Gastroenterology Flashcards
What is Rovsing’s sign and what does it indicate?
Palpation of LLQ increases pain in RLQ
Indicates appendicitis
How does Wilson’s disease usually present? (Age + 3 features)?
Excessive copper deposition
Presents age 10-25
(Autosomal recessive)
Hepatitis, speech/ behaviour problems, haemolysis, blue nails, asterixis (flapping tremour), chorea (kerky movements)
- Liver + neuro signs = think Wilsons
What triad of features are seen in acute liver failure?
Encephalopathy
Jaundice
Coagulopathy
What is an important complication of primary sclerosing cholangitis?
Cholangiocarcinoma (jaundice, weight loss and biliary symptoms) - 10% of all those with PSC
A 25-year-old female currently under investigation for secondary amenorrhoea presents with jaundiced sclera. On examination spider naevi are present along with tender hepatomegaly. Blood tests show: Hb 11.6 g/dl Plt 145 * 109/l WCC 6.4 * 109/l Albumin 33 g/l Bilirubin 78 µmol/l ALT 245 iu/l What is the most likely diagnosis?
Autoimmune hepatitis
The combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest autoimmune hepatitis
What are the histological findings in coeliac disease?
Villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia
What is Gilberts syndrome?
Autosomal recessive
Unconjugated hyperbilirubinemia
Reduced glucuronyltransferase
What is Virchow’s node?
Swollen LN in left supraclavicular region
- Indicates gastric cancer
You suspect bowel obstruction, what investigations must be done as a minimum?
AXR
PR exam
What is primary sclerosing cholangitis?
Fibrosis of intra and extrahepatic ducts, possibly autoimmune
- Associated with UC (80%)
What investigations could be done for suspected PSC? (3)
US then MRCP
pANCA may be +ve
LFT’s (obstructive)
What triad is typically seen in mesenteric ischemia?
CVD - look for AF
Poorly localised abdo pain (worse than exam would suggest)
Vomiting or diarrhoea
(High lactate)
What advice is given to patients awaiting OGD regarding their PPI’s?
Stop 2 weeks before gastroscopy
What antibody is highly specific for primary billiary sclerosis?
anti-Mitochondrial antibody
M’s (mitochondrial ab, Middle aged women, IgM)
What are the two hepatitis A antibodies and what do they show?
Hep A IgM = Current infection
Hep A IgG = Past infection or vaccination
(think G=gone)
Which blood test can be used to look for current hepatitis B?
HBsAg
(HBs antigen = acute disease)
HBeAg is a marker of infectivity
Also anti-HBc MAY be +ve
What are the two main antibodies seen in hepatitis B, what do they each show?
Anti-HBs = Immunity (either infection or vaccine)
Anti-HBc = Previous or current infection
C is CORE so will only be infection, not vaccination
A healthcare professional has been vaccinated against Hep B but never had the disease, what will a hep B screen show?
Anti-HBs = +ve Anti-HBc= -ve (shows current/ past infection) HBsAg = -ve (shows current infection) HBeAg = -ve (shows current infectivity)
A patient has previous had Hep B and is now immune, what will their bloods show? (Assuming no current active disease)
Anti-HBs = +ve Anti-HBc = +ve HBsAg = -ve HBeAg = -ve
How do you manage Hep A?
rest, fluids, anti-emetics
Stop alcohol and paracetamol
Recovery 3-6months
How do you manage Hep B?
(as Hep A) +
- No intercouse til non-infective
- If HBeAg +ve then give peginterferon alpha for a year
Symptoms resolve in 4-8 weeks (10% become chronic)
How do you manage Hep C?
Supportive as A/B
+ Peginterfron alpha and ribavarin
85% become chronic
What serology can be checked for Hep C, what does each indicate?
Anti-HCV = Current or recovered infection
HCV RNA = Active infection (the ones to be treated)
Name 5 symptoms of hepatitis?
Malaise Weakness Pruritus Jaundice (dark urine + pale stools) Anorexia Hepatomegaly
How does coeliac disease usually present? (5)
Abdo pain Bloating Diarrhoea FTT or weight loss Fatigue Frothy or fatty stools
Anaemia/ vit deficiency/ low ferritin all possible
What investigations can be done for coeliac disease?
TTG and endomyseal antibody (on gluten for at least 6 weeks prior)
Jejunal biopsy to confirm
How should coeliac be managed (what foods to avoid + any other)?
Avoid wheat (bread, pasta, pastry, barley etc)
Vaccines for flu and pneumococcal
Name 2 investigations which could be done for hepatocellular carcinoma?
USS
AFP bloods
(these are done to screen all high risk groups)
What three tests can help diagnose Wilsons disease?
Reduced serum caeruloplasmin
Reduced serum copper
Increased 24 urinary copper excretion
What is used to manage Wilsons disease?
Penicillamine
trientine hydrochloride may become first line soon
What is the most common type of PUD? Name 3 risk factors
DU are 4x more common than GU (GU most common only in elderly)
- H.pylori (95% DU and 80%GU)
- NSAIDS or steroids
- Smoking, alcohol, stress
A patient presents with dyspepsia, name 5 red flags which would warrant a 2ww OGD?
A- Anorexia L- Loss of weight A- Anaemia R- Recent onset <55yrs M- Melena/ haematemesis S- Swallowing difficulty
How should new dyspepsia in a 50year old male be managed? (First 3 steps)
1) Lifestyle (OTC antacids, avoid NSAIDS, alcohol etc)
+ 4 week course of PPI
+ test for H.Pylori
2) If +ve for h.pylori treat with triple therapy AND test for eradication with urea breath test at 6-8weeks post tx
3) If still present after 8 weeks consider endoscopy
A patient has an ulcer, likely causes by NSAIDS, how long should it take to heal with lanzoprazole and stopping of the NSAID?
Around 8 weeks
What is initial tx for a mild-moderate flare up of UC? (4points)
1) Oral ASA (Mesalazine)
- Consider adding topical aminosalicylate OR oral steroid depending on patient preferences (or if more moderate)
2) Oral pred if ASA’s not tolerated or CI (add if no improvement within 4 weeks or if syx worsen despite tx)
What is the initial management of a severe flare up of UC?
Admit, NBM and IV hydration
+ IV hydrocortisone
+ rectal hydrocortisone
(if improvement in 5 days transfer to oral pred)
What is first, second and third line management to maintain remission in UC?
1) 5ASA (mesalazine)
2) Azathioprine
3) Biologics
A patient with UC has a flare up restricted, how do you manage?
1) PR Mesalazine
- Can add PR steroid
Name two general measures with regard to Crohns management?
1) Smoking cessation key
2) Avoid anti-diarrhoeals in acute episodes (toxic megacolon)
What are the first 3 lines of crohns maintainance management?
1) Azathioprine (>2 flare ups per year or relapse on steroid therapy)
2) Mercaptopurine or methotrexate
3) BIologics
How do you manage a mild to moderate flare up of crohns disease?
Oral pred (40mg/d for 1wk then taper over 7 weeks)
How do you manage severe flares of Crohns?
Admit, NBM and IV hydration
+ IV hydrocortisone
+ rectal hydrocortisone
(if improvement in 5 days transfer to oral pred)
How are flare ups of UC classified? (Truelove and Witt’s)
Mild: <4 stools, no systemic disturbance, normal ESR and CRP
Moderate: 4-6 stools/day, minimal systemic disturbance
Severe: >6 stools a day, systemic disturbance
Where does pain tend to occur for each type of IBD?
Crohns = LRQ UC = LLQ
What histological features characterise each type of IBD?
Crohns = Granuloma’s and increased goblet cells
UC = Cryptitis and crypt abscess’
What complications tend to characterise each type of IBD?
Crohns = Strictures, fistula’s, perianal disease
UC = Toxic megacolon, colorectal cancer more likely
What diseases are associated with each type of IBD?
Crohns = Ank spond, polyarthritis, erythem nodosum
UC = Primary sclerosing cholangitis and uveitis
Name 3 things which are risk factors for both crohns and UC?
FHx NSAID use High fat diets Oral contraceptives Hygiene hypothesis
What is the peak diagnosis age for both UC and crohns?
15-30
You suspect a patient has IBD, what investigations should be performed? (5)
- FBC, CRP, U+E, LFT
- Iron/ B12/ folate (low more likely crohns)
- Calprotectin (distinguish IBS/IBD)
- Stool culture and microscopy (?infective cause)
How is perianal disease managed in Crohns?
MRI and exam under GA
Tx: Oral AB’s, immunosuppresion, local surgery +/- seton stitch insertion
What are the criteria for diagnosing IBS?
At least 6 months of (abdo pain or bloating or altered bowel habit)
- Relieved by defecation OR be with altered bowel frequency
PLUS 2 of:
- Altered passage
- Bloating, distension or tenderness
- Symptoms worse on eating
- Passage of mucus
What aspect of FHx should always be covered when suspecting IBS?
Ensure you always ask about FHx of CRC, as a +ve history of family member <50 should lower the threshold for referral and investigation.
Weight loss IS NOT a feature of IBS
What investigations should be performed for a patient meeting the IBS criteria?
FBC (normal) ESR and CRP (normal, raised could be IBD) Coeliac screen CA-125 Feacal calprotectin
Name 5 management options in IBS
Regular meals (avoid long gaps)
Lots of fluids, restrict caffeine, alcohol, fizzy drinks
Limit high fibre food
Limit FODMAP foods (85% report improvement after reducing)
Diarrhoea: Loperamide
Constipation: Senna
Spasm pain: Buscapan/ pepermint oil
How does GORD typically present?
Heartburn (burning from stomach to lower chest/ neck), related to meals
Lying down or straining makes symptoms worse
Acid or bitter taste in mouth
- Possible excessive salvia and odynophagia
What is Barrett’s oesophagus?
Chronic acid reflux leads to change from squamous to columnar epithelium
What is the most common cancer following GORD and Barrett’s?
Adenocarcinoma
Name 5 indications for endoscopy in a patient presenting with GORD?
New in >55yrs A- Anaemia L- Loss of weight A- Anorexia R- Recent onset/ progessive ( M- Masses S- Swallowing difficulty
Name 3 conservative measures to treat GORD?
Weight loss
Smoking cessation
Small regular meals instead of large ones
Avoid hot drinks, alcohol, spicy foods and fizzy drinks
Don’t eat <3hrs before bed
How should GORD be managed medically?
Full dose PPI for one month
+ gaviscon
If no resolution (post endoscopy to r/o serious cause)
1) Up PPI dose
2) Add ranitidine
How should Barrett’s Oesophagus be managed?
If no pre-malignant change: - High dose PPI - Regular endoscopy (1-3yrs) If pre-malignant change: - Oesophageal resection
Name 4 risk factors for oesophageal cancer?
GORD Diet (nitrosamines) Alcohol excess Smoking Achalasia
What is a hiatus hernia?
Herniation of part of the abdominal viscera (most commonly stomach) through the oesophageal aperture in the diaphragm
How does a hiatus hernia usually present, what’s the best way to investigate it?
Presents similar to GORD
Investigate with endoscopy
How should hiatus hernia be managed?
As GORD
Emphasis on weight loss
> Can consider surgery in some cases
What is the most common abdominal wall hernia? What groups is it most common in?
75% are inguinal hernia’s
95% of hernia’s are in men, meaning males have 25% lifetime risk
Name 5 risk factors for an inguinal hernia?
(Increased pressure or weakness of wall)
- Chronic cough
- Constipation
- Heavy lifting
- Old age
- Obesity
How do inguinal hernia’s most commonly present?
Commonly painless swelling in groin which develops over time
- May come and go, i.e. after heavy lifting or straining
Syx can include:
- Pain when coughing
- Change in bowel habit (constipation)
- Burning sensation
- Scrotal swelling
How are inguinal hernias managed?
Surigcal (open or laproscopic)
- To prevent obstruction (bowel contents), strangulated (blood flow) or incarceration (can’t be pushed back)
Which hernia’s are most likely to experience strangulation? What group are they most common in?
Femoral (as femoral canal is very tight)
More common in females
Coeliac disease pre-disoposes to what malignancy?
Enteropathy-associated T cell lymphoma (EATL)
What is the most common cause of liver disease worldwide?
NAFLD
What are the stages of NAFLD?
Thought to be linked to insulin resistance
- Steatosis
- Steatohepatitis
- Fibrosis and cirrhosis
What blood test is used to diagnose NAFLD?
ELF (a triple test similar to that for downs)
How is NAFLD treated?
Weight loss and other lifestyle changes
Which antibiotics most commonly caused c.diff?
Clindamycin Cephalosporins - Ceftriaxone, cefataxime Fluroquinolones - Ciprofloxacin Penicillins
First two lines of c.diff treatment?
Oral metronidazole (10-14days) - No improvement give oral vancomycin
If severly unwell IV metronidazole + oral vanc
Name 3 differences between a colostomy and an ileostomy on examination?
Colostomy in LIF, Ileostomy in RIF
Colostomy usually has solid faeces, ileostomy usually liquid
Colostomies are flush to the skin, ileostomies are spouted
How do you distinguish between an ileostomy and a urostomy?
Bag contains urine not faeces in a urostomy
Both are in RIF, both are spouted
Name 3 presenting features of a pancreatic ca?
Painless, progressive, obstructive jaundice (dark urine, pale stools, pruritus).
May have epigastric discomfort of RUQ mass
A px had suspect pancreatic ca, what investigations would you perform?
Obs
BB - CA19-9 (+FBC, LFT, U+E) - could also do pancreatic enzymes/ glucose (insulin etc)
I- USS followed by staging CT
How is pancreatic ca treated?
Surgical only
Adj chemo can be used
What are the most common causes of pancreatitis?
Gallstones
Alcohol
Idiopathic
ERCP
How does pancreatitis most commonly present?
Severe epigastric/ upper abdominal pain which penetrates through to the back
Prominent vomiting
Dehydration
Tachycardia, jaundice (if alcohol or gallstones cause), mild fever, hypoxia
Name two eponymous signs associated with pancreatitis?
Grey turners sign - Bilateral flank blue discolouration
Cullens sign- Periumbilical blue discolouration
Both seen in hemorrhagic pancreatitis
What investigations would you do if suspecting a patient has pancreatitis?
Obs
B- ECG (r/o MI), ABG (hypoxia common)
B- Amylase (3x UL), CRP (WCC, Ca, LFT, Glucose for Glasgow score)
I- Start with USS (gallstones) then do abdo CT
D- MI, obstruction, AAA
What scoring systems can be used for pancreatitis?
Glasgow Prognostic Score
(acronym is PANCREAS)
(Any score over 3 needs transfer to HDU or ITU)
What are your first three management steps for acute pancreatitis?
ABCDE R- Refer ITU if Glasgow score >3 O- Regular (hourly) obs C- NBM M- Fluids, analgesia (morphine), NG tube, catheter to monitor UO S- ERCP and gallstone removal if needed If CT shows abscess may need debridement
Name 3 indications to do an ERCP?
Gallstones in common bile duct Acute pancreatitis due to gallstones Diagnosis of pancreatic or biliary malignancy Stent insertion in chronic pancreatitis Dilation of benign strictures
How is chronic pancreatitis managed?
C- Supportive (lifestyle cutting down alcohol etc)
M- Analgesia (paracetamol and NSAID to start)
Pancreatic enzyme supplementation if needed
S- ERCP to dilate strictures
What investigations are performed for suspected chronic pancreatitis?
Secretin stimulation test
MRCP
Standard bloods etc
How is ERCP performed?
Sedation but no GA
Endoscope down throat, find ampulla
Dye injected so images can be taken
Now also theraputic (lithotripsy, ballooning etc.)
How does diverticular disease present?
Lower left abdo pain
Exacerbated by eating, relieved by flatus
Bloating, constipation and rectal bleeding all possible
How should suspected diverticular disease be investigated and managed?
I: Colonoscopy
M: High fibre diet, bulk forming laxatives, paracetamol for pain
A 60yoM patient presents with LLQ pain, fever, tachycardia, localised tenderness and N+V. What is your top differential and what investigations would you like to perform?
Diverticulitis
Investigations:
- Obs
- BB (FBC, U+E, LFT)
- I (Upright CXR to exclude pneumoperitoneum), AXR and possible CT with contrast
- D (If red flag symptoms consider endoscopy but not otherwise)
How is diverticulitis managed?
R- Admit if (Severe pain, can’t hydrate with fluids or oral AB’s not tolerated, frail, bleeding etc)
O- Obs for baseline
C- Hydration
M- Analgesia (paracetamol) and AB’s 7 days (Co-Amoxiclav)
Liver cancer or metastasis is commonly associated with what paraneoplastic syndrome? How does it present and what investigation is done?
Carcinoid tumours (release serotonin)
Presentation: Flushing, diarrhoea, weight loss
Investigate: 24hr urinary 5-HIAA (metabolite of serotonin)
Which eponymous sign is associated with appendicitis?
Rosvigs sign
Palpation in LLQ increases pain in RLQ
What investigations should be performed for a patient presenting with RLQ pain where you suspect appendicitis?
O- Get obs
B-
B- FBC, U+E, LFT, preg test if F
I- All get USS, CT reserved only for diagnostic uncertainty
D- R/o ectopic, ovarian pathology etc (pelvic USS)
How is suspected appendicits treated?
R- To surgeons O- Regular obs, ABCDE C- N/A M- Analgesia, pre-op AB's S- Appendectomy
What is zollinger-ellison syndrome and how does it present?
Rare condition cause by a gastrin secreting tumour in either pancreas or duodenal wall
Presentation: Recurrent ulcers
(Do surgical resection of tumour)
Where does colorectal cancer commonly metastasize to?
Liver
Followed by lungs, brain and bone
- 20% have mets on presentation
Name 5 RF’s for CRC?
FHx (under 60) or personal hx (incl endometrial, breast/ ovarian)
IBD
FAP
Diet (meat, fat, low fibre)
Lifestyle (obesity, smoking, alcohol)
Hormones (nulliparity, late first preg, early menopause)
A 2ww referral for CRC should be done for a 40year old in what circumstances?
Rectal bleeding + change in bowel habit for 6 weeks or more
What are the main functions of the large and small intestine?
Large: Water re-absorption
Small: Absorb nutrients
A 2ww referral for CRC should be done for a 60year old in what circumstances?
Any rectal bleed for >6weeks
OR
Any change in bowel habit >6 weeks
A 2ww referral for CRC should be done for a patient of any age with what symptoms and signs?
RLQ mass OR Palpable rectal mass OR Men with unexplained Hb <11 Or Non-menstruating women with unexplained Hb <10
How does gallstones, cholecystitis and ascending cholangitis present?
Gallstones: RUQ Pain
Cholecystitis: RUQ + Fever
Ascending cholagnitis: RUQ + Fever + Jaundice (Charcot’s triad)
How should you investigate potential gallstones, cholecystitis and cholangitis?
Obs
B- N/A
B- FBC, U+E, LFT, clotting (vit K needs fat to absorb)
I- USS
D- R/o MI (ECG), pneumonia (CXR), stones (urine dip)
How is gallstones managed?
R
O
C- Lifestyle advice around weight, diet etc.
WATCH AND WAIT
M- Simple analgesia
S- Laproscopic cholecystecomy only if severe pain
How is cholecystitis managed?
R (generally admit if pain+ fever) O- Monitor obs C- N/A M- PO Morphine and PR Diclofenac S- Lap cholecystecomy
How is ascending cholangitis managed?
R- Surgeons involved early O- Regular monitoring C- N/A M- Analgesia (morphione/ diclofenac), IV AB's and fluids S- Endoscopic biliary drainage
How does liver disease commonly present?
Malaise Fatigue Jaundice Portal hypertension (acities, varicies) Abnormal bleeding or itching Anorexia or weight loss RUQ pain
What is Budd-chiari syndrome and how does it present? How should it be investigated?
Obstruction of hepatic venous outflow. Normally occurs in patient with hypercoagulable state (antiphospholipid syndrome) but c-an also be because of physical obstruction (tumour)
P: RUQ pain, acscities, aki, jaundice etc
I: Prolonged prothrombin time, high protein in ascitic fluid
How should a suspected hepatocellular carcinoma be investigated?
US is gold standard
AFP of >400 is almost diagnostic (10-20 is normal)
What is primary billiary cirrhosis, how does it present?
Autoimmune chronic liver disorder, which may progress over decades, stereotypically affecting middle aged females. It causes inflammation, chronic cholestasis and may progress to cirrhosis.
P: Fatigue, pruritus, RUQ pain. Possible jaudince or sjogrens (dry eyes/ mouth)
Give an example medication that could be used to treat itching?
Cholestyramine (from biliary causes as removes bile from body)
Ursodeoxycholic acid (breaks down gallstones and can be used for itching, i.e. cholestasis of pregnancy)
What scoring system is used to grade the severity of liver cirrhosis?
Child-Pugh (gives either grade A, B or C)
What is the first line anti-diarrhoea medication for IBS?
Loperamide
A 35-year-old former intravenous drug user is reviewed in the liver clinic. He has recently been diagnosed with hepatitis C after being found to have abnormal liver function tests. It is decided as part of his work-up that he should be assessed for liver cirrhosis. What is the most appropriate test to perform?
Transient elastography (Fibroscan)
What is indicated by thumb printing of the small bowel?
Thumbprinting is a radiographic sign of bowel wall thickening. It is seen in a variety of conditions causing colitis (Crohn disease, ulcerative colitis, pseudomembranous colitis, ischaemic colitis)
Name 3 causes of pre-hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?
Pre-hepatic jaundice = unconjugated (not reached liver yet to be conjugated).
1) Gilberts disease (autosomal recessive)
2) Haemolytic anaemia (spherocytosis/ pernicious anaemia)
3) Thalassemia
Name 5 causes of hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?
Hepatic jaudice = Mixed picture
1) Hepatitis (Viral, alcoholic, autoimmune, drug induced)
2) Cirrhosis (decompensated)
3) Hepatocellular carcinoma
4) Primary billiary cirrhosis
5) Primary sclerosising cholangitis
Name 3 causes of post-hepatic jaundice, would this show a hyperbillirubinaemia which is conjugated or unconjugated?
Post-hepatic = Conjugated
1) Stones (in common bile duct) i.e. ascending cholangitis
2) Pancreatitis
3) Pancreatic cancer/ cholangiocarinoma/ cancer of the gallbladder
What advice should patients be given before a gastroscopy?
Don’t eat for 4-6 hours before the test
If having sedation will need someone to drive home, otherwise can go home after 30mins
OGD takes around 10 mins to complete
- Very small risk of bleeding or perforation
What advice should patients be given before a colonoscopy?
Special diet for a few days before and then bowel prep (make sure you take properly)
- Procedure takes around 30mins
- If had sedative need someone to drive you home, otherwise can go after 30 mins
- Very small risk of bleeding or perforation
What are the common features of both small and large bowel obstruction?
Not passing flatus or stools (1st in LB)
Vomiting (1st in SB)
Abdominal distension
How do you manage a bowel obstruction?
NG tube with fluids (drip and suck). Give catheter for fluid balance, often will need many litres
+ Analgesia/ antiemetics
Endoscopy to clear
If severe laparotomy
What features of bowel obstruction are seen on AXR? (Small and large)
Small:
- <3cm, central location, valvulae conniventes cross whole bowel
Large:
- <6cm, peripheral location, haustra cross only halfway
Name two common symptoms of vitamin C deficiency?
Scurvy
Gingivitis, bleeding
Name a common symptom of vitamin A deficiency?
Night blindness (nyctalopia)
Name a common manifestation of vitamin B1 deficiency?
(B1 = Thiamine)
Polyneuropathies, wenicke-korsakoff syndrome, heart failure
Name a common manifestation of vitamin B9 deficiency?
B9 = Folic acid
Megaloblastic anaemia, if in pregnancy = NTD
How do you manage an acute GI bleed?
ABCDE R- Get senior help Obs- Nurse do 15 min obs + C M- (Cannula in, bloods incl crossmatch out) > Fluids in stat > Blood into other arm if hypotension > Correct clotting (vit K, FFP, platlets)
If varicies give terlipressiin and broad spectrum AB’s
S- Urgent endoscopy
What scoring systems are used for upper GI bleeds?
Blatchford Score - Calculates risk when first happens (any score over 1 needs admission and endoscopy)
Rockall score calculates post endoscopy risk of re-bleeding (<3 is low risk and can early discharge)
A patient presents with dysphagia, what history questions should you ask in the HPC of the consultaiton?
Solids/ liquids (motility vs. obstructive)
Timing (all the time or just sometimes)
Onset
Progressive?
Name 6 differentials for dysphagia and some key points which may indicate each?
Benign peptic stricture > Progressive, with pain, GORD in Hx
Oesophageal cancer > As above, no pain, other RF’s
Candidasis > Painful with HIV/ steroid RF’s
Achalasia > Solid+Liquid, regurg + cough
Pharangeal pouch > As achalasia + hallitosis + gurgling
Diffuse oesophageal spasm > Intermittent symptoms
Name the 4 categories of laxatives and give at least one example in each?
Bulk forming - Fybogel (ispaghula husk)
Osmotic - Lactulose or magrogol
Stimulant - Senna, sodium pixosulfate, bisocodyl
Softners - Docusate, glycerol
Short term constipation should be treated with…?
1) Bulk forming laxative (fybogel)
- If stools remain hard add or switch to an osmotic (lactulose or magrogol)
- If stools are soft add a stimulant (senna) laxative
Opioid induced constipation should be treated with?
1) Softner + stimulant (Docusate and senna)
Avoid bulk forming (fybogel)
How should faecal impaction be treated?
Hard stools = Give osmotic (macrogol)
Soft stools = Give stimulant (senna)
If not working add PR bisacodyl (stimulant) if soft or glycerol (softener) if hard
How should chronic constipation be treated?
1) Bulk former (Fibogel)
- If stools remain hard add or change to macrogol or lactulose
(Aiming for 1-2 soft stools per day)
How should children be treated for constipation?
First line is an osmotic (magrogol (i.e. Movicol)), if needed add stimulant (bisocodyl)
- Continue for several weeks after regular movements return
Name 5 differentials for epigastric pain?
Cardiac causes GORD Gastric/ duodenal ulcer Pancreatitis Biliary disease (more likely RUQ)
Name 5 differentials for RUQ pain?
Hepatic (including PSC or PBC) Gallbladder (stones/ cholecystitis) Ascending cholangitis Gastric or duodenal ulcer (more common epigastric) Renal causes (more likely flank) Pneumonia
Name 5 differentials for RLQ pain?
Appendicitis Crohns Female (Ectopic, ovarian) Incarcerated hernia Renal pathologies
Name 3 differentials for LUQ pain?
Pneumonia
Renal
Ruptured spleen
Name 4 differentials for LLQ pain?
Diverticulitis
UC
Renal
Ovarian pathology
Name 4 differentials for suprapubic pain?
Retention
Testicular torsion
Cystitis
Placental abruption
What are the common causes of ascities with a high SAAG (Serum ascities albumin gradient)?
High SAAG = Portal hypertension (so losing fluid and higher protein concentration)
- Liver cirrhosis
- Liver mets
- Cardiac failure
- Alcoholic liver disease
- Budd-chiari syndrome
How does hepatic encephalopathy present? (3)
New confusion
Altered GCS
Asterix (liver flap)
How is hepatic encephalopathy treated?
1) Lactulose (thought to increase gut ammonia metabolism)
2) Rifaximin (antibiotic for secondary prophylaxis)
What is a volvulus and how does it present?
Torsion of colon causing obstruction
(80% sigmoid, 20% caecum)
Presents as obstruction
How should a sigmoid volvulus be managed?
1) Rigid sigmoidoscopy with rectal tube insertion
If caecal then management is operative, R hemicolectomy often needed
What is the difference between hepatic and wernicke’s encephalopathy?
Hepatic - Caused by general toxin build up (ammonia etc)
Wernicke’s - Caused by thiamine B1 deficiency
(Wernickes = ataxia, confusion, opthalmaplegia)
What is the gold standard test for pancreatitis?
MRCP and CT
What is Plummer-Vinson Syndrome? How is it treated?
This is a triad of dysphagia, glossitis and iron-deficiency anaemia (some definitions additionally include cheilitis in the syndrome).
Tx: Correct IDA, do dilation of the oesophageal webs causing the dysphagia!
How do you differentiate between an inguinal or femoral hernia on examination?
Starts above + medial to pubic tubercle (next to pubic symphisis) = INGUINAL
Starts below + lateral to pubic tubercle = FEMORAL
- Note femoral are often smaller and pea sized, but have a higher risk of strangulation
How do you distinguish between direct and indirect inguinal hernia?
Reduce hernia, press on deep inguinal ring (in mid point between ASIS and pubic symphisis). Ask patient to cough.
If hernia comes back out = Direct
If stays in = Indirect
Note not a very good test, needs surgery to determine true site and doesn’t change management at all.
What is the SAAG and what does it indicate?
Serum Ascites Albumin Gradient (normal <11g/L)
- If raised it indicates the ascities is due to portal hypertension
(Budd-Chiari, cirrhosis, hepatitis, splenomegaly etc)
What is the most common cause of inherited CRC?
HNPCC
(5% of all CRC cases and strongly associated with endometrial cancer)
(FAP is second most common)
BOTH ARE AUTOSOMAL DOMINANT
What is Courvoisiers sign?
Courvoisier’s sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.
What characterises chronic mesenteric ischemia (also called intestinal angina)?
Triad: Severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
- Normally increasing age and CVS risk factors
Anti-smooth muscle antibodies are typically associated with?
Autoimmune hepatitis
One parent of a patient has an autosomal recessive condition, the other parent is not a carrier. What is the chance any offspring will have the condition?
0%
(Need two copies of gene if autosomal recessive, one parent is homozygous so they are guaranteed to be a carrier but will not be effected as the gene from the second parent will be normal)
Name 5 presenting features of haemochromotosis?
Fatigue, erectile dysfunction and arthralgia
- Bronze skin
- Diabetes
- Liver disease
How is haemochromotosis inhertied?
Autosomal recessive (So both parents need to pass on gene to be affected)
Which anti-emetic should be avoided in bowel obstruction?
Metoclopramide should be avoided as it is a pro-kinetic anti-emetic so could cause a perforation in bowel obstruction.
What bug is most commonly responsible for SBP?
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli
- If transudate (due to cirrhosis etc) on ascitic tap then need long term antibiotics as prophylaxis
What are the best tests to assess the function of the liver?
Prothrombin time
Albumin
Numerous polyps in GI tract/ early diagnosis of CRC + pigmented lesions on lips/ palms/ soles + FHx = ?
Peutz-Jeghers syndrome
Autosomal dominant
