Gastro Presentations Flashcards
Abdominal distention
Coeliac disease IBS Volvulus Hepatocellular carcinoma Portal hypertension Ascites Intestinal ischaemia Intestinal obstruction
Abdominal mass
Anal/PR
- Colorectal cancer
- Perianal abscess/fistulae
Epigastric/RUQ
- Cholangiocarcinoma
- Pancreatic cancer
- Gastric cancer
Other
- Appendicitis
- Femoral hernias
- Intestinal ischaemia
- Intestinal obstrution
Common differentials for acute abdomen
Adhesions Incarcerated/strangulated hernia Cholecystitis Perforated gastric ulcer Appendicitis Ectopic pregnancy Pelvic inflammatory disease Acute pancreatitis Acute diverticulitis Ulcerative colitis Crohn's disease Cholelithiasis Gastrointestinal malignancy Mallory-Weiss tear Diabetic ketoacidosis Opioid withdrawal Hepatitis Gastroenteritis Infectious colitis Sickle cell crisis Endometriosis Testicular torsion Kidney stones Pyelonephritis
Common differentials for ascites
Hepatitis C Alcoholic liver disease Congestive heart failure Nephrotic syndrome Pancreatitis
How does colonic bleeding typically present?
Bright red or dark red blood per rectum
Rarely meleaena
What does colonic bleeding rarely present as melaena?
Blood in the colon has a powerful laxative effect and is rarely retained long enough for transformation to occur
How can you generally differentiate between right-sided bleeds and left sided?
Darker coloured - right-sided
What are the presenting features of colitis?
Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal x-ray may show featureless colon.
What are the presenting features of diverticular disease?
Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur sporadically.
75% all will cease spontaneously within 24-48 hours. Bleeding is often dark and of large volume.
What are the presenting features of colonic cancer?
Bleeding may be first sign of disease
What are the presenting features of hemorrhoidal bleeding?
Typically bright red bleeding occurring post defecation.
Although patients may give graphic descriptions bleeding of sufficient volume to cause haemodynamic compromise is rare.
What are the indications for surgery for a lower GI bleed?
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
What is the surgical intervention for GI bleeds?
Selective mesenteric embolisation
What are the clinical features of an upper GI bleed?
Haematemsis (most common)
Melena
Raised urea
What are the presenting features of oesophageal varicies?
Usually a large volume of fresh blood.
Swallowed blood may cause melena.
Often associated with haemodynamic compromise.
May stop spontaneously but re-bleeds are common until appropriately managed.
What are the presenting features of oesophagitis?
Small volume of fresh blood, often streaking vomit. Malena rare.
Often ceases spontaneously.
Usually history of antecedent GORD type symptoms.
What are the presenting features of a Mallory-Weiss tear?
Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Malena rare. Usually ceases spontaneously.
What are the oesophageal causes of GI bleeds?
Oesophageal varicies
Oesophagitis
Cancer
Mallory Weiss Tear
What are the gastric causes of GI bleeds?
Gastric ulcer
Gastric cancer
Dieulafoy lesion
Diffuse erosive gastritis
What are the presenting features of gastric ulcers?
Small low volume bleeds are more common so would tend to present as iron deficiency anaemia.
Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.
What are the presenting features of gastric cancer?
Frank haematemesis or altered blood mixed with vomit
Prodromal features of dyspepsia and may have constitutional symptoms
What is a dieulafoy lesion?
An arteriovenous malformation typically found in the stomach
Presents with haematemesis and melena
What are the presenting features of diffuse erosive gastritis?
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage.
Large volume haemorrhage may occur with considerable haemodynamic compromise
What are the duodenal causes of GI bleeds?
Duodenal Ulcer
Aorto-enteric fistula
Where are duodenal ulcers found? Why does this cause bleeding?
Posteriorly sited and may erode the gastroduodenal artery
What are the presenting features of duodenal ulcers?
haematemesis, melena and epigastric discomfort
pain occurs several hours after eating
What is an aorto-enteric fistula?
In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
How can you risk assess upper GI bleeding?
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
What is taken into account in the Blatchford score?
Urea ‘protein’
Haemoglobin low
BP low
Pulse high
How are GI bleeds managed?
Wide-bore IV access
Platelet transfusion if actively bleeding
FFP if low fibrinogen or high PT/APTT
Endoscopy after resuscitation (within 24 hours)
How do you manage variceal bleeding?
Prophylactic Abs
Band ligation and injections of N-butyl-2-cyanoacrylate
Transjugular intrahepatic portosystemic shunts (TIPS)
What can cause dark stool?
GI bleeding
Vitamin K deficiency
What can cause pale stools?
Hepatitis
Obstructive jaundice
What are the presenting features of PUD? Duodenal
Epigastric pain relieved by eating
What are the presenting features of PUD? Gastric
Epigastric pain worsened by eating
What are the presenting features of appendicitis?
Pain initial in the central abdomen before localising to the right iliac fossa
Anorexia is common
Tachycardia, low-grade pyrexia, tenderness in RIF
Rovsing’s sign: more pain in RIF than LIF when palpating LIF
What are the presenting features of acute pancreatitis?
Usually due to alcohol or gallstones
Severe epigastric pain
Vomiting is common
Examination may reveal tenderness, ileus and low-grade fever
Periumbilical discolouration (Cullen’s sign
What are the presenting features of biliary colic?
Pain in the RUQ radiating to the back and interscapular region
May be following a fatty meal
Obstructive jaundice may cause pale stools and dark urine
Female, forties, fat and fair
What are the presenting features of acute cholecystitis?
History of gallstones symptoms
Continuous RUQ pain
Fever, raised inflammatory markers and white cells
Murphy’s sign positive (arrest of inspiration on palpation of the RUQ)
What are the presenting features of diverticulitis?
Colicky pain typically in the LLQ
Fever, raised inflammatory markers and white cells
What are the presenting features of AAAs?
Severe central abdominal pain radiating to the back
Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock)
What are the presenting features of intestinal obstruction?
History of malignancy/previous operations
Vomiting
Not opened bowels recently
‘Tinkling’ bowel sounds
Define constipation
Infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation
What are the possible complications of constipation?
overflow diarrhoea
acute urinary retention
haemorrhoids
What are some causes of constipation?
IBS Rectal prolapse Volvulus (absolute) Obstruction (absolute) Appendicitis
What can cause reduced appetite?
Hepatocellular carcinoma Depression Medication side effect Stomach ulcers Crohn's UC Coeliac disease Gastroenteritis
What are some causes of groin masses?
Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix
What are key questions to ask when investigating a groin lump?
Cough impulse?
Pulsatile and expansile?
Are both testes intrascrotal?
Signs of malignancy/infection? (lymph nodes)
How would a lipoma present?
Soft, small, superficial lump
How are groin lumps diagnosed normally?
Clinically
If not clear then via US
When is an urgent surgical assessment necessary for a groin lump?
Suspected:
Strangulation of hernia
Pseudoaneurysms of the femoral artery
How many lymph nodes are present in the groin region?
1-2 deep inguinal lymph nodes
Roughly 11 superficial
What medications can cause meleana?
Blood thinners e.g Warfarin or Asprin
Iron tablets
What are the 2 general mechanism of nausea and vomiting?
Neurological
Peripheral
What are the features of neurological nausea?
Stimulation of area postrema that sense noxious chemical agents
Evokes nausea
Co-ordinates the emesis reflex
OR
Diseases of the CNS e.g. infection or tumour evoke N+V via vagal pathways
What are the features of peripheral nausea?
Diseases etc. that originate in peripheral organ systems e.g. GI tract
Again stimulate vagal efferent motor nuclei
What are common differentials for nausea and vomiting?
Gastritis GORD PUD Acute gastroenteritis Food poisoning Chronic post-viral Migraine Motion sickness BPPV Stroke Hypercalcaemia Hypothyroidism Small bowel/colon obstruction Choledocholithiasis Cholecystitis Post-GI surgery Severe constipation Irritable bowel syndrome Anorexia/Bullimia nervosa Pregnancy Drug-induced
What are urgent presentations of splenomegaly?
Sudden pain
Splenic sequestration crisis of sickle cell anaemia
Splenic/Portal vein thrombosis
What are some common differentials for splenomegaly?
Alcohol induced Hepatic steatosis Primary biliary cholangitis Haemochromatosis Hodgkin's lymphoma AML CML Polycythemia Vera RA Malaria Thalassaemias
Define pruritus
an unpleasant sensation that causes a desire to scratch
What defines chronic pruritus?
Pruritus lasting >6 weeks is defined as chronic pruritus
What are some common differentials for pruritus?
Atopic dermatitis Urticaria Insect bite Psoriasis CKD Depression Schizophrenia
What is rectal prolapse associated with?
Associated with childbirth and rectal intussceception.
May be internal or external
What is rectal prolapse?
e last part of the rectum or bowel
becomes stretched and protrudes (bulging) from the bottom (anus)
What are the 3 types of rectal prolapse?
Full thickness - protrusion of the full thickness of the rectal wall through the anus.
Mucosal prolapse - the rectal mucosa (not the entire wall) from the anus.
Internal prolapse - a part of the intestine which folds into the
section next to it.
What can cause rectal proplase?
age chronic constipation straining pregnancy / child birth poor bowel control neurological disorders, for example, Dementia weakness of the pelvic floor
What are the symptoms of rectal prolapse?
mucus discharge bulging on straining sensation of incomplete bowel motion faecal incontinence anal pain constipation rectal bleeding
What is the mangement for rectal prolapse?
Delorme’s procedure
Define dysphagia
difficulty with the act of swallowing solids or liquids
What are common differentials for dysphagia?
Pharyngitis (throat pain) Oesophageal candidiasis Stroke Oesophageal spasm GORD Hiatus hernia
What are the 2 mechanisms of N+V?
Neurological
Peripheral
What causes neurological N+V?
Stimulation of the area postrema, which ‘senses’ noxious chemical agents
Stimulates the vagal nuclei which evokes the emesis reflex
What causes peripheral N+V?
Peripheral disorders e.g. GI stimulate vagal or spinal afferent nerves that conect with the vagal sensory
Tumours, infections, drugs
What are some common differentials for vomiting?
Gastritis GORD PUD Gastroenteritis Food poisoning Post-viral Migraine Motion sickness BPPV Storke Hypercalcaemia Cholecystitis IBS Anorexia/Bulimia
What can be the consequence of a misplaced NG tube?
Aspiration pneumonia and death
many hospitals now require a radiologist to report on these x-rays before the NG tube can be used
