Gastro/Hep Flashcards
1
Q
What peptide component is coeliac immune response against?
A
- gliadin in gluten
2
Q
What genetic component is coeliac
A
HLA- DQ2
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
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,
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
6
Q
tx coeliac
A
- lifelong gluten free diet- wheat, spelt, rye, barley, bread, pasta, cerelas, beer, cakes, cookies, pastries
7
Q
histology of coeliac
A
- crypt hyperplasia
- itraepithelial WBC
- villous atorphy
- reduced duodenal folds
8
Q
tx dermatitis herpetiformis
A
topical dapsone
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
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
- spread to lymph nodes
- metastatic to distant organs (liver, lungs)
11
Q
sx of colorectal cancer
A
- haematochezia
- changes in frequency, consistency of bowel movements
- anaemia
- unexplained wt loss
- N+V
- fatigue
- abdo pain
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
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
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
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
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
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
18
Q
what are hemicolectomies
A
- whole + top of ascending (R)
- whole and top of descending (L) bowel is resected
19
Q
what is a high anterior resection
A
- sigmoid colon resected +- upper rectum
20
Q
what is a low anterior resection
A
- rectum/part of rectum is removed and colon is joined to remaining rectum
21
Q
what is a abdominoperianal resection
A
- anus, rectum and sigmoid colon is removed (will need permanent end colostomy bag)
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
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
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)
25
What is the screening for colorectal cancer
- 55yo- one off sigmoidoscopy
- 60-74- FIT every 2 years
- positive FIT- colonoscopy
26
describe the anatomy of the biliary tree
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
27
what does the pancreas produce
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
28
how is GB emptying stimulated
- duodenum fills with food
| - produces Cholecystokinin (CCK) in response to fatty foods
29
describe the bilirubin ccyle
- 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
30
what types of gallstones are there
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
31
sx of biliary stones
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
32
why do the sx of obstructive jaundice occur
- 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)
33
What is Murphy;s sign
- pt has 'catch breath' on palpation of just below the costal margin on RUQ mid-clavicular line
34
ix ?GB stone
- 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
35
tx GB stone
- 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
36
what is cholecystitis
- GB inflammation
37
causes of cholecystitis
- gallstones- particularly acute onset (stuck in neck/cystic duct)
- trauma
- infection (coliforms- E.coli, klebsiella, enterobacter)
38
sx and signs acute cholecystitis
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) )
39
sx chronic cholecystitis
- flatulence
- nausea
- fat intolerance (vomiting)
- distension
40
ix for ?cholecystitis
- 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
41
tx cholecystitis
- IV fluids
- Co-amox (covers coliforms if infection)- IV then oral
- analgesia
- cholecystectomy
42
What is acute cholangitis/ascending cholangitis
- inflammation of biliary tree
43
causes of acute cholangitis
- 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
44
sx, signs of cholangitis
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
45
ix for ?cholangitis
- FBC- WCC, ESR, CRP, lFT, UE< blood cultures, Amylase
- abdo USS
- AXR
- contrast enhanced dynamic CT
46
management of cholangitis
- fluids
- coamox
- endoscopic biliary drainage to tx obstruction
47
what is primary sclerosing cholangitis
inflammation and fibrosis of the intraheptic and extrahepatic bile ducts
- biliary strictures
- cirrhosis
- secondary if as a result of infection, thrombosis, iatrogenic or trauma
48
sx/signs of primary sclerosing cholangitis
- 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
49
what condition is primary sclerosing cholangitis associated with
IBD
50
ix ?primary sclerosing cholangitis
- MRI
- Abnormal LFTs, bilirubin, albumin, PTT
- USS- not diagnostic
- ERCP or transhepatic cholangiography
- liver biopsy for staging
51
management of primary sclerosing cholangitis
- 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
52
What is primary biliary cholangitis (primary biliary cirrhosis)
- destruction of small interlobular bile ducts, causing intrahepatic cholestasis, leading to scarring, cirrhosis
53
phases of primary biliary cholangitis
- preclinical
- asx
- sx
- liver insufficiency
54
sx/signs primary biliary cholangitis
- 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
55
what conditions of coincides with primary biliary cholangitis
Sjogrens
hypothyroid
renal tubular necrosis
56
Ix primary biliary cholangitis
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
57
tx primary biliary cholangitis
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
58
Differences in primary sclerosing and primary biliary cholangitis
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
59
RFs for gastric cancer
- 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
60
sx gastric cancer
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)
61
ix for ?gastric cancer
- 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
62
2ww gastric cancer
- new onset dysphagia
| - aged >55yp with wt loss, upper abdo pain, reflux or dyspepsia
63
cancer cell type in gastric cancer
- gastric adenocarcinoma - most common
- MALT lymphoma
- carcinoid and stromal are rare
64
tx gastric cancer
- surgery- total /subtotal gastrectomy
- chemo, RT
- resection if confined to mucosa
- If HER2 positive- HER2 inhibitors- tyrosine kinase inhibis (herceptin)
- pallitation
65
sx of gastritis
- syspepsia/epigastric discomfort- gnawing/burning
- N+V
- loss of appetite
- severe emesis
- acute abod pain
- fever
66
common causes of gastritis
- H.pylori
- NSAIDs
- alochol
- prev gastric surgery
- stress
- autoimmune
67
urgent endoscopy indications
- GI bleeding
- ealry satiety
- unexplained wt loss >10%
- progressive dysphagia
- odynophagia- painful swallowing
- persistent vomiting
68
ix for ?gastritis
```
H.pylori urea bretah test
H.pylori faecal antigen test
- FBC
- endoscopu
- histology
```
69
tx for H.pylori
- PPI and 2 antibacterials-- amoxicillin and either clarithro or metro, 14 days
use clarithro and metronidazole with PPI if pen allergic (no amox)
70
tx gastritis
- 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
71
ix for GI bleed
- 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
72
what scoring system is used for a GI bleed
- Glasgow-Blacthford score
73
Management of GI bleed due to peptic ulcer
- 2x wide bore cannulas
- ABCDE
Peptic ulcer
- injections of adrenaline
- Cauterisisaiton
High dose PPI +- H.pylori eradication
74
management of GI blee d (non variceal)
- clips +- adrenaline
- thermal coagulation with adrenaline
- fibrin or thrombin with adrenaline
- PPIs
75
management of variceal bleed
- 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
76
hwo to differentiate location of GI bleed
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
77
Upper PR bleed ddx
- peptic ulcers
- gastritis.oesophagitis
- varices
- malignancy
- mallory weiss
- trauma
- infections
78
intestinal and colon ddx PR bleed
- polyps, cancer
- diverticular disease, Meckels
- intussusecption
- IBD
- trauma/foreign bodies
* *- ischaemic colitis
- infection- infective colitis
79
ddx PR bleed rectum/anus
- haemorrhoids
- cancer
- anal fissures
- radiation proctitis
- IBD
- trauma
- foreign bodies
- infections
80
ix PR bleed
* ***- 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
81
management of PR bleed
- 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
82
what is meckles diverticulum, sx, tx
- 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
83
what is Crohn's
- anywhere mouth to anus
- ulcers are deep into bowel wall (tranmural), fissuring, granulomas
- cobblestone, patchy appearance
84
genetic mutation in crohns
NOD2, CARD15
85
what is UC
- colon and rectum only
- continuous inflammation of the wall
- mucosa and submucosal only
- T cell destruction of the wall
86
sx Crohns
- 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
87
tx crohns
- stop smoking
Monotherapy - to induce remission
1. pred/methylpred/hydrocortisone
consider aminosalicylate (mesalazine/sulfalazine) in first flare in 12 month period if steroids CIed
2. - add to above
- azathioprine, mercaptopurine
3. 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
88
sx UC
- severe, frequent diarrhoea +- blood
- systemic illness
- pain LIF
- flare- tachy, fever, malaise, tender distended abdo
89
tx UC
Acute- mild-mod
- diarrhoea- loperamide, codein
- constipation- macrogol
- 1. aminosalicylates- sulfalazine/mesalazine- enema and/or PO depending on if in descending colon
2. corticosteroids
3. 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
90
IBS sx
- bloating
- mucus in stool
- pain that imprves after bowel moevement/ flatulence
- 'disorders of defacation'- diarrhoe, contipation with straining, incomplete evacuation
91
tx IBS
- 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
```
92
causes of infective gastroenteritis
- viral- norovirus, rotavirus, adenovirus
- bacterial- campylorbacter, E.coli O157, salmonella, shigella, S.areus, C.diff, yersinia
- parasites- cryptosporidium, giardia, entamoeba
93
what organisms cause bloody diarrhoea
* *- shigella
- E.coli
- salmonella
- campylobacter
* *- yersinia
- entamoeba histolytica
94
ix gastroenteritis
- 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
95
when to admit a pt with diarrhoea ?gastroenteritis
- 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
96
tx of diarrhoea ?gastroenteritis
```
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
97
what antibiotics predispose pts of C.diff
- ampicillin
- amox, co-amox
- cepahlosporins- ceftriaxone, cefuroxime, cephalexin
- clindamycin
- quinolones- cipro, ofloxacin, levofloxacin
98
signs and sx of c.diff
- 5-20days following abx
- watery diarrhoea +- blood staining
- abdo cramps
- fever, rigors
- risk of sepsis
99
ix ?c.diff
- FBC- WCC
- UE
- hypoalbuminaemia- protein losing enteropathy
- stool sample
100
Management of c.diff
- 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
101
sx H.pylori
- dyspepsiea (aching, burning, worse when hungry)
- no red flags- wt loss, dysphagia, early satiety
- loss of appetite
- diarrhoea, loose stools
- frequent burping, bloating
102
what can cause false negative on urea 13C breath test
- PPI within 2w
| abx within 4w
103
What is barrett's oesophagus
- normal stratified squamous epithelium replaced with simple collumnar (glandular)
104
red flags of upper GI malignancy
- wt loss
- dysphagia (progressive)
- early satiety
- worsening dyspepsia despite PPI
- malaise
- loss of appetite
105
ix ?barrett's
oesophago-gastro duodenoscopy- biopsy, oesophagus looks red and velvety, with smoe preserved pale islands
106
sx barretts
- GORD
- retrosternal pain
* **- excessive belching
- odynophagia
- chronic cough
- hoarseness
107
management of barretts
- 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
108
what lifestyle factors worsen GORD
```
big meals
wt
smoking
**stress
food evening
** tight clothes
**alcohol
caffeine, spicy, acidic foods
```
109
what cell type if oesophgeal cancer
adenocarcinoma (developed world) or sq cell carcinoma (developing world)
110
sx oesophageal cancer
late presentation
- progressive dysphagia
- significant wt loss
- odynophagia
* *- hoarseness
111
ix ?oesophageal cancer
- 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
112
qs to ask with dysphagua
- 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
113
tx oesophageal cancer
- stent
- RT, CT
- oesophageal resection
114
what oesophageal motility disorders are there
- achalasia
| - diffuse oesophageal spasm
115
what is achalasia
Failure of relaxation of the lower oesophageal sphincter
| progressive failure of contraction of the oesophageal smooth muscle
116
ix for ?oesophgeal motility disorder
- urgent endoscopy- exclude oesophageal cancer
- oesophageal manometry- pressure probe
achalasia-- absence of peristalsis, sphincter tone high
diffuse oes. spasms- repetitive, simultaneous , ineffective contractions
117
tx oesophageal motility disorders
- chew food
- fluids with meals
- elevate head when sleeping
- CCB/nitrates
- botox injections
- endoscopic ballooon
- myotomy
118
what are sx diffuse oesophageal spasms
- severe dysphagia
| - central chest pain exacerbate by food
119
sx achalasia
- prgressive dysphagia
- vomiting, regurg of food, coughing
- chest discomfort/pain
- wt loss
- sx vary day to day
120
what is a mallory weiss tear
- usually tear after prfuse vomiting
| - generally small and self limiting
121
what is boerhaave's syndrmoe
- perf of oesophagus
- stomach contents into mediastinum and pleural cavity-- inflam response
- physiological collapse, multiorgan failure
- surgical emergency
122
sx oesophageal tear and rupture
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
ix ?oes tear
- 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
Management of oes tear
- 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
what are exocrine and endocrine tumours of the pancreas
exocrine- enzyme producing- adenocarcinomas (most common)
| - endocrine- hormone producing eg insulinomas (less common, often benign)
126
what mutations are assoc with pancreatic cancer
- BRCA1 , BRCA2, PALB2, ATM, TP53
127
sx and signs pancreatic cancer
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
ix ?pancreatic cancer
- serum amylase, lipase
- CEA, CA199
- bilirubin, ALP, AST, ALT
- MRI, MRCP, ERCP
129
tx pancreatic cancer
CT
| surgery
130
Causes of pancreatitis (acute and chronic)
```
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
sx pancreatitis
- severe epigastric pain radiating to back
- N+V
- exocrine- wt loss, diarrhoea, steatorrhea
- Endocrine - diabetes
- jaundice
132
ix pancreatitis (acute and chronic)
```
amylase, lipase
CT
ERCP ?stones
biopsy
secretin stimulation test
```
133
tx chronic pancreatitis
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
signs of acute pancreatitis
- Cullen- umbilical bruising, suggests intraperitoneal haemorrhage
- Grey-turner's- bruising on L flank- retroperitoneal haemorrhage
135
tx acute pancreatitis
- NBM
- abx- coamox?
- IV fluids
- analgesia
- ERCP stone removal
- cholcystectomy
136
ddx for dysphagia, dyspepsia
- 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
ddx for epigastric/RUQ pain+- jaundice
- 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
What organs are retroperitoneal
```
SAD PUCKER
Suprarenal glands (adrenals)
Aorta and IVC
Duodenum
Pancreas (except tail)
ureters
colon (ascending and descending)
Kidneys
Esophagus
Rectum
```
139
mutations assoc with primary peritoneal cancers
BRCA1 BRCA2
140
sx peritoneal cancer (primary or secondary)
```
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
ix ?peritoneal cancer (distended, bloated abdo with wt loss and b sx)
- CT abdo, pelvis,
- MRI
- ascites fluid aspiration (risk of seeding)
- CA125, HE4
- laparoscopy or laparotomy with biopsy - GOLD STANDARD
142
tx peritoneal cancer
- omentectomy
- debulking/cytoreduction surgery
- chemo/RT
- monoclonal antibodies
- Poly-ADP ribose polymerase inhibitors- block NA repair- olaparib
- angiogenesis inhibs
- hormonal therapy
- immunotherapy
143
primary causes of peritonitis
spontaneous:
- cirrhosis and ascites- fluid is static and become infected,
- peritoneal dialysis
144
causes of secondary peitonitis
- GI perf- appendix, diverticulum, peptic ulcer, bowel, intestine, GB
- obstruction
- IBD, diverticulitis
- pancreatitis
- PID
- surgery
- trauma
- splenic rupture
- AAA rupture
145
signs of peritonitis
- 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
ix peritonitis
- blood/urine cultures, CRP, ESR
- XR
- CT
- explorative surgery
- paracentesis if ascitic
147
tx peritonitis
- IV abx- cepahlosporin (eg cefuroxime) plus metro/gent plus metro
- surgical repair of cause
- tx cause
148
Function of the spleen
- immune- WBCs, igG, properdin, tuftsin
- removes old/dead/damaged RBcs
- removes platelets
- clears microorganisms and antigens
- stores RBCs and plts
149
Causes of splenomegaly
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
sx splenomegaly
- abdo pain, ***radiates to shoulder/back, chest pain
- satiety if compressing on stomach
- fatigue
- easy bleeding, brusiing
- frequent infections
- anaemia
- asx
151
investigation of splenomegaly
- RBC, WCC, plt, LFT
- bone marrow- reticulocytes, blood disorders
- CT, USS
- magnetic resonance angiography (blood through spleen)
152
sx splenic rupture
- abdo pain- LUQ, peritonism
- Kehr's sign- (L) shoulder pain due to blood irritating diaphragm
- confusion, tiredness,
- dizziness, fainting shock
153
ix ?splenic rupture
- 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
tx splenic rupture
- 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
what is an acute abdomen?
- sudden severely painful abdomen
| - often assoc with N+V
156
ddx of acute abdo with pain in epigastrium
- pancreatitis
- MI
- peptic ulcer
- acute cholecystitis (infeciton, stone)
- perf oeseophagus/mallory weiss
157
ddx of acute abdo with pain in RUQ
- acute cholecystitis
- duodenal ulcer
- hepatitis
- congestive hepatomegaly
- pyelonephritis
- appendicitis
- R pneumonia
158
ddx of acute abdo with pain in LUQ
- splenic rupture
- gastric ulcer
- AAA+- rupture
- perfe colon
- pyelonephritis
- L pneumonia
159
ddx of acute abdo with pain in RLQ
- 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
ddx of acute abdo with pain in RLQ
- sigmoid diverticulitis
- strangluatedhernia
- colon perf
- crohns
- UC
- renal stones
GYNAE
- salpingitis (PID)
- tubo-ovarian abscess
- ovarian torsion
- ectopic pregnancy +- rupture
161
ddx of acute abdo with pain in umbilicus
- intestinal obstruction
- acute pancreatitis
- early appendicitis
- mesenteric thrombosis
- AAA
- diverticulitis
162
location of spleen
- around fundus of stomach
163
function of liver
- 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
causes of acute liver failure
- 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
sx of acute liver filaure
- jaundice
- weakness
- confusion, mental state change
166
ix acute liver failure
- 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
tx acute liver failure
- 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
main causes of chronic liver failure
- 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
what is budd chiari
- hepatic veins blocked/narrowed by clot
170
sx of chronic liver failure
- 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
what system is used to calculate how severe chronic liver disease is
- Child-Pugh
172
ix chronic liver disease
- 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
what drugs do you need to be cautious in hepatic impairement
- opioids
- NSAIDS
- paracetemol
- Diuretics
- methotrexate, isoniazid oestrogen, salicylates, tetracyclines
174
complications of chronic liver failure
- 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
what is decompensated liver failure
new jaundice, asscites, SBP, encephalopathy, AKI
may be precipitating cause- infection, dehydration, constipation, drugs/alc, ischaemia, portal thrombosis
176
ix decompendated liver failure
- 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
management decompensated liver failure
- 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
causes of hepatitis
- viral infection
- alochol, paracetemol
- autoimmune
179
presentation of acute hepatitis
- malaise/lethargy
- jaundice
- vomiting
- abdo pain
- diarrhoea
- often arthralgia if viral
180
hep A- spread how
shellfish, faecal-oral (water)
181
hep B- spread how
blood products
IVDU
sexual contact
birth
182
hep c- spread how
blood- IVDU, transfusion, poorly cleaned medical equipment, vertical
183
tx hep a,b,c
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
viral causes of hepatitis
- Hep A,B,C,D,E
- EBV
- CMV
- leptospirosis (parasite)
- malaria
- syphilis
- yellow fever
185
presentation of autoimmune hepatitis
- acute hepatitis and sx of other autoimmune disease- efevr, malaise, urticarial rash, pleurisy, glomerulonephritis
- jaundice
- amenorrhea
186
ix autoimmune hepatitis
- increase bili AST ALT ALP
- increased Ig
- ANA, ASMA
- anaemia, low WCC and plts
- liver biopsy- CD4 cells, fibrosis and cirrhosis
187
management of autoimmune hepatitis
- steroids- pred
- azathioprine
- transplant
188
drugs that cause hepatitis/hepatotoxicity
- augmentin, fluclox, erythro, TB
- chlorpromazine, carbamazepine, valproate, paroxetine
- immunosups
- NSAIDs, paraceteol
- PPIs
- dietary supplements
189
sx drug induced hepaitis
- RUQ pain
- jaundice
- coagulopathy
- encephalopathy- mental status change, confusion
190
tx of drug induced encephalopathy
- stop offending med
- fluids, analgesia
- antidote - look on toxbase
191
management of paracetemol overdose
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
sx of alcoholic liver disease
- malaise, anorexia
- diarrhoea an vomiting
- tender hepatomegaly
- haundice
- bleeding, coagulopathy
- ascites
- encphalopathy
193
ix ?alcoholic liver disease
- clotting
- ABDO USS/CT
- biopsy- mallory bodies from accumulation of injured liver cells
194
management of alcoholic liver disease
- tx liver failure and complications
- prednisolone
transplant
- tx alochol withdrawal
- stop alcohol intake
195
tx ascites
- tx cause
- sprinolactone/furosemide- avoid massive diuresis as can precipitate encephalopathy
- fluid and salt restriction
- paracentesis
- IV albumin replacement
- Transjugular intraheptatic portosystemic shunt
196
what generally causes spontaneous bacterial peritonitis
- E.coli/klebsiella -- gram negative
197
Management of spontaneous bacterial peritonitis
- abx- cefotaxime
| - prokinetics to reduce small bowle overgorwth
198
sx portal HTN
- Ascites
- 0 abdo pain
- varies- haematoemesis
- blood in stool (rectal varices)
- thrombocytopenia (spleen consumes plts)-- bleeding, bruising
199
ix portal HTN
- US abdo + doppler (low velocity)
- CT/MRI abdo
- hepatic venous pressure gradient- GOLD STANDARD
200
tx portal HTN
- shunts- splenorenal, TIPS
| - propanolol, terlopressin, banding to prevent varicela bleeding
201
sx of hepatorenal syndrome
- jaundice, altered mental state, ascites
- oliguria
- low BP
202
tx hepatorenal syndrome
- stop diuretics and all nephrotoxic drugs
- vasopressors
- haemodialysis/liver dialysis
- liver transplant
203
tx hepatic encephalopathy
lactulose
rifaximin
transplant
204
ix hepatic encephalopathy
- 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
presentation of NAFLD
- liver failure- jaunice, confusion, ascites, RUQ pain
206
ix NAFLD
- adbo USS
- elevated LDH
- livery biopsy- fatty
-
207
tx NAF:D
- wt loss
- monitor
- screen for diabetes
- continue statins- consider stopping if enzymes double within 3 m of starting them
- pioglitazine or vit E
208
LFTs
- 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
presentation of hepatic venous occlusion
(causes portal HTN and congestive hepatopathy)
acute liver failure- ascites, abdo pain, jaundice, bruising
210
what is haemochromatosis
- uncontrolled iron absorption
| - deposition in liver, heart, pancreas, joints, pituitary, skin
211
presentation of haemochromatosis
- slate grey skin
- arthralgia/joint pain
- decreased libido, hypogonadism
- diabetes
- liver failure
- HF
212
ix haemochrmoatosis
- raised ferritin and transferrin
- HFE genotyping
- biopsy- Perl's stain
- Abdo MRI- deposits in liver
213
enetic mutaiton for haemochromatosis
- HFE
214
tx of haemochromatosis
- venesection
- desferrioxamine- irone chelation
- genetic screneign for 1st degree relatives
215
causes of excess iron
- haemochromatosis
- multiple blood transfusions
- haemolysis
- alcoholic liver disease
216
what is wilsons
genetic build up of Cu in liver and brain
217
wilsons and haemochromatosis inheritance patternr
recessive
218
sx wilsons
- 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
ix ?wilsons
- raised urin Cu
- decreased caeruloplasmin (depleted stores)
- liver biopsy
- MRI
- slit lamp- KF rings
- genetic testing
220
manaagemet of wilsons
- avoid hgih Cu foods
- monitor urinary CU and protein
- penicillamine- chelating drug for Cu
- liver transplant
- genetic screengn for 1st degree relatives
221
what is alpha 1 antitrypsin deficiency
- defect in that enzyme, whihc breaks down neutrophil elastase and trypsins
- elastase destroys tissues in liver and lungs
222
defective gene in alpha 1 antitrypsin deficiency
SERPINA1
223
presentation of alpha 1 antitrypsin deficiency
Liver disease- abdo pain, N+V, jaundice, ascites, coagulopathy, confusion
Lung- emphysema- SOB, wheeze, spontaneous PTX
224
ix A1ATD
- serum A1AT deficient
- liver biopsy- eaosinophilic A1AT proeitn globules
- LFTs deranged
- spirometry
- genetic testing
225
management of A1ATD
- smokingcessation
- infection prophylaxis- vaccines
- inhaled steroids
- liver/lung transplant
226
tumour marker in liver cancer
alpha fetoprotein
227
ix for ?liver cancer
- MRI
- alphafetoproteine
- biopsy
- hepaitits serology r/o
228
management of hepatocellular carcinoma
- standard chemo is sueless
- resection, local ablation
- tranplsant
- sorafenib (kinase inhib) to prolong life
229
presentation of liver tumours
- fever, malaise
- anorexia, wt loss
- jaundice (late)
- RUQ pain
- hepatomegaly
- intraperitoneal haemorrhage if rupture- tumour lysis
230
cell type of hepatoceullular carcinoma
- adenocarcinmoa resemblinf normal hepatocytes
231
tx of haemangioma
benign
- often incidental finding
- no tx, avoid biopsy
232
causes of liver adenoma, tx
- anabolic steroids, COCP, pregnancy
| - resect if sx
233
tx of different liver abscesses
- 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
CAGE
- feel yu should cut down
- annoyed when people criticise your drinking
- Guilt about drinking
- Eyeopener in the morning needed?
235
Withdrawal sx of alcohol
- tremulous
- anxiety/agitation
- tachy
- HTN
- N+V
- fever
236
tx withdrawal (no delirium tremens) alcohol
- chlordiazepoxide/librium to prevent seizures
- can use benzos if above unsuitable (eg diazepam, lorazepam)
- baclofen- stomach cramps
- thiamine
- fluids
237
sx delirium tremens
- tremors
- agitation
- confusion, disorientation
- hallucainations (lilliputian)
- sensitivity to light.sound
- hyperthermia
- seizures
238
tx delirium tremens
- PO lorazepam
| - IV lorazapam/haloperidol
239
sx of wernicke-korsakoffs syndrome
- 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
management of wernicke's
- PO thiamine to alcoholics to prevent
- thiamine hydrochloride (B1), pabrinex IV 5d
- Mg sulfate IV
- folic acid
- multivit
- supportive- fluid, dextrose
241
what drugs are there for alcoholics wanting to stop?
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
differentiating sx for duodenal/gastric ulcers
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
GORD- causes
- 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
what drugs cause GORD
- TCA
- anticholinergics
- nitrates
245
sx GORD
- 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
complications of GORD
- oesophagitis, ulcers, strictures, adenocarcinoma
- Barrett's
- aspiration pneumonia
- aspiration pneumonia
- Fe deficiency
247
ix GORD
- endoscopy
- Barium swallow if ?obstruction oesophagus
- 24hour oesophageal pH monitoring
- manometry- r/o LOS inefficieny
- H.pylori
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ddx GORD
- NSAID, herpes, candida
- oes cancer, spasm
- cardiac disease (ACS)
249
tx GORD
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
ix ?oes stricture
barium swallow
CT
endoscopy
251
management of oes stricture
- tx cause
| - surgery and stent/bougie implantation with pull dose PPI long term
252
ix petic ulcer
- endoscopy
| - H.pylori breath test or stool antigen
253
management of peptic ulcer
- PPI full dose for 8w
- stop NSAIDs
- exclude malignancy, crohns, zollinger ellison if non healing
254
what is zollinger ellison syndrome
- rare cause of peptic ulcers
- gastrin secretin adenocarcinomas (usually pancrea, stomach, duodenum)
- leads to overstimulation of pareital cells -- HCL
255
sx zollinger ellison syndrome
- abdo pain
- dyspepsia (due to peptic ulcer)
- chronic diarrhoea, steatorrhoea- due to inactivation of panc enzymes
256
ix of zollinger ellison
- fasting serum gastrin (high)
- gastric pH (~2)
- endoscopic USS, CT
257
Management of Zollinger Ellison
- hgih dose PPI
- surgery to remove lesion
- somatostatin analogues- octreotide, lancreotide- or CT (doxorubicin, cisplatin
258
Tropical Sprue- what is it
- chronic intestinal inflammation due to environmental enteropathy
- causes change in absorption of food, vitamins and minerals
259
presentation of topical sprue
- 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
ix ?tropical sprue
- endoscopy
- biopsy
- bloods- vits, albumin, Ca, folate
- imaging- thickened small bowel forms
261
management of tropical sprue
- abx- tetracycline or sulfamethoxazole/trimethoprim (co-trimoxazole) for 3-6months
- supplementation of vits
- generally good prognosis with no recurrence
262
sx and signs appendicitis
Murphys traid
- abdo pain- central--> localised RUQ pain
- N+V
- mild fever
- anorexia, diarrhoea
- guarding and rebound
263
sx mesenteric ischaemia
- severe abdo pain out of prop to clinical findings
- often after eating
- wt loss
264
ix ?mesenteric ischaemia
- vasc surgeon review
| - angiogram, CT doppler
265
management of mesenteric ischaemia
- analgesia, supportive fluids
- urgent surgical resection
- balloon angioplasty, stenting
266
difference between mesenteric ischaemia and ischaemic colitis
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
sx ischaemitc colitis
- bloody diarrhoea
| - abdo pain (moderate)
268
ix ?ischaemic colitis
- CT
- clotting (if bloody), CRP, renals
- colonoscopy within 48 hours
269
management of ischaemic colitis
- aggressive resus of fluids
- analgesia
- UO, ABG, BM monitoring
- surgery- if haemorrhage, perf, peritonitis
270
haemorrhoids- sx
- bright red blood after bowel movement
- mucus
- pruritis ani
- tenesmus
- perianal mass if prolapsed
- pain
271
management of haemorrhoids
- 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
sx anal fistulae
- 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
ix anal fistula/haemorrhoids
- PR
- protoscopy
- colonoscopy/sigmoidoscopy to r/o cancer
274
tx anal fistulaes
- fistulotomy
- laser ablation
- fibrin glue
275
sx anal fissure, ix
- PR bleeding (bright)
- severe pain upon defecation
ix- examination- demarcated fissure, may see muscle fibres if chrnoic
276
management if anal fissure
ACUTE
- laxatives
- diet
- baths
- topical analgesia
- review in 6-8w
CHRONIC
- glyceryl trinitrate rectal pointment
- local botox injection (specialist)
277
perianal abscess sx
- red, tender swelling around anus
- throbbing pain
- fever, discharge, constipation
278
management of perianal abscess
- requires drainage
- MC&S
- internal packing if large
- ABx
279
sx pilonodal abscess--> cyst
- asx unles infected
- infected- red, swelling, pain, fever
- if discharging foul smelling stool- has become sinus
280
management of pilonodal abscess/cyst
- not infected- watch and wait, if recurrent infections-- refer to repair
- if infected- Abx (metronidazole or coamox), analgesia, drain, surgical closure
281
sx of diverticular disease
- intermittent LIF/LLQ pain
- pain tirggered by eating, reliveed by passage of stool/flatus
- constipation/diarrhoea
ocassional large rectal bleed
- bloating
- mucus
282
ix ?diverticular disease
- routine colonoscopy
| - CT abdo
283
management diverticular disease
- lifestyle- high fibre diet, laxatives, hydration, smoking
| - admission if ?diverticulitis, acute GI bleed
284
presentation of diverticulitis
- 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
ix ?diverticulitis
- bloods- CRP, WCC, FBC (anaemia)
- stool sample r/o infection
- CT abod within 24 hours
286
management of diverticulitis
- 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
causes of obstruction
- tumours - in or out
- ileus (gallstone, postop)
- crohns inflammation
- diverticulitis
- hirchsprung's
- adhesions
- volvulus
288
presentation of obstruction
- colicky abdo pain- poorly localised
- vomiting- SBO, late in LBO
- constipation
- abdo distension- more if LBO
- loss of flatulence if true obstruction
289
ix ?obstruciton
- G&S
XR
CT
290
management obstruction
- 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
most common cause of SBO
- adhesions
thwn crohns
hernias, malignancy, appenicitis, volulvulus, hypertrophic pyloric stenosis
292
sx SBO
- projectile vomiting
- severe abod pain and distension
- late- constipation
293
cause LBO
- tumours
- consipation
- voluvulus
- IBD
- adhesions
- imperforate anus, hirschspung;s
294
sx LBO
distansion
- no stool
- pain
- flaeculent vomiting (late)
295
on AXR you see a coffee bean sign- what does this mean
- volulus
296
tx volvulus
- sigmoidoscopy and decompression
- caeopexy- fix caecum to abdo wall
- bowel resection
297
what is pesudo osbtruction
- dilation of colon due to adynamic bowel, no mechnical obsturction
298
tx pseudoobstruction
- NG decmopression/sigmoidocsopy
- IV neostimgmine (anticholinesterase)
- surgical resection
299
Deterioration- new RUQ pain, jaundice in patient with hepatitis B - red flag sx for?
? hepatocellular carcinoma
300
what is orlistat
inhibits pancreatic lipases so reduces absorption of lipids from intestine
301
criteria for the use of orlistat fro obsesity
- 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
what antTB drug most commonly causes hepatitis
isoniazid
pyrazinamide also causes it
