Gastroenterology Flashcards
Dyspepsia (new):
Management
>55 OR Anaemia Loss of weight Anorexia Recent onset Melaena/haematemesis Swallowing problems --> refer for upper GI endoscopy
H pylori regimes
PPI + 2 abx
PAC500
PMC250
Bd for 7 days
Review after 4w
Melaena:
Causes
Peptic ulcers Mallory-Weiss Varices Drugs (NSAIDs) Dudodenitis Malignancy
Appendicitis:
Presentation
Periumbilical pain moves to RIF (guarding, rebound) anorexia Vomiting Constipation Fever Tachycardia
Leukoplakia
Oral musical white patch
Does NOT rub off
Refer - premalignant
Oral hairy leukoplakia
Shaggy patch on sides of the tongue
In HIV
caused by EBV
Sliding hiatus hernia
GOJ slides up into chest
Reflux as LES becomes less competent
Diagnose - barium swallow
Tx - lose weight, treat reflux, surgery last line
Rolling hiatus hernia
GEJ remains in abdo, but stomach herniated into stomach alongside esophageal
Less common to have bad GORD
Diagnose - barium swallow
Tx - lose weight, GORD Tx, surgery last line
Pancreatitis:
Symptoms and signs
Gradual or sudden severe central abdominal pain Radiates to back Alleviated sitting forward Vomiting Tachycardia Fever Jaundice Rigid tender abdo Cullen's sign Grey Turners sign
Cullen’s sign
Peri umbilical bruising - sign of pancreatitis
Grey turners sign
Flank bruising - in pancreatitis
Pancreatitis:
Ix
Serum amylase >1000 (but can be normal) Serum lipase raised ABG - monitor O2 and acidosis AXR - no psoas shadow CXR - can exclude other causes eg perforation CT/MRI to assess severity ERCP is deteriorating LFTS
Pancreatitis:
Management
Fluids Analgesia Monitor closely ERCP + gallstone removal if progressive jaundice Retreat imaging to monitor progress
Pancreatitis:
Complications
Pancreatic necrosis +pseudocyst Access Bleeding/thrombosis Bowel fistulae Recurrent pancreatitis
Glasgow Criteria for pancreatitis
To assess severity PANCREAS
PaO2 55 Neutrophilia Calcium Renal function Enzymes Age Sugar
Ulcer pain relieved by eating
Duodenal
Skip lesions
Crohn’s disease
Painless jaundice+steatorrhea
Pancreatic cancer
Post-splenectomy vaccines
Hib Pneumococcal Meningococcal Pen V (2 years to life) Medicard
Peritonitis signs
T tenderness and tachycardia R reflex and rigidity A absent bowel sounds P pyrexia P percussion pain E extremely unwell R rovsing sign
Gout:
Acute management
NSAIDS (colchicine if ulcer etc)
Intraarticular steroid injection
Oral steroids if above CI
If already taking allopurinol then continue
Gout:
Allopurinol prophylaxis
Not until 2w after attack has settled
Initially 100mg then titration, aim for Uric acid
Gout:
Allopurinol indications
Recurrent attacks Tophi Renal disease Uric acid stones Prophylaxis if on gout causing meds
Ginigivitis:
Causes
Pregnancy
AML
Vit C deficiency
Phenytoin, cicoosporin, nifedipine
Gastric ulcer
Worse when eating, relieved by antacids
Weight loss
Need to biopsy if worried gastric ca
Duodenal ulcer
Same risk factors as gastric
Relieved by eating or drinking milk
Portal hypertension:
Causes
Prehepatic: thrombosis
Hepatic: cirrhosis, schistosomiasis
Post hepatic: buds chiari, right heart failure
Varicies:
Prophylaxis
Primary: propanalol, band ligation
Secondary: TIPS, banding
Varicies:
Acute bleed management
Fluid resus
Vit K if abnormal clotting, FFP, platelets
IVI terlipressin
Banding/ balloon compression
Hepatorenal syndrome
Cirrhosis+ascites+renal failure
Liver failure causes renal vasoconstriction even though all others are vasodilation
Spontaneous Bacterial Peritonitis
Sudden deterioration of patient with ascites
E. coli, klebsiella, strep
Broad spec ABx
Haemochromatosis:
Signs and symptoms
Tiredness Joint pain Grey skin Signs if liver disease Diabetes Hypogonadism
Haemochromatosis:
Blood results
Raised LFTS
Raised serum ferritin
High glucose
Primary billiary Cirrhosis:
Signs and features
Lethargy Pruritis ⬆️ alk phos AMA +ve Jaundice Pigmented skin Hepatosplenomegaly Hyperlipidaemia
Primary billiary cirrhosis:
Blood results
⬆alk phos ️⬆GGT️ Mildly⬆ AST, ALT ⬇️albumin ️⬆Billirubin ⬆PT, immunoglobulins, cholesterol
Primary billiary cirrhosis:
Management
Treat pruritis and diarrhea
Give vitamin DAK
Osteoporosis prophylaxis
Eventually liver transplant
PBC vs PSC
PSC affects intra and extra hepatic bile ducts
Only PBC has AMA
PSC 90% have IBD
PSC mainly men can also be children, PBC only adults
PSCcan cause various malignancies
Primary sclerosing cholangitis:
Features
Pruritis Fatigue Often IBD Liver disease Male Ascending cholangitis
Primary sclerosing cholangitis:
Blood results
⬆️alk phos
⬆️bilirubin
Hypergammaglobuminaemia
Primary sclerosing cholangitis:
Management
Management pruritis
Liver transplant for end stage
ABX for bacterial cholangitis
NAFLD:
Presentation
Middle aged Obese Women DM, dislipidaemia Amiodarone, methotrexate, tetracycline Raised LFTs with fatty liver on USS
Never proximal to ileocaecal valve
UC
Inflammation of entire colon
UC
UC:
Presentation
Diarrhoea +- blood, mucus
Cramps
Frequency/urgency/tenesmus
Attacks: fever, malaise, anorexia, weight loss
Aphthous ulcers
Conjunctivitis/episcleritis/arthritis/ank spond
Goblet cell depletion Mucosal ulcers Crypt abscesses Inflammatory infiltrate Mucosal thickening/islands
UC
AXR findings for UC
No face cal shadows
Mucosal thickening/islands
Colonic dilatation
Colonoscopy findings for UC
Inflammatory infiltrate Goblet feel depletion Glandular distortion Mucosal ulcers Crypt abscesses
Complications of UC
Toxic dilation
Venous thrombosis when inpatient
Malignancy - needs regular colonoscopy
UC:
Treatment
5ASAs - sufalazine
Steroids - pred (oral/suppositories for mild, enema mod)
IV hydrocortisone for severe (or rectal)
Ciclosporin or infliximab
Immunomodulation last line - azothiaprine, methotrexate
GI inflammation anywhere from mouth to anus
Crohns
Not continuous - areas of unaffected in between bowel inflammation - skip lesions
Crohns
Crohns:
Symptoms
Diarrhea Urgency Weight loss Fever malaise anorexia Aphthous ulcers Abdo tenderness Perianal abscess or fistula
Crohns:
Complication
Toxic dilatation Small bowel obstruction Access Fistulae Peroration Rectal haemorrhage Cancer
Barium enema findings for Crohns
Cobblestone
Rose thorn ulcers
Colon strictures
Crohns:
Treatment
Pred Or hydrocortisone if severe Metronidazole Infliximab Azothiaprine/sufalazine
Painless obstructive jaundice
Carcinoma of pancrea
No inflammation beyond submucosa
UC
Acute cholecysitis:
Presentation
Continuous epigastric or RUQ pain Vomiting Fever Local peritonitis GB mass
Acute cholecysitis vs billiary colic
AC is inflammatory - so raised WCC, fever, local peritonism
Murphys sign
Fingers over RUQ ask patient to breathe in, they stop breathing due to pain as inflamed gallbladder hits your fingers
Only positive if same in LUQ doesn’t hurt
+ve shows acute cholecysitis
Acute cholecysitis:
Ix
Bloods show raised WCC
USS shows thick walled shrunken GB, pericholecystic fluid, stones,
Acute cholecysitis:
Treatment
NBM
Pain relief
Broad spec eg cefuroxime
Chronic cholecysitis:
Presentation
Chronic inflammation Colic Flattening dyspepsia Abdo distention Fat intolerance
Billiary colic:
Presentation
RUQ pain radiating to back +-jaundice
Cholangitis:
Presentation
RUQ pain, jaundice, rigors
Billiary colic vs acute cholecysitis vs cholangitis
Billiary colic: RUQ pain
Acute cholecysitis: RUQ pain + fever⬆️WCC
Cholangitis: RUQ pain + fever⬆️WCC + jaundice
Boerhaave syndrome
HSevere vomiting –> esophageal rupture
Plummer-Vinson syndrome
Triad of
Dysphasia (from esophageal webs) + glossitis + IDA
Mesenteric ischemia:
Presentation
Elderly patient
Vascular history/risk factors
Abdo pain, rectal bleeding, diarrhea, fever
Metabolic acidosis
Rovsing sign
Pressing left lower quadrant causes pain in right lower quadrant
Appendicitis
Hirschprungs disease
failure of mesenteric plexus to develop
Neonate so fail/delay to pass meconium or older children constipated
More common in males and downs
Budd-Chiari syndrome
Hepatic vein thrombosis
Usually from haematological or coagulation disorder
E.g polycythaemia, pregnancy, COCP
Sudden severe abdo pain, ascites, tender hepatomegaly
Cholangiocarcinoma
Persistent biliary colic symptoms
Jaundice, anorexia, weight
Palpable gallbladder (Courvosier)
Kantors string sign
Crohns
Gallstones ileus
Small bowel obstruction secondary to impacted gallstone
Abdo pain, distention, vomiting +- hx of gallstones
Most common travelers diarrhea
Watery stools
Cramps and nausea
E. coli
Infective diarrhea, prolonged non bloody
Giardia
Infective diarrhea
Bloody diarrhea, vomiting and Abdo pain
Shigella
Infective diarrhoea
Flu symptoms then cramps Abdo pains, fever, diarrhoea
Can cause GBS
Campylobacter
C diff treatment
Metronidazole
Barium enema with loss of hays teal markings creating lead pipe colon
Ulcerative colitis
