Gastro / Nutrition Flashcards

Question

Hernia (surgery) - def? types? Mx?

Answer 1

Def: protrusion of a viscus through its wall Types: * Incisional hernia - iatrogenic following surgery * Groin hernia - ASIS & pubic tubercle palpated: * Femoral (W\>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation * **Inguinal** - above & medial to the pubic tubercle * Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring * Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring * Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear * Other groin lumps: * Lymphadenopathy - along inguinal ligament * Vascular - pulsatile varicose veins below inguinal ligament Mx: surgical (mesh) NOTE: hernias are safer the larger the defect as less likely to strangulate

Answer 2

* Midline sternotomy - AAA, laparotomy * Rooftop scar - liver transplant, Whipple's procedure, gastric surgery, oesophagectomy * Kocher – open gallbladder surgery * Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick) * Lanz/McBurney’s = Appendicectomy * Pfannenstiel = C-section/prostatectomy/cystectomy

Answer 3

Presentation: * Bowel habit change * Palpable mass * IDA, PR bleed (clots, fresh) * Acute (obstruction, perforation) Ix: colonoscopy Mx: based on TNM staging post-CT --> surgery +/- chemo/radio Screen: 60-74yrs FIT testing (or FOB)

Answer 4

Upper: * RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis * Epigastric pain: PUD, GORD, pancreatitis Middle: * Flank pain: pyelonephritis (loin to groin pain) * Umbilical pain - AAA (consider if \>65yrs, HTN) Lower: * RIF pain: appendicitis, ureteric colic, hernia, testicular torsion * Suprapubic pain: UTI * LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion * In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID * Ask about **_P**_ain, _**P**_regnancy, _**P**_V bleeding, _**P_**V discharge NOTE: also consider psych cause of generalised abdo pain (esp in kids)

Answer 5

* **_Right and left hepatic ducts_** merge to form the common hepatic duct * **Gallbladder** - stores & concentrates bile and releases it to emulsify fats * _Cystic duct_ connects gallbladder to the biliary tree * Cystic duct and common hepatic duct come together to form the **_common bile duct_** * _Pancreatic duct_ feeds into the common bile duct - where it secretes exocrine hormones * All of the above feed through the **_Ampulla of Vater_** into the duodenum --\> allowing secretion of bile into the intestines

Answer 6

**RFs (5Fs):** Fat, Female, Fertile, Forty, Fair **Types of gallstone:** mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous) **RUQ Pain Ix:** * Abdo USS * Stone in CBD (common bile duct) --\> ERCP * Deranged LFTs/dilated ducts --\> MRCP * None of above --\> cholecystectomy **Biliary colic:** * **Def:** pain due to blockage of bile flow due to a gallstone * **Presentation:** RUQ pain, worse after fatty meals (stimulates gallbladder contraction --\> bile release for fat emulsification) **Cholecystitis:** * **Def:** inflammation of the gallbladder (typically in context of gallstones) * **Presentation:** RUQ pain (+ tenderness - Murphy's sign), _FEVER_ * Murphy's only +ve if not present on the left as well * Ix: * Urine dip – infection, bHCG * Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen * Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum) **Ascending cholangitis:** * **Def:** inf ascending the biliary tree, usually in the context of gallstone * **Presentation** (due to obstruction of Common Bile Duct - bile stagnates and becomes infected): * Charcot's triad - RUQ pain, fever, _JAUNDICE_ * Reynold's pentad (severe) - above + **shock** + **confusion** * **Surgical EMERGENCY** - Mx via _sepsis 6_ protocol (abx = Tazocin) + drain obstruction: * **Endoscopic retrograde cholangiopancreatography (ERCP)** - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system * Complications: **_pancreatitis_**, bleeding (from dilation of AoV), perforation * **Percutaneous transhepatic cholangiogram (PTC)** - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree --\> dislodge stone/alternative route for bile to flow - leave in cholecystostomy * **Cholecystostomy** - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy * Patients will likely require a later _cholecystectomy_ (after dealing with the acute infection)

Answer 7

Presentation: * Acute umbilical to _RIF pain_ (McBurney's point) * Tenderness + guarding (if rigid abdo - perforated apendix) * N&V --\> anorexia (not wanting to eat anything from nausea), change in bowel habit * Rovsig's sign - pain in RIF on LIF palpation * Psoas sign & Obturator sign DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction Ix: * Urinalysis, bloods - FBC, U&E, CRP * USS abdo/pelvis --\> consider contrast-enhanced CT-AP **Alvarado score** - \>4 = likely appendicitis Mx: * A-E (incl. fluids) * Sepsis bundle - abx when Dx confirmed * **Laparoscopic appendicectomy** * Conservative only if uncomplicated appendicitis

Answer 8

**Immediate Mx:** * NBM, Ryles tube (aspirate stomach contents) * IV fluids * AXR -\> CT (identify transition point of obstruction) **Small bowel obstruction:** * _Causes_: _Adhesions_ (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian) * _Features_: central dilated loops of bowel, \>3cm, valvulae coniventes * _Mx_: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative) **Large bowel obstruction:** * _Causes_: tumour, volvulus * _Features_: peripheral dilated loops of bowel, \>6cm, haustra * _Mx_: surgery, flatus tube (in sigmoid volvulus) NOTE: 3/6/9 rule

Answer 9

**Right hemicolectomy** - right colon * Indication: problems affecting the right side of the colon e.g. malignancy * Process: removing from ileocaecal valve to 1/3 the way along the transverse colon * What are you left with: * Primary anastomoses (ileum attached to the remaining colon) * Sometimes left with a stoma **Left hemicolectomy** - left colon * Indication: problems affecting the descending colon e.g. tumour * Process: removing from 2/3 the way along the transverse colon to the sigmoid area * What are you left with: primary anastomoses from the transverse colon to the sigmoid colon **Panproctocolectomy** - total colon & rectum e.g. UC * Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC * Process: remove full colon & rectum (from ileocaecal valve to the anus) * What are you left with: **_end ileostomy_** (loose end of ileum brought to the skin) **Total colectomy vs subtotal colectomy** * Total colectomy: * Process: remove full colon but not the rectum * What are you left with: **_ileal-pouch anal anastomosis_** (loose end of ileum used to reform a rectum, don't need a stoma) * Subtotal colectomy: * Process: remove colon except for the rectum and part of the sigmoid colon * What are you left with: **_end-ileostomy & rectal/sigmoid stump_** **Hartmann procedure** - emergency sigmoid colon * Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don't want to create anastomoses as unlikely to succeed) * Process: sigmoidectomy * What are you left with: **_end-colostomy and rectal stump_** --\> at a future date can be reversed but many just stay with end-colostomy **Anterior vs AP resection** - for rectal tumours (A higher; P lower) * Anterior: * Indication: _higher_ rectal tumours * Process: removing sigmoid colon + top part of the rectum * What are you left with: end-colostomy/primary anastomoses ± **_defunctioning loop ileostomy_** * DLI - loop of ileum brought to surface, split so 2 lumens on surface --\> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing * NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains) * AP (abdominoperineal): * Indication: _low_-lying rectal tumours * What are you left with: end-colostomy * Process: remove everything up to the top of the sigmoid colon **Colostomy (ileal conduit)** * Indications: * Bladder cancer (had cystectomy) * Neurogenic bladder Radiation injury to the bladder * Chronic pelvic pain * Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch

Answer 10

Colostomy - RIF, flushed, normal faecal matter Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer * NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf) Stoma examination: * Hands around stoma and ask to cough --\> check for hernia + check for skin changes * Offer stoma rectal examination (finger into stoma)

Answer 11

Indications: * Traumatic rupture * Idiopathic thrombocytopenia * Spherocytosis Problem: increased risk from encapsulated bacteria e.g. strep pneumo Prophylaxis: * Vaccines: Pneumococcus, Meningococcus, Haemophilus Influenzae Type B * Penicillin V

Answer 12

**Def:** sudden, severe abdo pain that requires urgent medical/surgical attention **Immediate Tx & Ix:** * Immediate Tx - _NBM_, IV fluids, analgesia * Bedside - urine dip * Bloods - basics, VBG (lactate), amylase, G&S, clotting * Imaging - errect CXR, AXR (bowel obstruction): * USS/MRCP/ERCP - gallstones * CT-KUB - renal stones * CT-AP - perforation/obstruction * CT-angiogram - ischaemic/bleed/AAA

Answer 13

**Presentation:** progressive dysphagia (solids --\> then liquids) + FLAWS **Types:** * Squamous cell carcinoma (SCC) - less common in UK, **_middle oesophagus_**, RFs: alcohol, smoking * Adenocarcinoma - most common in UK, **_lower oesophagus_**, assoc w/ _GORD_ (long-term --\> metaplasia - Barrett's oesophagus --\> eventually become dysplastic/ malignant) **Mx:** SURGICAL * **Ivor Lewis oesophagectomy** - involves _midline laparotomy_ + _right thoracotomy_ (stomach is mobilised and pushed through oesophageal hiatus) * **McKeown oesophagectomy** - as above + _left neck incision_ (oesophagus can be pulled up through neck incision)

Answer 14

* Causes: alcohol, gallstones (GET SMASHED) * Duct obstruction: _gallstones (50%),_ trauma, tumours * Metabolic/toxic: _alcohol (33%),_ drugs, hypercalcaemia/hyperlipidaemia * Ischaemia: shock * Infection/inflammation: viruses (mumps), AI * Patterns of injury: * **Periductal** – cause: duct obstruction * Necrosis of acinar cells near ducts * **Perilobular** – cause: ischaemia (shock) * Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected * **Panlobular** – develops as ½ progress * **Pathophysiology:** vicious cycle **-** activated enzymes --\> acinar necrosis --\> enzyme release * Lipase release --\> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits) * Ix: * Bloods – FBC, U&E, LFTs, CRP, Amylase * Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR * NOTE: Epigastric pain --\> remember to do rectal exam (looking for melaena) * Mx - supportive (IV fluids + analgesia first) * Resus patient (IV fluids, analgesia, antiemetic, abx) --\> ITU if glasgow score \>3 * VTE prophylaxis * Complications: * Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue --\> can be infected --\> abscess * Systemic: shock, hypoglycaemia, hypocalcaemia Severity criteria = **GLASGOW score (PANCREAS):** * **P**aO2 * **A**ge * **N**eutrophils (WBC) * **C**a * **R**enal funct (urea) * **E**nzymes (LDH) * **A**lbumin * **S**ugar (glucose)

Answer 15

**Diverticulosis:** colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet) **Diverticular disease:** above + Sx **Diverticulitis:** infection & inflammation of diverticulum * **Hinchey classification** for acute diverticulitis: 1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess \<4cm 2. Pelvic/interloop abscess/abscess \>4cm 3. Purulent peritonitis 4. Faeculent peritonitis Presentation: * RFs: \>50yrs, low dietary fibre * LIF pain, raised WCC, fever, painless rectal bleed Ix: * FBC, U&E, CRP, (BC, ABG & lactate if septic) * **_Contrast CT abdo_** (if suspected acute diverticulitis) * Other imaging: * CXR (rule out pneumoperitoneum) * Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia) * CT angiogram (if excess bleeding) Mx: * Asymptomatic diverticulosis: * Increased fibre & fluids * Excercise, weight loss, stop smoking * Fybogel - if constipated * Symptomatic diverticular disease: * Above + paracetamol * _PO Dicycloverine_ = anti-spasmodic (for abdo cramping) * Acute diverticulitis: * Uncomplicated: * Low-residue diet + Paracetamol + PO Dicycloverine * Oral abx (amoxicillin) * Complicated: * Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery) * Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx * Reccurent = open/laparoscopic resection

Answer 16

Indications: * Acute liver failure - acute viral hep, paracetamol overdose * Chronic liver failure Unsuitable for liver transplant: * Sign. co-morbidity (renal/heart failure) * Excess weight loss/malnutrition * Active hep B/C (other inf), end-stage HIV * Active alcohol - 6 months abstinence needed Surgery: Rooftop/Mercedes Benz scar Post-transplant care: * IS - steroids, azathioprine, tacrolimus (careful drug monitoring) * Conservative - no alcohol/smoking, monitor for disease recurrence, cancer, transplant rejection (fatigue, fever, jaundice, abn LFTs) * Tx opportunistic inf

Answer 17

High risk of variceal bleed: * MASSIVE --\> balloon tamponade * Assess - A-E approach: * Circulation --\> _blood transfusion_ (Hb \<70) but if haemodynamically unstable and waiting give IV fluids * Drugs * _IV Terlipressin_(/Somatostatin) - blanked vascoconstriction * _Ceftriaxone_/Norfloxacin (apparently helps outcomes) * Intervention - **endoscopic band ligation****** **F1 essentials:** 2x large bore cannula, VBG, G&S + X-Match, bleep the bleed registrar (arrange endoscopy)

Answer 18

Glucagonoma - NE tumour of pancreatic islet cells that secrete glucagon (most solitary but <10% assoc with MEN 1) * Diarrhoea, Decreased weight, Depression * Dermatosis (90%) - necrolytic migratory erythema (NME) * Diabetes (T2, 80%) * DVTs (50%)

Answer 19

A1AT produced by liver to neutralise enzymes produced by neutrophils in lungs in presence of infection/inflam/smoking. * Without A1AT neutrophil enzymes destroy alveoli -> emphysema **A1AT def** - common AD condition amongst white people - produced but can't pass out of liver into blood to reach lungs -> congestion causes cell distruction * Normally presents in 30-40s (10yrs earlier if smoking) with Sx simmilar to COPD - dyspnoea, wheeze, cough * Present with some mild LFT abn (can have hep/fibrosis/cirrhosis/liver failure)