Gastroenterology Flashcards
1
Q
what is achalasia ? pathology of what ?
A
myenteric plexus degeneration => loss of coordinated peristalsis + lower oesophageal sphincter fails to relax in response to swallowing => dysphagia, regurgitation + weight loss
2
Q
achalasia px ?
A
dysphagia to solids + liquids, regurgitation, retrosternal pain
(slowly progressive over months or years)
=> weight loss
3
Q
achalasia Ix ?
A
endoscopy (exclude malignancy)
barium swallow
4
Q
achalasia Mx ?
A
CCB (verapamil)
- endoscopic balloon dilatation + PPIs
5
Q
what is dyspepsia ?
A
sx that suggest issue of upper GI issue - epigastric pain, burning, early satiety, bleaching, bloating, nausea, disconfmot
- with no underlying cause
-
6
Q
when would you do investigations in a patient who presents with dyspepsia ? what investigations ?
A
> 60 or <60 + alarm feature => endoscopy (to rule out malignancy)
<60 => non invasive test for H.pylori
7
Q
what are the alarm features for dyspepsia ?
A
VBAD
- vomiting
- bleeding
- abdo mass
- dysphagia
8
Q
what is a peptic ulcer ?
A
break in mucosal lignin of stomach (5cm diameter) to submucosa
9
Q
what leads to peptic ulcer formation ? kind RF
A
- factors promoting mucosal damage (gastric acid/pepsin/bile salts, H. pylori, NSAIDs/steroids
10
Q
what factors protect against peptic ulcer formation ?
A
those promoting gasproduodenal defence
- blood flow
- mucus/mucin
- prostaglandins
- bicarbonate (neutralise acid)
11
Q
what causes increased stomach acid production ?
A
- stress
- alcohol (high alcohol % can be corrosive)
- excessive caffeine
- smoking
- spicy food
12
Q
what does gastric mucosal ischaemia cause ?
A
(if low blood flow/mucosal ischaemia)
=> mucin barrier not as good => acid can kill cell => attack surrounding cells => ulcer formation
13
Q
gastric ulcer presentation ?
A
- epigastric discomfort + pain + tenderness to palpation (often related to hunger)
- N+V
- dyspepsia (indigestion)
- haematemesis
- coffee ground vomit
- tarry bloody stools
- iron deficiency anaemia (due to constant bleeding
14
Q
how could gastric ulcer cause anaemia ?
A
big ulcer => deeper => hits artery => haemorrhage (into peritoneal cavity) => bloody stool
15
Q
what investigations for gastric ulcer ?
A
- endoscopy
- rapid measure test (CLO test, to check for H.pylori)
16
Q
gastric ulcer Mx ?
A
- weight loss, stop dyspepsia-causing drugs
- PPI
- if H.pylori: (CAP) clarithromycin, amoxicillin, PPI
- metronidazole if penicillin allergic
17
Q
when would you consider endoscopy in gastric ulcer presentation ?
A
if dysphagia OR >55 plus ALARM Sx => upper GI endoscopy (2WW)
18
Q
what are the ALARM Sx for peptic ulcer presentaiton ? (6)
A
- Anaemia (iron deficiency)
- loss of weight
- anorexia
- recent onset/prgoressive sx
- malaria/haematemesis
- swallowing difficulties
19
Q
what is H-pylori ? staining ? found where ? why is it bad ?
A
gram -ve aerobic bacteria that lives in the stomach
- avoids acidic environment by forcing its way into gastric mucosa + releases chemical mediator => increase acid production + inflammatory mediators
20
Q
how does H.Pylori lead to gastric damage ?
A
lives in gastric mucosa and increases acid production => breaks in mucosa => expose epithelial cells => damage cells => gastritis, ulcers and increase risk of stomach cancer
- also produces ammonia which neuraltises acid but damages gastric epithelial cells
21
Q
how can H.Pylori be tested for ? what is requirement for these ?
A
(ned 2 weeks without PPI for accurate result)
- urea breath test
- stool antigen test (looks for h pylori antigen
- rapid urease test (done during endoscopy)
22
Q
what is the urea breath test ? test for what ? explain results
A
H. Pylori testing
- patient drink radio labelled C-13 drunk and if H.PYlori present, it breaks it down and if CO2 exhaled with C-13 then H.PYlori presence confirmed)
23
Q
H Pylori Mx ?
A
triple therapy with PPI (omeprazole) + 2 Abx (amoxicillin + clarythromycin) (7days)
24
Q
what is GORD ?
A
it is where acid +/- bile from stomach refuses through lower oesophageal sphincter => irritates oesophageal lining
25
describe the epithelium in oesophagus vs stomach
oesophagus: stratified squamous
stomach: simple columnar
26
how does GORD present ?
- dyspepsia (indigestion)
- heartburn
- acid regurgitation
- retrosternal pain
- epigastric pain
- blasting
- nocturnal cough (when lying flat)
- chronic cough
27
GORD RF ? (6)
- high BMI
- alcohol
- smoking
- CCB (reduces lower oesophageal sphincter pressure)
- pregnancy
28
GORD Ix ?
clinical dx
- diagnosis confirmed by Mx trial
29
red flags for cancer in a GORD presentaiton ?
- dysphagia
- >55
- weight loss
- upper abdo pain
- treatment resistant dyspepsia
- nausea and vomiting
- low haemoglobin
- high playlet count
30
GORD Mx ?
- lifestyle advice
- antacids: gaviscon, PPIs
31
describe GORD lifestyle advice
- reduce tea/coffee/acohol intake)
- weight loss
- quite smoking
- smaller meals
- stay upright after meal
- avoid eating <3 hrs before bed
32
GORD complications ?
- stricture
- Barretts oesophagus
- oesophageal carcinoma
- oesphagitis
33
What is Barretts oesophagus ?
log period of acid reflux into oesophagus (through lower oesophageal sphincter) => metaplasia (stratified squamous => simple columnar)
34
describe why the cellular metaplasia occurs in barrels oesophagus ?
stomach cells have neutral mucin buffer to protect but squamous cells delicate => gastric acid kills quick => grow back as glandular epithelium => unstable like this => predisposes to adenocarcinoma
35
barretss O RF ?
- middle aged
- white
- male
- GORD
- tobacco smoking
- obesity
36
Barretts oesophagus presentation ?
- heartburn
- regurgitation
- dysphagia
(similar to GORD)
37
Barretts oesophagus Ix ?
endoscopy to monitor for adenocarcinoma
- histological diagnosis: endoscopy with mucosal biopsy required
38
Barretts oesophagus Mx ?
PPI (omeprazole)
- ablation treatment (during endoscopy): destroy epithelium so replaced by normal cells
39
What is a hernia ?
protrusion of a viscus through. defect of the walls its containing cavity into an abnormal position (weka point of cavity wall)
40
what are the 3 complications of hernias ?
- incarceration (hernia is irreducible => obstruction/strangulation)
- obstruction (BO)
- strangulation (=> ischaemia, surgical emergency)
41
abdo hernias general Mx ?
- conservative Mx: leave hernia along (when hernia has wide neck => low risk of complications)
- tension-free repair (surgical): mesh placed over abdo wall defect
- tension repaire (surgical): suture muscles + tissue back together
42
what location is the most common hernia site ?in men ? in women ?
inguinal hernia (most common type in M+F)
43
differential for lump in inguinal region ? (7)
- inguinal hernia
- femoral hernia
- lymph node
- saphena varix
- femoral aneurysm
- abscess
- undescended testes
44
what are the two types of inguinal hernia ? which most common ?
- indirect (around 80%)
- direct
45
describe indirect inguinal hernia ?
where bowel herniates through inguinal canal
- can strangulate more easily than direct
46
what is direct inguinal hernia ? due to weakness where ?
occurs due to weakness in th hesselbachs triangle (not along canal or tract)
47
how to distinguish between direct and indirect inguinal hernias ?
- reduce the hernia and occlude deep (internal) ring
- ask patient to cough
- if hernia restrained => indirect
(gold standard for distinguishing is surgery)
48
what is the contents of the inguinal canal (in males)
- external spermatic fascia
- spermatic cord (vas deferens, blood vessels, nerves, lymphatic vessels)
- ilioinguinal nerve
49
what is a hiatus hernia ? defect of what
herniation of the stomach up through the diaphragm
- diaphragm opening should be at the lower oesophageal sphincter
- opening of diaphragm wider than should be => stomach enter through the diaphragm => contents of stomach can relax into oesophagus
50
-how many types of hiatus hernia re there ? most common ?
4 types
- type 1 - sliding (most common - 80%)
51
hiatus hernia Ix ?
can be intermittent so not always seen on imaging
- CXR
- CT
- Endoscopy
52
hiatus hernia Mx ?
- lose weight
- treat GORD
- consider surgery for treatment resistance sx: laparoscopic fundoplication b
53
what is an upper GI bleed ?
medical emergency
- bleeding from oesophagus, stomach or duodenum
54
causes of upper GI bleed ? most common
- oesophageal varices
- mallory weiss tear
- peptic ulcers (most common), caused by drugs
- gastritis
- drugs
- malignancy
55
what drugs could cause upper GI bleed ?
- NSAIDs
- aspirin
- steroids
- anticoags
56
upper GI bleed Presentation ?
- haematemesis
- coffee ground commit (vomiting digested blood)
- malaena (tar, black, greasy, stinky stool)
- haemodynamic instability
- epigastric pain or dyspepsia (if stomach ulcer cause)
- weight loss (if cancer)
57
describe the urea trends with an upper GI bleed ?
upper GI bleed associated with increased serum urea (raised urea in proportion to creatinine indicates massive blood meal)
- digestive enzymes break down/digest blood => increase urea absorption
58
what tool used to estimate risk of upper GI bleed ?
glasgow-blatchford score
59
upper GI bleed Mx ?
(assess state and haemodynamic stability of patient (shocked ?))
ABATED
- ABCDE approach (oxy + fluids)
- Bloods (FBC, U+E)
- access (2 large bore cannulas)
- transfusion (or IV fluids while awaiting cross match)
- arrange urgent endoscopy (IV before endo)
- stop drugs (anticoags, NSAIDs)
- consider terlipressin
60
why IV PPI before endoscopy in upper GI bleed Mx ?
helps blood aggregate so easier to visualise
61
if you think upper GI bleed is due to varices what do you also give ?
Give IV terlipressin (reduces mortality)
62
after initial upper GI bleed Mx, then what do you do ? after endoscopy (3)
- transfuse to keep Hb > 70 g/L
- consider FFP if > 4 units transfused
- Rockall score (after endoscopy): estimates risk of rebreeding
63
What are oesophageal varices ? form as a result of what ?
Dilated collateral blood vessels that develop as consequence of portal hypertension
64
explain how liver cirrhosis leads to oesophageal varices ? occur where
portal HTN and varices
- liver cirrhosis => increased back pressure in portal system (portal HTN) => swelling at anastomoses between portal system + systemic venous system => varices
- occur at gastro-oesophageal, ileocaecal junction, rectum
65
causes of portal HTN ? (4)
- thrombosis (splenic/portal vein)
- cirrhosis (80%)
- RHF
- constrictive pericarditis
66
RF for vatical bleeds ? (2)
- increased portal pressure
- variceal size
67
oesophageal varices symptoms ?
don't cause symptoms until they start bleeding => bleed out quickly (sig mortality + morbidity)
- active bleeding varices: haematemesis, melaena
68
managment of stable oesophageal varices ?
- BB - propanolol (reduce bleed risk - prophylaxis)
- elastic band ligation
- transjugular intra-hepatic portosystemic shunt (if all fails)
(prevent bleeding)
69
management of bleeding oesophageal varicies ?
ABATED + terlipressin (vasopressin analogue)
- plus endoscopic variceal band ligation (definitive treatment)
70
what is mallory Weiss tear ?
oesophageal mucosal tear of the mucus membrane => upper GI bleed
- the haemorrhage is self limiting in 80-90% of patients
71
mallory Weiss tear aetiology ?
coughing, retching, chronic cough, heavy alcohol use
72
mallory Weiss tear presentation ?
haematemsis (fresh streaks of blood)
FBC (anaemia)
73
mallory Weiss tear Ix ?
upper GI endoscopy (diagnostic)
74
mallory Weiss tear Mx ?
mostly self limiting, so supportive care
- if actively bleeding: resuscitation and therapeutic endoscopy
75
how does the type and quantity of bacteria change forms tomach to colon ?
(from stomach => colon)
aerobes => anaerobes
small => big quantity
76
what counts as diarrhoea ?
passage of loose watery stools (>3 in last 24 hrs)
77
name some non-infective causes of diarrhoea ? (5)
- cancer
- chemical
- radiation
- IBD
- IBS
78
name some causes of watery infective diarrhoea ?
- bacterial (cholera, E.coli (ETEC), c.diff)
- virus (morovirus, rotavirus)
- parasitic (giardia)
79
name some causes of bloody infective diarrhoea ?
- bacterial (campylobacter, e.coli (EIEC), shigella, salmonella)
80
what does diarrhoea + low MCV anaemia indicate ? (2)
- coeliac disease
- colon cancer
81
what does diarrhoea and high MCV indicate ? (2)
- alcohol abuse
- or low B12 absorption (coeliac or crohns)
82
when would you admit someone present with diarrhoea ? (3)
- fever >39
- clinical dehydration
- diarrhoea + visible blood > 2 weeks
83
What is clostridium difficile (c.diff) ? associated with what
gram +ve rod shaped anaerobic bacteria
- infection associated with repeated use of Abx, PPIs, healthcare settings
- asymptomattic carriage: 2-5% of all adults
84
which Abx are most associated with C.diff ? (3)
- clindamycin
- ciprofloxacin
- cephalosporins
85
c.diff Ix and Mx ?
stool sample (c.diff antigen)
- Abx: stop causative one, start oral vancomycin
86
what is gastroenteritis ?
acute gastritis is inflam of the stomach and enteritis is inflam of the intestines
- so presents with nausea, vomiting and diarrhoea
87
what is E.coli ? how is it spread ? how does it present ?
normal intestinal bacteria (certain strains cause gastroenteritis)
- spread through contract with infected faces, contaminated water
- E.coli 0157 makes shiga toxin => abdo cramps, bloody diarrhoea, vomiting (+HUS)
- abx should be avoided
88
what is campylobacter jejuni ? how is it spread ? symptoms ? Mx ?
gram -ve bacteria (travelers diarrhoea)
- spread by raw/undercooked poultry, unpasteurised milk
- symptoms: abdo crampes, bloody diarrhoea, vomiting, fever
- abx: azithromycin
89
complications of diarrhoea ? (4)
- lactose intolerance
- IBS
- reactive arthritis
- Gillian bare syndrome
90
what is constipation ?
pelvic dysfunction or increased transit time => <2 bowel motions/week
91
what does constipation + rectal bleeding indicate ?
cancer
92
what does constipation + distension + active bowel sounds indicate ?
stricture/GI obstruction
93
what does constipation + menorrhagia indicate ?
hypothyroidism
94
when would you consider test in constipation ? (4)
- lowing weight
- abdominal mass
- PR blood
- Fe deficiency anaemia
95
how do bulking agents work ? give example
ispagula husk
- increase faecal mass => stimulate peristalsis (take with plenty of fluid, may take a few days to work)
96
how do stimulant laxative work ? give example
Senna, sodium pico sulfate
- increase intestinal motility (so DONT use in intestinal obstruction of acute colitis)
97
how do osmotic laxative works ? give example ?
lactulose, macrogol
- retain fluid in the bowel
98
name sone drugs that cause constipation ? (5)
- opiates
- anticholingerics
- iron
- diuretics
- CCB
99
What is IBD ? what conditions ? both involve what ?
IBD is umbrella term for 2 main disease that cause inflam of GI tract
- UC + crowns both involve inflam of walls of GI tract + associated with periods of remission + exacerbation
100
what causes raised faecal calprotectin ? what conditions ?
released from intestines when inflammation
- Cancer, IBD
101
what investigations for IBD ? diagnostic ?
- bloods (raised CRP, anaemia)
- faecal calprotectin
- endoscopy + biopsy (diagnostic)
- CT or MRI (to look for fistulas, abscesses, strictures)
102
where in GI tract is Crohns disease ? most common ?
usually seen in terminal ileum (70%)
- but can be anywhere gum to bum
103
what are skip lesions and what IBD condition associated with them ?
Crohns disease
- normal bowel mucosa between diseased parts
104
describe granuloma formation in crohns disease ?
lesion starts as inflammatory infiltrate around intestinal crypts => ulceration => inlammation gets deeper => granulomas (collection of histiocytes)
105
what acronym for Crohns disease ? what does it stand for ?
Crohn's (crows) NESTTS
- No blood or mucus (less common)
- Entire GI tract (mouth to anus)
- Skip lesions
- Terminal ileum (most affected)
- Transmural (full thickness of wall)
- smoking (RF - don't set the nest on fire!)
106
signs and symptoms of crohns disease ? (7)
- chronic diarrhoea
- weight loss
- right lower quadrant abdo pain (mimicking acute appendicitis)
- blood in stool
- fever
- fatigue
- bowel obstruction
107
Crohns disease Mx ?
- induce remission: steroids (during flare up)
- maintain remission: azathioprine or methotrexate or infliximab
- surgery: surgical removal (if only affects distal ileum)
108
Crohns disease complications ?
- Intestinal obstrution
- abscess fomration
- distal formation
- reduced QOL
- sero -ve arthirits, ank spond
109
what is UC ? involves where ?
type of IBD, involves rectum and variably extends to colon (can have sharp pathological cut off line)
- potential autoimmune disease initialed by inflammatory response to colonic bacteria
110
UC risk factors ?
- fam history
- HLA-B27 (identified in most UC patients)
- infection
111
UC signs and symptoms ? (6)
- rectal bleeding
- diarrhoea
- blood in stool
- abdo pain/tenderness
- arthritis
- malnutrition
112
UC accronym and what does it stand for ?
CLOSE UP
- Continuous inflam (no skip lesions on endoscopy)
- Limited to colon + rectum
- Only superficial mucosa
- Smoking is protective
- Excrete blood + mucus
- Use aminosalicylates
- Primary sclerosis cholangitis
113
what biopsies are required for UC diagnosis ?
2 biopsies forma t least 5 sites along colon
- diagnosis requires endoscopy with biopsy and negative stool culture
114
UC Mx ?
induce remission: aminosalicylate (mesalazine) or IV corticosteroids
- ongoing: continue aminosalicylate
- surgery: remove colon + rectum
115
UC complicaitons ?
- toxic megacolon
- bowel adenocarcinoma
116
What is coeliac disease ?
it is an autoimmune condition where exposure to gluten causes autoimmune reaction => inflammation of small bowel
- usually developed in early childhood
117
coeliac disease pathophys ?
autoantibodies are created in response to exposure to gluten => target epithelial cells of small intestine => inflam => atrophy of intestinal villi => malabsorption
118
what autoantibodies associated with coeliac ? and what genetic link
anti-TTG
anti-EMA
(go up and down with disease activity)
- HLA-DQ2/DQ8 (-ve predicative value of around 100%, but most ppl with these genes do NOT develop coeliac)
119
coeliac disease presentation ? what skin condition associated ?
- asymptomattic
- failure to thrive
- diarrhoea
- tireness
- weight loss
- fatigue
- mouth ulvers
- anaemia
- dermatitis herpetiformis (abdo rash)
120
how is coeliac disease diagnosed ? (3)
investigations must be carried out on gluten containing diet
- check total IgA levels (to exclude IgA deficiency)
- raised anti-TTG antibodies
- Endoscopy + intestinal biopsy (crypt hypertrophy + villous atrophy)
121
with what other conditions is coeliac associated with ? (4)
autoimmune conditions
- T1DM
- thyroid disease
- primary biliary cirrhosis
- primary sclerosis cholangitis
122
coeliac disease complications ? (4)
- vit d deficiency
- anaemia
- osteoporosis
- NHL
123
coeliac disease Mx ?
life long gluten free diet is curative
124
What count as functional gut disorders ? (2)
- IBS
- functional dyspepsia
125
what are functional gut disorders ?
chronic GI symptoms in the absence of organic disease to explain the symptoms (>6 months)
126
What is IBS ? characterised by ?
chronic condition characterised by abdo pain, bowel dysfunction, pain relieved on defecation, abdo bloating
127
IBS pathosphsy ?
altered gut reactivity (motility + secretion) in response to stimuli (environment, person life stress/abuse) or luminal (certain foods, toxins, inflammation) =? pain, constipation, diarrhoea
- dysregulation of the gut-brain axis
128
IBS Ix ?
- FBC: normal (anaemia suggests non IBS cause)
- serology for coeliac
129
IBS Mx ?
- aim to reduce severity of symptoms, life style changes, reduce stress, reduce potential precipitating food (caffeine, lactose, fructose), low FODMAP diet, probiotics, laxative, antispasmodics (if experiencing pain and bloating)
130
What is chronic pancreatitis ? most common cause
chronic inflammation in pancreas => fibrosis (irreversible) = reduced function
- alcohol is most common cause
131
chronic pancreatic presentation ?
Similar to acute but less intestinal and longer lasting (sx release and worsen)
132
chronic pancreatitis complications ?
- chronic epigastric pain
- loss of exo + endocrine function (=> diabetes, steatorrhoea, malnutrition)
- abscess
- pseudocyst formation
133
chronic pancreatitis RF ? (4)
- alcohol
- smoking
- FHx
- coeliac disease
134
chronic pancreatitis Ix ? what confirms Dx ?
- US +/- CT
- pancreatic calcifications confirm the dx
135
chronic pancreatitis Mx ? (6)
- stop smoking + alcohol
- analgesia
- replacement of pancreatic enzymes (creon)
- sub cut insulin
- ERCP withs tenting (Hilary obstruction)
- surgery
136
most common aetiology of carcinoma of the pancreas ? most arise where anatomically ?
- mostly ductal adenocarcinoma
- 60% arise from pancreatic head
137
pancreatic cancer RF ? (5)
- smoking
- alcohol
- DM
- chronic pancreatitis
- 95% have mutation in KRAS2 gene
138
pancreatitis cancer px ?
epigastric apin (radiates to back and relieved by sitting forward)
- similar to pancreatitis presentation
- painless jaundice
139
pancreatic cancer Ix ? what would be seen
- imagine: US/CT (pancreatic mass +/- dilated biliary tree +/- hepatic metastases)
140
pancreatic cancer prognosis ?
v poor (mean survival < 6 months)
141
what are carcinoid tumours? tumours of what cell?
how likely to metastasize?
tumours of enterochromaffin cells (can be many locations)
- 80% of tumours > 2cm will metastasise
142
carcinoid syndrome mx ?
- octreotide (somatostatin analogue)
- surgery: resection is the only cure for carcinoid tumours (whipples - removes head of pancreas)
143
what is chronic liver disease ?
progressive deterioration of liver function for more than 6 months
144
what is liver failure ?
development of coagulopathy ( INR>1.5) and encephalopathy + jaundice
145
prescribe in liver failure: avoid what drugs ?
- avoid drugs that constipate (antimuscarinics, opioids)
- sedating meds (opioids, benzos, hypnotics)
(=> increase risk of encephalopathy)
146
liver failure symptoms + signs ? (9)
- yellowing skin and eyes (jaundice)
- abdominal pain + swelling (ascites)
- swelling in legs + ankles
- itchy skin
- dark urine
- pale stool
- chronic fatigue
- bruise easily
- astarixis
147
causes of liver failure ? (7)
- viral hep (B, C, CMV)
- leptospirosis
- paracetamol overdose
- alcohol
- fatty liver disease
- primary biliary cholangitis
- primary sclerosing cholangitis
148
what is liver cirrhosis ? what does this lead to ?
(end stage of any liver disease)
- cirrhosis is the fibrosis and conversion to abnormal nodules (regenerative nodules) => this leads to portal hypertension, liver failure, HCC
149
CLD and liver failure RF ? (7)
- heavy alcohol consumption
- obesity
- T2DM
- tattoos and piercings
- sharing needles
- unprotected sex
- FHx of liver disease
150
what is ascites ? explain. caused by what ?
increased extravascular fluid pressure => fluid accumulation in anterior peritoneal cavity
- caused by systemmic vasodilation and increased intrahepatic resistance
151
ascites Mx ? (4)
- restrict fluid
- low salt diet
- weigh daily
- dietetics (spironolactone)
152
what are some of the complications of liver failure ?
- cerebral oedema
- ascites
- bleeding
- encephalopathy
153
treating liver failure complications: cerebral oedema ? (2)
- 20% mannitol
- hyperventilate
154
how does liver failure lead to cerebral oedema ?
nitrogenous waste (ammonia) build up => osmotic imbalance => fluid shift into astrocytes (cerebral oedema(
155
treating liver failure complications: bleeding ? (3)
- IV vit K
- platelets
- FFP + blood as needed
156
how does liver failure cause encephalopathy ? explain the ammonia
ammonia is produced when intestinal bacteria break down protein => absorbed into gut => enter blood stream
- ammonia builds up as liver cells no function properly => not metabolised right
- colateral vessels between portal + systemic system mean liver bypassed
- leads to brain exposure to ammonium (neurotoxin)
157
hepatic encephalopathy presentation ?
vary, mild alteration in mental state to coma (often reversible with treatment)
- mood/sleep/motor disturbances
158
hepatic encephalopathy diagnosis ?
- based on neurological defects + lab abnormalities showing liver dysfunction
- head CT (fuel out differential, may show oedema)
159
hepatic encephalopathy Mx ? what abx
- 20 degree head up tilt in ITU
- correct electrolytes
- laxatives (lactulose), promote ammonia excretion
- nutritional support
- Abx (rifaxamine) => reduce number of intestinal bacteria that produce ammonia
160
what is hepatorenal syndrome (HRS) ?
cirrhosis + ascites + renal failure
- life threatening condition that consist of rapid deterioration of kidney
161
what are the 3 main features of liver cirrhosis ?
- jaundice
- ascites
- encephalopathy
162
what is liver cirrhosis ?
it is the result of chronic inflam + damage to liver cells (pathological end stage of CLD)
=> fibrosis and nodular degeneration
- damaged liver cells replaced with scare tissue (fibrosis) which forms nodules within liver
163
how does the fibrotic change affect liver ?
fibrosis affects liver blood flow and increase resistance in vessels leading to liver (portal hypertension)
164
causes of liver cirrhosis ? (10)
(any CLD)
- alcohol liver disease
- NAFLD
- hep B/C
- autoimmune hep
- primary biliary corrhosis
- haemochromatosis
- Wilsons disease
- alpha 1 antitrypsin disease
- CF
- drugs (amiodarone, methotrexate)
165
signs of liver cirrhosis ?
- juandice
- hepatomegaly (only early on)
- splenomegaly (due to portal HTN)
- spider naval
- bruising (due to low clotting factors)
- ascites
- asterixis
- leukonychia (from hypoalbuminaemia)
166
what would US show in liver cirrhosis ?
modularity of liver, enlarged portal vein, ascites, splenomegaly
167
how confirm liver cirrhosis diagnosis ?
liver biopsy
168
what can be used as marker for HCC
alpha-feto protein is tumour marker for HCC
169
what scoring tool assess severity of liver cirrhosis ?
child Pugh score (5 -15)
- bilirubin, INR, ascites, encephalopathy
170
liver cirrhosis general Mx ? what ongoing monitoring ? how often ?
US + alphafetoprotein every 6 months to screen for HCC
- endoscopy every 3 years in patients with known clarifies
- high protein, low salt diet
- MEDL score every 6 months to assess mortality + need for liver transplant
- treat underlying cause and complications
171
liver cirrhosis complications ?
- hepatic failure: coagulopathy, encephalopathy, hypoalbuminaemia (oedema), sepsi (pneumonia), spontaneous bacterial peritonitis (SBP), hypoglycaemia
- portal HTN: ascites, splenomegaly, oesophageal varices
172
what should you suspect in patient with ascites who deteriorates ? most common cause ?
spontaneous bacterial peritonitis (SBP)
- e.coli, klebsiella
173
what are the most common aetiology of liver tumours ?
90% are metastases
(from stomach, lung, colon, breast)
174
What is hepatitis ? when does it count as chronic ?
it is inflammation of liver
- can vary form chronic low level to severe inflam => necrosis + liver failure
(>6 months: chronic)
175
hepatitis presentation ?
- asymptomattic
- abdo pain
- fatigue
- pruritus
- muscle + joint aches
- N&V
- jaundice
- fever
176
name some infective causes of acute hepatitis ?
- viral (hep A, B+/- D, C, E), HPV
- non-viral: syphillus, TB
177
name some non-infective causes of acute hepatitis ? (4)
- alcohol, drugs, toxins
- NAFLD
- pregnancy
- autoimmune hepatitis
178
which viral hepatitis can lead to chronic hepatitis ?
hep B+/-D, C
(+E in immunocompromised patients)
179
hepatitis A:
- what type of virus ?
- how transmitted ?
most common worldwide (but rare in UK), problem for travellers
- RNA virus
- transmitted via faeco-oral route (contaminated food + water)
180
Hep A Px ?
- N&V
- anorexia
- jaundice
- cholestasis
- hepatomegaly
- dark urine
- pale stools
181
Hep A Ix ?
- Serological markers: IgM anti hepatitis A virus serology (+ve)
- deranged LFTs
- raised bilirubin
- prolonged PTT
- raised serum creatinine
182
Hep A Mx ? prognosis ?
usually resolves by itself in 1-3 months
- so supportive mx (+analgesia)
- avoid alcohol
- have immunity after infection (can't get infected twice)
- public health notifiable disease
183
Hep B
- what type of virus is it ?
- how is it transmitted ?
DNA virus
- transmitted by blood or body fluid (sex, shared needles, vertical transmission)
184
hep B RF ? (6)
- prenatal exposure
- multiple sexual partners
- MSM
- IVDU
- born in endemic area (Asia, Africa)
- harm-dialysis
185
hep B prognosis ?
most people recover within 2 months but 10% => chronic hep B carriers (viral DNA has integrated into own DNA => continue to produce viral proteins => cirrhosis, hepatocellular cancer, decompensation)
186
acute hep B Mx ? whole approach/ what. else other than medicine (6)
- antiviral meds (entecavir): to slow progression and reduce infectivity
- test for complications (fibroscan for cirrhosis, USS for HCC)
- screen at risk patients for hep B?C, HIV
- notify public health
- stop smoking + alcohol (minimise liver damage)
- inform and immunise sexual contacts
187
what hep B screening ?
- antenatal screening
- universal blood product screening
188
describe the hep B vaccination ?
- involves infecting hep B surface antigen (which triggers immune response => hep B surface Abs)
- vaccinated patients are tested for hep B Ab to confirm response to vaccine
189
Hep C
- what type of virus
- how transmitted ?
- RNA virus
- spread by blood and bodily fluids
190
hep C prognosis ?
1/4 make full recovery (without treatment)
3/4 => chronic hep C
(no available vaccination but is now curable with direct acting anti-viral meds)
191
hep C Px ?
- often asymptomattic
- fatigue
- joint stiffness
- jaundice
192
how hep C diagnosed ?
- hep C antibody test
- if +ve: hep C RNA PCR test (confirm diagnosis + viral load)
193
hep C Mx ?
(same as hep B)
- antiviral med (glecaprevir) to slow progression and reduce infectivity
- test for complications (fibroscan, USS)
- screen at risk patients for Hep B/C + HIV
- notify public health
- stop smoking + alcohol (minimise liver damage)
194
Hep D
- what type of virus
- transmission ?
RNA virus
- only present in patients with hep B infection. attaches to hep B surface antigen (required to survive)
- blood Bourne
195
Hep D Ix and Mx ?
- hep D antibody
- treat: pegylated interferon alpha
- B + D increases risk of complications, more severe disease (cirrhosis, decompensation)
196
Hep E
- what type of virus ?
- transmission ?
- RNA virus
- transmitted by faecal-oral route
(rare in the UK)
197
hep E prognosis ?
usually mild illness, cleared within a months
- no treatment required
- rarely can progress to chronic hep and liver failure (but can in immunocompromised)
198
hep E Ix ?
viral serology: initially anti-HEV IgM and then anti-HEV IgG
199
hep E Mx ? acute ? chronic ?
acute: supportive, monitor for fulminant hep (severe liver impairment)
- chronic: reverse immunosuppression
- notify public health
200
what is autoimmune hepatitis ? characterised by what ?
inflam liver disease of unknown cause (possible environmental factor)
- characterised by abnormal T-cell function + autoantibodies directed against hepatocyte surface antigens
=> liver cirrhosis => liver failure
201
autoimmune hepatitis Px ?
- fatigue
- malaise
- anorexia
- abdo pain
- hepatomegaly
- jaundice
- amonrrhoea
202
autoimmune hepatitis Ix ? Dx ?
- raised transaminases
- high IgG levels
- autoantibodies (anti smooth muscle)
- Diagnosis: confirmed with liver biopsy (and positive autoantibodies)
203
autoimmune hepatitis Mx ?
- high dose steroids (prednisolone), other immunosuppressant (azathioprine)
- life long immunosuppression (remission achievable in 80% patients)
- if advanced liver disease => liver transplant
204
what are cholelithiasis ? when do they cause symptoms ?
gallstones: presence of stones in gall bladder that may exit into bile ducts
- cause symptoms when stone obstruct cystic duct, common bile duct, pancreatic duct
205
what is purpose of gall bladder ? what makes it contract ?
stores bile waiting for signal form stomach that there is fat (CCK) => gallbladder contract
206
what are the main constituents of gallstones ?
>90% consist of cholesterol and bile pigment
( cholesterol supersaturation and increased haemoglobin breakdown => stone formation)
207
gall stone RF ? (5)
- female
- fat
- forties
- fertile (pregnancy)
- rapid weight loss
208
gall stones Px ?
- mostly asymptomattic
- binary colic pain (often after eating)
- RUQ tenderness + pain
- jaundice
209
what is the scan of choice for suspected gallstones ?
abdominal US (shows presence of stones in GB, dilated CBD
210
what could raised WCC in biliary colic presentation suggest ?
consider acute cholecystitis
211
biliary colic Mx ?
- Analgesia (NSAID, paracetamol)
- rehydrate
- NBM
- elective laparoscopic cholecystectomy (early or delayed)
212
complications of gallstones ? (4)
- biliary colic
- acute and chronic cholecystitis
- acute cholangitis
- acute pancreatitis
213
What is acute cholecystitis ? caused by what ?
it is inflammation of gall bladder caused by blockage of cystic duct or neck of GB => prevent GB drainage
- key complications of gall stones
214
how do gall stones cause acute cholecystitis ?
trapped gallstones => irritation + pressure => inflammation
215
acute cholecystitis Presentaiton ?
- pain in RUQ, radiating to R shoulder
- fever
- nausea
- vomiting
- tachycardia
- tachynpiena
- Murphys signs
- raised WCC
(no jaundice )
216
acute cholecystitis Ix ? what would they show ?
- abdo US (thickened GB wall, stones (main cause), fluid around GB)
- MRCP (if bile duct stone suspected but not seen on US)
217
acute cholecystitis Mx ? (5)
- bit by mouth (rest gall bladder)
- IV fluids
- IV Abx (co-amox)
- ERCP (remove sones trapped in CBD)
- laparoscopic cholecystectomy (GB removal)
218
what is charcots triad ? what does it indicate ?
Acute cholangitis
- RUQ pain
- Fever/raised WCC
- Jaundice
219
what is Acute cholangitis ?
infection and inflammation in the bile ducts
- surgical emergency
220
what causes Acute cholangitis ?
caused by obstruction in bile ducts (gallstones) or infection introduced in ERCP (e.coli, klebseilla, enterococcus)
- can quickly become acute, septic life threatening disease
221
Acute cholangitis RF ? (4)
- >50
- cholelithiasis
- benign or malignant stricture
- prev ERCP procedure
222
Acute cholangitis presentaiton ?
- Charcot's triad (RUQ pain, fever, jaundice)
- pale stools (jaundice), pruritus (high bile acids)
223
Acute cholangitis Mx ? (6)
(surgical emergency)
- NBM
- IV fluids
- Analgesics
- Sepsis screen
- Start IV Abx
- ERCP: required to investigate and remove the stones blocking bile duct
224
What is primary biliary cirrhosis ? what does it lead to ?
immune system attacks small bile ducts in liver (first affecting interlobular ducts) => obstruction of outflow of bile => cholestasis => increase back pressure => fibrosis => cirrhosis => liver failure
(progressive bile duct damage => eventual loss)
225
explain PBC pathophys ? how does it explain the symptoms ?
- obstruction to outflow => increase bile acids, bilirubin and cholesterol in blood => pruritus, jaundice + xanthelasma (cholesterol deposits in skin)
- lack of bile in gut (usually helps digest fat) => GI disturbances, fat malabsorption, greasy stools (steatorrhoea)
226
PBC presentation ? (8)
- fatigue
- pruritus
- GI disturbance
- abdo pain
- jaundice
- pale stools
- xanthelasma
- signs of cirrhosis and liver failure (ascites)
227
how is primary biliary cirrhosis diagnosed ?
- presence of autoantibodies (antimitochondiral Ab)
- raised ALP
- liver biopsy (for diagnosing and staging)
228
primary biliary cirrhosis Mx ? (5)
- bile acid analogue (ursodeoxycholic acid)
- immunosuppression (prednisolone)
- antipuruitic (cholecystamine)
- vitamin supplementation (ADEK)
- if end stage liver failure: liver transplant
229
what is primary sclerosing cholangitis ?
it is condition where intra + extra hepatic ducts become structured and fibrotic (narrowing + hardening) => obstruction to flow of bile out of liver into intestines
(progressive disease)
230
what doesprimary sclerosing cholangitis lead to ?
chronic obstruction of bile => back pressure of bile into liver => hepatitis => fibrosis => cirrhosis
231
which bile duct condition is UC associated with ?
primary sclerosing cholangitis
232
primary sclerosing cholangitis px ?
- jaundice
- chronic RUQ pain
- prurits
- fatigue
- hepatomegaly
233
primary sclerosing cholangitis Ix ? Dx ?
- LFTs (cholestatic picture: deranged ALP, high bilirubin, deranged transaminases)
- diagnosis: MRCP (gold standard) would show bile duct lesions or strictures
234
primary sclerosing cholangitis complications ? (3)
acute bacterial cholangitis
cirrhosis
liver failure
235
primary sclerosing cholangitis Mx ? (3)
liver transplant is only curative option (but not always best)
- ERCP (dilate + stent strictures
- cholesytamine (improve pruritus)
236
what are the stages of NAFLD ?
non alcohol fatty liver => non-alcoholic steatohepatitis (NASH) => fibrosis => cirrhosis
insulin resistance => triglyceride accumulation in liver => hepatic steatosis
237
NAFLD RF ? (8)
(same as CVD + diabetes)
- poor diet
- low citify levels
- obesity
- T2DM
- high cholesterol
- middle aged
- smoking
- HTN
238
NAFLD Px ? (8)
- absence of sig alcohol use
- fatigue
- malaise
- turncoat obesity
- hepatospenomegaly
- RUQ abdo disomfort
- Jaundice
- bruising
239
NAFLD Ix ? how diagnosed ?
diagnosis is based on excluding of other aetiologies (alcohol) + histology
- LFT (raised AST, raised ALT (typically this)), raised bilirubin, elevated PTT, low albumin)
- liver US can confirm fatty liver (but not severity or fibrosis)
- fibroscan
240
NAFLD Mx ? what vitamin supplement ?
- weight loss
- exercise
- stop smoking
- avoid alcohol
- med to control diabetes, HTN, cholesterol,
- Vit E (may improve history in fibrosis)
- if end stage liver failure: liver transplant
241
if NAFLD is cirrhotic, then what screening and how often ?
if cirrhotic
- screen for HCC with US + AFP twice yearly
242
what is alpha 1 antitrypsin deficiency ? affects which organs ?
it is an inherited deficiency of alpha 1 antitrypsin (protease inhibitor) => excess of protease enzymes (neutrophil elastase) => attack liver + lung tissue => liver cirrhosis + lung damage
243
what inheritance pattern is alpha 1 antitrypsin deficiency ?
autosomal recessive
244
alpha 1 antitrypsin deficiency. how does it affect each organ? briefly
lung (emphysema)
- lack of canton alpha => excess protease enzyme => attack connective tissue => bronchiectasis + emphysema
liver (cirrhosis and HCC)
- mutation => altered shape => aggregate in hepatocyte ER => fibrosis => cirrhosis => HCC
245
what is the chief cause of liver disease in children ?
alpha 1 antitrypsin deficiency
246
where is alpha 1 antitrypsin made ? what difference in the deficiency ?
made in liver
247
how is alpha 1 antitrypsin deficiency diagnosed ? (3)
- serum alpha 1 antitrypsin (low)
- liver biopsy
- high resolution CT thorax
248
alpha 1 antitrypsin deficiency mx ? (4)
- IV A1AT
- COPD Tx
- lung/liver transplant
- smoking cessation
(don't drink or smoke)
249
what is Wilsons disease ?
it is the excessive accumulation of copper in the body + tissues
250
Wilson's disease inheritance pattern ? what chromosome ?
mutation in the "Wilsons disease protein" on chromosome 13
- autosomal recessive
251
Wilson's disease pathosphsy ? explain each a bit
the copper can accumulate in many places (hepatic, neurological, physiatrics)
- copper deposition in liver => chronic hepatitis => liver cirrhosis
- copper deposition in CNS (e.g. basal ganglia) => neuro + psychiatric problems
252
wilds disease px ? signs and symptoms
- CLD signs
- concentration + coordination difficulties, dysarthria, dystonia, Parkinsonism
- depression, psychosis
- kayser, Fleischer rings (copper ring around iris), haemolytic anaemia, osteopenia
253
Wilsons disease Dx ?
- serum seruloplasmin (low suggests Wilsons disease) (protein that carries copper in blood)
- liver biopsy (definitive - will show high hepatic copper)
254
Wilsons disease Mx ? (5)
- trientine + zinc
- life long penecillamine
- avoid high copper foods
- if hepatic failure: liver transplantation
- screen siblings
255
What is haemochromatosis ? affects where ?
iron storage disorder => excessive total body iron + deposition of iron in tissues (joints, liver, heart, pancreas, skin)
256
what inheritance is haemochromatosis ? what gene ?
autosomal recessive
- human haemochromatosis gene (HFE)
257
what is hepcidin ? where made ? regulator of what ?
hepcidin: peptide made in hepatocytes
- It is a -ve regulator of gut iron absorption
- high iron => high hepcidin synthesis
258
describe hepcidin in haemochromatosis ?
gene mutation => low hepcidin => high Fe intestinal absorption => Fe deposition => organ failure
259
haemochromatosis Px ? (6) presents later in who ?
takes a while for iron overload to become symptomatic (40s), later in females (due to menstruation) usually after menopause
- chronic tiredness
- joint pain (Fe deposition in joints => arthritis)
- bronze skin discolouration
- hair loss
- sexual dysfunction (ED, amenorrhoea)
- mood + memory disturbance
260
haemochromatosis Dx ?
- serum ferritin levels, transferrin saturation
- if both high => iron overload => genetic testing to confirm diagnosis
- MRI can show liver deposits of iron
261
what can cause raised ferritin ?
Ferrari levels can be high due to inflammation (transferrin distinguishes iron overload form inflam)
262
haemochromatosis complications ?
think where deposited
- T1DM (iron deposit affects pancreas)
- liver damage and cirrhosis
- endocrine and sexual problems (hypogonadism, impotence, amenorrhoea, infertility)
- cardiomyopathy (=> HF)
- hypothyroidism
- pseudo gout
263
haemochromatosis Mx ?
venesection (weekly remove blood)
- monitor serum ferratin
- avoid alcohol
- monitor + treat complications
264
mass in the RIF - what could it be ? (4)
- appendix mass/abscess
- caecal carcinoma
- intussception
- crohns
265
what can cause hepatomegaly ? (4)
- hepatitis
- CCF
- sarcoidosis
- early alcohol cirrhosis
266
describe the parietal vs visceral nerve supplies of the peritoneal cavity ?
- parietal has rich nerve supply so pain relate to area
- whereas visceral has poor nerve supply (dermatomes)
267
clinical signs of peritonitis ?
- shock
- lying still
- positive cough test
- tenderness (+/- rebound/percussion pain)
- board-like abdo rigidity
268
what condition can mimic peritonitis so needs to be excluded ? how would you exclude ?
acute pancreatitis can cause all this but does not require laparotomy so check serum amylase
- also always check for ectopic ! do pregnancy test !
269
What is ascites ? due to what ?
accumulation of excess serous fluid in peritoneal cavity due to increased pressure in portal system
- can be some in a healthy female (20ml), men have none
270
describe pathosphsy of ascites ?
increase fluid in peritoneal space => reduced circulating vol => reduced blood to kidneys => increase renin => increase aldosterone => increase water + Na reabsorption => worsening ascites
271
most common cause of ascites ?
cirrhosis (75%)
272
what value can be used to group the different causes of ascites ? what does this value indicate ?
SAAG (serum ascites albumin gradient)
>11g/L => indicates portal HTN
<11g/L => other
273
name same conditions that would cause ascites with raised albumin ? 3 categories
(indicates portal HTN)
- liver disorders: cirrhosis/ALD, acute liver failure, liver mets
- cardiac: RHF, constrictive pericarditis
- other: oral vein thrombosis, budd-chiari syndrome
274
name same conditions that would cause ascites with low albumin ?
- hypoalbuminaemia (nephrotic syndrome, severe malnutrition
- malignancy
- infections
- pancreatitis
- BO
275
peritonitis mx ?
- low salt diet
- anti aldosterone dietetics (spiro)
- paracentesis
- prophylactic abx
276
what is spontaneous bacterial peritonitis ?
(10-20% mortality)
- infection of ascitic fluid that's not due to intraabdominal, inflammatory or surgical condition (so is haematogenous spread)
277
spontaneous bacterial peritonitis px ?
commonly asymptomattic
- fever
- abdo pain
- vomiting
- altered mental state
- GI bleeding
- signs of ascites
278
spontaneous bacterial peritonitis typical pathogens ? (3)
- E.Coli
- klebseilla penumonia
- s.aureus
279
spontaneous bacterial peritonitis Ix ?
- diagnostic paracentesis: ascitic fluid absolute neutrophil count > 250 cells/m2 +/- culture growth
280
spontaneous bacterial peritonitis Mx ?
ascitis culture before empirical IV Abx, albumin
- large volume paracentesis
281
what is the most common surgical emergency ?
appendicitis
(acute inflammation of the appendix)
282
appendicitis pathophys ? what could it lead to ?
appendix is small tube that arises from caecum
- there is single opening to appendix that connects to bowel + lead to head end => trap pathogens => infection + inflammation => necrosis and appendix rupture => faecal contents into peritoneal cavity => peritonitis
283
appenditcitis presentation ? signs and symptoms ?
- central abdo pain that moves to right iliac fossa, tenderness at mc Burneys point (1/3 distance from ASIS to umbilicus)
- fever (low grade)
- anorexia
- N&V
- guarding
- rebound tenderness
284
what is rovings sign ? what does this indicate ?
rovings sign: pain greater in RIF that LIF when the LIF is pressed
- indicates appendicitis
285
how is appendicitis diagnosed ? other investigations ?
clinical presentation + high inflam markers + high WBC
- CT to confirm diagnosis
- US in females (rule about differential)
286
appendicitis Mx ?
- emergency hospital admission
- appendicectomy (surgical)
- analgesia (paracetamol)
287
name some causes of functional intestinal obstruction ?
adynamic - no physical obstruction, no peristalsis
- electrolyte imbalance
- medication
- recent surgery
- neurological disease
288
what is bowel obstruction ? SBO or LBO more common ?
It is when the passage of food, fluid + gas through intestine is backed (surgical emergency)
- SBO more common than LBO
289
what can bowel obstruction lead to ? how does it cause fluid loss ?
obstruction => build up of gas + faecal matter proximal to obstruction => back pressure => vomiting + intestinal dilation (proximal)
- GI tract secrets fluid that is later absurd in colon but obstruction => fluid loss => hypovolaemia + chock (higher up the intestine => greater the fluid loss)
- oedema => bacterial colonisation => necrosis => perforation => peristalsis
290
what does loud bowel sounds associated with BO mean ?
if dynamic: peristalsis tries to move blockage => push harder => loud bowel sounds
291
what can cause bowel obstruction ? big three ?
big three
- adhesions (SB)
- hernias (SB)
- tumours (LB)
also: volvulus, diverticular disease, strictures (secondary to crohns)
292
what are adhesions ? where does it usually affect ?
pieces of scar tissue that bind abdo contents together => kinking + squeezing => obstruction (usually SB)
293
What is closed loop obstruction ?
it is where there are two points of obstruction along the bowel => no open end => closed loop section continues to expand => ischaemia + perforation
294
BO RF ? (6)
- prev abdo surgery
- malrotation
- crohns disease
- hernia
- appendicitis
- intensital malignancy
295
BO presentation ? variation between small and large bowel ?
- vomiting (green bilious)
- abdo distention
- abdo pain (colic)
- constipation (absolute) + lack of flatulance
- tinkling bowel sounds
- bloating
Small bowel: more acute and colicky because small bowel has v good blood supply
Large bowel: more vague symptoms, usually constipation
296
BO OE signs ?
- palpation: abdominal mass, hernias, tenderness
- rectal exam: impacted faeces
297
BO Ix ? diagnostic ?
- first line: abdo x ray (distended loops of bowel)
- contrast abdo CT exam (diagnostic)
298
what would abg show in BO ?
metabolic alkalosis (due to vomiting)
raised lactate (if bowel ischaemia)
299
BO Mx ?
(A-E) drip and suck
- NBM, IV fluids, NG tube with free drainage
- gastro graftin: hyperosmolar agent => causes bowel wall oedema to settle
- surgical intervention: adhesilysis, hernia repair, emergency resection of tumour
300
what is ileus ?
dynamic bowel/paralytic ileus: functional BO from reduced bowel motility
301
ileus causes ?
often just fowling surgery, usually reolsvess with supportive care within few days
- injury to bowel, inflam/infection, electrolyte imbalances
302
ileus mx ?
- NBM
- NG (if vomiting)
- IV fluids (prevent dehydration + replace electrolytes)
- mobilisation
- TPN
303
what is volvulus ?
when bowel twists on its mesentery (=> closed loop BO)
304
what does coffee bean sign on AXR indicate ? how does this affect ?
suggest sigmoid volvulus: affects older patient caused by chronic constipation (due to lengthening of the mesentery)
305
volvulus mx ?
same as BO - drip + suck
- NBM, NG tubes, fluids + conservative Mx
306
most common cause of LBO ?
colon cancer
307
most common cause of SBO ?
adhesions
308
what should be known to the patient about taking iron supplements while on levothyroxine ?
Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart
309
what is the treatment in life threatening c diff infection ?
In life-threatening C. difficile infection treatment is with ORAL vancomycin and IV metronidazole
310
most common etiological type of bowel cancer ?
adenocarcinoma
311
bowel cancer RF ? (9)
- fam history of bowel cancer
- familial adenomatous polyposis (autosomal dominant)
- Lynch syndrome
- IBD
- increasing age
- diet (high red meat, low fibre)
- obesity + sedentary lifestlye
- smoking
- alcohol
312
bowel cancer presentation ? (6)
- change in bowel habit (non specific)
- unexplained weight loss
- rectal bleeding
abdo pain
- iron deficiency anaemia
- abdo/rectal mass (mass PR in around 60%)
- could present with BO
313
when is a 2 week wait for bowel cancer indicated ? include the ages
2WW
> 40 with abdo pain + unexplained weight loss
> 50 with unexplained rectal bleeding
> 60 change in bowel habit or iron deficiency anaemia
314
what is FIT testing and when is it done ?
faecal immunochemical testing (FIT): look for amount of haemoglobin in stool
- used when don't qualify 2WW criteria, or for screening
315
when and what is the bowel cancer screening ?
FIT test
- all M+F 60-74 every 2 yrs
- if positive then => colonoscopy
316
investigations for bowel cancer ? gold standard Ix ?
- colonoscopy (gold standard)
- CT colonography
- Staging CT scan (TAP)
317
what is used to classify bowel cancer ?
TNM staging
(the old one was dukes classification)
318
Gastric cancer RF ? (4)
- pernicious anaemia
- h.pylori
- smoking
- pickled food
319
stomach cancer presentation ? (7)
- non specific
- dyspepsia
- weight loss
- vomiting
- dysphagia
- anaemia
- virvows node
320
stomach cancer Ix ?
gastroscopy
321
what marker is associated with pancreatic cancer ?
CA19-9
- most specific + sensitive for pancreatic adenocarcinoma
322
pancreatic cancer presentation ? (3)
- painless jaundice
- palpable gallbladder
- weight loss
323
patient presents in AF with abdo pain. what should you consider ?
consider mesenteric ischaemia
324
what are the 3 types of bowel ischaemia ?
- acute mesenteric ischaemia
- chronic mesenteric ischaemi
- chronic colonic ischaemia
(caused by lack of blood flow through mesenteric vessels)
325
describe the blood supply for the foregut ? midgut ? and handout ?
- foregut: coeliac artery
- midgut: superior mesenteric artery
- hindgut: inferior mesenteric artery
326
what is chronic mesenteric ischaemia ?
intestinal angina (result of borrowing of mesenteric blood vessels- often due to atherosclerosis)
327
chronic mesenteric ischaemia px ?
triad:
- central colicky abdo pain after eating
- weight loss (due to food avoidance)
- abdominal bruit (on auscultation)
328
how is chronic mesenteric ischaemia Dx ?
CT angiography
329
chronic mesenteric ischaemia Mx ?
- stop smoking
- secondary prevention (statins + antiplatelets)
- revascularisation, as there is risk of acute infarction (percutaneous mesenteric artery standing, open surgery)
330
what is acute mesenteric ischemia ? where is usually affected ?
- rapid blockage to usually superior mesenteric artery (usually thrombus)
- sichaemia => necrosis of bowel tissue + perforation
331
what is a big risk factor for acute mesenteric ischaemia ?
AF (thrombus for LA)
332
acute mesenteric ischaemia - what investigation ? what would blood gas show ?
Dx: contrast CT
- metabolic acidosis, raised lactate
333
acute mesenteric ischaemia Mx ? prognosis ?
- surgery (to remove necrotic bowel and remove/bypass the thrombus)
- prognosis: v high mortality (>50%)
334
what is acute pancreatitis ? chronic ?
- acute presents with rapid onset of inflammation + symptoms, then normal function returns
- chronic: long term inflammation + symptoms => progressive + permanent pancreatic deterioration
335
acute pancreatitis causes ? most common ? (3)
I GET SMASHED
- Iatrogenic
- Gallstones (*)
- Ethanol (*)
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion venom
- Hyperlipidamiea
- ERCP (*)
- Drugs
*: key causes
336
explain how gallstones causes pancreatitis ?
blocks ampulla of Vater => blocks bile pancreatic juice flow to duodenum => bile reflux => inflam of pancreas 9women, older patients)
337
acute pancreatitis presentation ?
- severe epigastric apin
- radiating to the back
- vomiting
- abdo tenderness
- systemically unwell (low grade fever, tachycardia)
- anorexia
338
how is acute pancreatitis diagnosed ?
- clinical diagnosis
- amylase levels (beyond 3 times normal range)
339
what score is used to assess severity of pancreatitis ? explain the components ?
glasgow score (PANCREAS)
- Pa02 (low)
- Age (>55)
- Neutrophils (high WBC)
- calcium (low)
- uRea (high)
- Enzymes (high high LDH, high AST/ALT)
- Albumin (low)
- Sugar (high glucose)
one point for each
340
acute pancreatitis Mx ?
- IV fluids
- NBM
- analgesia (ibuprofen)
- treat underlying cause (treamtne of gallstones, stop alcohol, abx - if specific infection)
(most patients improve within 3-7 days)
-
341
acute pancreatitis complications ? (4)
- necrosis of pancreas
- infection
- abscess formation
- chronic pancreatitis
342
what is diverticulum ? diverticulitis ? what is diverticular disease ?
a diverticulum is a pouch or pocket in bowel wall => diverticulitis + causes symptoms => diverticular disease (implies there are sx)
343
diverticular disease pathophys ? can lead to what ?
points where muscle layer penetrated by blood vessels => area of weakness (no covered by tense col indeed to let blood vessels through)
low fibre diet => colon must contact harder to push faecal matter => push mucosa through smooth muscle holes
- can rupture => faecal content in peritoneal cavity => peritonitis
344
diverticular disease RF ?
- common with increasing age
- low fibre diet
- NSAIDs
345
diverticular disease presentation ?
- altered bowel habit + L sided colic relieved by defectation
346
diverticular disease Ix ?
- colonoscopy
- CT scan (often incidental finding)
347
diverticular disease Mx ?
Mx not necessary if asymptomatic
- increase fibre in diet
analgesia (not NSAIDs tho)
348
what is acute diverticulitis ?
inflam in diverticular (may be caused by infection)
349
acute diverticulitis presentation ?
similar to diverticular disease (L sided colic received by defecation) + pyrexia
- diarrhoea
- N+V
- rectal bleeding
- palpable abdo mass
- raised CRP
- raised WBC
350
acute diverticulitis Mx ?
- oral co-amoxiclav
- analgesia (avoid NSAIDs)
- avoid solid food (only liquids until sx improve)
- if severe sx: urgent CT + surgery
351
what are haemorrhoids ?
they are enlarged anal vascular cushions (often associated with constipation + straining)
- can be prolapsed or not
352
haemorrhoids RF ?
- constipation
- straining
- pregnancy
- obesity
- increasing age
- weight lifting
353
haemorrhoids px ?
- asymptomattic
- painless bright red bleeding
- blood not mixed with stool
- anaemia
354
haemorrhoids o/e ?
- may appear (prolapse) if patient asked to "bear down" on inspection
355
in all rectal bleeding presentations, what 3 things should you do ?
- abdo exam (to roue out other diseases)
- PR exam (prolapsing piles are obvious, internal haemorrhoids not palpable)
- colonoscopy/flexible sigmoidoscopy to exclude proximal pathology (if >50 yrs)
356
haemorrhoids Mx ?
- reduce swelling
- prevent constipation (increase fibre + fluid)
- topical analgesics + stool softener (bulk forming)
- rubber band ligation
357
what is an anal fissure ? presentation ?
- split in the skin of the distal anal canal => pain on defecation + rectal bleeding
- severe pain (like passing broken glass), can last 1-2 hrs
- small amount of fresh blood is often passed on the stool
358
anal fisure Ix ?
clinical dignosis
- hx: mostly due to hard faeces
359
anal fissure Mx ?
- high fibre diet
- adequate fluid intake
- topical analgesia
- topical glycerol trinitrate
