Gastro - ix Flashcards
Extrinsic pathway of the clotting cascade
How is it measured
Normal value
Affected by
PT
14s
Warfarin, liver disease
Intrinsic pathway of the clotting cascade
How is it measured
Normal value
Affected by
APTT
34s
Heparin, Hemophilias, VWD
What is the Rockall score used for?
UGIB
Determines risk of re-bleeding + death
(1) Risk of rebleeding/mortality pre-endoscopy
(2) Risk of rebleeding/mortality post-endoscopy.
What does the Rockall score include?
Broken into an initial (pre-endoscopy) and final (post-endoscopy) score
Look at haematemesis + melaena for table
Intial Age <60 0 60-79 1 >80 2 Shock (BP+HR) HR >100 1 SBP <100 2 Co-morbidities HF, IHD 2 Renal failure, liver failure DIC 3
Final Stigmata of recent haemorrhage 2 Dx Mallory Weiss tear 0 Other dx 1 Malignancy of the UGIT 2
What is the glasgow Blatchford score?
Screening tool to assess the likelihood that a person with an acute UGIB will need to have medical intervention
What does the Glasgow Blatchford score include (8)?
Blood urea nitrogen Hb SBP HR Malaena Syncope Hepatic disease Cardiac disease
Achalasia ix
• Barium swallow
Bird’s beak appearance
• Manometry - gold standard for dx of achalasia
To distinguish achalasia from other motility disorders
a) high resting pressure in the lower oesophagus/cardiac sphincter, b) incomplete relaxation, c) absent peristalsis
• CXR
Dilated oesophagus behind the heart
May show aspiration pneumonia
Barrett’s oesophagus ix
- Endoscopy - metaplastic changes in the endothelium, “velvety epithelium”
- Histological - visible columnisation (normal: squamous epithelial lining, abnormal: metaplastic columnar epithelium can become invasive adeocarcinoma of the oesopahgus)
Oesophageal cancer ix
• OGD + biopsy any lesion seen
• Barium swallow
Rat’s tail appearance of the oesophagus
- Grade tumour histopathologically
- Stage tumour by CXR, CT, PET
• EUS (endoscopic US) used less commonly
Standard pre-treatment test
Can identify all the histological layers of the oesophagus + there by confirm the T-stage with 90% accuracy
Can identify abnormal or enlarged mediastinal and coeliac axis lymph nodes, and enable cytological examination by FNA
Crucial in planning treatment, particularly prior to durgery
Most accurate modality for local + regional staging (consistently better than CT, PET, MRI)
If there is no evidence of metastatic disease on PET-CT + patient is candidate for surgery
Provides useful info about intramural vs transmural disease + local lymph node involvement
Gastritis ix
1st line investigations:
• H pylori testing –> 13C urea breath test / stool antigen test
• FBC – ?iron deficiency anaemia
Investigation to consider: • Endoscopy • Biopsy • Serum vitamin B12 N/L AI gastritis
Peptic ulcer disease Ix
under 55 or no red flag symptoms
• H pylori testing
13C urea breath test
stool antigen test
• FBC – ?iron deficiency anaemia
over 55 or red flag symptoms or failed treatment or bleeding ulcer
• OGD + biopsy + urease testing
Warning sings >55+ o Chronic blood loss o Persistent vomiting o Epigastric mass o unexplained, persistent, recent-onset diarrhoea o Previous peptic ulcer disease o Previous gastric surgery o Pernicious anaemia (RF for linitis plastica - gastric carcinoma w liver mets) o NSAID use o Early satiety o FHx of gastric carcinoma
ALARMS o Anorexia o Loss of weight o Anaemia (iron deficiency anaemia) o Rectal bleeding o Melaena/Haematemesis o Swallowing difficulty (progressive dysphagia) o Suspicious barium meal
ALARMS symptoms
o Anorexia o Loss of weight o Anaemia (iron deficiency anaemia) o Rectal bleeding o Melaena/Haematemesis o Swallowing difficulty (progressive dysphagia) o Suspicious barium meal
GORD ix
• 1st line Ix
8 week trial PPI trial
• OGD
o If symptoms do not improve w therapeutic 8-week trial
o if pt >55
o If patient has ALARMS symptoms
o Annual endoscopic surveillance – looking for Barrett’s Oesophagus
• Ambulatory pH monitoring - can demonstrate exposure to oesophageal acid
if ph <4 for >4h –> GORD
• Combined impedance pH testing - can quantify exposure to oesophageal acid
GORD
first line ix OGD
in pt <55 or without red flag symptoms –> trial PPIs before proceeding with investigations
GLASGOW scale
Scoring mechanism used clinically for assessing severity + prognosis of pancreatitis
Based on results within 48h of admission
mnemonic: PANCREAS
PaO2 <8kpa or <60mmHg Age >55 years Neutrophilia >15x10^9 WBC/L Calcium <2.0mM Renal funcction: Urea >16mM Enzymes LDH >600 U/L or AST >200 U/L Albumin <32g/L Sugar >10mM (in non-diabetics)
if score >3 (incl 3) - severe pancreatitis likely, consider admission to ICU
Oesophageal spasm ix
Crockscrew appearance on barium swallow
Anal fissures ix
- Do not attempt a DRE – extremely painful
* Diagnosis is clinical + further Ix only required if there are features of underlying pathology
Rectal prolapse ix
• Imaging
o Barium enema +/- colonoscopy – evaluate the entire colon prior to surgery + exclude any other colonic lesions
o Rigid Proctosigmoidoscopy – asses the rectum for additional lesions
• Anal physiology tests
o Used to distinguish between mucosal and full-thickness prolapse
o Anal sphincter manometry, electromyography of the anal sphincter, defecography, continence tests, pelvic floor, nerve stimulation tests (Pudendal nerve studies)
• Haemorrhoid
o Differentiated by the presence of symmetrical circumferential folds/concentric rings of mucosa occurring in rectal prolapse
Assess underlying conditions
• Sweat Cl- test - CF
• Stool + microscopy cultures - GI infection
Haemorrhoids ix
• Proctoscopy
Pink mucosal swellings
• Rigid/flexible sigmoidoscopy/Colonoscopy
To exclude other pathology
Definitive test is colonoscopy
Flexible sigmoidoscopy combined with a barium enema to assess proximal colon in high-risk patients
• FBC – anaemia or infection
If concerned that the patient has experienced significant prolonged rectal bleeding + signs of anaemia are present
• DRE
Appendicitis ix
1st line Ix
• FBC
Increased WCC (polymorphonuclear leukocytes)
Increased CRP
• CT AP
o Abnormal appendix (diameter >6mm) / calcified appendicolith in association with peri-appendiceal inflammation / appendiceal wall thickening / peri-appendiceal fat stranding / appendiceal wall enhancement
• Abdominal ultrasound
- Urinalysis to exclude UTI
- Urinary pregnancy test - exclude ectopic pregnancy
2nd line Ix
• Urinalysis
• Alvarado scoring system
4-6 – CT investigation
>7 appendicectomy
Alverdo scoring system for appendicitis
Symptoms
Signs
Laboratory findings
Results
Symptoms - MAN
- migratory RIF pain
- Anorexia
- N+V
Signs - TRF
- Tenderness in RIF
- Rebound tenderness in RIF
- Fever >38
Laboratory findings - LS
- Increased WCC (2) >10
- Shift to the L of the neutrophils
5-6 possible
7-8 probable
>9 very probable
CT 4-6
Appendectomy >7
Ix to confirm obstruction
AXR
Small bowel >3cm
Large bowel >6cm
If large bowel >9cm - risk of imminent perforation + need for surgery
Colon cancer ix
Bloods • FBC Anaemia if bleeding • LFTs Liver is the first site of metastasis of colorectal cancer (enterohepatic circulation) • U&Es • CEA (not used for diagnosis but to monitor treatment, relapse, recurrence of disease) • FOBT – used as a screening test
Imaging
• Colonoscopy – GOLD STANDARD FOR DIAGNOSIS OF COLORECTAL CANCER
• CT scan CAP
Staging
• Liver USS
Staging
• Barium enema
Apple core stricture
Volvulus ix
Bloods
• FBC - low Hb, high WCC if sepsis, gangrene
• U+E
Dehydration
Sepsis (high lactate)
Acidosis
Hyponatraemia, hyperkalaemia, metabolic acidosis, raised U +Cr, hypochloraemia, lactic acidosis
Imaging
• Upper GI contrast studies - diagnostic test
• AXR (ordered in ED)
Sigmoid volvulus 65% - Coffee bean shape in RUQ, assosciated with large bowel dilation
Caecal volvulus 30% - caecal embryonic sign in LUQ, assosciated with small bowel dilation
• Erect CXR – if perforation is suspected
Choledocholithiasis ix
EUS/MRCP
Gallstones/biliary colic ix
• US abdo
Shows gallstones + sludge in the gallbladder
Dilated bile duct in choledocholithiasis
Allows measurement of the diameter of the CBD
Bloods
• FBC - raised WCC due to inflammation from a complication of cholelithiasis – acute cholecystitis, cholangitis, pancreatitis
• LFTs - raised ALP due to obstruction of the cystic or bile duct
• Serum lipase + amylase
o Pancreatitis is a complication of cholelithiasis
Cholecystitis ix
Imaging • RUQ US – initial test of choice o Thickened bladder wall (>3mm) o Distended gallbladder o Pericholecystic fluid/air o Gallstones o Positive sonographic Murphy’s sign
• HIDA (hepatobiliary iminodiacetic acid) scanning + MRI – helpful in cases where the US dx is unclear
o HIDA directly shows cystic duct obstruction
Bloods • FBC - raised WCC • Raised CRP • LFTs Cholestatic picture Raised ALP, GGT, bilirubin
Acute cholangitis ix
Imaging • US abdo to visualise stones • ERCP First line Ix Direct observation of bile duct stone or other obstruction Therapeutic – can be used for biliary stone extraction • Contrast CT abdo – second line • MRCP – third line
Bloods
• FBC - raised WCC
• LFTs - raised conjugated bilirubin (obstructive jaundice) + raised ALP + N LFTs
• Raised amylase - Indicates involvement of the lower part of the CBD (next to the pancreas)
• Blood cultures - Bacteria are usually gram-negative
Mallory Weiss tear ix
Imaging
• OGD
Diagnostic test
Needs to be performed within 24h – tears heal rapidly
• Angiography
If OGD is no available/is contra-indicated
Bloods
• FBC
• Coagulation studies + platelet counts to detect coagulopathies + thrombocytopenias
• Urea - High in patient with ongoing bleeding, part of the Glasgow-Blatchford Bleeding score
• LFTs - to rule out liver disease (+ hence oesophageal varices, gastric varices)
• ECG + cardiac enzymes – if myocardial ischaemia is suspected as a result of blood loss
Toxic megacolon ix
AXR >6cm
When should flexible sigmoidoscopy be used instead of colonoscopy toi investigate UC?
When there is a high risk of perforation
UC ix
Bloods • FBC (low Hb, high, WCC) • High ESR/CRP • Low albumin • B12/folate deficincy (malabsorption) • Fe deficiency (bleeding, malabsorption) • Anaemia of chronic disease
Stool
• Stool culture
To exclude infectious colitis/diarrhoea
C. Difficile has a higher prevalence in pt with IBD
CMV considered in severe or refractory colitis – reactivation is common in pt with IBD on immunosuppression
• Faecal calprotectin
Disitnguishes between inflammatory (IBD) + non-inflammatory (IBS) causes of diarrhoea
Conc in faeces correlates well with severity of intestinal perforation
AXR
• To rule out toxic megacolon + perforation
o Signs of toxic megacolon: abdominal tenderness + distention, tachycardia, fever, anaemia, transverse colon >6cm
Colonoscopy - not to be performed on an acute setting due to risk of perforation [Flexible sigmoidoscopy performed if there is risk of perforation]
Determines severity
Histological confirmation
Detection of dysplasia (UC pt at higher risk of colonic adenocarcinoma)
Gross uniform inflammation with a clear cut off point between normal and abnormal bowel
Indicated in UC pt who are not responding well to treatments
Biopsy
Inflamed crypts filled with fibrin and polymorphonuclear leukocytes
DCBE
Mucosal ulceration with granular appearance + filling defects (due to pseudopolyps)
Narrowed colon
Loss of haustral pattern – leadpipe appearance
Crohn’s disease ix
Blood • FBC (low Hb, high WCC, high plt) • High ESR/CRP • Low albumin • B12/folate deficiency (malabsorption) • Fe deficiency • Anaemia of chronic disease
Stool • Culture To exclude infective colitis/diarrhoea C. diff esp if Hx of recent Abx use Y enterocolitica – if RIF pain
• Faecal calprotectin
Disitnguishes between inflammatory (IBD) + non-inflammatory causes of diarrhoea (IBS)
Conc in faeces correlates well with severity of intestinal perforation
AXR
• To exclude toxic megacolon
• To assess CD severity
Colonoscopy
• Can help differentiate UC + CD
• Defines presence + severity of morphological recurrence + predicts clinical course
• Useful for monitoring malignancy + disease progression
• Histological confirmation
Biopsy
• Non-caseating granulomas in the bowel wall mucosa
Transmural chronic inflammation with infiltration of macrophages, lymphocytes, plasma cells
DCBE
• String sign of Kantor
• Rose thorn ulcers
• Cobblestone mucosa
What is Truelove’s and Witt’s severity index and what does it include (6)?
Classifies severity of UC
Includes
- Number of stools
- Blood in stools
- Anaemia
- Pulse rate (>90)
- Fever (>37.8)
- ESR/CRP (>30mm/h)
Cirrhosis ix
Bloods
• FBC
Low Hb – occult bleeding
Macrocytosis – alcohol abuse
Thrombocytopenia (<150, normal 150-450 x 10^9/L)
Most sensitive + specific laboratory finding for dx of cirrhosis in the setting of chronic liver disease
• LFTs
o Raised AST, ALT
o Elevation of ALT>AST - viral hepatitis
o Elevation of AST>ALT - alcoholic hepatitis
o Bilirubin normal at the start but as cirrhosis progresses, serum levels rise
Low Na
Low albumin
Prolonged PTT
Tests to consider
• Abdo US/CT/MRI
o Can detect signs of advanced cirrhosis + complications of cirrhosis (e.g. portal HTN)
o Signs of portal HTN: ascites, splenomegaly, increased diameter of the portal vein (>13mm), collateral vessels, hepatocellular carcinoma
• CXR
o Might show elevated diaphragm + pleural effusion
• Upper GI endoscopy
o Presence of gastro-oesophageal varices
• Transient elastography/acoustic radiation force impulse imaging
o Used to diagnose cirrhosis for people with NAFLD + advanced liver fibrosis
• Liver biopsy
o Most specific + sensitive test for dx of cirrhosis
o If liver elastography not suitable
o Not necessary in pt with advanced liver disease + typical clinical/laboratory/radiological findings of cirrhosis - ascites, coagulopathy, shrunken nodular-appearing liver
Cirrhosis ix
Bloods
• FBC
Low Hb – occult bleeding
Macrocytosis – alcohol abuse
Thrombocytopenia (<150, normal 150-450 x 10^9/L)
Most sensitive + specific laboratory finding for dx of cirrhosis in the setting of chronic liver disease
• LFTs
o Raised AST, ALT
o Elevation of ALT>AST - viral hepatitis
o Elevation of AST>ALT - alcoholic hepatitis
o Bilirubin normal at the start but as cirrhosis progresses, serum levels rise
Low Na
Low albumin
Prolonged PTT
Tests to consider
• Abdo US/CT/MRI
o Can detect signs of advanced cirrhosis + complications of cirrhosis (e.g. portal HTN)
• CXR
o Might show elevated diaphragm + pleural effusion
• Upper GI endoscopy
o Presence of gastro-oesophageal varices
• Transient elastography/acoustic radiation force impulse imaging
o Used to diagnose cirrhosis for people with NAFLD + advanced liver fibrosis
• Liver biopsy
o Most specific + sensitive test for dx of cirrhosis
o If liver elastography not suitable
o Not necessary in pt with advanced liver disease + atypical clinical/laboratory/radiological findings of cirrhosis - ascites, coagulopathy, shrunken nodular-appearing liver
Signs of portal HTN on UC/CT/MRI
Ascites Splenomegaly Increased diameter of the portal vein (>13mm) Collateral vessels Hepatocellular carcinoma
Signs of portal HTN on UC/CT/MRI
Ascites Splenomegaly Increased diameter of the portal vein (>13mm) Collateral vessels Hepatocellular carcinoma
What is the child-pugh-turcotte classification?
It estimates the prognosis in those with cirrhosis
What does the child-pugh-turcotte classification include?
- Serum albumin
- Serum bilirubin
- INR
- Ascites
- Encephalopathy
Tumour markers
Breast cancer Ovarian cancer Pancreatic cancer Biliary cancer (cholangiocarcinoma) Prostate cancer Colorectal cancer Hepatocellular carcinoma Non seminomatous germ cell tumours
Breast cancer - CA 15-3, CA27-29 Ovarian cancer - CA 125 Pancreatic cancer - CA 19-9 Biliary cancer (cholangiocarcinoma) CA 19-9, CA125, CEA Prostate cancer PSA Colorectal cancer CEA Hepatocellular carcinoma AFP Non seminomatous germ cell tumours AFP, bHCG, LDH
Tumour markers
Breast cancer Ovarian cancer Pancreatic cancer Biliary cancer (cholangiocarcinoma) Prostate cancer Colorectal cancer Hepatocellular carcinoma Non seminomatous germ cell tumours
Breast cancer - CA 15-3, CA27-29 Ovarian cancer - CA 125 Pancreatic cancer - CA 19-9 Biliary cancer (cholangiocarcinoma) CA 19-9 Prostate cancer PSA Colorectal cancer CEA Hepatocellular carcinoma AFP Non seminomatous germ cell tumours AFP, bHCG, LDH
Cholangiocarcinoma ix
• Abdo US first line
o To identify malignant vs benign lesions
o Mass lesion
o Dilated Intrahepatic ducts
• Contrast MRI
o Optimal imaging for dx of cholangiocarcinoma
• MRCP, ERCP, PTC
o Show site of obstruction
o ERCP/PCT can be used to obtain samples for biopsy or cytological analysis
• Tumour markers
o CA 19-9
o CEA
o CA-125
• Serum o Bilirubin raised o ALP raised o GGT raised o ALT – mildly elevated, o PTT – prolonged obstruction of the CBD/hepatic duct - subsequent reduction in fat-soluble vitamins (A, D, E, K)
Liver abscess ix
• Liver US
o Variably echoic lesion
o Biliary tree examination
o Guides aspiration + drainage
• Contrast CT abdo
o Gas within lesion - bacterial abscess
o Guides aspiration + drainage
• Gram stain + culture of aspirated abscess fluid
- FBC, ESR, CRP – raised
- LFT - raised ALP, Hypoalbuminaemia
- Blood cultures
- PTT, APTT - Aspiration contraindicated in the presence of abnormal clotting
Liver abscess ix if amoebiasis is suspected
o Serum ab test
o Stool Ag detection test (may contain cysts or trophozoites)
o Ag testing/PCR of aspirated abscess fluid for Entamoeba histolytica
Liver failure ix
Blood • FBC Leucocytosis - ?infection Iron deficiency anaemia Thrombocytopenia – chronic liver disease Raised INR (>1.5)
• LFTs
Raised transaminases
Normal ALP
Raised bilirubin
• U+Es
Raised U + Cr
Metabolic derangements in potassium, phosphate, magnesium
- ABG – metabolic acidosis in paracetamol overdose
- Arterial blood lactate – important prognostic indicator in paracetamol-associated ALF
• Low
o Pseudocholinesterase
o Glucose
• High
o Ammonia levels
o Lactate
o Creatinine
• Blood cultures – pt very susceptible to infection
• Viral serology
o Antihepatitis A IgM, antihepatitis B core IgM, hep B surface antigen, antihepatitis C IgG, antihepatitis E IgM
o May indicate infection that ppt hepatic failure
• Autoimmune hepatitis markers
o Antinuclear antibody (ANA), anti-smooth-muscle antibody, quantitative immunoglobulins (IgG)
• Test for specific conditions – Wilson’s disease, paracetamol levels (urine toxicology screen)
Imaging
• Doppler US
o Budd-Chiari syndrome – ?hepatic vein thrombosis
o Hepatic surface nodularity - ?cirrhosis
• CT/MRI
o Demonstrates hepatic anatomy
o Excludes other pathology (particularly patients with massive ascites, obesity, under consideration for transplantation)
- Head imaging – cerebral oedema
- EEG – level of encephalopathy
- Liver biopsy
Wernicke’s encephalopathy ix
- Diagnosis is clinical
- Therapeutic trial of parenteral thiamine (pabrinex) -Treated as an emergency
- Blood thiamine + its metabolites
- Blood magnesium - Mg deficiency may impair the therapeutic benefit of thiamine (Mg serves as a co-factor in enzymes that need thiamine pyrophosphate)
Investigate causes
• BM glucose
• Serum ammonia - exclude hyperammonaemia that causes hepatic encephalopathy (Wernicke’s is due to B1 deficiecy)
• Urinary + serum drug screen – to exclude concomitant intake by the patient
• Blood alcohol level
Monitor complications
• U+E - If condition goes unnoticed –> Hypotension + lactic acidosis - renal dysfunction + electrolyte abnormalities
MEDED
• ECG – pt may have cardiac abnormalities, do one before + after treatment
• CT – may help identify lesions resulting from the disorder
• Neuropsychological test – to determine severity of mental deficiencies
What does thumb printing on XR, CT mean?
Submucosal oedema or haemorrhage
First line ix for acute mesenteric ischaemia +findings
- CT angiogram
o Shows arterial blockage due to emboli or thrombus
o Evidence for extent of bowel compromise from ischaemia
o Stratification of patients to identify those who would benefit from mesenteric angiography from those who require primary surgery
o If findings are non-specific and non-diagnostic for colonic ischaemia – colonoscopy may be required
Bowel wall thickening, dilation
Thumb-printing sign suggestive of submucosal oedema or haemorrhage
Gas in ectopic places – Pneumatosis intestinalis, Portal venous gas
Occlusion of the mesenteric vasculature
Streaking mesentery
Solid organ infarction
• AXR (in advanced disease)
o Gasless abdomen
o Thickening of the bowel wall
o Pneumatosis (air within the bowel wall due to necrosis)
Intestinal ischaemia ix + findings
• FBC
o Leucocytosis
o Anaemia bc of melaena that exacerbates ischaemia
• ABG/lactate level
o Acidosis + increased serum amylase
o Degree of acidosis aids in determination of the severity of the illness
• CT angio • Sigmoidoscopy/colonoscopy (The best test to establish the diagnosis of colonic ischaemia) Mucosal sloughing Mucosal petechiae Submucosal haemorrhagic nodules, erosions, or ulcerations Submucosal oedema Luminal narrowing Necrosis Gangrene
• AXR (in advanced disease)
o Gasless abdomen
o Thickening of the bowel wall
o Pneumatosis (air within the bowel wall due to necrosis)
