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Gastroenterology 2 Flashcards

1
Q

Differential Diagnoses of Acute Abdmoinal pain

Generalised Abdo Pain

A
  • Peritonitis
  • Ruptured abdominal aortic aneurysm
  • Intestinal obstruction
  • Ischaemic colitis
    *
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2
Q

What are the main risk factors for heaptocellular carcinoma

A

Viral hepatitis (B and C)

Alcohol

Non alcoholic fatty liver disease

Other chronic liver disease

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3
Q

True or False

Cholangiocarcinoma is associated with primary billary cholangitis.

A

False

Cholangiocarcinoma is associated with primary sclerosing cholangitis.

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4
Q

What are the type common types of liver cancer?

A

hepatocellular carcinoma (80%) and cholangiocarcinoma (20%).

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5
Q

Ix for Liver cancer

A
  • Alpha-fetoprotein is a tumour marker for hepatocellular carcinoma.
  • CA19-9 is a tumour marker for cholangiocarcinoma.
  • Liver ultrasound can identify tumours.
  • CT and MRI scans are used for diagnosis and staging of the cancer.
  • ERCP can be used to take biopsies or brushings to diagnose cholangiocarcinoma.
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6
Q

There are several kinase inhibitors that are licensed as medical treatment for HCC. They work by inhibiting the proliferation of cancer cells. Some examples of these are

A

sorafenib, regorafenib and lenvatinib

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7
Q

Can Chemo and Radiotherapy used for Hepatocellular Carcinoma

A

No

HCC is generally considered resistant to chemo and radiotherapy.

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8
Q

Treatment of Hepatocellular Carcinoma

A

HCC has a very poor prognosis unless diagnosed early. Resection of early disease in a resectable area of the liver can be curative. Liver transplant when the HCC is isolated to the liver can be curative.

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9
Q

Treatment of Cholangiocarcinoma

A

Cholangiocarcinomas have a very poor prognosis unless diagnosed very early. Early disease can potentially be cured with surgical resection.

ERCP can be used to place a stent in the bile duct where the cholangiocarcinoma is compressing the duct. This allows for drainage of bile and usually improves symptoms.

Cholangiocarcinoma is also generally considered resistant to chemo and radiotherapy.

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10
Q

Cholangiocarcinoma often presents with _____ ________ in a similar way to pancreatic cancer.

A

Cholangiocarcinoma often presents with painless jaundice in a similar way to pancreatic cancer.

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11
Q

What is management for Crohn’s

A

First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)

If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance:

  • Azathioprine
  • Mercaptopurine
  • Methotrexate
  • Infliximab
  • Adalimumab
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12
Q

Maintianing remission for Crohns

What can patients take

A

First line:

  • Azathioprine
  • Mercaptopurine

Alternatives:

  • Methotrexate
  • Infliximab
  • Adalimumab
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13
Q

Management of Ulcerative Colitis

Mild to Moderate

Severe

A

Mild to moderate disease

  • First line: aminosalicylate (e.g. mesalazine oral or rectal)
  • Second line: corticosteroids (e.g. prednisolone)

Severe disease

  • First line: IV corticosteroids (e.g. hydrocortisone)
  • Second line: IV ciclosporin
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14
Q

Ulcerative Colitis

Maintaing Remission

A
  • Aminosalicylate (e.g. mesalazine oral or rectal)
  • Azathioprine
  • Mercaptopurine
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15
Q

What surgery can be used treat Ulcerative Colitis

A

Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease

Panproctocolectomy and formation of Ileostomy is the name given to the operation to remove the diseased part of your bowel.

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16
Q

What are you left with after a panproctocolectomy to treat UC

A

. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch).

This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.

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17
Q

Treatment for Coeliac Disease?

A
  • Lifelong gluten-free diet
  • Avoid:barley, rye, oats, wheat
  • OK:Maize, soya, rice
  • Verify diet by endomysial Ab tests
  • Pneumovax as hyposplenic
  • Dermatitis herpetiformis: dapson
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18
Q

Severe Vitamin A deficiency keads to

A

Xerophthalmia

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19
Q

What is Xerophthalmia

A

Xerophthalmia is a disease that causes dry eyes due to vitamin A deficiency. If it goes untreated, it can progress into night blindness or spots on your eyes. It can even damage the cornea of your eye and cause blindnes

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20
Q

What us mesenteric ischaemia?

A

is caused by a lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia.

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21
Q

the stomach and part of the duodenum, biliary system, liver, pancreas and spleen

are all supplied by?

A

coeliac artery.

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22
Q

from the distal part of the duodenum to the first half of the transverse colon

are all supplied by?

A

superior mesenteric artery.

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23
Q

from the second half of the transverse colon to the rectum

is supplied by?.

A

inferior mesenteric artery.

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24
Q

What is chronic mesenteric ischaemia?

A

Chronic mesenteric ischaemia (also known as intestinal angina) is the result of narrowing of the mesenteric blood vessels by atherosclerosis. This results in intermittent abdominal pain, when the blood supply cannot keep up with the demand. It is similar to the pathophysiology of angina, where the blood supply is reduced by coronary artery disease, resulting in intermittent symptoms.

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25
Q

What is the classic triad presentation for mesenteric ischaemia?

A

The typical presentation is with a “classic triad” of:

  • Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)
  • Weight loss (due to food avoidance, as this causes pain)
  • Abdominal bruit may be heard on auscultation
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26
Q

Risk factors for mesenteric ishcaemia?

A
  • Increased age
  • Family history
  • Smoking
  • Diabetes
  • Hypertension
  • Raised cholesterol
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27
Q

What is used to diagnose mesenteric ishcaemia?

A

Diagnosis is by CT angiography.

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28
Q

Management for mesenteric ischaemia?

A
  • Reducing modifiable risk factors (e.g., stop smoking)
  • Secondary prevention (e.g., statins and antiplatelet medications)
  • Revascularisation to improve the blood flow to the intestines
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29
Q

Revascularisation for mesenteric ischaemia may be performed by:

A
  • Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting)
  • Open surgery (i.e endarterectomy, re-implantation or bypass grafting)
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30
Q

What is acute mesenterich ischaemia?

What is it usually caused by?

A

Acute mesenteric ischaemia is typically caused by a rapid blockage in blood flow through the superior mesenteric artery.

This is usually caused by a thrombus (blood clot) stuck in the artery, blocking blood flow. The blood clot may be a thrombus that has developed inside the artery or an embolus from another site that has got stuck in the artery

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31
Q

What is a key risk factor for acute mesenteric ischaemia?

A

A key risk factor is atrial fibrillation, where a thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery, where it becomes stuck and cuts off the blood supply.

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32
Q

what can patients develop from mesenteric ischaemia?

A

Patients can go on to develop shock, peritonitis and sepsis.

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33
Q

Is mesenteric ischaemia metabolic acidosis or metabolic alkalosis?

A

metabolic acidosis

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34
Q

What are haemorrhoids?

A

enlarged anal vascular cushions.

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35
Q

What symptoms are usually associated with haemorrhoids?

A

constipation and straining

painless, bright red bleeding- the blood is not mixed with the stool

Sore / itchy anus

Feeling a lump around or inside the anus

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36
Q

Who are haemorrhoids typically seen in?

A

They are also more common with pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing)

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37
Q

Why would you get a haemorrhoids in pregnancy?

A

They often occur in pregnancy, most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissues.

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38
Q
A
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40
Q

What are anal cushions

A

The anal cushions are specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence, along with the internal and external sphincters. The blood supply is from the rectal arteries.

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41
Q

What is the classificaiton of haemorrhoids?

A
  • 1st degree: no prolapse
  • 2nd degree: prolapse when straining and return on relaxing
  • 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
  • 4th degree: prolapsed permanently
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42
Q

On examination what would you with haemorrhoids

A
  • External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa
  • Internal haemorrhoids may be felt on a PR exam (although this is generally difficult or not possible)
  • They may appear (prolapse) if the patient is asked to “bear down” during inspection
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43
Q

What is Proctoscopy?

A

is required for proper visualisation and inspection of haemorrhoids. This involves inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa.

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44
Q

differential diagnosis with rectal bleeding

A

Anal fissures

Diverticulosis

Inflammatory bowel disease

Colorectal cancer

Haemorrhoids

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45
Q

Name some topial treatment that can be used for symptomatic relief and help reduce swelling in haemorrhoids

A
  • Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)
  • Anusol HC (also contains hydrocortisone – only used short term)
  • Germoloids cream (contains lidocaine – a local anaesthetic)
  • Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)
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46
Q

Prevention and treatment of constipation involves:

A
  • Increasing the amount of fibre in the diet
  • Maintaining a good fluid intake
  • Using laxatives where required
  • Consciously avoiding straining when opening their bowels
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47
Q

There are a number of non-surgical treatments for haemorrhoids:

What are they?

A
  • Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply)
  • Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)
  • Infra-red coagulation (infra-red light is applied to damage the blood supply)
  • Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)
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48
Q

What are some Surgical Options for haemorrhoids?

A

Haemorrhoidal artery ligation involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.

Haemorrhoidectomy involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence.

Stapled haemorrhoidectomy involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.

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49
Q

What are Thrombosed Haemorrhoids caused by and what can it lead to?

A

Thrombosed haemorrhoids are caused by strangulation at the base of the haemorrhoid, resulting in thrombosis (a clot) in the haemorrhoid. This can be very painful.

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50
Q

What is intussusception?

A

Intussusception is a condition where the bowel “invaginates” or “telescopes” into itself. Picture the bowel folding inwards. This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel.

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51
Q

Intussusception typically occurs in who?

A

It typically occurs in infants 6 months to 2 years and is more common in boys.

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52
Q

Associated Conditions with Intussusception

A

It is associated with various conditions:

  • Concurrent viral illness
  • Henoch-Schonlein purpura
  • Cystic fibrosis
  • Intestinal polyps
  • Meckel diverticulum
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53
Q

Presentation of Intussusception

A
  • Severe, colicky abdominal pain
  • Pale, lethargic and unwell child
  • “Redcurrant jelly stool”- look out for this
  • Right upper quadrant mass on palpation. This is described as “sausage-shaped” - look out for this
  • Vomiting
  • Intestinal obstruction
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54
Q

How is Intussusception presented in infants

A

The typical child in the exam will have had a viral upper respiratory tract infection preceding the illness and will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention). Ultrasound is the initial investigation of choice.

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55
Q

Diagnosis for intussusception

A

Diagnosis is made mainly by ultrasound scan or contrast enema.

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56
Q

Management for intussusception

A

Therapeutic enemas can be used to try to reduce the intussusception. Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position.

Surgical reduction may be necessary if enemas do not work.

If the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated, then surgical resection is required.

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57
Q

Complications of intussusception?

A
  • Obstruction
  • Gangrenous bowel
  • Perforation
  • Death
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58
Q

Incidence for bowel cancer?

A

fourth most prevalent cancer in the UK

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59
Q

Are Small bowel and anal cancers are more/less common.

A

less

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60
Q

Risk Factors for bowel cancer

A

There are a number of factors that increase the risk of colorectal cancer:

  • Family history of bowel cancer
  • Familial adenomatous polyposis (FAP)
  • Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
  • Inflammatory bowel disease (Crohn’s or ulcerative colitis)
  • Increased age
  • Diet (high in red and processed meat and low in fibre)
  • Obesity and sedentary lifestyle
  • Smoking
  • Alcohol
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61
Q

Familial adenomatous polyposis (FAP) is an autosomal dominant/autosomal recessive

A

autosomal dominant

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62
Q

Familial adenomatous polyposis (FAP) has a malfunctionation gene called?

A

adenomatous polyposis coli (APC).

which is a tumour suppressor gene

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63
Q

What is (panproctocolectomy).

A

Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy).

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64
Q

Hereditary nonpolyposis colorectal cancer (HNPCC) is also known as

A

Lynch syndrome

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65
Q

how is HNPCC inherited

A

AD

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66
Q

HNPCC finds mutations in…

A

DNA mismatch repair (MMR) genes.

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67
Q

HNPCC increase your risk of?

A

colorectal cancer.

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68
Q

Presentation of bowel cancer?

A

The red flags that should make you consider bowel cancer are:

  • Change in bowel habit (usually to more loose and frequent stools)
  • Unexplained weight loss
  • Rectal bleeding
  • Unexplained abdominal pain
  • Iron deficiency anaemia (microcytic anaemia with low ferritin)
  • Abdominal or rectal mass on examination
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69
Q

Explain the two wait refferal for bowel cancer?

A
  • 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
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70
Q

______ _________ _______ on its own without any other explanation (i.e. heavy menstruation) is an indication for a “two week wait” cancer referral for ________ and _________ (“top and tail”) for GI malignancy. This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

A

Iron deficiency anaemia on its own without any other explanation (i.e. heavy menstruation) is an indication for a “two week wait” cancer referral for colonoscopy and gastroscopy (“top and tail”) for GI malignancy. This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

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71
Q

Faecal immunochemical tests (FIT) what is it?

A

look very specifically for the amount of human haemoglobin in the stool. FIT replaced the older stool test called the faecal occult blood (FOB) test, which detected blood in the stool but could give false positives by detecting blood in food (e.g., from red meats).

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72
Q

WHat can be used in GP if the patients dont fit the two week wait referal criteria for bowel cancer?

A

FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral, for example:

  • Over 50 with unexplained weight loss and no other symptoms
  • Under 60 with a change in bowel habit
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73
Q

How does the bowel cancer screening programme work?

A

In England, people aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy.

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74
Q

People with risk factors such as ______ ________ or ________ ______ _______ are offered a colonoscopy at regular intervals to screen for bowel cancer.

A

People with risk factors such as FAP, HNPCC or inflammatory bowel disease are offered a colonoscopy at regular intervals to screen for bowel cancer.

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75
Q

Ix for bowel cancer?

A

Colonoscopy is the gold standard investigation.

Sigmoidoscopy

CT colonography

Staging CT scan

Carcinoembryonic antigen (CEA)- tumour marker

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76
Q

WHat is the system used for bowel cancer?

A

Dukes’ Classification

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77
Q

Explain Dukes’ Classification

A

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

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78
Q

TNM classification

T for Tumour:

TX –

T1 –

T2 –

T3 –

T4 –

A

T for Tumour:

TX – unable to assess size

T1 – submucosa involvement

T2 – involvement of muscularis propria (muscle layer)

T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa

T4 – spread through the serosa (4a) reaching other tissues or organs (4b)

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79
Q

TNM classification

N for Nodes:

NX –

N0 –

N1 –

N2 –

A

N for Nodes:

NX – unable to assess nodes

N0 – no nodal spread

N1 – spread to 1-3 nodes

N2 – spread to more than 3 nodes

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80
Q

TNM classification

A

M for Metastasis:

M0 – no metastasis

M1 – metastasis

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81
Q

Management for bowel cancer

A

Surgical resection

Chemotherapy

Radiotherapy

Palliative care

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82
Q

WHat does surgery involve for bowel cancer?

A

Surgery involves:

  • Identifying the tumour (it may have been tattooed during an endoscopy)
  • Removing the section of bowel containing the tumour,
  • Creating an end-to-end anastomosis (sewing the remaining ends back together)
  • Alternatively creating a stoma (bringing the open section of bowel onto the skin)
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83
Q

WHat does Right hemicolectomy

A

involves removal of the caecum, ascending and proximal transverse colon.

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84
Q

What does left hemicolectomy?

A

involves removal of the distal transverse and descending colon.

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85
Q

What is high anterior resection?

A

involves removing the sigmoid colon (may be called a sigmoid colectomy).

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86
Q

WHat is low anterior resection?

A

involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus

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87
Q

WHat is Abdomino-perineal resection (APR)

A

involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

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88
Q

WHat is hartmann’s procedure?

A

is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

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89
Q

There is a long list of potential complications of surgery for bowel cancer

A
  • Bleeding, infection and pain
  • Damage to nerves, bladder, ureter or bowel
  • Post-operative ileus
  • Anaesthetic risks
  • Laparoscopic surgery converted during the operation to open surgery (laparotomy)
  • Leakage or failure of the anastomosis
  • Requirement for a stoma
  • Failure to remove the tumour
  • Change in bowel habit
  • Venous thromboembolism (DVT and PE)
  • Incisional hernias
  • Intra-abdominal adhesions
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90
Q

What is Low Anterior Resection Syndrome

A

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including:

  • Urgency and frequency of bowel movements
  • Faecal incontinence
  • Difficulty controlling flatulence
91
Q

Bowel Cancer

Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes

A

Serum carcinoembryonic antigen (CEA)

CT thorax, abdomen and pelvis

92
Q

What is Volvulus?

A

Volvulus is a condition where the bowel twists around itself and the mesentery that it is attached to

93
Q

Where does the bowel get its blood supply from?

A

The bowel gets its blood supply from the mesentery (through the mesenteric arteries).

94
Q

Twisting in the bowel leads to

A

a closed-loop bowel obstruction, where a section of bowel is isolated by obstruction on either side.

95
Q

What are the twp types of volvulus?

A

Sigmoid volvulus

Caecal volvulus

96
Q

Which type of volvulus is

  • more common
  • affects older patiens
  • caused by chronic constipation
  • associated with high fibre diet
  • excessive use of laxatives
A

Sigmoid volvulus

97
Q

Which type of volvulus is

  • less common
  • affect younger patients
A

caecal volvulus

98
Q

RF for volvulus?

A
  • Neuropsychiatric disorders (e.g., Parkinson’s)
  • Nursing home residents
  • Chronic constipation
  • High fibre diet
  • Pregnancy
  • Adhesions
99
Q

Presentation of volvulus

A

the signs and symptoms are akin to bowel obstruction, with:

  • Vomiting (particularly green bilious vomiting)
  • Abdominal distention
  • Diffuse abdominal pain
  • Absolute constipation and lack of flatulence
100
Q

DIagnosis for volvulus

A

Abdominal x-ray can show the “coffee bean” sign in sigmoid volvulus, where the dilated and twisted sigmoid colon looks like a giant coffee bean.

A contrast CT scan is the investigation of choice to confirm the diagnosis and identify other pathology.

101
Q

Management for Volvulus

A

The initial management is the same as with bowel obstruction (nil by mouth, NG tube and IV fluids).

Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis)

Surgical management involves:

  • Laparotomy (open abdominal surgery)
  • Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy)
  • Ileocaecal resection or right hemicolectomy for caecal volvulus
102
Q

Causes of Intestinal Obstruction

A

Meconium ileus

Hirschsprung’s disease

Oesophageal atresia

Duodenal atresia

Intussusception

Imperforate anus

Malrotation of the intestines with a volvulus

Strangulated hernia

103
Q

Presentation of Intestinal Obstruction

A
  • Persistent vomiting. This may be bilious, containing bright green bile.
  • Abdominal pain and distention
  • Failure to pass stools or wind
  • Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
104
Q

Diagnosis of intestinal obstruction

A

abdominal xray- dilated loops of bowel proximal to the obstruction and absence of air in the rectum.

105
Q

What is Pilonidal sinus

A

A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks, where they divide (the cleft). It does not always cause symptoms and only needs to be treated if it becomes infected.

106
Q

Treatments for an infected pilonidal sinus

A

Abx

Incision and drainage

Wide excision and open healing

Excision and wound closure, often with flattening of the groove between the buttock

Endoscopic ablation for a pilonidal sinus

107
Q

what is splenic rupture

A

A ruptured spleen is an emergency medical condition that occurs when the capsule-like covering of the spleen breaks open, pouring blood into your abdominal area. Depending on the size of the rupture, a large amount of internal bleeding can occur. Your doctor may refer to a ruptured spleen as a “splenic rupture.

108
Q

WHat are Adhesions:

A

scar-like tissue inside the body that bind surfaces together

109
Q

What is Fistula

A

an abnormal connection between two epithelial surfaces

110
Q

What is Tenesmus

A

the sensation of needing to open bowels without being able to produce stools (often accompanied by pain)

111
Q

What is another name for Whipple procedure

A

pancreaticoduodenectomy) – removal of the head of the pancreas, duodenum, gallbladder and bile duct

112
Q

A Kocher incision is for

A

open cholecystectomy

113
Q

Chevron / rooftop incision is used for

A

liver transplant, Whipple procedure, pancreatic surgery or upper GI surgery

114
Q

A Mercedes Benz incision is for

A

liver transplant

115
Q

A Midline incision is used for

A

a general laparotomy, allows good access to abdominal organs

116
Q

Paramedian incision used for

A

laparotomy (midline usually used instead)

117
Q

Hockey-stick incision is used for

A

renal transplant

118
Q

Appendix surgery:

Battle incision (paramedian) –

Gridiron incision / McBurney incision (oblique) –

Lanz incision (transverse) –

Rutherford Morrison incision (extended version of gridiron) –

A

Appendix surgery:

Battle incision (paramedian) – open appendicectomy

Gridiron incision / McBurney incision (oblique) – open appendicectomy

Lanz incision (transverse) – open appendicectomy

Rutherford Morrison incision (extended version of gridiron) – open appendicectomy and colectomy

119
Q

Caesarean section:

Pfannenstiel incision –

Joel-Cohen incision –

A

Caesarean section:

Pfannenstiel incision – curved incision two fingers width above the pubic symphysis

Joel-Cohen incision – straight incision that is slightly higher (this is the recommended incision)

120
Q

What is Laparoscopic surgery

A

involves several 5-10mm incisions to allow th

121
Q

what is Necrotising Fasciitis

A

Necrotizing fasciitis (NECK-re-tie-zing FASH-e-i-tis) is a rare bacterial infection that spreads quickly in the body and can cause death. Accurate diagnosis, rapid antibiotic treatment, and prompt surgery are important to stopping this infection

122
Q

what organism causes Necrotising Fasciitis

A

There are many types of bacteria that can cause the “flesh-eating disease” called necrotizing fasciitis. Public health experts believe group A Streptococcus (group A strep) are the most common cause of necrotizing fasciitis

123
Q

Differential Diagnoses of Acute Abdmoinal pain

RUQ pain

A

Biliary colic

Acute cholecystitis

Acute cholangitis

124
Q

Differential Diagnoses of Acute Abdmoinal pain

Epigastic Pain

A

Acute gastritis

Peptic ulcer disease

Pancreatitis

Ruptured abdominal aortic aneurysm

125
Q

Differential Diagnoses of Acute Abdominal Pain

Central abdominal pain:

A

Ruptured abdominal aortic aneurysm

Intestinal obstruction

Ischaemic colitis

Early stages of appendicitis

126
Q

Differential Diagnoses of Acute Abdominal Pain

Right iliac fossa pain

A

Acute appendicitis

Ectopic pregnancy

Ruptured ovarian cyst

Ovarian torsion

Meckel’s diverticulitis

127
Q

Differential Diagnoses of Acute Abdominal Pain

Left iliac fossa pain

A

Diverticulitis

Ectopic pregnancy

Ruptured ovarian cyst

Ovarian torsion

128
Q

Differential Diagnoses of Acute Abdominal Pain

Suprapubic pain

A

Lower urinary tract infection

Acute urinary retention

Pelvic inflammatory disease

Prostatitis

129
Q

Differential Diagnoses of Acute Abdominal Pain

loin to groin pain

A

Renal colic (kidney stones)

Ruptured abdominal aortic aneurysm

Pyelonephritis

130
Q

Differential Diagnoses of Acute Abdominal Pain

Testicular pain

A

Testicular torsion

Epididymo-orchitis

131
Q

Peritonitis refers to inflammation of the peritoneum, the lining of the abdomen. The signs of peritonitis are:

A
  • Guarding – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below
  • Rigidity – involuntary persistent tightness / tensing of the abdominal wall muscles
  • Rebound tenderness – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself
  • Coughing test – asking the patient to cough to see if it results in pain in the abdomen
  • Percussion tenderness – pain and tenderness when percussing the abdomen
132
Q

Why is group and save important

A

s essential prior to theatre in case the patient requires a blood transfusion.

133
Q

Initial managemet for any acute abdo pain management

A

Initial management involves:

  • ABCDE assessment
  • Alert seniors of unwell patients: escalating to the registrar, consultant and critical care as required
  • Nil by mouth if surgery may be required or they have features of bowel obstruction
  • NG tube in cases of bowel obstruction
  • IV fluids if required for resuscitation or maintenance
  • IV antibiotics if infection is suspected
  • Analgesia as required for pain management
  • Arranging investigations as required (e.g., bloods, group and save and scans)
  • Venous thromboembolism risk assessment and prescription if indicated
  • Prescribing regular medication on the drug chart if they are being admitted (some may need to be withheld)
134
Q

Further management steps if the patient requires surgery:

A
  • Taking consent for surgery (by someone suitably qualified)
  • Review by an anaesthetist
  • Putting on the theatre list
  • Crossmatch units of blood if required
135
Q

The peak incidence of appendicitis is in patients aged __ ___ __ years. It can occur at any age but is less common in young children and adults over 50 years.

A

The peak incidence of appendicitis is in patients aged 10 to 20 years. It can occur at any age but is less common in young children and adults over 50 years.

136
Q

Patho of Appendicitis

A

The appendix is a small, thin tube arising from the caecum. It is located at the point where the three teniae coli meet (the teniae coli are longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end.

Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel. Trapping of pathogens leads to infection and inflammation. The inflammation may proceed to gangrene and rupture. When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity. This leads to peritonitis, which is inflammation of the peritoneal lining.

137
Q

Signs and Symptoms of appendicitis

A

The key presenting feature of appendicitis is abdominal pain. This typically starts as central abdominal pain that moves down to the right iliac fossa (RIF) within the first 24 hours, eventually becoming localised in the RIF. On palpation of the abdomen, there is tenderness at McBurney’s point. McBurney’s point refers to a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

Other classic features are:

  • Loss of appetite (anorexia)
  • Nausea and vomiting
  • Low-grade fever
  • Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
  • Guarding on abdominal palpation
  • Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
  • Percussion tenderness (pain and tenderness when percussing the abdomen)

Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.

138
Q

Diagnosis of Appendicitis

A

Diagnosis is based on the clinical presentation and raised inflammatory markers. Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology. Ultrasound can also be useful in children, where a CT scan is less appropriate due to the dose of radiation.

Appendicitis is mostly a clinical diagnosis (meaning it is based on signs and symptoms rather than diagnostic tests). Where the diagnosis is unclear, a period of observation may be used, with repeated examinations over time to see whether the symptoms resolve or worsen.

When a patient has a clinical presentation suggestive of appendicitis, but investigations are negative, the next step is to perform a diagnostic laparoscopy to visualise the appendix directly. The surgeon can proceed to an appendicectomy during the same procedure, if indicated.

139
Q

Key Differential Diagnoses of Appendicitis

A

Ectopic Pregnancy

Ovarian Cysts

Meckel’s Diverticulum

Mesenteric Adenitis

140
Q

What is Appendix Mass

A

An appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa. This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.

141
Q

Management of appendicitis

A

Patients with suspected appendicitis need emergency admission to hospital under the surgical team.

Removal of the inflamed appendix (appendicectomy) is the definitive management for acute appendicitis. Laparoscopic surgery is associated with fewer risks and faster recovery compared to open surgery.

142
Q

Complications of Appendicectomy

A
  • Bleeding, infection, pain and scars
  • Damage to bowel, bladder or other organs
  • Removal of a normal appendix
  • Anaesthetic risks
  • Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
143
Q

What is ileus

A

Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.

144
Q

What is pseudo-obstruction

A

is a term used to describe a functional obstruction of the large bowel, where patients present with intestinal obstruction, but no mechanical cause is found. This is less common than ileus affecting the small bowel.

145
Q

Ileus causes

A

There is a long list of things that can make the bowel unhappy, leading to ileus. Common causes are:

  • Injury to the bowel
  • Handling of the bowel during surgery
  • Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
  • Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)

The most common time you will see ileus is following abdominal surgery. This usually resolves with supportive care within a few days.

146
Q

Signs and Symptoms of ileus

A

The signs and symptoms are akin to bowel obstruction, with:

  • Vomiting (particularly green bilious vomiting)
  • Abdominal distention
  • Diffuse abdominal pain
  • Absolute constipation and lack of flatulence
  • Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
147
Q

Management of ileus

A

The ileus will usually resolve with treatment of the underlying cause. Management involves supportive care.

Supportive care involves:

  • Nil by mouth or limited sips of water
  • NG tube if vomiting
  • IV fluids to prevent dehydration and correct the electrolyte imbalances
  • Mobilisation to helps stimulate peristalsis
  • Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
148
Q

What is a hernia

A

Hernias occur when there is a weak point in a cavity wall, usually affecting the muscle or fascia. This weakness allows a body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall.

149
Q

There are many types of hernias that present differently depending on where they are and what organs are involved.

The typical features of an abdominal wall hernia are:

A
  • A soft lump protruding from the abdominal wall
  • The lump may be reducible (it can be pushed back into the normal place)
  • The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity)
  • Aching, pulling or dragging sensation
150
Q

There are three key complications of hernias:

  • Incarceration
  • Obstruction
  • Strangulation
A
151
Q

What is Incarceration

A

is where the hernia cannot be reduced back into the proper position (it is irreducible). The bowel is trapped in the herniated position. Incarceration can lead to obstruction and strangulation of the hernia.

152
Q

What is Richter’s Hernia

A

A Richter’s hernia is a very specific situation that can occur in any abdominal hernia. This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

153
Q

What is Maydl’s Hernia

A

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

154
Q

There are general principles of management that apply to abdominal wall hernias. These are:

A

Conservative management

Conservative management involves leaving the hernia alone. This is most appropriate when the hernia has a wide neck (low risk of complications) and in patients that are not good candidates for surgery due to co-morbidities.

Tension-free repair (surgery)

Tension-free repair involves placing a mesh over the defect in the abdominal wall. The mesh is sutured to the muscles and tissues on either side of the defect, covering it and preventing herniation of the cavity contents. Over time, tissues grow into the mesh and provide extra support. This has a lower recurrence rate compared with tension repair, but there may be complications associated with the mesh (e.g., chronic pain).

Tension repair (surgery)

Tension repair involves a surgical operation to suture the muscles and tissue on either side of the defect back together. Tension repairs are rarely performed and have been largely replaced by tension-free repairs. The hernia is held closed (to heal there) by sutures applying tension. This can cause pain and there is a relatively high recurrence rate of the hernia.

155
Q

There are a number of differential diagnoses for a lump in the inguinal region

A
  • Femoral hernia
  • Lymph node
  • Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
  • Femoral aneurysm
  • Abscess
  • Undescended / ectopic testes
  • Kidney transplant
156
Q

An indirect inguinal hernia is where the bowel herniates through the inguinal canal.

What is the inguinal canal and its functions

A

The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).

In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum.

In females, the round ligament is attaches to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora.

157
Q

What is Direct Inguinal Hernia

A

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. The hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle (not along a canal or tract like an indirect inguinal hernia). Pressure over the deep inguinal ring will not stop the herniation.

158
Q

Hesselbach’s triangle boundaries (RIP mnemonic)

A

R – Rectus abdominis muscle – medial border

I – Inferior epigastric vessels – superior / lateral border

P – Poupart’s ligament (inguinal ligament) – inferior border

159
Q

What are femoral hernias

A

Femoral hernias involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh.

The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of:

  • Incarceration
  • Obstruction
  • Strangulation
160
Q

Boundaries of the femoral canal (FLIP mnemonic):

A

F – Femoral vein laterally

L – Lacunar ligament medially

I – Inguinal ligament anteriorly

P – Pectineal ligament posteriorly

161
Q

Don’t get the femoral canal confused with the femoral triangle. The femoral triangle is a larger area at the top of the thigh that contains the femoral canal. You can remember the boundaries with the SAIL mnemonic:

A

S – Sartorius – lateral border

A – Adductor longus – medial border

IL – Inguinal Ligament – superior border

162
Q

Use the NAVY-C mnemonic to remember the contents of the femoral triangle from lateral to medial across the top of the thigh:

A

N – Femoral Nerve

A – Femoral Artery

V – Femoral Vein

Y – Y-fronts

C – Femoral Canal (containing lymphatic vessels and nodes)

163
Q

What are Incisional Hernias

A

ncisional hernias occur at the site of an incision from previous surgery. They are due to weakness where the muscles and tissues were closed after a surgical incision. The bigger the incision, the higher the risk of a hernia forming. Medical co-morbidities put patients at higher risk due to poor healing.

Incisional hernias can be difficult to repair, with a high rate of recurrence. They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

164
Q

What are Umbilical Hernias

A

Umbilical hernias occur around the umbilicus due to a defect in the muscle around the umbilicus.

Umbilical hernias are common in neonates and can resolve spontaneously. They can also occur in older adults.

165
Q

What are Epigastric Hernias

A

An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).

166
Q

What is Spigelian Hernias

A

A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain. There may not be a noticeable lump.

An ultrasound scan can help establish the diagnosis.

Spigelian hernias generally have a narrower base, increasing the risk of incarceration, obstruction and strangulation.

167
Q

What is Obturator Hernias

Presentation

DIagnosis

A

Obturator hernias are where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis. They occur due to a defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries. They are often asymptomatic but may present with irritation to the obturator nerve, causing pain in the groin or medial thigh.

Howship–Romberg sign refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve.

It can also present with complications of:

  • Incarceration
  • Obstruction
  • Strangulation

CT or MRI of the pelvis can establish the diagnosis. It may be found incidentally during pelvic surgery.

168
Q

WHat is Hiatus Hernias

A

An hiatus hernia refers to the herniation of the stomach up through the diaphragm. The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place. A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus.

169
Q

There are four types of hiatus hernia:

A

Type 1: Sliding

Type 2: Rolling

Type 3: Combination of sliding and rolling

Type 4: Large opening with additional abdominal organs entering the thorax

170
Q

WHat is sliding and rolling hiatus hernia

A

Sliding hiatus hernia is where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax.

Rolling hiatus hernia is where a separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus

171
Q

Hiatus hernias present with dyspepsia (indigestion), with symptoms of

A

Heartburn

Acid reflux

Reflux of food

Burping

Bloating

Halitosis (bad breath)

172
Q

Hiatus hernias can be intermittent, meaning they may not be seen on investigations. Hiatus hernias may be seen on

A

Chest x-rays

CT scans

Endoscopy

Barium swallow testing

173
Q

Hiatus hernia

Treatment is either:

A
  • Conservative (with medical treatment of gastro-oesophageal reflux)
  • Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment

Surgery involves laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

174
Q

WHat are stomas

A

Stomas are artificial openings of a hollow organ (for example the bowel). The bowel or urinary system is artificially opened onto the surface of the abdomen, allowing faeces or urine to drain, bypassing the distal portions of the bowel or urinary tract. A specially adapted bag (stoma bag) is fitted around the stoma to collect the waste products and is emptied as required.

175
Q

WHat is a colostomy

A

A colostomy is where the large intestine (colon) is brought onto the skin. Colostomies drain more solid stools, as much of the water is reabsorbed in the remaining large intestine. They can be flatter to the skin (compared with ileostomies which have a spout), as the solid contents are less irritating to the surrounding skin. They are typically located in the left iliac fossa (LIF).

176
Q

What is ileostomy

A

An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin. Ileostomies drain more liquid stools, as the fluid content is normally reabsorbed later, in the large intestine. They have a spout, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin. They are typically located in the right iliac fossa (RIF).

177
Q

What is a gastrostomy

A

A gastrostomy involves creating an artificial connection between the stomach and the abdominal wall. This can be used for providing feeds directly into the stomach in patients that cannot meet their nutritional needs by mouth. Percutaneous endoscopic gastrostomy (PEG) refers to when the gastrostomy is fitted by an endoscopy procedure

178
Q

What is a urostomy?

A

A urostomy involves creating an opening from the urinary system onto the skin. They have a spout and are typically located in the right iliac fossa (RIF).

All patients with stomas should have training on how to manage the stoma and have regular follow-up with a specialist stoma nurse.

179
Q

What is a End Colostomy / End Ileostomy

A

An end colostomy is created after the removal of a section of the bowel, where the end part of the proximal portion of the bowel is brought onto the skin. Faeces are able to drain out of the end colostomy into a stoma bag. The other open end of the remaining bowel (the distal part) is sutured and left in the abdomen. It may be reversed at a later date, where the two ends are sutured together creating an anastomosis.

End colostomies are permanent after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed. These are usually located in the lower left abdomen.

End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus), for example in the treatment of inflammatory bowel disease or familial adenomatous polyposis (FAP). An alternative to this is to create an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back on itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion.

180
Q

What is Loop Colostomy / Loop Ileostomy

A

A loop colostomy or loop ileostomy is a temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery. They may be called a “covering” or “defunctioning” loop colostomy or ileostomy, as they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function. They are usually reversed around 6-8 weeks later. The bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle.

“Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto the skin. The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin. This distal end is flatter. This allows you to distinguish between the proximal and distal portions of the bowe

181
Q

Stomas have a number of possible complications:

A
  • Psycho-social impact
  • Local skin irritation
  • Parastomal hernia
  • Loss of bowel length leading to high output, dehydration and malnutrition
  • Constipation (colostomies)
  • Stenosis
  • Obstruction
  • Retraction (sinking into the skin)
  • Prolapse (telescoping of bowel through hernia site)
  • Bleeding
  • Granulomas causing raised red lumps around the stoma
182
Q

The risk factors for gallstones can be remembered with the four F’s mnemonic:

A

F – Fat

F – Fair

F – Female

F – Forty

183
Q

What does fatty food exacerbate biliary colic

A

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction. Exams may test this mechanism, so it is worth remembering.

184
Q

Raised bilirubin (jaundice) with pale stools and dark urine could suggest

A

obstruction

. Obstruction may be caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g., cholangiocarcinoma or tumour of the head of the pancreas).

185
Q

A raised ALP is consistent with

A

biliary obstruction in presence of right upper quadrant pain and/or jaundice

Raised alkaline phosphatase can also be caused by liver or bone malignancy, primary biliary cirrhosis, Paget’s disease of the bone and many other things.

186
Q

In patients with _______ (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).

A

In patients with cholestasis (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”).

187
Q

If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with _________ _______

A

If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (“a hepatitic picture”).

188
Q

FIrst line for gallstones

A

US

Ultrasound can be helpful in identifying:

  • Gallstones in the gallbladder
  • Gallstones in the ducts
  • Bile duct dilatation (normally less than 6mm diameter)
  • Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder)
  • The pancreas and pancreatic duct
189
Q

What is Magnetic Resonance Cholangio-Pancreatography

A

A magnetic resonance cholangio-pancreatography (MRCP) is an MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy.

MRCP is used in a number of scenarios for gaining a detailed picture of the biliary system, such as identifying biliary strictures or congenital abnormalities.

With gallstone disease, MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.

190
Q

WHat is Endoscopic Retrograde Cholangio-Pancreatography

A

An endoscopic retrograde cholangio-pancreatography (ERCP) involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system.

The main indication for ERCP is to clear stones in the bile ducts.

ERCP allows the operator to:

  • Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
  • Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
  • Clear stones from the ducts
  • Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
  • Take biopsies of tumours
191
Q

Key complications of ERCP are

A

Excessive bleeding

Cholangitis (infection in the bile ducts)

Pancreatitis

192
Q

What is Cholecystectomy

Complications

A

Cholecystectomy involves surgical removal of the gallbladder. It is indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis). Stones in the bile ducts can be removed before (by ERCP) or during surgery.

Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision), as it has less complications and a faster recovery.

Complications of cholecystectomy include:

  • Bleeding, infection, pain and scars
  • Damage to the bile duct including leakage and strictures
  • Stones left in the bile duct
  • Damage to the bowel, blood vessels or other organs
  • Anaesthetic risks
  • Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
  • Post-cholecystectomy syndrome
193
Q

What is Post-cholecystectomy syndrome

Symptoms

A

Post-cholecystectomy syndrome involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include:

  • Diarrhoea
  • Indigestion
  • Epigastric or right upper quadrant pain and discomfort
  • Nausea
  • Intolerance of fatty foods
  • Flatulence
194
Q

What is Acute cholecystitis

A

Acute cholecystitis refers to inflammation of the gallbladder, which is caused by a blockage of the cystic duct preventing the gallbladder from draining. It is a key complication of gallstones, and the majority of cases (around 95%) are caused by gallstones (calculous cholecystitis). Gallstones may be trapped in the neck of the gallbladder or in the cystic duct.

In a small number of cases, the dysfunction in gallbladder emptying is caused by something other than gallstones (acalculous cholecystitis). One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

195
Q

The main presenting symptom of cholecystitis is pain in the right upper quadrant (RUQ). This may radiate to the right shoulder.

Other features include:

A

Fever

Nausea

Vomiting

Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)

Right upper quadrant tenderness

Murphy’s sign

Raised inflammatory markers and white blood cells

196
Q

How do you perform Murphy’s sign

A
  • Place a hand in RUQ and apply pressure
  • Ask the patient to take a deep breath in
  • The gallbladder will move downwards during inspiration and come in contact with your hand
  • Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
    *
197
Q

The first step is an abdominal ultrasound scan. Signs of acute cholecystitis on ultrasound are:

A
  • Thickened gallbladder wall
  • Stones or sludge in gallbladder
  • Fluid around the gallbladder

Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

198
Q

Patients with suspected acute cholecystitis need emergency admission for investigations and management.

Conservative management involves:

A
  • Nil by mouth
  • IV fluids
  • Antibiotics (as per local guidelines)
  • NG tube if required for vomiting

Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct.

Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.

199
Q

Complications of acute Cholecystitis

A

Sepsis

Gallbladder empyema

Gangrenous gallbladder

Perforation

200
Q

What is Gallbladder Empyema

A

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options:

  • Cholecystectomy (to remove the gallbladder)
  • Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)
201
Q

What is Acute cholangitis

Main causes

A

Acute cholangitis is infection and inflammation in the bile ducts. It is a surgical emergency and has a high mortality due to sepsis and septicaemia.

There are two main causes of acute cholangitis:

  • Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct)
  • Infection introduced during an ERCP procedure
202
Q

Acute Cholangitis

Most common organisms

A

The most common organisms are:

  • Escherichia coli
  • Klebsiella species
  • Enterococcus species
203
Q

Acute cholangitis presents with Charcot’s triad:

A

Right upper quadrant pain

Fever

Jaundice (raised bilirubin)

204
Q

Management of Acute Cholangitis

A

Patients need acute management of sepsis and acute abdomen, including:

  • Nil by mouth
  • IV fluids
  • Blood cultures
  • IV antibiotics (as per local guidelines)
  • Involvement of seniors and potentially HDU or ICU

An endoscopic retrograde cholangio-pancreatography (ERCP) is required to remove stones blocking the bile duct. It involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. A number of procedures can be performed during an ERCP:

  • Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system
  • Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
  • Stone removal: a basket can be inserted and pulled through the common bile duct to remove stones
  • Balloon dilatation: a balloon can be inserted and inflated to treat strictures
  • Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours)
  • Biopsy: a small biopsy can be taken to diagnose obstructing lesions

Percutaneous transhepatic cholangiogram (PTC)

involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction. This is an option for patients that are less suitable for ERCP, or where ERCP has failed.

205
Q

The three key causes of pancreatitis to remember are:

A

Gallstones

Alcohol

Post-ERCP

206
Q

I GET SMASHED is a popular mnemonic for remembering a long list of causes of pancreatitis:

A

I – Idiopathic

G – Gallstones

E – Ethanol (alcohol consumption)

T – Trauma

S – Steroids

M – Mumps

A – Autoimmune

S – Scorpion sting (the one everyone remembers)

H – Hyperlipidaemia

E – ERCP

D – Drugs (furosemide, thiazide diuretics and azathioprine)

207
Q

Acute pancreatitis typically presents with an acute onset of:

A

Severe epigastric pain

Radiating through to the back

Associated vomiting

Abdominal tenderness

Systemically unwell (e.g., low-grade fever and tachycardia)

208
Q

Acute pancreatitis

Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score:

A

Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score:

  • FBC (for white cell count)
  • U&E (for urea)
  • LFT (for transaminases and albumin)
  • Calcium
  • ABG (for PaO2 and blood glucose)

Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function.

Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase.

C-reactive protein (CRP) can be used to monitor the level of inflammation.

Ultrasound is the initial investigation of choice in assessing for gallstones.

CT abdomen can assess for complications of pancreatitis (such as necrosis, abscesses and fluid collections). It is not usually required unless complications are suspected (e.g., the patient is becoming more unwell).

209
Q

The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present:

A

0 or 1 – mild pancreatitis

2 – moderate pancreatitis

3 or more – severe pancreatitis

210
Q

The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):

A

P – Pa02 < 8 KPa

A – Age > 55

N – Neutrophils (WBC > 15)

C – Calcium < 2

R – uRea >16

E – Enzymes (LDH > 600 or AST/ALT >200)

A – Albumin < 32

S – Sugar (Glucose >10)

211
Q

Management of Acute Pancreatitis

A

Patients with acute pancreatitis can become very unwell rapidly. They require admission to supportive management. Moderate or severe cases should be considered for management on the high dependency unit (HDU) or intensive care unit (ICU).

Management involves:

  • Initial resuscitation (ABCDE approach)
  • IV fluids
  • Nil by mouth
  • Analgesia
  • Careful monitoring
  • Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
  • Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
  • Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)

Most patients will improve within 3-7 days.

212
Q

Complications of Acute Pancreatitis

A

Necrosis of the pancreas

Infection in a necrotic area

Abscess formation

Acute peripancreatic fluid collections

Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis

Chronic pancreatitis

213
Q

Chronic Pancreatitis

Key complications are:

A
  • Chronic epigastric pain
  • Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
  • Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
  • Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
  • Formation of pseudocysts or abscesses
214
Q

Management of Chronic Pancreatitis

A

Abstinence from alcohol and smoking is important in managing symptoms and complications.

Analgesia can be used to manage the pain, although it can be severe and difficult to manage.

Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins.

Subcutaneous insulin regimes may be required to treat diabetes.

ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct.

Surgery may be required by specialist centres to treat:

  • Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue)
  • Obstruction of the biliary system and pancreatic duct
  • Pseudocysts
  • Abscesses
215
Q

What is living donor transplant.

A

The liver can regenerate as an organ. Therefore, it is possible to take a portion of the organ from a living donor, transplant it into a patient and have both regenerate to become two fully functioning organs. This is known as a living donor transplant.

216
Q

Indications for a liver transplant

A

Indications for liver transplant can be split into two categories: acute liver failure or chronic liver failure. They may also be used in specific cases of hepatocellular carcinoma.

Acute liver failure usually requires an immediate liver transplant, and these patients are placed on the top of the transplant list. The most common causes are acute viral hepatitis and paracetamol overdose.

Chronic liver failure patients can wait longer for their liver transplant and are put on a standard transplant list. It is normal for it to take around 5 months for a liver to become available.

217
Q

The British Society of Gastroenterologists provides guidelines on liver transplantation (2019), including when to refer and the contraindications.

Contraindications include:

A

Significant co-morbidities (e.g., severe kidney, lung or heart disease)

Current illicit drug use

Continuing alcohol misuse (generally 6 months of abstinence is required)

Untreated HIV

Current or previous cancer (except certain liver cancers)

218
Q

The liver transplant surgery is carried out in a specialist transplant centre. It involves a ______ or _______ ______ incision along the lower costal margin for open surgery. The liver is mobilised away from the other tissues and excised. The new liver, biliary system and blood supply is then implanted and connected.

A

The liver transplant surgery is carried out in a specialist transplant centre. It involves a “rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery. The liver is mobilised away from the other tissues and excised. The new liver, biliary system and blood supply is then implanted and connected.

219
Q

Post-Transplantation Care

Patients will require lifelong immunosuppression (e.g., steroids, azathioprine and tacrolimus) and careful monitoring of these drugs. They are required to follow lifestyle advice and require monitoring and treatment for complications:

A

Avoid alcohol and smoking

Treating opportunistic infections

Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis)

Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients

220
Q

Monitoring for evidence of transplant rejection:

A

Abnormal LFTs

Fatigue

Fever

Jaundice

221
Q
A

Diseases (40 decks)

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