Gastroenterology Flashcards
What is achalasia?
Absent or uncoordinated oesophageal muscular action with a failure of relaxation of the lower oesophageal sphincter
Recall the pathophysiology of achalasia
Breakdown of ganglion cells in mesenteric plexus
Recall the symptoms of achalasia
Intermittent dysphagia
Regurgitation at night
CP and heart burn
What is a common complication of achalasia to be wary of?
Aspiration pneumonia
What specialist investigation should be done for achalasia?
Barium swallow
Recall 3 causes of acute cholangitis
Biliary colic
Biliary stenosis
Cholangiocarcinoma
What is Charcot’s triad?
The triad used to describe symptoms of acute cholangitis
Recall Charcot’s triad and Reynold’s pentad
Triad: RUQ pain, jaundice, fever with rigors
Pentad = + confusion + septic shock
Describe the blood results of someone with acute cholangitis
High WCC
Raised CRP and ESR
LFTs similar to those you would expect in jaundice
If biliary stones are non-calcified, which investigation should be done?
MRCP
What is the first-line in management of acute cholangitis?
Broad-spectrum ABx
Why is the mortality of acute cholangitis high?
Can cause liver failure
Recall the names of each state of liver damage
Steatosis (fatty liver)
Hepatitis
Cirrhosis
Describe the liver in hepatitis
Necrotic with regions of fatty inflammation
Recall the mnemonic for and the signs of alcoholic hepatitis
Particularly Excessive Gin Drinking Can Make Hepatic Fatty Tissue Start Necrotising Palmar Eryhtema Gynaecomastia Dupuytren's Contracture Malnutrition Hepatomegaly Facial Telangiectasia Spider Naevi
Recall the mnemonic for and the symptoms of severe acute alcoholic hepatitis
BEAST Bruising Encephalopathy Ascites Splenomegaly Tachycardia
Recall 2 things of note in the FBC of someone with alcoholic hepatitis
High WCC
Macrocytic anaemia
What will be low in the LFTs of someone with alcoholic hepatitis?
Albumin
What is the most common cause of anal fissure?
Hard faeces
What is an anal fissure?
Tear in SQUAMOUS lining of lower anal canal
Recall some symptoms of anal fissure
Pain
Blood in stool
Pruritis ani
Recall the management of anal fissure
Conservative: high fibre diet, laxatives and hydration
Mecial: lidocaine, GTN (relaxes internal sphincter)
Surgical: lateral sphincterectomy (caution: often causes incontinence)
Summarise the pathophysiology of appendicitis
- Gut lumen obstruction
- Bacteria have opportunity to invade appendix
- Results in oedema, ischaemic necrosis and perforation
Recall one peculiar sign of appendicitis
Tongue-furring
Recall the 3 special signs that can be elicited in appendicitis
Rovsing’s: pushing down on LIF increases pain in RIF
Psoas: pain on hip extension
Cope: plain on flexion and internal rotation of hip
What is the test performed to confirm a diagnosis of appendicitis?
US/CT
What is the aetiology of autoimmune hepatitis?
Unknown
Recall 3 features of a blood test that are abnormal in autoimmune hepatitis
Hyperglobulinaemia (ANA, ASMA, Anti-LKM)
Same LFTs as alcoholic hepatitis (low albumin, high everything else)
WCC is LOW (unlike alcoholic hepatitis)
Recall the immunoglobulins present in type 1 and type 2 autoimmune hepatitis
Type 1: ANA, ASMA, Anti-SLA, AAA
Type 2: ALKM-1, ALC-1
Recall the aetiology of Barrett’s oesophagus
- Prolonged exposure of squamous epithelium to acid from GORD
- Mucosal inflammation and erosion
- Transformation into columnar epithelium (METAPLASTIC CHANGE)
What is the main sinister consequence of Barrett’s oesophagus?
Can lead to adenocarcinoma
What is water-brash and what is it a common symptom of?
Sour taste when swallowing: GORD, barrett’s oesophagus
What investigations need to be done to confirm a diagnosis of Barrett’s oesophagus?
OGD and biopsy
Recall the management of low-grade dysplasia in Barrett’s oesophagus
Endoscopic surveillance
Recall the management of high-grade dysplasia in Barrett’s oesophagus
For fit and well pt: mucosal resection
Otherwise: mucosal ablation
What causes the waves of pain in biliary colic?
Contraction of biliary tree around stone
Where may biliary colic pain radiate to and why?
Right scapula: due to diaphragmatic irritation
Recall 2 findings on ultrasound that indicate biliary colic
- Dilation of common bile duct
2. Hypertrophy of gallbladder wall
Recall 2 uses of ERCP in biliary colic
- Diagnostic
2. Therapeutic - can be sued to remove small stones
Recall the surgical management of biliary colic
Laparoscopic cholecystectomy
What is cholecystitis
The INFLAMMATION of the gallbladder that is caused by biliary stones
What is the composition of most gallbladder stones?
Mixed: cholesterol, calcium bilirubinate, protein and phosphate
What is Murphy’s sign used to diagnose?
Cholecystitis?
What is Murphy’s sign?
Ask patient to exhale then inhale deeply as you push your hand up under their rib cage on the RHS - causes lots of pain and they catch their breath
Recall the expected LFT abnormalities in cholecystitis
High ALP and GGT
Describe the histopathology of the liver in cirrhosis
Normal liver architecture replaced by diffuse fibrosis, nodules of regenerating hepatocytes present
Which types of hepatitis can lead to cirrhosis?
B and C
Define decompensated cirrhosis
Cirrhosis that is complicated by jaundice, encephalopathy, GI bleeding and ascites
Systematically recall the symptoms of liver cirrhosis
Systemic effects: anorexia, fatigue
Due to loss of synthetic function: easy bruising, ankle oedema
Due to loss of detox function: jaundice. amenorrhoea, personality change
Due to portal hypertension: haematemesis, melaena, abdominal swelling
Recall ALL the signs of liver cirrhosis
Easy bruising Gynaecomastia Dupuytren's contracture Spider Naevi Leukoonychia Asterixis Ascites Jaundice Clubbing Facial telangiectasia Caput medusae Scratch marks Palmar erythema Splenomegaly Hepatomegaly
What does an FBC show in liver cirrhosis and why?
Low platelets and haemaglobin
This is due to hypersplenism
Hypersplenism is a result of portal hypertension
What conditions can an elevated serum AFP be used to diganose?
Elevated: liver cirrhosis
Super-high: hepatocellular carcinoma
What is the use of an ascitic tap in liver cirrhosis?
Do MCS
If neutrophils are >250, is spontaneous bacterial peritonitis
Using what system is liver cirrhosis graded?
Child-pugh
Recall the histopathological appearance of the gut in coeliac disease
Subtotal villous atrophy
Crypt hyperplasia
What is the major cause of signs in coeliac disease?
Malnutrition
What sort of anaemia presents in coeliac disease?
Iron-deficiency
What is the key serological finding in coeliac disease?
Anti-gliadin
Summarise the defining characteristics of Crohn’s disease
- Granulomatous inflammation (so involves macrophages)
- Can be anywhere in length of gut
- May cause erosion into the deep mucosa
What stool symptoms are common in Crohn’s disease?
Diarrhoea and steatorrhoea
What external signs of crohn’s disease may be seen upon examination of the anus?
Perineal skin tags
Fistulae
Recall some extra-articular manifestations of Crohn’s diease
Finger clubbing
Mouth ulcers
Uveitis
Erythema nodosum
Which elements of the FBC are elevated in Crohn’s disease?
WCC
Platelets
Describe the ESR and CRP in Crohn’s disease
ESR high
CRP may be normal or high
How can you distinguish infective colitis from Crohn’s disease?
Stool MC&S
Describe the management of an acute flair up of Crohn’s disease
Corticosteroids
5-ASA analogues (mesalazine)
Analgesia
Describe the long-term management of chronic Crohn’s disease
Mesalazine/olsalazine
Anti-TNF/immunosuppression
Recall some common complications of Crohn’s disease
Strictures Perforation of bowel Fistulae Haemorrhage GI cancers
What are diverticulae?
Outpoachings of colonic mucosae/submucosae through a weakness in the muscular layer
Define diverticular disease
Diverticulitis PLUS COMPLICATIONS (haemorrhage, infection, fistulae)
Recall the aetiology of diverticulae formation
Low fibre diet –> higher intraluminal pressure required to expel stool
Higher pressure –> herniation of mucosa
Where do diverticulae most commonly appear?
At sites of nutritional artery penetration
What is the main complication of diverticulae?
They get obstructed with faeces leading to bacterial overgrowth and peritonitis
What are the Hinchley criteria used for?
Recall them
Staging of diverticular disease
1a: Phlegmon
1b: Localised abscesses
3: Purulent peritonitis
4: Faecal peritonitis
Where is right-sided diverticulitis most common?
Asia
What symptoms can be caused by fistulae?
Pneumaturia
Faecaluria
What is the diagnostic test used for diverticulae?
Barium enema
Do not use in acute setting in case of perforation
What is the management for diverticulitis?
Bowel rest
IV antibiotics
Rehydration
What does time of onset in gastroenteritis indicate about aetiology?
Toxins = early onset (1-24 hours)
Bacteria/viruses/protozoa have a later onset (12+ hours)
Recall and justify the blood tests that should be done for gastroenteritis
FBC
Blood culture (bactaraemia?)
U&Es (dehydrated?)
Where are the most common sites of gastrointestinal perforation?
Colon
Gastroduodenal
What are the most likely causes of colon perforation?
Cancer
Diverticulitis
Appendicitis
What is the most likely cause of gastroduodenal perforation?
Perforated ulcer
Describe the signs of GI perforation
Quite non-specific but they will be very unwell
Signs of shock, dehydration and pyrexia
What would a CXR show in GI perforation?
Air under diaphragm
Recall the surgical management of GI perforation
Peritoneal lavage
For large bowel perforation: resection
For small bowel perforation: close with omental patch
Recall 3 things that aggravate heartburn in GORD
Lying supine
Large meals
Alcohol
If someone has GORD and begins to experience dysphagia, what does this indicate?
Stricture has formed
Differentiate internal and external haemorrhoids
Internal: above dentate line, arising from superior haemorrhoidal plexus
External: below dentate line
Recall and define each degree of haemorrhoid classification
1st degree: no prolapse
2nd degree: prolapses on defaecation and resolves spontaneously
3rd degree: prolapses on defaecation and needs to be resolved manually
4th degree: Prolapse which cannot be reduced
Describe how haemorrhoidal blood appears in stool
Does not mix with stool
Which investigations must be done when haemorrhoids are suspected and why?
DRE
Flexible sigmoidoscopy
Need to exclude any other causes of blood in stool that are more sinister
Recall the management of haemorrhoids
Conservative: high fibre diet. laxatives, topical analgesic
Minor surgery: injection scleropathy (induces fibrosis of dilated veins) and banding (causes haemorrhoid to fall off in a few days)
Surgical: reserved for symptomatic 3rd/4th degree haemorrhoids
Which abdominal contents are protuding into the inguinal region in an inguinal hernia?
Peritoneum
Recall which type of inguinal hernia arises medial and lateral to the key blood vessel, and what that vessel is
Vessel = inferior epigastric vessels
Direct: medial
Indirect: lateral