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Gastroenterology 🚽 Flashcards

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1
Q

What are the risk factors for constipation?

A

Increasing age
Inactivity
Low fibre diet
Medications
Low calorie intake
Surgical procedures
Female

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2
Q

What are the symptoms of constipation?

A

Passing stools < 3 times per week
Difficulty passing stools
Sensation of incomplete evacuation - tenesmus
Abdominal distension
Abdominal mass in left or right lower quadrants
Haemorrhoids

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3
Q

What are the red flag features of constipation?

A

Weight loss
Dark stools
Abdominal mass
Loss of appetite

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4
Q

What investigations would you perform for a constipated patient?

A

DRE
FBC
U&E
TFTs
Abdominal XR
Colonoscopy
Barium enema

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5
Q

What are the causes of constipation?

A

Dietary - low calorie, low fibre
Behavioural - avoidance of defecation
Electrolyte disturbance
Drugs - opiates, calcium channel blockers, antipsychotics
Neurological disorders
Endocrine disorders
Colon disease - cancer, stricture
Anal disease - fissure

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6
Q

What is the initial management of constipation?

A

Lifestyle advice
- Increase fibre
- Increase calorie intake
- Increase fluid intake
- Regular exercise

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7
Q

What is the initial pharmacological management of constipation?

A

Bulk laxative
- ispaghula husk
- Methylcellulose

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8
Q

What other medications can be used to manage constipation?

A

Stool softeners - docusate sodium
Osmotic laxatives - lactulose, macrogol
Stimulant laxatives - senna

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9
Q

What other management options are there for constipation?

A

Enema if stool is impacted
Suppositories

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10
Q

What type of stools does constipation usually present with?

A

Type 1 or 2
Can be type 7 if there is overflow diarrhoea

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11
Q

What is coeliac disease?

A

An autoimmune condition that causes inflammation in the small intestine

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12
Q

What is the gene association of coeliac disease?

A

HLA-DQ2 gene

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13
Q

What are the gastrointestinal symptoms of coeliac disease?

A

Abdominal pain
Bloating
Steatorrhoea
Nausea and vomiting
Diarrhoea
Constipation

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14
Q

What are the systemic symptoms of coeliac disease?

A

Failure to thrive in children
Fatigue
Weight loss
Dermatitis herpatiformis
Severe or persistent mouth ulcers

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15
Q

What autoantibodies for coeliac disease exist?

A

Anti-TTG (tissue transglutaminase)
EMA - endomysial antibodies

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16
Q

What kind of antibodies are anti-TTG and EMA?

A

IgA

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17
Q

What is the first line investigation of coeliac disease?

A

Anti-TTG IgA

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18
Q

What else should be tested for in coeliac disease that could impact investigation results?

A

Total IgA level - IgG levels of anti-TTG can be used

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19
Q

What is the second line investigation of coeliac disease?

A

Anti-EMA

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20
Q

What is the definitive investigation of coeliac disease?

A

Small bowel biopsy

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21
Q

What would a small bowel biopsy show in a coeliac patient?

A

Crypt hyperplasia
Vilious atrophy
Lamina propria infiltrated with lymphocytes
Increase in intraepithelial lymphocytes

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22
Q

What is the definitive management of coeliac disease?

A

Life-long gluten free diet

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23
Q

What conditions is coeliac disease associated with?

A

Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary sclerosis
Primary sclerosing cholangitis

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24
Q

What type of malignancy is associated with coeliac disease?

A

Enteropathy associated T cell lymphoma

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25
What is the management of coeliac disease?
A life-long gluten free diet
26
What are the complications of coeliac disease?
Anaemia Iron, folate and vitamin B12 deficiency Hyposplenism Osteoporosis Lactose intolerance Subfertility
27
What is dermatitis herpetiformis?
An autoimmune skin disorder linked to coeliac disease
28
What is the presentation of dermatitis herpetiformis?
Itchy, painful blistering, or papular rash Commonly found at the buttocks and elbows
29
What are haemorrhoids?
Enlarged anal vascular cushions
30
What are the risk factors for haemorrhoids?
Straining Constipation Pregnancy Obesity Increased age Increased intra-abdominal pressure
31
What is an anal cushion?
Submucosal tissue in the anus that contains connections between arteries and veins, making it very vascular
32
What is the classification of haemorrhoids?
Class 1 - no prolapse Class 2 - prolapse on straining and return on relaxation Class 3 - prolapse on straining with no return on relaxation, but that can be pushed back Class 4 - prolapsed permenantly
33
What is the presentation of haemorrhoids?
Bright red bleeding upon wiping or after opening bowels Blood not mixed with stool Sore/itchy anus Intermittent protrusion
34
What are the differentials of haemorrhoids?
Anal fissure Crohn's disease Ulcerative colitis Bowel cancer Anal fistula Diverticulosis
35
What is the first line investigation of haemorrhoids?
Inspection and PR exam
36
What other investigations may be performed in the diagnosis of haemorrhoids?
FBC Colonoscopy (to exclude other conditions)
37
What is the management of haemorrhoids?
Topical treatments - anusol Rubber band ligation Sclerotherapy Surgical treatment - haemorrhoidal artery ligation or haemorrhoidectomy
38
What is a thrombosed haemorrhoid?
Where there is strangulation at the base of the haemorrhoid which causes thrombosis in the haemorrhoid
39
What lifestyle advice should be given to someone with haemorrhoids?
More dietary fibre Good fluid intake Using laxatives where required Avoid straining
40
What is a direct inguinal hernia?
A hernia that occurs due to a weakness in the abdominal wall
41
Where does a direct inguinal hernia protude through?
Hasselbach's triangle
42
What are the borders of hasselbach's triangle?
Lateral edge of rectus abdominus Inferior epigastric vessels (superiorly) Inguinal ligament (inferiorly)
43
What is an indirect inguinal hernia?
An inguinal hernia that protrudes through the deep inguinal ring
44
What populations are indirect and direct hernias typically seen in?
Indirect - young males, as they are typically congenital Direct - older males, due to abdominal wall laxity, or conditions that increase intra-abdominal pressure
45
What are the risk factors for developing an inguinal hernia?
Male Increasing age Raised intra-abdominal pressure (chronic cough, chronic constipation, heavy lifting) High BMI
46
What are the features of an inguinal hernia?
Groin swelling Pain Palpable mass
47
What features should be assessed on examination of a groin lump?
Cough impulse Location Reducibility If in the scrotum - is it separate from the testes
48
How can a direct hernia be differentiated from an indirect hernia?
A direct hernia is indicated by protusion despite occlusion of the deep inguinal ring If there is no protusion on occlusion of the deep inguinal ring, it is likely an indirect hernia
49
Where is the deep inguinal ring found?
At the midpoint of the inguinal ligament (between ASIS and pubic symphysis)
50
What investiagations may be performed for a suspected inguinal hernia?
WCC - may be raised if there is strangulation Blood gas - raised lactate Ultrasound (first choice of imaging) CT Abdominal X-ray if obstruction suspected
51
Where would a femoral hernia be located?
Groin - below and lateral to the pubic tubercle
52
What is the management of a strangulated hernia?
Urgent surgical repair IV antibiotics
53
What are the features of a femoral hernia?
Located inferolateral to the pubic tubercle Non-reducible Cough impulse is absent
54
What are the differentials of a femoral hernia?
Lymphadenopathy Abscess Femoral artery aneurysm Hydrocele Lipoma Inguinal hernia
55
What are the management of a femoral hernia?
Urgent surgical repair (due to risk of strangulation)
56
What is the management of an inguinal hernia?
All inguinal hernias should be referred for surgical repair
57
What is the management of a strangulated hernia?
Strangulated hernias require immediate surgical repair
58
What are the causes of acute pancreatitis?
I GET SMASHED I - iatrogenic G - gallstones E - ethanol T - trauma S - scorpion/spider bites M - mumps A - autoimmune S - steroids H - hypercalcaemia, hyperlipidaemia E - ERCP D - drugs
59
What drugs increase the risk of pancreatitis?
Valproate Azathioprine Thiazide diuretics Tetracyclines Mesalazine Oestrogen Sitagliptin
60
What are the risk factors for acute pancreatitis?
Increasing age Afro-carribbean ethnicity Obesity Type 2 diabetes Family history
61
What are the symptoms of acute pancreatitis?
Severe RUQ, LUQ or epigastric pain Pain that radiates to the back Nausea and vomiting Anorexia Steatorrhoea (seen in acute on chronic) Poor urinary output
62
What are the clinical signs of acute pancreatitis?
Abdominal distension Guarding Tachycardic Hypotension Cullen's sign Grey Turner's sign Fox's sign
63
What is cullen's sign?
Bruising around the umbilicus, that indicates periumbilical bleeding secondary to intraperitoneal haemorrhage
64
What is Grey Turner's sign?
Bruising or discoloration of the flanks - indicates a retroperitoneal bleed
65
What is Fox's sign?
Bleeding over the inguinal ligament secondary to retroperitoneal haemorrhage
66
What is the diagnostic criteria for acute pancreatitis?
2 out of 3 of the following features: - Clinical features consistent with pancreatitis - Elevation of serum amylase or lipase - Radiological features consistent with pancreatitis e.g inflammation on CT
67
What are the primary diagnostic investigations for acute pancreatitis?
Serum amylase (3 times upper limit of normal) Serum lipase - more specific
68
What investigations may be used to score severity of acute pancreatitis?
FBC U&E LFTs (gallstone related pancreatitis) ABG Serum glucose Serum LDH Serum calcium
69
What is the Glasgow score?
A score to determine severity of acute pancreatitis - If a patient has 3 or more points within the first 48 hours they should be considered for high-dependency care
70
What are the components of the Glasgow score?
pO2 < 8 Age > 55 WCC > 15 Calcium < 2 Urea > 16 AST > 200 Albumin < 32 Blood glucose > 10
71
What is the first line management of acute pancreatitis?
IV fluid resuscitation Catheterisation Oxygen supplementation Oral or enteral feeding
72
What is the specific treatment of gallstone pancreatitis?
ERCP Cholecystectomy
73
What are the complications of acute pancreatitis?
Peripancreatic fluid collection Pancreatic pseudocyst Pancreatic abscess Haemorrhage Necrotising pancreatitis Chronic pancreatitis Hypocalcaemia Hypovolaemic shock
74
How are the types of viral hepatitis transmitted?
A - Faecal-oral B - blood/bodily fluids C - blood D - with hepatitis B E - faecal-oral route
75
What are the other causes of hepatitis?
Alcoholic hepatitis Non-alcoholic hepatitis Autoimmune hepatitis Drug induced hepatitis
76
What are the clinical features of acute viral hepatitis?
Flu-like symptoms Jaundice Anorexia Nausea and vomiting Abdominal pain
77
What are the clinical signs of acute viral hepatitis?
Fever Hepatomegaly Splenomegaly Ascites
78
What LFT results would be seen in viral hepatitis?
High ALT and AST Raised ALP (but proportionally less of a rise compared to AST and ALT) Raised transaminases Raised bilirubin
79
What investigation is diagnostic of acute viral hepatitis A?
IgM antibodies to hepatitis A
80
What is the management of hepatitis A?
Supportive management - IV fluids - Analgesia Vaccination
81
What are the complications of hepatitis A?
Fulminant hepatitis (acute liver failure) Relapsing hepatitis
82
What are the risk factors for hepatitis B?
Unprotected sex Sharing needles Healthcare work
83
What does hepatitis B surface antigen (HBsAg) indicate?
Indicates current infection - If it has been present for more than 6 months - suggests chronic infection
84
What does hepatitis B e antigen (HBeAg) indicate?
Indicates high viral load Predictive of progression to chronic hepatitis
85
What do antibodies to hepatitis B core antigen (anti-HBc) indicate?
Indicated current or previous hepatitis B infection - IgM - infection within last 6 months - IgG - infection more than 6 months ago
86
What do antibodies to hepatitis B surface antigen (anti-HBs) indicate?
Indicates immunity to hepatitis B (may be due to vaccination or previous infection)
87
What is the management of hepatitis B?
Supportive management (IV fluids, analgesia) Vaccination Anti-virals - tenofovir or entecavir Pegylated interferon
88
What are the complications of chronic hepatitis B?
Chronic liver disease Liver cirrhosis Hepatocellular carcinoma
89
What are the risk factors for hepatitis C?
Sharing needles Healthcare work Unprotected sex (less common than hepatitis B)
90
What investigations are used to diagnose hepatitis C?
Hepatitis C antibody - screening Hepatitis C RNA testing - diagnostic
91
What is the management of hepatitis C?
Antivirals (8 to 12 weeks) - Telaprevir plus ribavarin - Sofosbuvir plus ribavirin - Simeprevir plus ribavarin
92
What are the complications of hepatitis C?
Chronic hepatitis Cirrhosis Hepatocellular carcinoma
93
What investigations are used in the diagnosis of hepatitis E?
LFTs - elevated ALT/AST, bilirubin, ALP and gamma-GT Hepatitis E IgM antibodies Viral PCR
94
What is the management of hepatitis E?
Supportive management - IV fluids - Analgesia
95
What antibodies are associated with autoimmune hepatitis?
ANA Anti-smooth muscle antibody (ASMA) Anti-SLA/LP (anti-soluble liver antigen/liver-pancrease antibody) Anti-LC1 (anti-liver cytosol 1 antibody)
96
What are the types of autoimmune hepatitis?
Type 1 - typically affects women in 40s/50s, presents after menopause and is less acute. Type 2 - usually affects young people, more commonly girls. Presents with acute hepatitis
97
What antibodies are associated with type 1 AIH?
ANA ASMA Anti-SLA/LP
98
What antibodies are associated with type 2 AIH?
Anti-LKM1 Anti-LC1
99
What HLA genotypes are associated with type 1 AIH?
DR3 and DR4
100
What HLA genotypes are associated with type 2 AIH?
DQB1 and DRB1
101
What are the symptoms of autoimmune hepatitis?
Fatigue Arthralgia Weight loss Nausea Amenhorrhoea
102
What are the clinical signs of autoimmune hepatitis?
Jaundice Gynaecomastia Splenomegaly Ascites Variceal bleed Encephalopathy Spider telangiectasia
103
What investigations are used to diagnose autoimmune hepatitis?
LFTs - Raised ALT and AST - Minimal change in ALP Raised IgG Liver biopsy - interface hepatitis seen Viral screen - exclude viral hepatitis Autoimmune screen
104
What is the management of autoimmune hepatitis?
First line - prednisolone and azathioprine Hepatitis A and B vaccines Second line - transplantation
105
What are the complications of autoimmune hepatitis?
Cirrhosis Osteoporosis Cushing's syndrome Hepatocellular carcinoma
106
What are the types of oesphageal cancer?
Adenocarcinoma Squamous cell carcinoma
107
What is the pathophysiology of oesophageal adenocarcinoma?
Most commonly arises from Barret's oesophagus
108
Where does oesophageal carcinoma most commonly occur?
In the lower third of the oesophagus (near the gasto-oesophageal junction)
109
What are the risk factors for oesphageal cancer?
Barrett's oesphagus Obesity Smoking Alcohol Achalasia
110
What is the presentation of oesophageal cancer?
Progressive dysphasia Regurgitation Odynophagia (painful swallowing) Weight loss Anorexia Hoarseness of voice Vomiting Lymphadenopathy Vocal cord paralaysis Melaena on DRE
111
Which patients should be referred for an urgent upper GI endoscopy?
Dysphagia OR > 55 years with weight loss and one of: - Epigastric pain - Reflux - Dyspepsia
112
What is the first line investigation for oesophageal cancer?
Upper GI endoscopy and biopsy
113
What investigations are used to stage oesophageal cancer?
CT chest, abdomen and pelvis (first line staging) Endoscopic ultrasound Staging laparoscopy PET CT HER2 testing
114
What is the management of oesophageal adenocarcinoma?
Surgical resection (only for patients with no metastatic disease) - Endoscopic mucosal resection - for very early lesions or barrett's oesophagus - Ivor Lewis oesophagectomy - most common procedure - McKeown oesophagectomy - performed for proximal tumours Chemotherapy - offered to all patients pre-operatively
115
What is the management of localised oesophageal squamous cell carcinoma?
Radical chemotherapy
116
What are the complications of oesophageal cancer?
Aspiration pneumonia Tracheo-oesophageal or broncho-oesophageal fistula Metastasis
117
What are the complications of oesophagectomy?
Anastomotic leak Reccurent laryngeal nerve injury Delayed gastric emptying
118
What type of oesophageal cancer does achalasia increase the risk of?
Squamous cell carcinoma
119
What is an anal fissure?
Small tears or cuts in the lining of the anal canal
120
What are the causes of anal fissure?
Primary or idiopathic - Associated with chronic constipation and straining Secondary - IBD - Malignancy - Trauma - STIs
121
What are the risk factors for anal fissures?
Chronic constipation Straining during bowel movements Persistent diarrhoea Passing hard or large stool Anal sex IBD Pregnancy and childbirth
122
What are the features of an anal fissure?
Severe pain during and after bowel movements Bright red blood on toilet paper Itching Visible tear in lining of anus Tenderness on rectal exam
123
What is the first line management of an anal fissure?
Dietary advice - high fibre diet Bulk forming laxatives e.g ispaghula husk GTN ointment - relaxes anal sphincter and reduced pressure on fissure Topical anaesthetics
124
What is the second line management of anal fissure?
Laternal internal sphincterotomy - for fissures that don't respond to conservative management
125
What is the most common cause of chronic pancreatitis?
Alcohol
126
What are the causes of chronic pancreatitis?
Alcohol Cystic fibrosis Haemochromatosis Ductal obstruction - Tumours - Stones Autoimmune pancreatitis
127
What are the symptoms of chronic pancreatitis?
Epigastric pain - radiates to back, improved by leaning forwards Steatorrhoea and diarrhoea Nausea and vomiting Weight loss Fatigue Features of diabetes - Polyuria - Polydipsia
128
What are the clinical signs of chronic pancreatitis?
Epigastric tenderness Signs of liver disease Skin nodules
129
What investigations are used in the diagnosis of chronic pancreatitis?
First line - CT abdomen LFTs - will be abnormal if co-existent liver disease HbA1c - reduced endocrine dysfunction Faecal elastase IgG4 - associated with autoimmune chronic pancreatitis
130
What might a CT abdomen show in chronic pancreatitis?
Pancreatic calcifications Pancreatic atrophy Duct dilatation
131
What is the first line management of chronic pancreatitis?
Lifestyle modifications Diet - low fat, high calorie diet Fat soluble vitamin supplementation Analgesia Pancreatic enzyme replacement - Creon
132
What is the second line management of chronic pancreatitis?
Endoscopic stenting Coeliac plexus nerve blocks - pain management Drainage of pseudocysts
133
What are the complications of chronic pancreatitis?
Malabsorption Duct obstruction Pseudocysts Diabetes mellitus Pancreatic cancer
134
What is a diverticulum?
A pouch or pocket in the bowel wall, usually ranging in size from 0.5-1cm
135
What is diverticulosis?
Presence of diverticula without inflammation or infection (in an asymptomatic patient)
136
What is diverticular disease?
Where diverticula cause symptoms, without inflammation and infection
137
What is diverticulitis?
Where diverticula become inflamed and infected
138
What are the risk factors for diverticulitis?
Low fibre diet Obesity NSAIDs Smoking
139
What is the presentation of acute diverticulitis?
Pain in the left iliac fossa Fever Diarrhoea or constipation Nausea and vomiting Rectal bleeding Left iliac fossa mass (if abscess has formed) Rigidity, guarding, rebound or percussion tenderness
140
What is the hinchey classification of diverticulitis?
Stage 1A - phlegmon (localised area of inflammation) Stage 1B - pericolic or mesenteric abscess Stage 2 - pelvic abscess Stage 3 - purulent peritonitis Stage 4 - faecal peritonitis
141
What investigations are used in the diagnosis of diverticulitis?
FBC - anaemia, leukocytosis, neutrophilia U&Es - pre-renal AKI CRP - elevated VBG - raised lactate if significant bleed Group and save Blood cultures
142
What is the investigation of choice in acute diverticulitis?
CT abdo/pelvis with contrast - Would show thickened bowel wall
143
What is the management of mild diverticulitis?
Analgesia - avoid NSAIDs and opiates Oral co-amoxiclav for 5 days (cefalexin with metronidazole if penicillin allergic) Liquid diet
144
What is the management of severe diverticulitis?
IV fluids and analgesia IV antibiotics - co-amoxiclav or cefuroxime with metronidazole if penicillin allergic Blood products may be needed if acute PR bleeding Surgery if bleeding is not controlled or perforation present
145
What are the complications of diverticulitis?
Fistulae Abscess Perforation Peritonitis Strictures Obstruction
146
What is appendicitis?
Acute inflammation of the appendix - a small thin tube arising from the caecum
147
What is the epidemiology of appendicitis?
Acute appendicitis most commonly occurs between ages 10 and 20
148
What is the aetiology of appendicitis?
Pathogens can get trapped at the point where the appendix meets the bowel - this causes infection and inflammation. This can proceed to gangrene and rupture
149
What is the presentation of appendicitis?
Loss of appetite Nausea and vomiting Low grade fever Abdominal guarding Abdominal pain - periumbilical pain that moves to the RIF Rovsing's sign - palpation of LIF causes tenderness in RIF Rebound tenderness
150
What investigations can be performed to diagnose appendicitis?
FBC CRP U&Es Group and save Abdominal ultrasound - exclused ovarian and gynae pathology Contrast-enhanced abominal CT - first diagnostic test in adults
151
What are the differential diagnoses of appendicitis?
Ectopic pregnancy Ovarian cysts Meckel's diverticulum Mesenteric adenitis Gastroenteritis Intussusception UTI
152
What is the definitive management of appendicitis?
Laparoscopic appendectomy (with prophylactic antibiotics before surgery)
153
What other treatment options are there for appendicitis?
Supportive treatment - Nil by mouth if being considered for surgery - IV maintenance fluids - Analgesia
154
What are the complications of appendicitis?
Perforation of appendix Peritonitis Surgical wound infection Abscess on appendix
155
What is the initial management of appendicitis?
Fluids Analgesia Antiemetics Pre-operative antibiotics
156
What are the stages of alcoholic liver disease?
Alcoholic fatty liver Alcoholic hepatitis Alcoholic liver cirrhosis
157
What are the complications of chronic alcohol consumption?
Alcohol related liver disease Cirrhosis Hepatocellular carcinoma Alcohol dependence and withdrawal Wernicke-Korsakoff syndrome Pancreatitis Increased risk of cardiovascular disease Increased risk of cancer
158
What is the symptoms of alcoholic liver disease?
Malaise Weakness Weight loss RUQ pain Pruritis Easy bruising
159
What are the clinical signs of alcoholic liver disease?
Palmar erythema Dupuytren's contractures Jaundice Ascites Spider naevia Confusion Hepatosplenomegaly Caput medusae
160
What is the CAGE questionnaire?
C - have you ever felt you needed to cut down on your drinking? A - have people annoyed you by criticising your drinking G - have you ever felt guilty about drinking? E - have you ever felt you needed a drink first thing in the morning?
161
What blood results may suggest alcoholic liver disease?
Raised MCV Raised ALT and AST AST:ALT ratio above 2 FBC - macrocytic anaemia Folate deficiency Deranged clotting Raised bilirubin in cirrhosis Low albumin Deranged U&Es in hepatorenal syndrome
162
What imaging can be used in the diagnosis of alcoholic liver disease?
Liver ultrasound Transient elastography - can be used to assess elasticity of liver and determine degree of fibrosis Endoscopy - assess for oesophageal varcies CT and MRI Liver biopsy - can confirm diagnosis
163
What is the general management of alcoholic liver disease?
Alcohol cessation and detoxification regime Weight loss Smoking cessation Nutritional supplementation Corticosteroids- prednisolone (severe alcoholic hepatitis) Liver transplant
164
What are the complications of alcoholic liver disease?
Alcohol withdrawal syndrome Ascites Hepatic encephalopathy Oesophageal varices Hepatocellular carcinoma
165
What is the most common site of colorectal cancer?
Rectum
166
What are the risk factors for colorectal cancer?
Family history of bowel cancer IBD Increased age Diet Obesity and sedentary lifestyle Smoking Alcohol
167
What genetic syndromes can predispose someone to colorectal cancer?
FAP - familial adenomatous polyposis HNPCC - hereditary nonpolyposis colorectal cancer (also known as Lynch syndrome)
168
What is the most common hereditary cause of colorectal cancer?
Lynch syndrome
169
What cancers is Lynch syndrome also associated with?
Endometrial cancer Pancreatic cancer
170
What is the presentation of colorectal cancer?
Progressive change in bowel habit Abdominal pain Unexplained weight loss Rectal bleeding Iron deficiency anaemia Abdominal or rectal mass
171
What are the criteria for a 2 week wait referral?
Over 40 years with abdominal pain and unexplained weight loss Over 50 years with unexplained rectal bleeding Over 60 years with a change in bowel habit or iron deficiency anaemia
172
When should a patient be offered a FIT test?
Any patient with: - An abdominal mass - Change in bowel habit - Iron deficiency anaemia Aged over 40 with unexplained weight loss and abdominal pain Aged under 50 with rectal bleeding and either abdo pain or weight loss Age over 50 with: - Rectal bleeding - Abdominal pain - Weight loss Aged over 60 with anaemia
173
What screening is offered for colorectal cancer?
All patients aged 60 to 74 are sent a FIT test in the post every 2 years
174
What is a FIT test?
Faecal immunochemical test - uses antibodies to detect and quantify human blood in a stool sample
175
What is the gold standard investigation for colorectal cancer?
Colonoscopy
176
What other investigations can be useful in the diagnosis of colorectal cancer?
FBC - iron deficiency anaemia FIT test U&Es LFTs Sigmoidoscopy - if only feature is rectal bleeding CT colonography Staging CT (CT thorax, abdo, pelvis) CEA (carcinoembryonic antigen) - tumour marker
177
What is Dukes' classification?
Dukes A - confined to mucosa and part of the muscle of the bowel wall Dukes B - extending through the muscle of the bowel wall Dukes C - lymph node involvement Dukes D - metastatic disease
178
What is the TNM staging of colorectal cancer?
T1 - submucosa involvement T2 - involvement of the muscularis propria T3 - involvement of the subserosa and serosa T4 - spread through the serosa (4a) and reaching other tissues/organs (4b) N0 - no nodal spread N1 - spread to 1-3 nodes N2 - spread to more than 3 nodes M0 - no metastasis M1 - metastasis
179
What are the management options for colorectal cancer?
Surgical resection Chemotherapy Radiotherapy Palliative care
180
What operation for colorectal cancer are there?
Right hemicoloectomy - removal of caecum, ascending and proximal transverse colon Left hemicoloectomy - removal of distal transverse and descending colon High anterior resection - removal of sigmoid colon Low anterior resection - removal of sigmoid colon and upper rectum Abdomino-perineal resection - removal of rectum and anus (leaves patient with permenant colostomy)
181
What types of cancer are most commonly associated with HNPCC?
Colon cancer (most common association) Endometrial cancer (next most common association)
182
What are the risk factors for cholecystitis?
Gallstones - Fair, fat, female, fertile, forties Crohn's disease Diabetes Systemic illness Dehydration
183
What are the symptoms of cholecystitis?
No jaundice RUQ pain Referred right shoulder tip pain Fever Nausea and vomiting Murphy's sign Abdominal mass
184
What is Murphy's sign?
Palpating the RUQ whilst the patient breathes in deeply causes pain, and the cessation of inspiration
185
Where may gallstones become impacted, causing cholecystitis?
The neck of the gallbladder or the cystic duct
186
What are the initial investigations in the diagnosis of cholecystitis?
Abdominal ultrasound - first line FBC LFTs - derangement suggests obstructing CBD stone U&Es - AKI secondary to infection Inflammatory markers
187
What results are seen on abdominal ultrasound in cholecystitis?
Thickened gallbladder wall (>3mm) Distended gallbladder Stones or sludge in the gallbladder Pericholecystic fluid
188
When is an MRCP used?
When there is a suspected CBD stone, in cases where ultrasound has not detected gallstones but a dilated CBD and/or LFTs are abnormal
189
What is the first line management of cholecystitis?
Conservative management: IV fluids Analgesia IV broad spectrum antibiotics
190
What procedures can be performed in the management of cholecystitis?
ERCP - can be used to remove stones trapped in the CBD Cholecystectomy
191
What are the complications of cholecystitis?
Sepsis Gallbladder empyema Gangrenous gallbladder Perforation
192
What are the most common causes of liver cirrhosis?
Alcohol related liver disease NAFLD Hepatitis B Hepatitis C
193
What are the rarer causes of cirrhosis?
Autoimmune hepatitis Primary biliary cirrhosis Haemochromatosis Wilsons disease Alpha-1 antitrypsin deficiency Cystic fibrosis
194
What medications can cause cirrhosis?
Methotrexate Isoniazid Methyldopa Amiodarone
195
What clinical signs may be seen in cirrhosis?
Cachexia Jaundice Hepatomegaly Splenomegaly due to portal hypertension Spider naevi Palmar erythema Gynaecomastia Bruising due to abnormal clotting Ascites Caput medusae Asterixis
196
What is part of a non-invasive liver screen?
Ultrasound liver Hepatitis B and C serology Autoantibodies Immunoglobulins Caeruloplasmin (Wilson's disease) Alpha-1 antitrypsin levels Ferritin and transferrin saturation
197
What autoantibodies are relevant to liver disease?
Antinuclear antibodies (ANA) Smooth muscle antibodies (SMA) Antimitochondrial antibodies (AMA) - primary biliary cirrhosis Antibodies to liver kidney microsome type 1 (LKM-1)
198
What other blood results might be seen in cirrhosis?
Deranged LFTs - Bilirubin, ALT, AST, ALP Low albumin Increased PTT Thrombocytopenia Hyponatraemia due to fluid retention Alpha-fetoprotein - hepatocellular carcinoma
199
What is the enhanced liver fibrosis test?
First line investigation for assessing cirrhosis in NAFLD. It uses three markers to determine the degree of fibrosis: - 10.51 or above - advanced fibrosis - Under 10.51 - unlikely advanced fibrosis
200
What might an ultrasound show in liver cirrhosis?
Nodularity of the surface of the liver Corkscrew appearance of the hepatic arteries Enlarged portal vein Ascites Splenomegaly
201
What is transient elastography?
High frequency sound waves help to determine the degree of fibrosis to test for cirrhosis. Used in the following patients: - Alcohol related liver disease - Heavy alcohol drinkers - NAFLD and advanced liver cirrhosis on ELF blood test - Hepatitis C - Chronic hepatitis B
202
What is the Child-Pugh score?
Used 5 factors to assess the degree of fibrosis - each is scored on a scale of 1-3 - A - albumin - B - bilirubin - C - clotting - D - dilation - E - encephalopathy
203
What monitoring do patients with cirrhosis have?
MELD score every 6 months Ultrasound and alpha-fetoprotein every 6 months Endoscopy every 3 years
204
What features would suggest the need for liver transplantation?
A - ascites H - hepatic encephalopathy O - oeseophageal varices bleeding Y - yellow (jaundice)
205
What are the complications of liver cirrhosis?
Malnutrition Portal hypertension Oesophageal varices and bleeding varices Ascites Spontaneous bacterial peritonitis Hepatorenal syndrome Hepatic encephalopathy Hepatocellular carcinoma
206
How does portal hypertension occur in cirrhosis?
Liver cirrhosis increases resistance to blood flow in the liver - There is then increased back pressure on the portal system - The back pressure of blood can result in splenomegaly
207
What are the other complications of portal hypertension?
Splenomegaly Oesophageal varices Caput medusae - dilated vessels in the anterior abdominal wall
208
What is the prophylaxis of bleeding of oeseophageal varices?
Non-selective beta blockers - propranolol Variceal band ligation - if beta blockers are contraindicated
209
What is spontaneous bacterial peritonitis?
Infection developing in the ascitic fluid and peritoneal lining, without a clear source of infection
210
What are the presenting features of spontaneous bacterial peritonitis?
Fever Abdominal pain Ileus Hypotension
211
What organisms commonly cause spontaneous bacterial peritonitis?
E. coli Klebsiella pneumoniae
212
What is the management of spontaneous bacterial peritonitis?
Ascitic fluid sample and culture before antibiotics IV broad-spectrum antibiotics - piperacillin with tazobactam
213
What is the pathophysiology of hepatorenal syndrome?
- Portal hypertension causes the portal vessels to release vasodilators - Vasodilation leads to reduced blood pressure in the abdominal blood vessels - Kidneys activate RAAS in response to reduced blood pressure - This leads to vasoconstriction of the renal vessels, and renal hypoperfusion
214
What is hepatic encephalopathy?
Ammonia, which is neurotoxic, is unable to be metabolised into waste products
215
What are the risk factors for hepatic encephalopathy?
Constipation Dehydration Electrolyte disturbance Infection GI bleeding High protein diet
216
What is the management of hepatic encephalopathy?
Lactulose Antibiotics e.g rifaximin, to reduce the number of intestinal bacteria producing ammonia Nutritional support
217
What is acute cholangitis?
Infection and inflammation of the biliary tree
218
What are the causes of cholangitis?
Gallstones in the CBD Infection introduced during ERCP Cholangiocarcinoma Biliary strictures
219
What organisms most commonly cause acute cholangitis?
E. coli Klebsiella Enterococcus
220
What is charcot's triad?
RUQ pain Fever Jaundice
221
What are the clinical signs and symptoms of acute cholangitis?
RUQ abdominal pain Jaundice Fever Pruritis Dark urine and pale stool Confusion Hypotension
222
What is Reynold's pentad?
Charcot's triad + Confusion and hypotension
223
What imaging is used in the diagnosis of acute cholangitis?
Abdominal ultrasound scan - first line CT scan MRCP - gold standard Endoscopic ultrasound
224
What other investigations are useful in the diagnosis of acute cholangitis?
FBC LFTs - obstructive jaundice - ALP > ALT U&Es CRP VBG Blood cultures - before commencing antibiotics
225
What is the initial management of acute cholangitis?
IV antibiotics - broad spectrum with gram-negative and anaerobic cover IV fluids
226
What is the definitive management of acute cholangitis?
ERCP - first line PTC (percutaneous transhepatic cholangiogram)
227
What is PTC?
A drain is inserted radiologically through the skin and liver, into the bile ducts - this drain relieves the immediate obstruction
228
What procedures can be performed during ERCP?
Cholangio-pancreatography - visualising biliary system Sphincterotomy - makes a cut in the sphincter to dilate it and allow stone removal Stone removal Balloon dilatation Biliary stenting Biopsy
229
What is primary sclerosing cholangitis?
An immune mediated chronic liver disease, where the intrahepatic and extrahepatic bile ducts become inflamed, fibrosed and destroyed
230
What condition is primary sclerosing cholangitis associated with?
Ulcerative colitis
231
What are the risk factors for primary sclerosing cholangitis?
Male Aged 30-40 Ulcerative colitis Family history
232
What is the presentation of primary sclerosing cholangitis?
RUQ pain Pruritis Fatigue Jaundice Hepatomegaly Splenomegaly
233
What blood tests are used in the diagnosis of primary sclerosing cholangitis?
ALP Gamma-GT Bilirubin ALT/AST pANCA ANA
234
What is the diagnostic investigation of choice for primary sclerosing cholangitis?
MRCP
235
What is the management of primary sclerosing cholangitis?
Observation and lifestyle optimisation Cholestyramine - relieves pruritis Fat soluble vitamin supplementation Liver transplantation - advanced disease
236
What are the complications of primary sclerosing cholangitis?
Biliary strictures Acute bacterial cholangitis Cholangiocarcinoma Cirrhosis Fat soluble vitamin deficiency Osteoporosis
237
What is primary biliary cholangitis?
An autoimmune condition characterised by granulomatous destruction of the intrahepatic bile ducts - This leads to cholestasis and subsequent leakage of bile into the circulation - The back pressure of bile can lead to liver fibrosis and cirrhosis
238
What conditions are associated with primary biliary cholangitis?
Sjogren's syndrome Raynaud's syndrome Autoimmune thyroid disease Rheumatoid arthritis Systemic sclerosis
239
What is the presentation of primary biliary cholangitis?
Fatigue Pruritis Abdominal pain Jaundice Pale, greasy stools Dark urine Xanthoma and xanthelasma Hepatomegaly
240
What investigations are used in the diagnosis of primary biliary cholangitis?
ALP, GGT, bilirubin - raised Coagulation profile Raised IgM Antibodies: - AMA - ANA - Smooth muscle antibodies
241
What is the first line treatment of primary biliary cholangitis?
Ursodeoxycholic acid Fat soluble vitamin supplementation Cholestyramine
242
What is ursodeoxycholic acid?
A bile acid analogue - Dampens the inflammatory response and improves cholestasis
243
What are the complications of primary biliary cholangitis?
Malabsorption of fat-soluble vitamins Hypercholesterolaemia Liver cirrhosis Hepatocellular carcinoma
244
What are the risk factors for ulcerative colitis?
Family history HLA-B27 Caucasian Non-smoker
245
What are the clinical features of ulcerative colitis?
Diarrhoea Blood and mucus in stool Urgency and tenesmus LLQ pain Weight loss (but more commonly seen in Crohn's) Fatigue
246
What are the risk factors for Crohn's?
Family history HLA-B27 Caucasian Ashkenazi Jewish Smoking
247
What are the features of Crohn's disease?
Diarrhoea Abdominal pain Bloody stools (more common in UC) Weight loss Lethargy Delayed puberty in children
248
What are the differentiating features of Crohn's?
NESTS N - no blood or mucus E - entire GI tract affected S - skip lesions on endoscopy T - terminal ileum most affected and transmural inflammation S - smoking is a risk factor
249
What are the differentiating features of UC?
CLOSEUP C - continuous inflammation L - limited to colon and rectum O - only superficial mucosa affected S - smoking may be protective E - excrete blood and mucus U - use aminosalicylates P - primary sclerosing cholangitis
250
What are the extraintestinal manifestations of IBD?
Erythema nodosum Pyoderma gangrenosum Enteropathic arthritis Episcleritis (Crohn's > UC) Uveitis (UC > Crohn's) Primary sclerosing cholangitis - UC Autoimmune hepatitis - UC
251
What initial investigations are performed for IBD?
Faecal calprotection - raised FBC - leukocytosis in flare LFTs CRP/ESR Anti-TTG - exclude coeliac disease
252
What is the definitive investigation for diagnosis of IBD?
Colonoscopy with multiple intestinal biopsies
253
What will be seen on histology in Crohn's disease?
Transmural inflammation Goblet cells Granulomas
254
What will be seen on histology in ulcerative colitis?
Shallow ulceration Pseudopolyps Crypt abscesses Goblet cell depletion Continuous inflammation
255
How is remission induced in mild to moderate acute ulcerative colitis (proctitis)?
First line - topical aminosalicylate Second line - add oral aminosalicylate Third line - add topical or oral corticosteroid
256
How is remission induced in proctosigmoiditis and left sided UC
First line - topical aminosalicylate Second line - add high dose oral ASA or switch to high dose oral ASA and topical corticosteroid Third line - stop topical therapy and commence high dose oral ASA and oral corticosteroid
257
How is remission induced in extensive UC disease?
First line - topical ASA and high dose oral ASA Second line - stop topical therapy and commence high dose oral ASA and oral corticosteroid
258
What is the management of a UC flare?
Admit to hospital First line - IV corticosteroid Second line - add IV ciclosporin Third line - colectomy
259
How is remission maintained in UC?
First line - aminosalicylate (oral or rectal mesalazine) Azathioprine Mercaptopurine
260
How is remission induced in Crohn's disease?
First line - glucocorticoids Second line - aminosalicylates Add on medications: Azathioprine Mercaptopurine Methotrexate Infliximab Adalimumab
261
How is remission maintained in Crohn's?
First line - azathioprine or mercaptopurine Second line - methotrexate
262
What are the complications of UC?
Toxic megacolon Perforation Colonic adenocarcinoma Strictures and obstruction
263
What are the complications of Crohn's disease?
Peri-anal abscess Anal fissure Anal fistula Strictures and obstruction Perforation Colorectal cancer Anaemia and malnutrition
264
What is the maintenance of UC in a patient with more than 2 flare ups in the past year?
Oral azathioprine or oral mercaptopurine
265
What is the pathophysiology of IBS?
IBS is a functional disorder that is caused by a disturbance of the gut-brain interaction
266
What are the key features of IBS?
Abdominal pain Bloating Change in bowel habit Stool abnormalities - watery/hard/associated with mucus Symptoms persisting for at least six months
267
What are the common symptoms of IBS?
Abdominal pain Diarrhoea Constipation Fluctuating bowel habit Bloating Worse after eating Improved by opening bowels Passing mucus
268
What are common triggers for IBS?
Anxiety Depression Stress Sleep disturbance Illness Medications Certain foods Caffeine Alcohol
269
What are the differentials of IBS?
Bowel cancer Inflammatory bowel disease Coeliac disease Ovarian cancer Pancreatic cancer
270
What red flag features should be ruled out when investigating IBS?
Rectal bleeding Unexplained weight loss Family history of bowel or ovarian cancer Onset after 60 years of age
271
What are the initial investigations for IBS?
FBC ESR CRP Coeliac disease screen Faecal calprotectin CA125
272
What are the criteria for diagnosis of IBS?
At least 6 months of abdominal pain with at least one of: - Pain or discomfort relieved by opening bowels - Bowel habit abnormalities - Stool abnormalities At least two more symptoms of: - Straining, an urgent need to open bowels - Bloating - Worse after eating - Passing mucus
273
What lifestyle advice can be offered to those with IBS?
Drinking enough fluids Regular small meals Adjusting fibre intake according to symptoms Limit caffeine, alcohol and fatty foods Low FODMAP diet Probiotic supplements Reduce stress Exercise regularly
274
What are the first line medical treatments of IBS?
Diarrhoea - loperamide Constipation - bulk-forming laxatives Cramps - antispasmodics such as mebeverine, hyoscine butylbromide
275
What is the second line medical management of IBS?
Low dose tricyclic antidepressants - amitriptyline SSRI antidepressants CBT Linactolide
276
What is GORD?
Reflux of the gastric contents back into the oesophagus, through the lower oesophageal sphincter
277
What is the epithelial lining of the oesophagus?
Squamous epithelium (which is more sensitive than columnar epithelium to the effects of stomach acid)
278
What are common triggers for GORD?
Greasy/spicy foods Coffee/tea NSAIDs Stress Smoking Obesity Hiatus hernia
279
What is the pathophysiology of GORD?
Increased sphincter relaxation Raised intragastric pressure Reduced sphincter tone Oesophageal dysmotility
280
What are the risk factors for GORD?
Age Family history Obesity Pregnancy Hiatus hernia Smoking and alcohol Fatty foods
281
What is the presentation of GORD?
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
282
What are the red flag symptoms of GORD?
Dysphagia Weight loss Upper abdominal pain Reflux Treatment-resistant dyspepsia Nausea and vomiting Upper abdominal mass Low haemoglobin Raised platelets
283
What investigations are used in the diagnosis of GORD?
H. pylori testing Endoscopy - normal 24 hour pH study Oeseophageal manometry
284
What is the first line management of GORD?
Lifestyle changes - Weight loss - Avoidance of triggers - Smoking cessation - Eating smaller meals, not eating before bed Medication review PPI - full dose PPI for 1-2 months
285
What is the second line management of GORD?
Histamine H2-receptor antagonists Surgery - laparoscopic fundoplication
286
What are the complications of GORD?
Barrett's oesophagus Oesophageal ulceration Oesophageal stricture Anaemia Aspiration pneumonia Dental problems
287
What is the pathophysiology of peptic ulcers?
Disruption to the mucus barrier of the stomach, or an increase in stomach acid increases the risk of mucosal ulceration
288
Where are ulcers most common?
In the proximal duodenum
289
What are the risk factors for peptic ulcer disease?
Increasing age H. pylori NSAIDs Other drugs - SSRIs, corticosteroids and bisphosphonates Smoking and alcohol Raised ICP Severe burns
290
What is the presentation of peptic ulcer disease?
Duodenal ulcer - Pain relieved by eating and worse when hungry Gastric ulcer - Pain worsened by eating Nausea and vomiting Coffee-ground vomiting or melaena Reduced appetite and weight loss Anaemia Evidence of bleeding - Hypotension and tachycardia Epigastric tenderness
291
What is the gold standard investigation for diagnosis of peptic ulcer disease?
Endoscopy
292
What other investigations are helpful in the diagnosis of peptic ulcer disease?
H. pylori breath test FBC U&Es LFTs and coagulation profile
293
What is the glasgow blatchford score?
Score that assesses risk for upper GI bleed. Factors taken into account include: - Haemoglobin - Urea - Initial systolic blood pressure - Gender - Tachycardia - Melaena - History of syncope - Cardiac failure
294
What is the management of peptic ulcers with no active bleeding?
Medication cessation PPI for one month until ulcer has healed Triple eradication therapy if H. pylori positive
295
What is the management of peptic ulcer disease with active bleeding?
IV crystalloid ABCDE and wide-bore IV access Blood transfusion Upper GI endoscopy - within 24 hours High dose IV PPI
296
What are the complications of peptic ulcer disease?
Bleeding from ulcer Gastric outlet obstruction Perforation - peritonitis
297
What lifestyle advice can be offered to those with peptic ulcer disease?
Smoking and alcohol cessation Avoid trigger foods Eat smaller meals Eat evening meals 3-4 hours before bed
298
What type of cancer are most pancreatic tumours?
Adenocarcinomas
299
What is the presentation of pancreatic cancer?
Painless obstructive jaundice - Yellow skin and sclera - Pale stools - Dark urine - Generalised itching Upper abdominal pain Unintentional weight loss Change in bowel habit Nausea and vomiting New-onset diabetes
300
What are the risk factors for pancreatic cancer?
Increasing age Male Smoking Diabetes Chronic pancreatitis Multiple endocrine neoplasia Genetics - hereditary non-polyposis colorectal carcinoma, BRCA1 and BRCA2 mutations
301
When should patients be referred on a 2 week wait for pancreatic cancer?
Over 40 with jaundice Over 60 with weight loss plus an additional symptom: - Diarrhoea - Back pain - Abdominal pain - Nausea or vomiting - Constipation - New onset diabetes
302
What is Courvoisier's law?
A palpable gallbladder with jaundice is unlikely to be gallstones - it is usually cholangiocarcinoma or pancreatic cancer
303
What investigations are diagnostic of pancreatic cancer?
CT pancreas Histology from biopsy
304
What other investigations are useful in the diagnosis of pancreatic cancer?
LFTs CA19-9 Staging CT scan - CT TAP MRCP - assess obstruction of biliary system ERCP - relieve obstruction and obtain biopsy
305
What is the management of localised pancreatic cancer?
Surgery - Total pancreatectomy - Distal pancreatectomy - Whipple's procedure
306
What is removed during a whipple's procedure?
Head of the pancreas Pylorus of stomach Duodenum Gallbladder Bile duct Relevant lymph nodes
307
What palliative treatment is available for pancreatic cancer?
ERCP with stenting Palliative chemotherapy Palliative radiotherapy
308
Where do most pancreatic cancers occur?
In the head of the pancreas
309
What is volvulus?
Torsion of the colon around itself and the mesentery that it is attached to
310
What complication does volvulus lead to?
Closed loop bowel obstruction - a section of bowel is isolated by obstruction on either side
311
What are the two main types of volvulus?
Sigmoid volvulus - most common Caecal volvulus
312
What are the risk factors for volvulus?
Neuropsychiatric disorders Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions
313
What is the clinical presentation of volvulus?
Vomiting - bilious Abdominal distention Diffuse abdominal pain Constipation Lack of flatulence
314
What initial investigation is used in the diagnosis of volvulus?
Abdominal XR
315
What is seen on XR in volvulus?
Coffee bean sign in sigmoid volvulus
316
What is the gold standard investigation for diagnosis of volvulus?
Contrast CT scan
317
What is the management of volvulus?
Same as bowel obstruction: - NBM - NG tube - IV fluids Endoscopic decompression (sigmoid volvulus), using a flexible sigmoidoscope
318
What is the surgical management of volvulus?
Laparotomy Hartmann's procedure - removal of rectosigmoid colon and formation of colostomy Ileocecal resection or right hemicolectomy for caecal volvulus
319
What are haemorrhoids?
Enlarged anal vascular cushions
320
What is an anal cushion?
Specialised submucosal tissue that contains connections between arteries and veins - it is very vascular
321
How is the location of pathology in the anus described?
Described as a clock face - with 12 o clock towards the genitals, and 6 o clock towards the back
322
Where are the anal cushions located?
At 2, 7 and 11 o clock
323
What is the classification of haemorrhoids?
1st degree - no prolapse 2nd degree - prolapse when straining and return on relaxing 3rd degree - prolapse when straining, no return on relaxing, but can be pushed back 4th degree - prolapsed permanently
324
What is the dentate line?
The dentate line is situated 2cm from the anal verge, and divides the upper two thirds of and lower third of the anal canal
325
What is the pathophysiology of haemorrhoids?
Factors that contribute to raised intra-abdominal pressure can lead to swelling of the haemorrhoid tissue cushion, which can sweel or bleed
326
What is the presentation of haemorrhoids?
Bright red rectal bleeding Blood is not mixed with stool Anal itching
327
When are haemorrhoids painful?
External haemorrhoids can often be painful, particularly if thrombosed Internal haemorrhoids are often painless, unless thrombosed and strangulated
328
What is seen on DR examination of a patient with haemorrhoids?
External haemorrhoids are visible on inspection Internal haemorrhoids may be felt on PR exam, although this is difficult Internal haemorrhoids can be seen on proctoscopy
329
What is the first line management of haemorrhoids?
Ensure patient is not constipated - increase fluid intake and dietary fibre Analgesia Topical haemorrhoid preparations - Anusol - first line
330
What are the non-surgical options for haemorrhoids?
Rubber band ligation Injection sclerotherapy Infra-red coagulation
331
What are the surgical options for management of haemorrhoids?
Haemorrhoidal artery ligation Haemorrhoidectomy Stapled haemorrhoid
332
What is mesenteric adenitis?
A self-limiting inflammatory condition that affects the lymph nodes in the mesentery
333
What is the pathophysiology of mesenteric adenitis?
Commonly seen after a viral or bacterial infection that triggers an immune response, leading to inflammation of the mesenteric lymph nodes.
334
What is the clinical presentation of mesenteric adenitis?
Diffuse abdominal pain Low-grade fever Generalised abdominal tenderness Pharyngitis or sore throat Nausea Diarrhoea
335
What are the differentials of mesenteric adenitis?
Appendicitis Inflamed Meckel's diverticulum IBD
336
What investigations would be performed in suspected mesenteric adenitis?
FBC - normal USS abdomen - enlarged mesenteric lymph nodes
337
What is the management of mesenteric adenitis?
Analgesia Sufficient fluid intake Monitoring and safety netting about worsening symptoms
338
What is the most common type of gastric cancer?
Adenocarcinoma
339
What are the risk factors for gastric cancer?
Smoking Pernicious anaemia H. pylori infection High alcohol intake Smoked and preserved foods Obesity Blood type A Gastric adenomatous polyps Lynch sydrome
340
What is the clinical presentation of gastric cancer?
Anaemia Weight loss Anorexia Melaena Haematemesis Dysphagia Lymphadenopathy Abdominal pain
341
What are the criteria for 2ww referral for upper GI endoscopy?
Dysphagia OR >55 years with weight loss and one of: - Epigastric pain - Reflux - Dyspepsia
342
What is the first line investigation for gastric cancer?
Upper GI endoscopy and biopsy
343
What are the differentials for gastric cancer?
Peptic ulcer disease Gastritis Gastrointestinal stromal tumour (GIST)
344
What further investigations are useful in the diagnosis of gastric cancer?
CT CAP for detection of metastatic disease PET - staging Staging laparoscopy - looking for peritoneal metastasis HER-2 testing Endoscopic ultrasound - staging
345
What is the management of gastric cancer?
Oesophagogastrectomy - Tumours that extend into the oesophagus Total gastrectomy - Proximal tumours within 5cm of the GOJ Sub-total gastrectomy - If the tumour is <5cm away from the GOJ Endoscopic submucosal resection Chemotherapy - Offer chemotherapy to ALL PATIENTS before and after surgery
346
What are the complications of gastric cancer?
Bleeding Gastric outlet obstruction Perforation Metastasis
347
What are the complications of gastrectomy?
Malabsorption Small bowel bacterial overgrowth Dumping syndrome
348
What is dumping syndrome?
Where sugar moves too quickly into the small bowel - Early dumping syndrome occurs 30 minutes after a meal and can cause dizziness/palpitations - Late dumping syndrome occurs more than 30 minutes after a meal, and can result in hyperinsulinemia and subsequent hypoglycaemia
349
What is Barrett's oesophagus?
An oesophagus in which any part of the distal squamous epithelial lining has been replaced by metaplastic columnar epithelium
350
What are the risk factors for Barrett's oesophagus?
Longstanding GORD Obesity Smoking Hiatus hernia Increasing age
351
What is the presentation of Barrett's oesophagus?
Same as in GORD: - Pain in upper abdomen and chest - Heartburn - Acid taste in the mouth - Bloating - Belching
352
What is the two week wait referral criteria for those with GORD?
Dysphagia Over 55 with weight loss and any of the following: - upper abdominal pain - reflux - dyspepsia
353
What is the gold standard investigation for diagnosis of Barrett's oesophagus?
OGD
354
What is the management of Barrett's oesophagus?
<3cm - Repeat OGD every 3 to 5 years >3cm - Repeat OGD every 3-2 years
355
What is the management of patients with dysplasia?
Endoscopic ablation therapy
356
What is the primary complication of Barrett's oesophagus?
Progression to oesophageal adenocarcinoma
357
What is mesenteric ischaemia?
A sudden onset of hypoperfusion to a portion of the small intestine
358
Which artery does mesenteric ischaemia primarily affect?
The superior mesenteric artery
359
What are the causes of mesenteric ischaemia?
Arterial embolism Arterial thrombosis Venous thrombosis Non-occlusive mesenteric ischaemia
360
What is the presentation of mesenteric ischaemia?
Sudden severe abdominal pain and guarding Nausea and vomiting Shock Metabolic acidosis
361
What are the differentials of mesenteric ischaemia?
Peptic ulcer disease Acute pancreatitis Acute cholecystitis Acute appendicitis Diverticulitis
362
What investigations are used in the diagnosis of mesenteric ischaemia?
FBC, LFTs, U&Es, coagulation profile Lactate levels ABG - metabolic acidosis CT angiography
363
What is the diagnostic investigation for mesenteric ischaemia?
CT angiography
364
What is the management of mesenteric ischaemia?
Resuscitation Anticoagulation Embolectomy, arterial bypass or bowel resection Thrombolysis
365
What is ascites?
Accumulation of fluid within the peritoneal cavity
366
What is the clinical presentation of ascites?
Abdominal distension Abdominal pain Dyspnoea Reduced mobility Anorexia and early satiety Tense abdomen Shifting dullness
367
What is the primary investigation for ascites?
Ascitic tap
368
What other investigations are useful in ascites?
SAAG - serum ascites albumin gradient FBC, U&Es, LFTs, CRP Imaging - CT abdomen, CXR
369
What are the causes of a high SAAG?
SAAG >11g/dL : - Cirrhosis - Budd Chiari syndrome - Constrictive pericarditis - Hepatic failure
370
What does a high SAAG suggest?
Ascites is due to raised portal pressure
371
What are the causes of a low SAAG?
Cancer of the peritoneum Metastatic disease TB Peritonitis Pancreatitis Hypoalbuminaemia
372
What is the first line management of ascites?
Spironolactone
373
What is recommended in the treatment of ascites with a high SAAG?
Fluid restriction, and a low sodium diet
374
What is the management of ascites refractory to medical management?
Regular therapeutic paracentesis
375
What is the most serious complication of ascites?
Spontaneous bacterial peritonitis
376
What is the diagnostic criteria for SBP?
Ascitic tap with neutrophils >250
377
What is the prophylactic treatment of SBP?
1st line - ciprofloxacin
378
What is the indication for prophylaxis of SBP?
Ascites due to cirrhosis, and ascites protein <15g/L Previous SBP Hepatorenal syndrome
379
What is a hiatus hernia?
The protrusion of the abdominal contents through an enlarged oesophageal hiatus in the diaphragm
380
What are the two types of hiatus hernia?
Sliding hiatus hernia Rolling hiatus hernia
381
What is a sliding hiatus hernia?
The gastro-oeseophageal junction slides up into the chest
382
What is a rolling hiatus hernia?
The gastro-oesophageal junction stays in the abdomen, but a part of the stomach protrudes into the chest alongside the oesphagus
383
What are the signs and symptoms of a hiatus hernia?
Heartburn Dysphagia Regurgitation Odynophagia Shortness of breath Chronic cough Chest pain
384
What is the most sensitive test for hiatus hernia?
Barium swallow
385
What is the conservative management of a hiatus hernia?
Weight loss Elevating the head of the bed Avoidance of large meals Avoidance of eating before bedtime Smoking cessation
386
What is the medical management of hiatus hernia?
PPI
387
What is the surgical management of hiatus hernia?
Nissen's fundoplication - closes the defect
388
What is the acute treatment of a variceal haemorrhage?
ABCDE Terlipressin Prophylactic IV antibiotics Endoscopic variceal band ligation
389
What is used for the prophylaxis of variceal haemorrhage?
Propranolol Endoscopic variceal band ligation
390
What is pernicious anaemia?
An autoimmune disorder affecting the gastric mucosa that results in vitamin B12 deficiency
391
What is the pathophysiology of pernicious anaemia?
Antibodies form to intrinsic factor and/or gastric parietal cells This reduces the absorption of vitamin B12
392
What are the features of pernicious anaemia?
Lethargy Pallor Dyspnoea Peripheral neuropathy Subacute combined degeneration of the cord
393
What investigations are used in the diagnosis of pernicious anaemia?
FBC Vitamin B12 and folate levels Antibodies - Anti intrinsic factor antibodies - Anti gastric parietal cell antibodies
394
Which antibodies are the most specific to pernicious anaemia?
Anti intrinsic factor antibodies
395
What is the first line management of pernicious anaemia?
IM hydroxocobalamin
396
How often is treatment given in pernicious anaemia?
IM vitamin B12 given 3 times per week for two weeks, followed by 3 monthly injections
397
What are the causes of bowel obstruction?
Adhesions Hernias Malignancy Volvulus Diverticular disease Strictures Intussusception
398
What is the most common cause of small bowel obstruction?
Adhesions
399
What is the most common cause of large bowel obstruction?
Malignancy
400
What is a closed loop obstruction?
Two points of obstruction along the bowel causing an area sandwiched between the points
401
What is the presentation of bowel obstruction?
Vomiting Abdominal distention Diffuse abdominal pain Absolute constipation Lack of flatulence Tinkling bowel sounds
402
What are the upper limits of the normal diameter of bowel?
3cm - small bowel 6cm - colon 9cm - caecum
403
What is seen on abdominal XR in obstruction?
Distended loops of bowel
404
What is the initial management of bowel obstruction?
Nil by mouth IV fluids NG tube with free drainage
405
What is the initial investigation in bowel obstruction?
Abdominal XR Erect CXR - air under the diaphragm in perforation
406
What investigation is required for diagnosis of bowel obstruction?
Contrast abdominal CT
407
What are the complications of bowel obstruction?
Hypovolaemic shock Bowel ischaemia Bowel perforation Sepsis

Finals 🩺 (28 decks)

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