiety
  • worsening dyspepsia despite PPI
  • malaise
  • loss of appetite
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105
Q

ix ?barrett’s

A

oesophago-gastro duodenoscopy- biopsy, oesophagus looks red and velvety, with smoe preserved pale islands

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106
Q

sx barretts

A
  • GORD
  • retrosternal pain
  • **- excessive belching
  • odynophagia
  • chronic cough
  • hoarseness
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107
Q

management of barretts

A
  • PPI
  • switch to histamine (H2) receptor antagonist if no response in 8 w– cimetidine, ranitidine
  • stop/ower dose of NSAIDs, alpha blockers, anticholinergics, benzos, beta blockers, bisphosphnates, CCBs corticosteroids, nitrates, theophyllines, TCA
  • lifestyle
  • regular endoscopu
  • endoscopic mucosal resection
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108
Q

what lifestyle factors worsen GORD

A 
big meals
wt
smoking
**stress
food evening
** tight clothes
**alcohol
caffeine, spicy, acidic foods
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109
Q

what cell type if oesophgeal cancer

A

adenocarcinoma (developed world) or sq cell carcinoma (developing world)

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110
Q

sx oesophageal cancer

A

late presentation

  • progressive dysphagia
  • significant wt loss
  • odynophagia
  • *- hoarseness
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111
Q

ix ?oesophageal cancer

A
  • endoscopy with biopsy (any pt with dysphagia, any pt >55 with wt loss and abdo pain, dyspepsia or reflux)
  • CT chest-abdo-pelvis
  • hoarseness/haemoptysis- bronchoscopy
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112
Q

qs to ask with dysphagua

A
  • wt loss
  • abdo pain
  • reflux
  • hoarseness
  • **- is there difficult initiating the swallow (neuro)
  • do they cough when swallowing
  • have the choked
  • do they have to swallow a few times to get it down
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113
Q

tx oesophageal cancer

A
  • stent
  • RT, CT
  • oesophageal resection
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114
Q

what oesophageal motility disorders are there

A
  • achalasia

- diffuse oesophageal spasm

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115
Q

what is achalasia

A

Failure of relaxation of the lower oesophageal sphincter

progressive failure of contraction of the oesophageal smooth muscle

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116
Q

ix for ?oesophgeal motility disorder

A
  • urgent endoscopy- exclude oesophageal cancer
  • oesophageal manometry- pressure probe
    achalasia– absence of peristalsis, sphincter tone high
    diffuse oes. spasms- repetitive, simultaneous , ineffective contractions
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117
Q

tx oesophageal motility disorders

A
  • chew food
  • fluids with meals
  • elevate head when sleeping
  • CCB/nitrates
  • botox injections
  • endoscopic ballooon
  • myotomy
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118
Q

what are sx diffuse oesophageal spasms

A
  • severe dysphagia

- central chest pain exacerbate by food

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119
Q

sx achalasia

A
  • prgressive dysphagia
  • vomiting, regurg of food, coughing
  • chest discomfort/pain
  • wt loss
  • sx vary day to day
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120
Q

what is a mallory weiss tear

A
  • usually tear after prfuse vomiting

- generally small and self limiting

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121
Q

what is boerhaave’s syndrmoe

A
  • perf of oesophagus
  • stomach contents into mediastinum and pleural cavity– inflam response
  • physiological collapse, multiorgan failure
  • surgical emergency
122
Q

sx oesophageal tear and rupture

A

Tear

  • haematemesis
  • melena
  • hx of retching may be absent
  • most cases resolves in 24-48hours
Rupture
Mackler's triad
- severe, sudden onset retrosternal pain
- resp distress
- Subcut emphysema- often absent
  • haemodyn unstable
123
Q

ix ?oes tear

A
  • G&S
  • duodenoscopy if unstable/bleeing not resolved
  • urgent CT chest abdo pelvis with IV and oral contrast
  • Erect CXR- penumoperitonium/intrathoracic air level
124
Q

Management of oes tear

A
  • fluid resus
  • O2
  • broad spec abx
  • endoscopy if not perfed for angioembolisation
  • thoracotomy if perf- washout and control
  • jejunostomy feeding
  • CT contrast 10-14 days before starting oral intake
125
Q

what are exocrine and endocrine tumours of the pancreas

A

exocrine- enzyme producing- adenocarcinomas (most common)

- endocrine- hormone producing eg insulinomas (less common, often benign)

126
Q

what mutations are assoc with pancreatic cancer

A
  • BRCA1 , BRCA2, PALB2, ATM, TP53
127
Q

sx and signs pancreatic cancer

A

late presentation

  • N+V
  • wt loss (malabs due to abstruction of panc duct, appetite reduced)
  • steatorrhea
  • epigastric pain, radiates to lower back, worse when lying
  • trousseau sign- blood clots felt as small lumps under skin
  • courvoisier sign- enlarged, palpable GB, non tender (unlike stones)

Obstructive jaundice (head of panc tumour)

  • pruritis
  • dark urine, pale stools
  • loss of appetite
128
Q

ix ?pancreatic cancer

A
  • serum amylase, lipase
  • CEA, CA199
  • bilirubin, ALP, AST, ALT
  • MRI, MRCP, ERCP
129
Q

tx pancreatic cancer

A

CT

surgery

130
Q

Causes of pancreatitis (acute and chronic)

A 
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
***Hyperlipidaemia, hypothermia, hyperparathyroid
Endoscopic retrograde cholangiopancreatography/emboli
Drugs- azathioprine, valproic acid, liraglutide, mesalazine

hereditary
tropical chronic pancreatitis
biliary tract disease

131
Q

sx pancreatitis

A
  • severe epigastric pain radiating to back
  • N+V
  • exocrine- wt loss, diarrhoea, steatorrhea
  • Endocrine - diabetes
  • jaundice
132
Q

ix pancreatitis (acute and chronic)

A 
amylase, lipase
CT
ERCP ?stones
biopsy 
secretin stimulation test
133
Q

tx chronic pancreatitis

A

drug and alcohol, smoking

  • paracetemol, NSAID, weak opioids, amitriptyline, gabapent, pregab
  • lipase- (creon) replacement
  • ERCP stenting/stone removal
  • surgical resection/splanchnicetomy of splanchic nerves
  • annual Hba1c screening and DXA for OP
  • dietician referral
134
Q

signs of acute pancreatitis

A
  • Cullen- umbilical bruising, suggests intraperitoneal haemorrhage
  • Grey-turner’s- bruising on L flank- retroperitoneal haemorrhage
135
Q

tx acute pancreatitis

A
  • NBM
  • abx- coamox?
  • IV fluids
  • analgesia
  • ERCP stone removal
  • cholcystectomy
136
Q

ddx for dysphagia, dyspepsia

A
  • oesophageal cancer
  • oes strictures (food gets stuck, choking)
  • pharyngeal pouch (bad breath, chronic cough, neck lump)
  • gastric cancer
  • gastritis, peptic ulcer
  • neuro- MG, MS, post stroke, CN 9-12 nerve damage post surgery (eg thyroid, carotids)
  • muscle- difuse oes spasms, achalasia
137
Q

ddx for epigastric/RUQ pain+- jaundice

A
  • gastritis, gastric tumour, peptic ulcer, reflux, oesophagitis
  • pancreatic/GB tumour
  • gallstones
  • cholangitis
  • cholecystitis
  • pancreatitis
  • hepatic tumour, hepatitis
  • GB tumour
  • ACS, pericarditis
  • right lower lobe pneumonia, PE
  • IBS, appendicitis, IBD
  • aortic dissection, mesenteric ischaemia, small bowel obstruction
  • DKA, sickle cell crisis, narcotic withdrawal, heavy metal poisoning
138
Q

What organs are retroperitoneal

A 
SAD PUCKER
Suprarenal glands (adrenals)
Aorta and IVC
Duodenum
Pancreas (except tail)
ureters
colon (ascending and descending)
Kidneys
Esophagus
Rectum
139
Q

mutations assoc with primary peritoneal cancers

A

BRCA1 BRCA2

140
Q

sx peritoneal cancer (primary or secondary)

A 
late presentation
- abdo discomfort- bloating, cramps, indigestion
- satiety, loss of appetite
- constipation, diarrhoea
- urinary frequency
- peripheral oedema
- lower back pain
- extreme fatigue, wt loss/gain
- rectal/vaginal bleeding
signs
- Ascites- SOB, N+V, pain, fatigue-- shifting dullness/fluid thrill
- bloated
141
Q

ix ?peritoneal cancer (distended, bloated abdo with wt loss and b sx)

A
  • CT abdo, pelvis,
  • MRI
  • ascites fluid aspiration (risk of seeding)
  • CA125, HE4
  • laparoscopy or laparotomy with biopsy - GOLD STANDARD
142
Q

tx peritoneal cancer

A
  • omentectomy
  • debulking/cytoreduction surgery
  • chemo/RT
  • monoclonal antibodies
  • Poly-ADP ribose polymerase inhibitors- block NA repair- olaparib
  • angiogenesis inhibs
  • hormonal therapy
  • immunotherapy
143
Q

primary causes of peritonitis

A

spontaneous:

  • cirrhosis and ascites- fluid is static and become infected,
  • peritoneal dialysis
144
Q

causes of secondary peitonitis

A
  • GI perf- appendix, diverticulum, peptic ulcer, bowel, intestine, GB
  • obstruction
  • IBD, diverticulitis
  • pancreatitis
  • PID
  • surgery
  • trauma
  • splenic rupture
  • AAA rupture
145
Q

signs of peritonitis

A
  • lying completely still (unlike colic pain- squirming)
  • **- pt keep hips flexed to reduce abdo wall tension
  • Guarding (involuntary)- abdominals tense on palpation
  • rigid/distended abdo
  • **- percussion tenderness
  • rebound tenderness
146
Q

ix peritonitis

A
  • blood/urine cultures, CRP, ESR
  • XR
  • CT
  • explorative surgery
  • paracentesis if ascitic
147
Q

tx peritonitis

A
  • IV abx- cepahlosporin (eg cefuroxime) plus metro/gent plus metro
  • surgical repair of cause
  • tx cause
148
Q

Function of the spleen

A
  • immune- WBCs, igG, properdin, tuftsin
  • removes old/dead/damaged RBcs
  • removes platelets
  • clears microorganisms and antigens
  • stores RBCs and plts
149
Q

Causes of splenomegaly

A

Congestion

  • increased BP in splenic vein
  • eg splenic vein thrombosis (complication of pancreatitis), compression, or portal HTN (cirrhosis, RHF)

Infiltration

  • malignancy- lymphomas, leukaemia, mets, melanoma
  • amyloidosis, sarcoidosis

Proliferation- hypersplenism

  • infection- CMV, HIV, EBC, TB, syphilis, edocarditis, histoplasmosis, malaria
  • spherocytosis, haemoblobinopathies, sickle cell, haemolytic anaemia
  • thrombocytopenia (plt), polycythemia vera (RBC)
  • drug reactions
  • autoimmune disorders- RA
  • immunosupressive states- marrow damage, AIDs
  • trauma
150
Q

sx splenomegaly

A
  • abdo pain, ***radiates to shoulder/back, chest pain
  • satiety if compressing on stomach
  • fatigue
  • easy bleeding, brusiing
  • frequent infections
  • anaemia
  • asx
151
Q

investigation of splenomegaly

A
  • RBC, WCC, plt, LFT
  • bone marrow- reticulocytes, blood disorders
  • CT, USS
  • magnetic resonance angiography (blood through spleen)
152
Q

sx splenic rupture

A
  • abdo pain- LUQ, peritonism
  • Kehr’s sign- (L) shoulder pain due to blood irritating diaphragm
  • confusion, tiredness,
  • dizziness, fainting shock
153
Q

ix ?splenic rupture

A
  • haemodynamically unstable + peritonism + hx of trauma –> immediate laparotomy
  • stable- urgent CT chest-abdo-pelvis IV contrast
  • FAST scan in A&E- should not delay CT/surgica intervention
154
Q

tx splenic rupture

A
  • ATLS, fluid resus
  • unstable/ severe injury- urgent laparotomy

Stable + less severe on CT
- strict bed rest on HDU and repeat CT in 1 week , any evidence of worsening tenderness/peritonism- reimage/laparotomy

Post splenectomy
- prophylactic vaccines against strep pneumonia, HIB, meningococcal at discharge, lifelong penicillin

155
Q

what is an acute abdomen?

A
  • sudden severely painful abdomen

- often assoc with N+V

156
Q

ddx of acute abdo with pain in epigastrium

A
  • pancreatitis
  • MI
  • peptic ulcer
  • acute cholecystitis (infeciton, stone)
  • perf oeseophagus/mallory weiss
157
Q

ddx of acute abdo with pain in RUQ

A
  • acute cholecystitis
  • duodenal ulcer
  • hepatitis
  • congestive hepatomegaly
  • pyelonephritis
  • appendicitis
  • R pneumonia
158
Q

ddx of acute abdo with pain in LUQ

A
  • splenic rupture
  • gastric ulcer
  • AAA+- rupture
  • perfe colon
  • pyelonephritis
  • L pneumonia
159
Q

ddx of acute abdo with pain in RLQ

A
  • appendicitis
  • stranglulated hernia
  • mesenteric adenitis
  • meckles diverticulitis
  • crohns
  • bowel perf
  • psoas abscess
  • renal/uteric stone

GYNAE

  • salpingitis (PID)
  • tubo-ovarian abscess
  • ovarian torsion
  • ectopic pregnancy +- rupture
160
Q

ddx of acute abdo with pain in RLQ

A
  • sigmoid diverticulitis
  • strangluatedhernia
  • colon perf
  • crohns
  • UC
  • renal stones

GYNAE

  • salpingitis (PID)
  • tubo-ovarian abscess
  • ovarian torsion
  • ectopic pregnancy +- rupture
161
Q

ddx of acute abdo with pain in umbilicus

A
  • intestinal obstruction
  • acute pancreatitis
  • early appendicitis
  • mesenteric thrombosis
  • AAA
  • diverticulitis
162
Q

location of spleen

A
  • around fundus of stomach
163
Q

function of liver

A
  • CHO metab- gluconeogensis, glycolysis, glycogenesis (gluc-glyc)
  • Storage- Glycogen, vit b12, lipid soluble vits (ADEK), iron, copper
  • Bile production
  • toxin breakdown- cytochromes, ammonia, alcohol, Hb
  • oestrogen breakdown

Synthesis

  • protein S, C
  • plasminogen activator inhibitor
  • antithrombin III
  • factors 2,7,9,10 (vit K)
  • albumin
  • immune proteins
  • ferritin
  • foetal RBCs in firts 3 months of life
  • angiotensinogen
  • sex hormones binding globulin
164
Q

causes of acute liver failure

A
  • poisoning- paracetemol, alcohol, death cap mushroom
  • Adverse drug reactions- tetracycline, palloides
  • vrial hepatitis- A or B, yellow fever
  • acute fatty liver of pregnancy
  • reye’s syndrome
  • Wilsons disease
  • Bacillus cereus
  • idiopathic
165
Q

sx of acute liver filaure

A
  • jaundice
  • weakness
  • confusion, mental state change
166
Q

ix acute liver failure

A
  • PTT- prolonged by 4-6 s
  • high INR
  • ABG, lactate- ?inflammation, bleeding poisoning
  • clotting, LFTs, UE, FBC, G&S
  • viral hep serologies
  • EBV/CMV serologies
  • ANA, ASMA, LKMA, Ig
  • ceruloplasmin- Wilsons
  • pregnancy test
  • ammonia
  • HIV status
  • a
    paracetemol levels/toxicology screen
167
Q

tx acute liver failure

A
  • lactulose for encaphalopathy
  • stop anticoags. vit. K, FFP, prothrombin complex
  • PPI prevents GI bleed
  • fluid resus
  • monitor urine and blood cultures for infection
  • transplant
168
Q

main causes of chronic liver failure

A
  • obsesity (NAFLD, NASH)
  • chronci/undiagnosed viral infection- hepB/C
  • acoholism
  • primary biliary cholangitis, sclerosing cholangitis, Autoimmune hepatitis, alpha 1 antitrypsin deficiency
  • haemochromatosis, wilsons
  • Budd-chiari
  • liver cancer
169
Q

what is budd chiari

A
  • hepatic veins blocked/narrowed by clot
170
Q

sx of chronic liver failure

A
  • fatigue, ethargy, malaise
  • loss of libido
  • jaundice, ithcy skin- bilirubin
  • loss of appetite, wasting, N+V- toxins, bilirubin
  • RUQ pain
  • Ascites, oedema- hypoalbuminaemia
  • Haematemesis- varices
  • easy bleeding- coagulopathy
  • portal HTN sx
  • men - gynaecomastia (oestrogen)
171
Q

what system is used to calculate how severe chronic liver disease is

A
  • Child-Pugh
172
Q

ix chronic liver disease

A
  • sexual hx, alcoholic hx, autoimmune diseases, blood products, IVDU
  • child pugh
    clotting, LFT, UE, FBC
  • viral serologies
  • AMA, ANA, ASMA, Coaliac, Igs
  • iron and Cu studies
  • alpha antitrypsin level
  • abdo CT, (USS, MRI)
173
Q

what drugs do you need to be cautious in hepatic impairement

A
  • opioids
  • NSAIDS
  • paracetemol
  • Diuretics
  • methotrexate, isoniazid oestrogen, salicylates, tetracyclines
174
Q

complications of chronic liver failure

A
  • ascites
  • spont bacterial peritonitis
  • coagulopathy and bleeds
  • portal HTN- ascites, hypersplenism, varices, GI bleeds
  • Hepatorenal syndrome
  • hyersplenism due to splanchinic vein HTN-
  • infection and sepsis
  • ED, gynaecomastia, ammenorrhea(-ve feedback)- decreased sex hormone binding globulin- high free circulating sex hormones
175
Q

what is decompensated liver failure

A

new jaundice, asscites, SBP, encephalopathy, AKI

may be precipitating cause- infection, dehydration, constipation, drugs/alc, ischaemia, portal thrombosis

176
Q

ix decompendated liver failure

A
  • hx- alcohol, infection
  • FBC UE LFT coag, glucose, infection, G&S
  • septic screen
  • USS abdo
  • portal vein doppler
  • ascitic tap
  • echo r/o HF
177
Q

management decompensated liver failure

A
  • VTE prophylaxis if bleeding/plt <50
  • suspend statins
  • GI review in 24hours
  • monitor clotting, LFTs UE daily

COagulopathy- 3d vit. K

  • GI bleed- terlipressin
  • encaphalopathy- lactulose, consider CT head r/o stroke
  • phopshate enema is contipated
  • AKI- fuid resus, UO monitoring, dialysis
  • SBP- coamox
  • infection- tx
  • alcohol- IV pabrinex
178
Q

causes of hepatitis

A
  • viral infection
  • alochol, paracetemol
  • autoimmune
179
Q

presentation of acute hepatitis

A
  • malaise/lethargy
  • jaundice
  • vomiting
  • abdo pain
  • diarrhoea
  • often arthralgia if viral
180
Q

hep A- spread how

A

shellfish, faecal-oral (water)

181
Q

hep B- spread how

A

blood products
IVDU
sexual contact
birth

182
Q

hep c- spread how

A

blood- IVDU, transfusion, poorly cleaned medical equipment, vertical

183
Q

tx hep a,b,c

A

a- supportive only , vaccination

B

  • antivirals- interferona alfa, tenofovir
  • vaccine
  • screenning pregnant women and giving positiv eindividuals Hep B Ig at birth and vaccinate at risk babies
  • NB- sx aswell as acite hep– urticaria

C
-antivirals- sofosbuvir, simeprevir
- no vaccine
(NB: most cases of C are silent and chronic–> liver failure)

184
Q

viral causes of hepatitis

A
  • Hep A,B,C,D,E
  • EBV
  • CMV
  • leptospirosis (parasite)
  • malaria
  • syphilis
  • yellow fever
185
Q

presentation of autoimmune hepatitis

A
  • acute hepatitis and sx of other autoimmune disease- efevr, malaise, urticarial rash, pleurisy, glomerulonephritis
  • jaundice
  • amenorrhea
186
Q

ix autoimmune hepatitis

A
  • increase bili AST ALT ALP
  • increased Ig
  • ANA, ASMA
  • anaemia, low WCC and plts
  • liver biopsy- CD4 cells, fibrosis and cirrhosis
187
Q

management of autoimmune hepatitis

A
  • steroids- pred
  • azathioprine
  • transplant
188
Q

drugs that cause hepatitis/hepatotoxicity

A
  • augmentin, fluclox, erythro, TB
  • chlorpromazine, carbamazepine, valproate, paroxetine
  • immunosups
  • NSAIDs, paraceteol
  • PPIs
  • dietary supplements
189
Q

sx drug induced hepaitis

A
  • RUQ pain
  • jaundice
  • coagulopathy
  • encephalopathy- mental status change, confusion
190
Q

tx of drug induced encephalopathy

A
  • stop offending med
  • fluids, analgesia
  • antidote - look on toxbase
191
Q

management of paracetemol overdose

A

Look at chart and if above tx line- tx

within 1 hour- activated charcoal

acetylecysteine infusion-

  • potentiates the enzyme gluthione transferase, whihc replenishes glutathione stores
  • loading dose over 1 hour, followed by 4 hour infusion and then 16 hour infusion at different concentrations

-monitor coag, UEs, acid-base balance, glucose levels (hypo risk) and GCS/mental state

192
Q

sx of alcoholic liver disease

A
  • malaise, anorexia
  • diarrhoea an vomiting
  • tender hepatomegaly
  • haundice
  • bleeding, coagulopathy
  • ascites
  • encphalopathy
193
Q

ix ?alcoholic liver disease

A
  • clotting
  • ABDO USS/CT
  • biopsy- mallory bodies from accumulation of injured liver cells
194
Q

management of alcoholic liver disease

A
  • tx liver failure and complications
  • prednisolone
    transplant
  • tx alochol withdrawal
  • stop alcohol intake
195
Q

tx ascites

A
  • tx cause
  • sprinolactone/furosemide- avoid massive diuresis as can precipitate encephalopathy
  • fluid and salt restriction
  • paracentesis
  • IV albumin replacement
  • Transjugular intraheptatic portosystemic shunt
196
Q

what generally causes spontaneous bacterial peritonitis

A
  • E.coli/klebsiella – gram negative
197
Q

Management of spontaneous bacterial peritonitis

A
  • abx- cefotaxime

- prokinetics to reduce small bowle overgorwth

198
Q

sx portal HTN

A
  • Ascites
  • 0 abdo pain
  • varies- haematoemesis
  • blood in stool (rectal varices)
  • thrombocytopenia (spleen consumes plts)– bleeding, bruising
199
Q

ix portal HTN

A
  • US abdo + doppler (low velocity)
  • CT/MRI abdo
  • hepatic venous pressure gradient- GOLD STANDARD
200
Q

tx portal HTN

A
  • shunts- splenorenal, TIPS

- propanolol, terlopressin, banding to prevent varicela bleeding

201
Q

sx of hepatorenal syndrome

A
  • jaundice, altered mental state, ascites
  • oliguria
  • low BP
202
Q

tx hepatorenal syndrome

A
  • stop diuretics and all nephrotoxic drugs
  • vasopressors
  • haemodialysis/liver dialysis
  • liver transplant
203
Q

tx hepatic encephalopathy

A

lactulose
rifaximin
transplant

204
Q

ix hepatic encephalopathy

A
  • UE r/o eletrlyte disturbance
  • blood - ammonia
  • US abdo- liver diease
  • CT head/ECG- r/o other causes
  • paracentesis and MCS if ascites present
205
Q

presentation of NAFLD

A
  • liver failure- jaunice, confusion, ascites, RUQ pain
206
Q

ix NAFLD

A
  • adbo USS
  • elevated LDH
  • ## livery biopsy- fatty
207
Q

tx NAF:D

A
  • wt loss
  • monitor
  • screen for diabetes
  • continue statins- consider stopping if enzymes double within 3 m of starting them
  • pioglitazine or vit E
208
Q

LFTs

A
  • Cholestatic- high conjugated bili, ALP, GGT
  • hepatic- high unconj and conj bili, high ALT, AST

Haemolytic- high unconj bili

ALT, AST- hepatocellular injury, acute biliary obstruction

ALP- cholestasis (p for Plug), bone disease, pregnancy

GGT- cholestasis, meds, ethanol

Bilirubin- liver disease

209
Q

presentation of hepatic venous occlusion

A

(causes portal HTN and congestive hepatopathy)

acute liver failure- ascites, abdo pain, jaundice, bruising

210
Q

what is haemochromatosis

A
  • uncontrolled iron absorption

- deposition in liver, heart, pancreas, joints, pituitary, skin

211
Q

presentation of haemochromatosis

A
  • slate grey skin
  • arthralgia/joint pain
  • decreased libido, hypogonadism
  • diabetes
  • liver failure
  • HF
212
Q

ix haemochrmoatosis

A
  • raised ferritin and transferrin
  • HFE genotyping
  • biopsy- Perl’s stain
  • Abdo MRI- deposits in liver
213
Q

enetic mutaiton for haemochromatosis

A
  • HFE
214
Q

tx of haemochromatosis

A
  • venesection
  • desferrioxamine- irone chelation
  • genetic screneign for 1st degree relatives
215
Q

causes of excess iron

A
  • haemochromatosis
  • multiple blood transfusions
  • haemolysis
  • alcoholic liver disease
216
Q

what is wilsons

A

genetic build up of Cu in liver and brain

217
Q

wilsons and haemochromatosis inheritance patternr

A

recessive

218
Q

sx wilsons

A
  • children with cirrhosis, failure of liver
  • woung adults with CNS sx- tremor, dysarthria, dysphagia, dyskinesia, pakrinsonism, ataxia, low mood, reduce memory, poor cognition, delusions
  • arthritis
  • hypermobile
  • grey skin
  • blue lunulae- blue nails
  • Krayser- fleischer rings
219
Q

ix ?wilsons

A
  • raised urin Cu
  • decreased caeruloplasmin (depleted stores)
  • liver biopsy
  • MRI
  • slit lamp- KF rings
  • genetic testing
220
Q

manaagemet of wilsons

A
  • avoid hgih Cu foods
  • monitor urinary CU and protein
  • penicillamine- chelating drug for Cu
  • liver transplant
  • genetic screengn for 1st degree relatives
221
Q

what is alpha 1 antitrypsin deficiency

A
  • defect in that enzyme, whihc breaks down neutrophil elastase and trypsins
  • elastase destroys tissues in liver and lungs
222
Q

defective gene in alpha 1 antitrypsin deficiency

A

SERPINA1

223
Q

presentation of alpha 1 antitrypsin deficiency

A

Liver disease- abdo pain, N+V, jaundice, ascites, coagulopathy, confusion
Lung- emphysema- SOB, wheeze, spontaneous PTX

224
Q

ix A1ATD

A
  • serum A1AT deficient
  • liver biopsy- eaosinophilic A1AT proeitn globules
  • LFTs deranged
  • spirometry
  • genetic testing
225
Q

management of A1ATD

A
  • smokingcessation
  • infection prophylaxis- vaccines
  • inhaled steroids
  • liver/lung transplant
226
Q

tumour marker in liver cancer

A

alpha fetoprotein

227
Q

ix for ?liver cancer

A
  • MRI
  • alphafetoproteine
  • biopsy
  • hepaitits serology r/o
228
Q

management of hepatocellular carcinoma

A
  • standard chemo is sueless
  • resection, local ablation
  • tranplsant
  • sorafenib (kinase inhib) to prolong life
229
Q

presentation of liver tumours

A
  • fever, malaise
  • anorexia, wt loss
  • jaundice (late)
  • RUQ pain
  • hepatomegaly
  • intraperitoneal haemorrhage if rupture- tumour lysis
230
Q

cell type of hepatoceullular carcinoma

A
  • adenocarcinmoa resemblinf normal hepatocytes
231
Q

tx of haemangioma

A

benign

  • often incidental finding
  • no tx, avoid biopsy
232
Q

causes of liver adenoma, tx

A
  • anabolic steroids, COCP, pregnancy

- resect if sx

233
Q

tx of different liver abscesses

A
  • bacterial/pyogenic- E.coli, L. pneumonia, Strep.- coamox, drain
  • hyatid (dog tapeworm)- vermicide (albendazole)
  • Amoebic- metronidaozle, aspirate if large
  • divertiular- E.coli- co-amox
234
Q

CAGE

A
  • feel yu should cut down
  • annoyed when people criticise your drinking
  • Guilt about drinking
  • Eyeopener in the morning needed?
235
Q

Withdrawal sx of alcohol

A
  • tremulous
  • anxiety/agitation
  • tachy
  • HTN
  • N+V
  • fever
236
Q

tx withdrawal (no delirium tremens) alcohol

A
  • chlordiazepoxide/librium to prevent seizures
  • can use benzos if above unsuitable (eg diazepam, lorazepam)
  • baclofen- stomach cramps
  • thiamine
  • fluids
237
Q

sx delirium tremens

A
  • tremors
  • agitation
  • confusion, disorientation
  • hallucainations (lilliputian)
  • sensitivity to light.sound
  • hyperthermia
  • seizures
238
Q

tx delirium tremens

A
  • PO lorazepam

- IV lorazapam/haloperidol

239
Q

sx of wernicke-korsakoffs syndrome

A
  • wernicke’s encaphalopathy can lead to lasting psychosis/memory issues – korsakoffs

Wernicke

  • ophthalmoplegia (nystagmus, pupil abn)
  • mental status change
  • ataxia

Korsakoff

  • poor memory/amnesia
  • confabulation
  • poor learning
  • ataxia
240
Q

management of wernicke’s

A
  • PO thiamine to alcoholics to prevent
  • thiamine hydrochloride (B1), pabrinex IV 5d
  • Mg sulfate IV
  • folic acid
  • multivit
  • supportive- fluid, dextrose
241
Q

what drugs are there for alcoholics wanting to stop?

A

Naltrexone

  • reduces positive reward of alcohol
  • blocks endogenous opioid pathway

Acramprosate

  • increase effects of GABA, reducing glutamate surge
  • makes alcohol not effective

Dilsulfiram- aversion, antabuse
- prevents acetaldehyde breakdown

242
Q

differentiating sx for duodenal/gastric ulcers

A

Gastric-

  • pain AFTER eating (30min)
  • vomiting

Duodenal

  • pain on EMPTY stomach
  • made better by eating
  • then pain 2-3 hours after eating
  • H.pylori is most common cause
  • dark , tarry stools
243
Q

GORD- causes

A
  • hiatus hernia
  • oesophageal dysmotility eg sclerosis
  • obsesity
  • fatty diet
  • gastric hypersecretion
  • gastroparesis/delayed emptying
  • smoking, alcohol, drugs, coffee, chocolate
  • pregnancy- progesterone causes LOS relaxation
  • H.pylori
  • stress
244
Q

what drugs cause GORD

A
  • TCA
  • anticholinergics
  • nitrates
245
Q

sx GORD

A
  • heartburn (after meal, lying down, stopping, chest pain)
  • belching
  • bad breath in taste in mouth
  • increased salivation
  • enamel erosion
  • odnophagia
  • noctural dysphagia
    current- largyngitis, sinusitis
246
Q

complications of GORD

A
  • oesophagitis, ulcers, strictures, adenocarcinoma
  • Barrett’s
  • aspiration pneumonia
  • aspiration pneumonia
  • Fe deficiency
247
Q

ix GORD

A
  • endoscopy
  • Barium swallow if ?obstruction oesophagus
  • 24hour oesophageal pH monitoring
  • manometry- r/o LOS inefficieny
  • H.pylori
248
Q

ddx GORD

A
  • NSAID, herpes, candida
  • oes cancer, spasm
  • cardiac disease (ACS)
249
Q

tx GORD

A

lifestyle- wt , smokign, small frequent meals, 3 hours before bed, avoid nitrates, antichol, CCBs NSAIDs, bisphos

  • OTC anatcids- Mg, alginates (gaviscon)
  • PPIs- lanzoprazole etc
  • H2 blokcer- cimetidine, ranitidine
  • laparoscopic Nissen fundoplication to narrow LOS
  • other surgical techniques
250
Q

ix ?oes stricture

A

barium swallow
CT
endoscopy

251
Q

management of oes stricture

A
  • tx cause

- surgery and stent/bougie implantation with pull dose PPI long term

252
Q

ix petic ulcer

A
  • endoscopy

- H.pylori breath test or stool antigen

253
Q

management of peptic ulcer

A
  • PPI full dose for 8w
  • stop NSAIDs
  • exclude malignancy, crohns, zollinger ellison if non healing
254
Q

what is zollinger ellison syndrome

A
  • rare cause of peptic ulcers
  • gastrin secretin adenocarcinomas (usually pancrea, stomach, duodenum)
  • leads to overstimulation of pareital cells – HCL
255
Q

sx zollinger ellison syndrome

A
  • abdo pain
  • dyspepsia (due to peptic ulcer)
  • chronic diarrhoea, steatorrhoea- due to inactivation of panc enzymes
256
Q

ix of zollinger ellison

A
  • fasting serum gastrin (high)
  • gastric pH (~2)
  • endoscopic USS, CT
257
Q

Management of Zollinger Ellison

A
  • hgih dose PPI
  • surgery to remove lesion
  • somatostatin analogues- octreotide, lancreotide- or CT (doxorubicin, cisplatin
258
Q

Tropical Sprue- what is it

A
  • chronic intestinal inflammation due to environmental enteropathy
  • causes change in absorption of food, vitamins and minerals
259
Q

presentation of topical sprue

A
  • acute diarrhoea, fever, malaise
  • indigestion, cramps
    Vits deficiency-
  • anaemia- B12, folate
  • immune dysfunction
  • Vit A- hyperkeratosis, skin scales
  • Vit D, Ca- spam, bone pain, numbness, tingling
  • Vit K- bruising, bleeding
260
Q

ix ?tropical sprue

A
  • endoscopy
  • biopsy
  • bloods- vits, albumin, Ca, folate
  • imaging- thickened small bowel forms
261
Q

management of tropical sprue

A
  • abx- tetracycline or sulfamethoxazole/trimethoprim (co-trimoxazole) for 3-6months
  • supplementation of vits
  • generally good prognosis with no recurrence
262
Q

sx and signs appendicitis

A

Murphys traid

  • abdo pain- central–> localised RUQ pain
  • N+V
  • mild fever
  • anorexia, diarrhoea
  • guarding and rebound
263
Q

sx mesenteric ischaemia

A
  • severe abdo pain out of prop to clinical findings
  • often after eating
  • wt loss
264
Q

ix ?mesenteric ischaemia

A
  • vasc surgeon review

- angiogram, CT doppler

265
Q

management of mesenteric ischaemia

A
  • analgesia, supportive fluids
  • urgent surgical resection
  • balloon angioplasty, stenting
266
Q

difference between mesenteric ischaemia and ischaemic colitis

A

mesenteric ischaemia

  • poor circulation in the vessels supplying mesenteric organs (stomach, liver, colon , instestines)
  • Embolic- VTE/atherosclerosis
  • sudden onset
  • total- affecetd segment
  • abdo pain
  • urgent surgery

Ischaemic colitis

  • ischaemia of colon– mucosal ulceration, inflammation, haemorrhage
  • mutlifactoral- HF, atherosclerosis, thrombotic, pahrmac (CT, NSAIDs, vassopressors), surgical
  • onset over hours
  • moderate abdo pain with bloody diarrhoea
  • usually conservative management
267
Q

sx ischaemitc colitis

A
  • bloody diarrhoea

- abdo pain (moderate)

268
Q

ix ?ischaemic colitis

A
  • CT
  • clotting (if bloody), CRP, renals
  • colonoscopy within 48 hours
269
Q

management of ischaemic colitis

A
  • aggressive resus of fluids
  • analgesia
  • UO, ABG, BM monitoring
  • surgery- if haemorrhage, perf, peritonitis
270
Q

haemorrhoids- sx

A
  • bright red blood after bowel movement
  • mucus
  • pruritis ani
  • tenesmus
  • perianal mass if prolapsed
  • pain
271
Q

management of haemorrhoids

A
  • hydration
  • hgih fribre intake
  • laxative
  • gentle wiping/washing
  • cut down caffeine, alcoho, fatty foods, ice packs
  • anusol cream
  • rubber ban ligation, sclerotherapy, electrotherapy
  • haemorrhoidectomy, haemrrhoidal artery ligation
272
Q

sx anal fistulae

A
  • skin irritation around the anus
  • anal pain- constant, throbbing
  • offensive discharge near anus
  • passing blood/pus when passing stool
  • anal swelling/redness
  • temp
  • faecal incontinence
273
Q

ix anal fistula/haemorrhoids

A
  • PR
  • protoscopy
  • colonoscopy/sigmoidoscopy to r/o cancer
274
Q

tx anal fistulaes

A
  • fistulotomy
  • laser ablation
  • fibrin glue
275
Q

sx anal fissure, ix

A
  • PR bleeding (bright)
  • severe pain upon defecation

ix- examination- demarcated fissure, may see muscle fibres if chrnoic

276
Q

management if anal fissure

A

ACUTE

  • laxatives
  • diet
  • baths
  • topical analgesia
  • review in 6-8w

CHRONIC

  • glyceryl trinitrate rectal pointment
  • local botox injection (specialist)
277
Q

perianal abscess sx

A
  • red, tender swelling around anus
  • throbbing pain
  • fever, discharge, constipation
278
Q

management of perianal abscess

A
  • requires drainage
  • MC&S
  • internal packing if large
  • ABx
279
Q

sx pilonodal abscess–> cyst

A
  • asx unles infected
  • infected- red, swelling, pain, fever
  • if discharging foul smelling stool- has become sinus
280
Q

management of pilonodal abscess/cyst

A
  • not infected- watch and wait, if recurrent infections– refer to repair
  • if infected- Abx (metronidazole or coamox), analgesia, drain, surgical closure
281
Q

sx of diverticular disease

A
  • intermittent LIF/LLQ pain
  • pain tirggered by eating, reliveed by passage of stool/flatus
  • constipation/diarrhoea
    ocassional large rectal bleed
  • bloating
  • mucus
282
Q

ix ?diverticular disease

A
  • routine colonoscopy

- CT abdo

283
Q

management diverticular disease

A
  • lifestyle- high fibre diet, laxatives, hydration, smoking

- admission if ?diverticulitis, acute GI bleed

284
Q

presentation of diverticulitis

A
  • constant abdo pain
  • severe, usually in hypogastrium before localising to LLQ/LIF
  • fever
  • change in bowel habit
  • PR bleed
  • N+V
  • dysuria
  • urinary frequency
  • possible abdo mass/distension
285
Q

ix ?diverticulitis

A
  • bloods- CRP, WCC, FBC (anaemia)
  • stool sample r/o infection
  • CT abod within 24 hours
286
Q

management of diverticulitis

A
  • admit
  • oral Abx- IV if unwell (co-amox)
  • abscess- drain
  • anastomosis and bowel resection if perfed
  • lifestyle advice- diet fibre, laxative, hydration, smoking cessation
287
Q

causes of obstruction

A
  • tumours - in or out
  • ileus (gallstone, postop)
  • crohns inflammation
  • diverticulitis
  • hirchsprung’s
  • adhesions
  • volvulus
288
Q

presentation of obstruction

A
  • colicky abdo pain- poorly localised
  • vomiting- SBO, late in LBO
  • constipation
  • abdo distension- more if LBO
  • loss of flatulence if true obstruction
289
Q

ix ?obstruciton

A
  • G&S
    XR
    CT
290
Q

management obstruction

A
  • NBM
  • Analgesia
    Drip and suck:
  • fluid resus
  • NG tube- deompress prox tract, release pressure on obstruction
  • urinary catheter, fluid balance
  • watch and wait
  • surgery- washout if perf, abx
291
Q

most common cause of SBO

A
  • adhesions
    thwn crohns

hernias, malignancy, appenicitis, volulvulus, hypertrophic pyloric stenosis

292
Q

sx SBO

A
  • projectile vomiting
  • severe abod pain and distension
  • late- constipation
293
Q

cause LBO

A
  • tumours
  • consipation
  • voluvulus
  • IBD
  • adhesions
  • imperforate anus, hirschspung;s
294
Q

sx LBO

A

distansion

  • no stool
  • pain
  • flaeculent vomiting (late)
295
Q

on AXR you see a coffee bean sign- what does this mean

A
  • volulus
296
Q

tx volvulus

A
  • sigmoidoscopy and decompression
  • caeopexy- fix caecum to abdo wall
  • bowel resection
297
Q

what is pesudo osbtruction

A
  • dilation of colon due to adynamic bowel, no mechnical obsturction
298
Q

tx pseudoobstruction

A
  • NG decmopression/sigmoidocsopy
  • IV neostimgmine (anticholinesterase)
  • surgical resection
299
Q

Deterioration- new RUQ pain, jaundice in patient with hepatitis B - red flag sx for?

A

? hepatocellular carcinoma

300
Q

what is orlistat

A

inhibits pancreatic lipases so reduces absorption of lipids from intestine

301
Q

criteria for the use of orlistat fro obsesity

A
  • BMI of 28 kg/m^2 or more with associated risk factors
  • BMI of 30 kg/m^2 or more
  • continued weight loss e.g. 5% at 3 months

orlistat is normally used for < 1 year and to be used as part of overall plan to lose wt

302
Q

what antTB drug most commonly causes hepatitis

A

isoniazid

pyrazinamide also causes it

Finals (15 decks)

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