Gastro + Surgery Flashcards
STOMATITIS
Causes
Inflammation of oral cavity
Non-infective: Crohn’s, Behcet’s, coeliac, normal population
Infective: herpetic, oral candidiasis (NB uncommon in DM)
Causes of glossitis
Different appearances
Stomatitis (various causes), deficiencies (esp B vitamins, folic acid)
Acute: tongue is beefy-red, raw, painful
Chronic: tongue appears moist and unduly clean
What is Chagas’ disease?
Infection by Trypanosoma cruzi - cause of secondary achalasia due to destruction of myenteric plexus
(S America)
Difference between urea breath test and CLO test?
CLO is invasive: you add biopsy to kit
Most commonly prescribed prophylaxis for gut surgery?
Co-amoxiclav
Define Zollinger-Ellison syndrome
A gastrin-secreting tumour of the pancreatic G cells, resulting in gastric gland hyperplasia and gastric hypersecretion
Common to have multiple peptic ulcers and diarrhoea
What is absorbed in the proximal small intestine and what is absorbed in the terminal ileum?
Proximal: iron, folate, calcium
Terminal: B12
Most common causes of UGIB
Other causes
PUD
Oesophageal varices
Other causes: oesophagitis, gastritis, malignancy, M-W tear, vascular malformation…
Risk factors for UGIB
Alcohol abuse Chronic renal failure NSAIDs Age Low socio-economic class
Risk factors for re-bleeding following UGIB
Age over 60 Presence of shock on admission Coagulopathy Pulsatile haemorrhage Cardiovascular disease
Examination of UGIB
Signs of shock and blood loss: obs, postural hypotension, pallor, urine output…
Elicit cause:
stigmata of liver disease
signs of tumour
s/c emphysema (oesophageal perf)
Investigations for UGIB
FBC (serially every 4-6 hours) Cross-match (between 2-6 units) Coagulation profile LFTs U&Es Calcium (effect of blood transfusions) Gastrin (rare gastrinomas)
ENDOSCOPY
Risk assessments in UGIB
Blatchford at first assessment
Rockall after endoscopy
Medication to give for suspected variceal bleeding
Terlipressin
Prophylactic abx
How to reconcile drug chart for bleeding patients
(Some hospitals say to give PPI for all UGIB, but better to wait til post-endoscopy)
Consider stopping all anticoag and antiplatelets during acute phase
Low-dose aspirin usually okay to continue later
Discuss with specialist risk/ benefits of clopi
SSRIs should be used with caution
CS will need careful concomitant PPI
Ix for rectal bleeding
FBC
Consider: G&S Ferritin and iron studies Clotting studies LFTs Faecal calprotectin
M-W vs Boerhaave
M-W: tear at gastro-oesophageal jct
Boerhaave: transmural oesophageal rupture
Meds associated with GORD
NSAIDs
Doxycycline
Bisphosphonates
those affecting motility: TCAs, anticholinergics, nitrates, CCBs
What is the normal oesophageal histology? What happens in Barrett’s?
from normal stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the stomach
Mx reflux (if no alarm symptoms)
PPI for one-month
Next: H2-receptor antagonist
Types of hiatus hernia (how common and definition)
Sliding (85-95%): gastro-esophageal jct slides up
Rolling (5-15%): jct remains in place but a part of stomach (or other organ) herniates up
Presentation of hiatus hernias
Asymptomatic
Dyspepsia/ GORD
Para-oesophageal may also present with chest pain, epigastric pain, fullness, sx of obstruction
Histological types of oesophageal cancer
SCC: alcohol + smoking,
AC: growing incidence - possibly more common in developed countries
Barrett’s oesophagus is a precursor of which ca?
AC
SCC associated with chronic inflammation and stasis, eg achalasia
Why does oesophageal ca present late?
Need obstruction of ~75% for ‘food sticking’
Difference between acute gastritis and acute erosive gastritis
Acute: almost always caused by drugs (aspirin) and alcohol - chemical exfoliation of surface epithelium
Acute erosive: partial loss of gastric mucosa - shock, severe burns, toxic substances
What is pernicious anaemia a risk factor for?
Carcinoma of stomach
What is reactive gastritis?
AKA reflux gastritis - duodenal contents into stomach
Caused by irritants: NSAIDs, alcohol, biliary reflux
or compromised motility
Causes of delayed gastric emptying.
Symptoms.
Mechanical: tumour, bezoar
Non-mechanical: gastroparesis
Asymptomatic or bloating, belching, N&V, weight loss…
Describe H.pylori
motile, Gram-negative spiral bacilli
PUD nearly always associated with
H.pylori
NSAIDs
Relationship between H.pylori and:
Gastric ca
GORD
Increased risk of gastric AC
Associated with gastric MALT-lymphoma
Potential inverse relationship with GORD
Recommended first-line treatment of H.pylori
7 days BD: PPI, 1g amox, 400 mg metronidazole
If allergic: 500 mg clarithromycin
(If recently already had clarith, use alternative)
If had only dyspepsia, no need to re-test
If has PUD, re-test in 6-8 weeks
Uses for probiotics/ lactobacilli
Reduce activity of H.pylori
Causes PUD
H.pylori NSAIDs Steroids Smoking Alcohol Stress
Which ulcer better after eating?
Food worse for gastric
Better for duodenal
Investigations for dyspepsia
FBC
Testing for H.pylori
Endoscopy
Complications of PUD
Erosion > haematemesis/ melaena
Perforation > acute abdomen
Scarring > pyloric stenosis
Risk factors for gastric cancer
Age Men Low socio-economic class H.pylori Smoking Poor fruit diet/ high salt + preserved Familial Pernicious anaemia
Poor signs associated with gastric carcinoma
Epigastric mass Hepatomegaly Jaundice Ascites Troisier's sign Acanthosis nigricans
Definition of acute pancreatitis
Acute inflammation leading to release of exocrine enzymes/ autodigestion
Causes of acute pancreatitis
Gallstones (blocking bile duct)
Excess alcohol
Post-ERCP Viral (Coxsackie, hep, mumps) Metabolic (lots) Ischaemia Malignancy IBD (maybe associated with mesalazine)
Symptoms and signs of acute pancreatitis
Sudden onset severe upper abdo pain with vomiting
(can radiate to back, can be peri-umbilical)
Pain tends to decrease over 72h
Looks unwell - possible jaundice
Hypoxaemia is characteristic
Tachycardia (dehydrated)
Mild pyrexia common (can be hypothermic)
Ix for acute pancreatitis
Serum lipase
FBC, U&Es, glucose, CRP, bone profile (hypocalcaemia), LFTs
AXR (eliminate other causes)
CXR (ARDs etc)
USS to visualise gallstones
Mx acute pancreatitis
MILD: IV Fluids NBM Pethidine or buprenorphine + IV benzos (morphine can cause spasticity of sphincer of Oddi) (NG only for severe vomiting)
SEVERE:
ITU/ HDU
IV abx if evidence necrosis
Complications of acute pancreatitis
Necrosis (rising CRP, confirmed by dynamic CT)
Infection/ abscess (requires surgery)
Ascitic fluid collection
Pseudo-cyst: pancreatic juice in wall of fibrous or granulation tissue - requires surgery (can rupture/ haemorrhage) - occurs ~4 weeks after
Systemic complications of acute pancreatitis
Resp: pulm oedema pleural effusions consolidation ARDs
Cardiovascular:
hypovolaemia
DIC
Renal: dysfunction due to hypovolaemia/ intravascular coagulation
Metabolic
GI:
haemorrhage
ileus
Presentation of chronic pancreatitis
Abdo pain: typically epigastric, radiating to back N&V Decreased appetite Steatorrhoea (exocrine dysfunction) DM (endocrine dysfunction)
Why is chronic pancreatitis hard to diagnose?
Generalised symptoms
No dose-related link with alcohol
Amylase normal
Small-duct pancreatitis not easily seen on imaging
Tumour marker in pancreatic ca
CA19-9
Investigations for malabsorption
FBC CRP Vit B12/ folate Ferritin Clotting (for vit K) Serum albumin/ LFTs Calcium Coeliac screen Mg
Consider:
stool sample
hydrogen breath test (bacterial overgrowth)
Where is gluten found?
Wheat, rye and barley
Prevalence of coeliac
1% in UK
Skin problem with coeliac
Dermatitis herpetiformis
Classical histological finding in coeliac
Subtotal villous atrophy
Types of diarrhoea
Osmotic: reduced absorption of electrolytes
Secretory
Rapid transit (stasis can also cause diarrhoea by facilitating bacterial overgrowth)
Histology of C.difficile
Gram positive rod
Mx Cdiff
Fluids & electrolytes
Metronidazole or vancomycin
Avoid anti-diarrhoeals
NOTIFIABLE
Extra-intestinal manifestations of Crohn’s
common
iritis, arthritis (sacroiliitis, ank spond) , erythema nodosum, pyoderma gangrenosum
clubbing
Similar UC
Basically steroids for everything
Common ages for Crohns
Young
And 50-70
Similar UC
When does Crohn’s require urgent admission
Severe abdo pain Severe diarrhoea (8+/day) Bowel obstruction! Systemically unwell
How to induce remission in Crohn’s
If first presentation/ one per year: GC (eg pred)
If not tolerated: 5-aminosalicylate (5-ASA)
If more:
azathioprine add-on
or others
*anti-diarrhoeals contra-indicated during relapse
How many Crohn’s require surgery?
50% within 10 years
Complications of Crohn’s
Bowel: strictures, fistulae, perfs, increased risk carcinoma
Osteoporosis (esp if on steroids)
Deficiencies..
Gallstones (usually oxalate)
Serological markers to differentiate Crohn’s and UC
p-ANCA UC
ASCA Crohns
Mx of UC relapse
Mesalazine - first choice
CS (no role in maintenance)
Triad of IBS
6 months:
abdo pain
bloating
change in bowel habit
Ix IBS
FBC CRP Coeliac CA 125 Faecal calprotectin
What is contained in an abdominal hernia?
Always contains portion of peritoneal sac - may contain viscera (usually small bowel)
Definition ileus
non-mechanical intestinal obstruction
Causes of small bowel obstruction
Adhesions, strangulated hernia, volvulus, malignancy (of caecum - small bowel malignancy rare)
Causes of large bowel obstruction
Malignancy
What does severe pain in bowel obstruction indicate
Ischaemia or perf
Why may a person with bowel obstruction be dehydrated?
Water unabsorbed in bowel
Reduced oral intake
vomiting
Ix bowel obstruction
Fluid chart
FBC, U&Es, G&S, cross-match, glucose
AXR
Diverticulosis
Diverticular disease
Diverticulitis
Got em
Cause symptoms
Evidence of inflammation (eg systemic sx)
Where does colorectal ca metastasise?
Liver
Lungs, brain, bone
these are unusual in absence of liver mets
Which tumours require anterior resection?
Low sigmoid/ high rectum
Biochemical jaundice vs clinical jaundice
Bili 25 +
35+ to see (in sclera, good light!)
Signs of post-hepatic jaundice
Dark urine
Pale stools
Itching
Increased GGT and AP (damage to biliary tree)
Signs of pre-hepatic jaundice
Normal urine (unconjugated bili is insoluble) Increased bili
Signs of hepatic jaundice
(mixed)
increased clotting (lack of bile > malabsorption of lipids/ vit K
Increased ALT and AST
Signs of liver disease
Spider naevi Palmar erythema Gynaecomastia Testicular atrophy Flapping tremor Splenomegaly Finger clubbing Ascites Peripheral oedema
False negatives for urinary bili
Rifampicin
Old urine
Blood test for haemolysis
Lactate dehydrogenase is raised
Vitamin K affects which clotting blood
Prolonged prothrombin time
Signature serology for PBC
Antimitochondrial antibody
about 35% have ANAs
Medication for pruritus
UDCA
can be used as prophylaxis for gallstones, eg post-bariatric surgery
Why should HRT be avoided in PBC?
oestrogens promote cholestasis
Most common type of biliary stone
Cholesterol (80%)
Main difference between biliary colic and cholecystitis
inflammatory component: local peritonism, fever, raised WCC
Bedside test for cholecystitis
Murphy’s sign
Ix gallbladder disease
FBC
LFTs
Uss
How does gallbladder empyema present?
Markedly toxic, markedly fever, leucocytosis
What is gallstone ileus?
Occlusion of intestinal lumen by stone
Pain relief for biliary colic/ cholescystitis
Morphine or pethidine parenterally
and/ or diclofenac suppository
Sometimes IV abx
Why are ppl with Crohn’s predisposed to gallstones?
Malabsorption of bile salts from terminal ileum
Why do ppl with haemolytic anaemias get gallstones?
Increase in billi
Why may cholecystitis cause intercapsular pain?
T5-9 innervates gallbladder
Shoulder pain: C3-5 if inflammation irritates diaphragm
What is Charcot’s triad?
jaundice
fever (usually with rigors)
RUQ pain
ascending cholangitis
Levels of alcoholic liver disease
Equiv levels in non-alcoholic fatty liver disease
Hepatic steatosis
Alcoholic hepatitis
Alcoholic cirrhosis
NAFLD
NASH
Cirrhosis
Why does alcohol excess cause fatty liver?
Metabolism of EtOH prioritised over lipid metabolism and it builds up in hepatocytes
Risk factors for NAFLD
Obesity, DM, hyperlipidaemia
+ any hepatotoxin
How to diagnose NASH
Biopsy
Or practically, based on EtOH intake
What is the most common cause of deranged LFTs in developed countries?
NAFLD
Blood tests suggestive of NAFLD
ALT mildly increased, relative to AST
Then reverses
(Up to 50% may have normal LFTs)
Imaging of NAFLD
USS: hyper-echogenic bright image
CT: may be helpful to monitor
MRI: fatty infiltration + other liver disease
Mx NAFLD
Weight loss, control of co-morbidities
Vit E
Do ulcers require endoscopic follow-up?
Gastric: yes, at 8 weeks
Duodenal: only if symptoms recur (H.pylori breath test indicated)
Mx autoimmune hepatitis
Prednisolone and azathioprine indedinitely - remission in 90% cases
May need liver transplant
Can present as mild or acute liver failure
Presentation of acute Hep A
2-6 weeks incubation time
prodrome of mild-flu symptoms
can progress to icteric phase, with tender hepato-splemogegaly + lymphadenopathy
full recovery can take 6 months - complications v rare
Presentation of acute hep B
Incubation 60-90 days
subclinical or flu-like prodrome
acute infection may include jaundice or liver failure (including decompensated or fatal fulminant failure…)
How is chronic hep B divided?
Hep E antigen positive (higher rates of viral replication) or negative
Presentation of chronic hep B
Can be indolent
sometimes low-grade symptoms
higher chances HCC or cirrhosis - if significant fibrosis or other risk factors will be offered HCC screening
Presentation of hep C
acute: can present with jaundice
usually only presents in chronic state: at least 6 sub-types
usually non-specific symptoms
Which viral hepatitis unusual?
Hep D requires presence of HBV to replicate
How is Hep E transmitted?
Unlike others, the main resevoir is pigs/ contamination of water supplies
similar presentation as HAV
Earliest neurological sign in Wilson’s
asymmetrical tremor
other neuro signs can be difficulty speaking, excess salivation, ataxia, personality changes
usually in 20s-30s
Diagnosing Wilson’s
low caeroloplasmin + Kayser-Fleischer rings
can be treated! chelating agents and block Cu absorption
Presentation haemochromatosis
usually in 40s-60s
non-specific initially
diabetes, bronzing of skin, hepatomegaly, arthropathy, impotence/ hypogonadism, cardiac disease (arrhythmias, cardiomyopathy), neuro or psych disturbance
Causes of cirrhosis
EtOH Hep B Hep C Wilson's Haemachromatosis Drugs Autoimmune hepatitis Congestive heart failure or TR others
Classification of liver failure
Fulminant (within 8 weeks)
Late-onset (within 6 months)
Chronic (6 months+)
Causes portal HTN
Prehepatic: blockage of portal vein, eg portal vein thrombosis
Hepatic, eg cirrhosis
Posthepatic: blockage in venous sx after liver, eg Budd-Chiari, severe R HF
4 sites porto-systemic varices
Oesophageal
Rectal
Caput medusae
bare areas of GIT
Aetiology HCC
HBV or HCV Alcoholism haemachromotosis metabolic sx primary biliary cirrhosis
Name ca biliary treee
cholangiocarcinoma
Causes jaundice
Pre-hepatic: Gilbert’s, haemolytic anaemias
Hepatic: viral hepatitis, alcoholic hepatitis, autoimmune hepatitis, drug-induced hep, decompensated cirrhosis
Post-hepatic: bile duct strictures, CBD stone, pancreatitis, tumours
Causes of abnormal plts number in gastro disease
Low: portal HTN, hypersplenism
High: chronic GI blood loss, inflammatory disease
How to read an AXR
Patient details/ indications Date Projection (usually AP) Technical adequacy (hemidiaphragms to pubic symphysis) Obvious abnormalities
BOWEL
Large from rectum (<6cm, except caecum), bowel wall thickness
Small (<3 cm), wall thickness
PRESENCE OF PNEUMOPERITONEUM (extra-luminal gas)
LIVER, GALLBLADDER, SPLEEN
URINARY TRACT
MAJOR VASCULATURE
SKELETON
IATROGENIC ABNORMALITIES (stents, clips etc.)
How to differentiate small and large bowel markings?
Haustra (partial) - large bowel Valvulae conniventes (full width) - small bowel
Only indications for AXR
acute abdo ?obstruction
acute exacerbation IBD ?megacolon
Causes of pneumoperitoneum
Perf
recent laparotomy
intra-abdo infection with gas-causing bugs
What is gallstone ileus?
Misnomer
Mechanical obstruction: will see dilated loops of small bowel, pneumobilia and a calcific entity at ileo-caecal valve
Which organs does the MRCP look at?
Pancreas
Biliary tree
MRI scan
What does ERCP look at?
Bile duct and pancreatic duct
good for gallstones and pancreatitis
What does faecal elastase look for?
Pancreatic insufficiency
>200 diagnostic
<100 negative
Which younger patients are eligible for bowel ca screening?
Familial adenomatous polyposis - other plyp diseases
Peutz-Jehgers
Strong family history
IBD affecting colon or rectum
acromegaly
people who have had bowel ca/ polyps in past
frequency depends on risk
E&D for endoscopy
nothing for 6 hours
E&D for sigmoidoscopy
fluids only 12h before procedure
how far does sigmoidoscope go?
colonoscopy?
splenic flexure
usually no sedation needed
ileo-caecal valve
usually sedation
alternatives to colonoscopy you might consider for older person
CT colonography
Ba swallow
Which GORD mx shouldn’t be given with clopidogrel?
Omeprazole
reduces efficacy - other PPIs ok
Which anti-emetics have prokinetic effects?
Side-effects?
D2 receptor antagonists: metaclopramide, domperidone
extra-pyramidal effects, esp children and YAs
Which anti-emetic to be avoided in hepatic encephalopathy?
Cyclizine (sedating effects)
also avoid in BPH (anticholinergic effects)
Which anti-emetics best with chemo/ GA?
5-HT3 anatagonists: ondansetron
not great with vertigo
When to avoid bulk-forming laxatives?
In ileus - causes obstruction
Indications for N-acetylcysteine
Paracetamol OD
prevent contrast nephropathy
mucolytic to decrease resp secretions
FISTULA
abnormal communication between 2 epithelial surfaces
SINUS
blind-ending track
ULCER
abnormal area of discontinuity in an epithelial surface
ABSCESS
cavity filled with pus
Post-op bleeding
primary
reactive
secondary
during procedure
within 24h
7-10 days after op
Abx prophylaxis for UGIB
co-amox (cipro if pen-allergic)
Who gets sucralfate?
1g qds following banding
Signs of acute flare IBD
6+ motions in 24hrs and at least 1 of: fever above 37.5 tachycardia above 90 inflamm markers up (CRP above 45) Hb below 100 Albumin below 30
Gastro causes of clubbing
IBD
Cirrhosis
Coeliac disease
What is sialodenosis
Parotid enlargement - might see in EtOH excess
What causes fetor hepaticus
hepatic failure - mercaptan accumulation
extra-intestinal manifestations of IBD
Clubbing Eyes: episcleritis, conjunctivitis Mouth: ulcers (esp Crohns) Skin: EN, PG Joints: seronegative spondyloarthropathy PSC (esp Crohns)
When might you hear a bruit in the liver?
TIPSS
HCC
AV malformation
When might you have a pulsatile liver?
TR
McBurney’s point
One-third between umbilicus and ASIS (appendicitis)
Obturator sign
Pain upon internnal rotation of leg: appendicitis and pelvic abscess
Bend leg at knee and rotate towards midline
Psoas sign
pain upon extending hip (straight leg pulled back)
appendicitis
psoas inflammation
Rovsings’ sign
palpation of LLQ results in pain in RLQ
appendicitis
What is dumping syndrome?
delivery of large amount hyperosmolar chyme into small bowel
following vagotomy and gastric drainage procedure
autonomic instability, abdo pain, diarrhoea
Fitz-Hugh-Curtis sx
Perihepatic gonorrhea sx
Plummer-Vinson sx
oesophageal web iron-deficiency anaemia dusphagia spoon shaped nails atrophic tongue/ oral mucosa
typically elderly women
10% will develop SCC
Short gut sx
<200 cm viable gut
Most common indication for surgery in Crohns
SBO
most common electrolyte deficiency causing ileus
hypokalaemia
most common cause of free peritoneal air
Perforated PUD
Primary
Secondary
Tertiary intention
Immediate closure in theatre
allowed to remain open and granulation tissue form (for dirty wounds)
delayed primary closure (with debridement)
Which parts of GI tract are retroperitoneal?
most of duodenum
ascending colon
descending colon
pancreas
Locations of:
foregut
midgut
hindgut
mouth to ampulla of vater
ampulla of vater to distal third of transverse colon
distal third transverse colon to anus
Normal diameter CBD
< 4 mm until age 40 - then add 1 mm per decade
if gallbladder been removed: 8-10 mm
Likely cause of high-output NG
In duodenum
