Gastroenterology

Question 1

Bowel obstruction

• Symptoms
• complications
• investigations
• management/treatment

Answer 1

Symptoms - vomiting, abdominal distention, extreme crampy pain (sometimes constipation)
Signs - hyperactive tinkling bowel sounds, tenderness
Invest - AXray, Erect CXray, CT, Labs - electrolyte
Management - IV fluids, antibiotics, analgesia
-NG tube - suction, Nil by mouth
Surgical - bowel resection - if strangulation present
Endoscopic stenting - palliation, or before surgery

OTHER INFO
Common causes - SBO - adhesions, hernias
LBO - colon cancer, constipation, volvulus
Management general - cause, site, speed of onset, completeness of obstruction
1. NGT tube (suction of fluids), IV fluids
2. Analgesia (morphine) + Inv
3. Catheterise to monitor fluid status
-antibiotics can be given if surgically operating or risk of rupture

Diagnose

• Xray (dilated fluid filled bowel and a transition zone at site of obstruction)
• CT - to see cause

Complications –> perforation –> sepsis
Normal SB - 3.5cm , vavluae go full way across
Normal LB - 5.5cm - haustra extend a third across
Sigmoid volvulous - older patients, large dilated bowel loops + coffee bean sign

Question 2

Ulcerative colitis

Answer 2

General - continuous inflammation starts at rectum, damages mucosa and submucosa, associated with many other autoimmune conditions - PSC, arthritis ect, smoking increases risk. Diagnosis - colon biopsy

Question 3

Cholelithiasis - Symptoms
Diagnosis
Treatment

Answer 3

Cholelithiasis - Gallstones

• Colicy RUQ pain, radiates to the shoulder , worse with fatty foods (more contraction of the gall bladder)
• Diagnosis - US
• Treatment - cholecystectomy - done when patient want
• Non surgical - ursodeoxycholic acid

Question 4

Cholecystitis

• symptoms
• diagnosis
• treatment

Answer 4

Cholecystitis - inflamed gall bladder (due to stone stuck in duct) - get inflammation

Symptoms - constant RUQ pain
Postitive murphys sign
inflammation - mild fever, mild leukocytosis
(pain will no longer be colliky, it will be constant)

Diagnosis - RUQ ultrasound - looking for
-Pericholecystic fluid
-thickened wall
-gallstones
–> if doesnt show this - then get hydroscan
(hydroscan looks at perfusion) - failure for gallbladder to fill

Treatment
-Nil by mouth, IV fluids, IV antibiotics , cholecystetctomy - urgent (dont want gall bladder perforated, and harder to see where stone is with time)
Non-surgical canditate - cholecystectomy (drain fluid)

Question 5

Choledocolethiasis

Answer 5

• If stone is at ampula vater, then can cause liver, pancrease and gall bladder inflammation due to blockage
• Inflammation of liver - AST, ALT
• Pancreatitis - elevated amylase and lipase
• get dilation of the duct, get bile backflow - jaundice

Cause - gallstones in common bile ducts

• can get pancreatitis, hepatitis, but will definitely have jaundice
• Painful jaundice = gallstone
• positive murphys sign
• inflammation - mild fever and leukocytosis

Diagnosis - RUQ ultrasound - look for dilated ducts (if this is negative with symptoms) –> get MRCP

treatment -NPO, IV Fluids, antibiotics
urgent ERCP or straight to cholecystectomy (but this is electively when patient wants it) - or Gastroenterologist can go with a scope and do a sphincterotomy and pull out the stones and then later on surgeon does cholecystecotomy

-can get a stone going up and down and this can get some days LFT elevated, and some days not

Question 6

Cholangitis

Answer 6

-similar to above, but have stagnant fluid - and get an infection
-gallstone in CBD with infection
Infection - from gut flora - gram negative rods, anerobes

Patient presents with RUQ pain, Jaundice, and fever –> Charcots triad

-if they have hypotension and altered mental statis –> reynolds pentad

Diagnosis - RUQ ultrasound - dilated ducts,

• -> Need stone to be removed asap by ERCP - emergently
• then cholecystectomy - either urgently or electively

IV fluids
IV antibiotics
NPO

Question 7

What antibiotics to use for above - gallbladder

Answer 7

Need to cover gram negative rods and anaerobes

In script app - amoxicillin + getamicin

Ciprofloxacin + metronidazole
ampycillin + genatmicin + metronidazole
-Dont pick Pip-taz - expensive - also covers gram positives

Question 8

What antibiotics for a non-neutropenic sepsis

Answer 8

Augmentum + gentamicin

or Ceftriaxone if allergic to penicillin

Question 9

Peritonitis treatment

Answer 9

Amoxicillin + gent + metronidazole

Question 10

ESBL treatment

Answer 10

Meropenam

Question 11

Causes of Jaundice linked to cause

Answer 11

Prehepatic - Haemolysis main cause = unconjugated

Hepatic - mixed

Posthepatic - obstruction main cause (painless - cancer, stricture, PSC, PBS, painful - gallstones) - Conjugated