Gastroenterology Flashcards
What is achalasia?
An oesophageal motor disorder of unknown aetiology, characterised by oesophageal aperistalsis and insufficient lower oesophageal sphincter (LOS) relaxation in response to swallowing.
What are the risk factors of achalasia?
Allgrove syndrome Herpes and measles viruses Autoimmune disease HLA class II antigens Consanguineous parents
What are the symptoms of achalasia?
Dysphagia Weight loss Retrosternal pressure Recurrent chest infections Sensation of lump in throat Hiccups Heartburn
What are the signs of achalasia?
Regurgitation
Slow eating
Coughing while recumbent
Postural aid rqd while swallowing
What Investigations may be used for Achalasia?
OGD Barium swallow/ timed barium swallow CXR CT chest Oesophageal manometry Radionucleotide Oesophageal emptying studies
What may an OGD or Barium swallow show in someone with achalasia?
OGD- Obscured mucosa by frothy saliva, sigmoid oesophagus(Timed)
Barium swallow- Loss of peristalsis, delayed oesophageal emptying and transit, dilated oesophagus which tapers towards LOS
What may you see in a CXR or CT chest in achalasia?
CXR- Absence of gastric bubble or unusual oesophagus shape
CT Chest- dilation of oesophagus, potential wall thickening
What is acute cholangitis?
It is an infection of the biliary tree, most commonly caused by obstruction. (Also known as ascending cholangitis)
What are the risk factors of acute cholangitis?
Age >50 yrs Cholelithiasis Benign or Malignant Stricture Post procedure injury of bile ducts History of primary or secondary sclerosing cholangitis Also: HIV
How does acute cholangitis progress?
Usually caused by bacteria ascending from its junction with the duodenum (first part of the small intestine). It tends to occur if the bile duct is already partially obstructed by gallstones.
What are the presenting symptoms of acute cholangitis?
Alcoholic stools
Pruritis
Mental status change
[Plus Charcots triad]
What are the signs of acute cholangitis?
Charcots traid:
RUQ pain and tenderness
Jaundice
Fever
And Hypotension
What investigations would you consider for acute cholangitis?
Bloods
ERCP
Transabdominal US
Who gets acute cholangitis?
Relatively Uncommon
Both male and female
Median age is between 50-60
What is Charcot’s triad?
RUQ pain and tendernessJaundice Fever (often with rigors)
What is Reynolds pentad?
Charcot’s triad (right upper quadrant pain, jaundice, and fever) Shock (low blood pressure, tachycardia) Altered mental status
What Bloods would you do for acute cholangitis?
FBC (raised WCC, low plts)Cr (raised)LFTs (Raised transaminases, alk phos and BR)CRP (Raised)U&E’s (Raised U, decreased K and Mg)Coagulation panel (raised PT)ABG (met. acidosis)
How would you manage acute cholangitis?
IV antibioticsBiliary decompresssionLithotripsyOpioid analgesics
What are the possible complications of acute cholangitis?
Acute pancreatitisInadequate biliary drainageHepatic abscess
What is the prognosis/ indicators for acute cholangitis?
Improved drainage helpsPoor prognosis- hyperbilirubinaemia, high fever, leukocytosis, older age, hypoalbuminuria
Define Alcohol withdrawal
Alcohol withdrawal syndrome occurs when an alcohol dependent person decreases or stops their intake. It normally begins 4-12 hours after the patients last drink.
What is the aetiology of alcohol withdrawal?
Blood alcohol level drops below what the patient normally has causing withdrawal symptomsCommon where there is a family history or abrupt withdrawal
Who and where is alcohol withdrawal prevalent?
Over 15’s (more in 18-25 than over 26)Binge drinkers>excessive drinkers
What are the symptoms of alcohol withdrawal?
Alcohol useChange in mental status HallucinationsDelusions
What are the signs of alcohol withdrawal?
TremorHypertensionNause/ vomiting
What are the investigations of alcohol withdrawal and how would you interpret them?
Bloods> U&E- lactic acidosis, dehydration (low U), hypokalaemia> Cr- elevated> Ethanol- positive> FBC- infection riskCT head (normal, rules out differentials)CXR (normal, rules out differentials)
What is the management of alcohol withdrawal?
Benzodiazepine/ clomethiazoneSupportive careADJUNCTS: Phenobarbital/ Vitamin supplements/ propofol/ dexmedetomidine
What are the complications of alcohol withdrawal?
Delirium tremensOver sedationSeizuresStatus epilepticusDeath
What is the prognosis of alcohol withdrawal?
Relapse may occurGenerally not deadly if well controlled
What is alcoholic hepatitis?
Inflammation and necrosis of hepatocytes caused by excessive alcohol intake, it is a stage in the progression of alcoholic liver disease.
What are the risk factors for alcoholic hepatitis?
Chronic heavy alcoholHep CFemaleCigaretteObese, >65HispanicGenetics
What is the epidemiology of alcholic hepatitis?
Harmful use of alcohol resulted in 3 million deaths worldwide. ALD is common and has high risk.
What are the signs and symptoms of alcoholic hepatitis?
Abdominal painHepatomegalyAscitesWeight changeCachexiaAnorexiaFatigue(jaundice, asterixis, ascites, hepatic mass, palmar erythema, splenomegaly, venous collaterals, haematemesis and melaena, spider naevi)
What investigations might you do to identify alcoholic hepatitis?
BloodsHepatic US
What may you see in the blood results or on US in alcoholic heptatitis?
BloodsSerum AST/ ALT/ ALP/ BR/ GGT (All elevated)Serum albumin (low)FBC (Anaemia, leukocytosis, thrombocytopenia, high MCV)Serum AST/ALT ratioU/ECrINR/PTHepatic ultrasoundEnlargement or fatty
What is the management of alcoholic heptatitis?
Alcohol management Risk factor managementNutritional supportImmunisationsSteroidsSodium restriction and diureticsPentoxifyllineLiver transplant
What are the possible complications of alcoholic hepatitis?
Hepatic encephalopathyGI bleed (varices)Portal HypertensionCoagulopathyRenal failureHepatorenal syndromeHepatocellular carcinomaSepsis
What is the prognosis of alcoholic hepatitis?
Maddrey’s Discriminant Function Some damage (cirrhosis) may be irreversibleHigh mortality
What is an anal fissure?
Anal fissure is a split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding.
What are the risk factors of an anal fissure?
Hard stoolPregnancy Opiate analgesia
What is the epidemiology of anal fissures?
Incidence is 1 in 350Equally common in men and women15-40 yrs
What are the signs and symptoms of anal fissures?
Pain on defaecationTearing sensation when passing stoolFresh blood on stool or paperAnal spasmIntermittencySentinel puleVisible fissure
What are the appropriate investigations for anal fissures?
Clinical diagnosisAnal manometryAnal US
What results may you expect with anal fissures?
Clinical historyLow resting pressure via manometryUS- defects in internal or external anal sphincter
What is the management plan for anal fissures?
> Conservative treatment (high fibre diet, fluids, topical analgesia and stool softeners)> Topical GTN> Topical Diltiazem> Botulinum toxin, surgical sphincterotomy, anal advancement flap
What are the complications of anal fissures?
Chronic anal fissureIncontinence (post surgery)Recurrence
What is the prognosis of patients with anal fissures?
Approximately 60% of patients will achieve healing of their fissure at 6 to 8 weeks. A further 20% will heal after a course of topical diltiazem. Some of these patients may subsequently relapse; around 30% will require a surgical option.
What is appendicitis?
Acute appendicitis is an acute inflammation of the vermiform appendix
What causes appendicitis?
Most likely due to obstruction of the lumen of the appendix (by faecolith, normal stool, infective agents, or lymphoid hyperplasia)
What are the signs and symptoms of appendicitis?
Abdo painAnorexiaRLQ tendernessNauseaFeverDiminished bowel soundsTachycardiaFetorRovsing’s/ psoas/ obturator sign
What are the RFs of appendicitis?
<6mths of breastfeedingLow dietary fibreImproved personal hygieneSmoking
What is the epidemiology of appendicitis?
Male (slightly more) 15-59Low fibre diet countries
What are the investigations that are appropriate for appendicitis?
Bloods- FBC (Mild leukocytosis)CT abdo pelvis (wall thickening, inflammatory changes)Urinary pregnancy test (negative)
How do you manage appendicitis?
Appendectomy and supportive care (IV fluids, NBM)IV antibiotics
What are the complications of appendicitis?
PerforationGeneralised peritonitisAppendicular massAppendicular abscessSurgical wound infection
What is the prognosis of appendicitis?
Good if treated quicklyWound infection/ abscess which may decrease QoL
What are the complications of an appendicectomy?
> High APACHE score may indicate high mortality> Intra-abdominal Abscesses
What is autoimmune hepatitis?
Autoimmune hepatitis (AIH) is a chronic inflammatory disease of the liver of unknown aetiology.
What are the RFs for AIH?
> Female> Genetic predisposition> Immune dysregulation > Viruses and drugs
What is the epidemiology of AIH?
> Northern Europeans> Previous CLD> 10-30 and also 40-60> F>M
What are the signs and symptoms of AIH?
FatigueAnorexiaAbdominal discomfortHepatomegalyJaundiceEncephalopathy(Plus pruritis, arthralgia, nausea, fever and spider angiomata)
Which investigations would you do for AIH?
Bloods:> Aspartate and Alanine Transaminase (Higher, non specific)> Bilirubin (Raised)> GGT (Raised)> Alk Phos (raised)> Serum Globulin (Raised)> Serum Albumin (Decreased)> Prothrombin time (Prolonged)
What is Barrett’s Oesophagus?
Barrett’s oesophagus is a change in the normal squamous epithelium of the oesophagus to specialised intestinal metaplasia.
What are the RFs of Barrett’s Oesphagus?
GORD/ refluxOlder peopleWhiteMaleObesity/ smoking/ FHx
What are the signs and symptoms of Barrett’s Oesphagus?
Heartburn, regurgitation, dysphagia, chest pain, cough, wheeze
What investigations would you do for Barrett’s oesophagus and what might they show?
OGD with biopsy (Metaplasia)Barium Oesophagogram (Identifies hiatal hernia and reflux)
What is the management of Barrett’s oesophagus?
PPI plus surveillanceRadiofrequency ablationAnti-reflux surgery plus survellanceOesophagectomy
What are the complications of barrett’s oesophagus?
Dysplasia/ AdenocarcinomaOesophageal strictureQuality of life deficit
What is the prognosis of people with Barrett’s Oesophagus?
Pretty good if it doesn’t become malignant
Define cholangiocarcinoma
Cholangiocarcinomas are cancers arising from the bile duct epithelium
Explain the risk factors of cholangiocarcinoma
Over 50’sBiliary diseaseUCPSCCirrhosis, ALDLiver fluke infectionHep B, C, HIV, typhoid (Carrier), thorium dioxide exposure
Summarise the epidemiology of cholangiocarcinoma
Aged 50-70Slight male predominanceHigh rates in north east Thailand
Identify appropriate investigations for cholangiocarcinoma and interpret the results
Bloods: (serum)> BR, Alk Phos, GGT, aminotransferase (elevated)> Prothrombin time (Increased)> CA 19-9, CEA, CA-125 (Elevated)Abdominal US (dilations of ducts or mass lesions)CT/ MRI/ ERCP or MRCP may also be helpful
What is Cholecystitis?
Acute cholecystitis is acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones
What are the RFs for cholecystitis?
> gallstones> severe illness> total parenteral nutrition (TPN)> diabetes
What is the epidemiology of cholecystitis?
The distribution and incidence of acute cholecystitis follow that of cholelithiasis because of the close relationship between the two.The prevalence rates are relatively low in Africa and AsiaF>M 3:1
What are the signs and symptoms of cholecystitis?
Previous biliary painRUQ painPositive murphys signAbdominal massRight shoulder painAnorexianauseaFeverVomiting Jaundice
What investigations would you use for cholecystitis and how would you interpret them?
FBC (High WBC)CRP (High)LFTs (High Alk Phos, GGT and BR)RUQ US scan (Thickened GB wall, distended GB, fluid, +ve murphys sign)
How do you manage cholecystitis?
> Supportive care (NBM, IV fluids, analgesia, Abx)> Oral Abx (e.g. cefuroxime)> NSAIDs> Cholecystectomy> GB drainage
What complications may occur in cholecystitis?
> Perforation> Suppurative cholecystitis> Gangrenous Cholecystitis> Bile duct injury> Gallstone ileus
What is the prognosis of patients with cholecystitis?
> Lower risk of mortality if no perforation or if found on time
What is a cholecystectomy?
Removal of the gallbladder
What are the complications of a cholecystectomy?
> Infection> bleeding> Bile leakage> Tissue injury > DVT
What is Cirrhosis?
Cirrhosis is a diffuse pathological process, characterised by fibrosis and conversion of normal liver architecture to structurally abnormal nodules known as regenerative nodules
What are the risk factors for cirrhosis?
alcohol misuseintravenous drug useunprotected intercourseobesitycountry of birth
What is the epidemiology of cirrhosis?
Liver disease is the third biggest cause of premature mortality in the UK
What are the signs and symptoms of cirrhosis?
Abdo distensionJaundice and pruritisHaematemesis and melaenaPeripheral stigmata of liver diseaseConstitutional symptomsLower extremity swellingHepatic fetorMuscle wastingPeripheral oedema
What investigations would you do for cirrhosis?
Bloods> LFTs (deranged)> GGT (Elevated)> Serum albumin (Decreased)> Serum sodium (Decreased)> PT (Prolonged)> Plt count (Decreased)> Hep C antibodies (Present)> Hep B antigens (Present)
What is the management of cirrhosis?
> Treatment of underlying condition> Monitor for complications> Sodium restriction/ diuretics> Liver Transplant
What are the complications of cirrhosis?
AscitesGastro oesophageal varicesHepatocellular carcinomaBleeding and thrombosisSBPHepatic hydrothoraxPortosystemic encephalopathyAKI-HRSHepatopulmonary syndromePortopulmonary syndromeFeminisationHepatic osteodystrophy
What is the prognosis of cirrhosis?
The overall median survival of patients with cirrhosis is approximately 10 years, but prognosis depends on the stage of the disease. (Higher stage, higher mortality)
Define coeliac disease
Coeliac disease is a systemic autoimmune disease triggered by dietary gluten peptides found in wheat, rye, barley, and related grains.
Explain the aetiology / risk factors of coeliac disease
> family history of coeliac disease> immunoglobulin A deficiency> type 1 diabetes> autoimmune thyroid disease> Down’s syndrome> Sjogren’s syndrome> inflammatory bowel disease> primary biliary cirrhosis
Summarise the epidemiology of coeliac disease
Coeliac disease is a common disorder in the US and in Europe. A relatively uniform prevalence has been found in many countriesWomen are slightly more likely to be affected
Recognise the signs and symptoms of coeliac disease
immunoglobulin (IgA) deficiencydiarrhoeabloatingabdominal pain/discomfortanaemiaosteopenia/osteoporosisfatigueweight lossfailure to thrive
Identify appropriate investigations for coeliac disease and interpret the results
FBC and blood smearimmunoglobulin A-tissue transglutaminase (IgA-tTG)endomysial antibody (EMA)skin biopsy (granular deposits of IgA)IgG DGP (deamidated gliadin peptide) or IgA/IgG DGPIgG-tTGsmall bowel - macroscopic (scalloping, nodularity and mosaic pattern of mucosa)small bowel - histology (Intra epithelial lymphocytes, villous atrophy, crypt hyperplasia)
Generate a management plan for coeliac disease
> Diet restriction (gluten)> Calcium and Vit D supplements> Referral to dietician> Rehydration and correction of electrolyte abnormalities> Corticosteroids
Identify the possible complications of coeliac disease and its management
OsteoporosisDermatitis herpetiformisMalignancyPancreatitisPneumococcal infection
Summarise the prognosis for patients with coeliac disease
The prognosis for patients with coeliac disease is good
When would you use a colonoscopy?
> Suspected IBD or malignancy> Unidentified bleeding, pain or obstruction> Consistent diarrhoea or constipation> Unidentified constitutional symptoms
What are the complications of a colonoscopy?
PerforationBleedingInfectionAdverse reaction to drugs
Define colorectal carcinoma
The majority of colorectal cancers are adenocarcinomas derived from epithelial cells
Explain the aetiology / risk factors of colorectal carcinoma
AgeAPC mutationHNPCCMYH- associated polyposisHamartomatous polyposis syndromeIBDObesityAcromegalyLimited physical activityLack of dietary fibre
Summarise the epidemiology of colorectal carcinoma
Colorectal cancer is the third most common cancer in the Western world.The lifetime risk of developing colorectal cancer is 5.42%.
What are the signs and symptoms of colorectal carcinoma?
Rectal BleedingChange in Bowel habitRectal massAbdominal massAnaemiaWeight loss/ anorexiaDistensionPalpable lymph nodes
What are appropriate investigations for colorectal carcinoma? and interpret the results
> Local excision/ radical resection> Preoperative/ perioperative/ postoperative Chemoradiotherapy/ radiotherapy> Monoclonal Ab> stenting (Adjunct)
What is Crohn’s disease?
Crohn’s disease (CD) is a disorder of unknown aetiology characterised by transmural inflammation of the gastrointestinal (GI) tract.
What are risk factors for Crohn’s Disease?
white ancestryage 15-40 or 60-80 yearsfamily history of CD
How does Crohn’s come about?
TriggerLesion with inflammatory infiltrates around intestinal crypts causing ulceration of superficial mucosa and deepens.Also involves lymph nodes.Hyperaemia and oedema of inflamed mucosa.Leads to bowel obstructionHISTOPATHOLOGY= cobblestone appearance in gut
What is the epidemiology of Crohn’s?
Highest incidence in Northern climates and more developed areas.Equally prevalent men and womenHigher in white and Ashkenazi JewsMay be higher in smokers
What may you find in the history and examination of someone with Crohn’s disease?
abdominal painprolonged diarrhoeaperianal lesionsbowel obstructionblood in stoolsfeverfatigueabdominal tenderness
What investigations may you do for Crohns?
Bloods> FBC (anaemia, leuc)> Iron studies (def.)> Serum B12 (N/L)> Serum folate (N/L)> Metabolic panel (hypo nutrient)> CRP/ ESR (elev.)Stool test (rule out infection)Yersinia sero (neg.)Plain abdo film (inflammation, calcifications, abcsesses)CT Abdo (skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistula)MRI Abdo/ Pelvis (skip lesions etc. same as CT)
How do you manage Crohn’s?
Treating the inflammation:> Observation then budesonide plus 5ASA (e.g. pentasa, mesalazine)> Conventional steroids> Biologic therapy (e.g. Infliximab)> AzathioprineSymptoms and risk management:> LIfestyle and nutritional advice> PPI > Antispasmodic and antidiarrhoeal
What are the complications of Crohn’s Disease?
> Obstruction> Sepsis> Toxic megacolon> Anaemia> Malignancy> Short bowel syndrome> Absorption and metabolic disorders> Extraintestinal complications
Do Crohn’s die?
Yes, life expectancy is decreased with Crohn’s disease as time spent with the disease goes on.
What is endoscopy?
An endoscope is a long, thin, flexible tube that has a light and camera at one end. This is inserted into the GI tract to have a look inside.
When would you need an endoscopy?
> Unresponsive dyspepsia> Systemic signs> Persistent GORD> Occult GI bleeds> Malignancy surveillance
What are the complications of an endoscopy?
Perforation (tear in the gut wall)
Reaction to sedation
Infection
Bleeding
What is an ERCP?
Endoscopic Retrograde Cholangio Pancreatography looks at the biliary system
When would you do an ERCP?
> Biliary Disease> Jaundice (obstructive)> Drainage > Sphincter of Oddi causes> Strictures or leaks
What are the possible complications of an ERCP?
Pancreatitis, bleeding, perforation and infection/cholangitis
What is enteral and parenteral feeding?
Enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person’s caloric requirementsParenteral nutrition refers to the delivery of calories and nutrients into a vein
What are the indications for CANH?
Enteral> Anorexia or malnutrition> Coma> Liver failureParenteral> Obstruction> Malabsoprtion (SBS)> Fistula
What are the complications of CANH?
Enteral> Aspiration> tube malposition> Refeeding syndrome> Metabolic/ nutritional imbalanceParenteral> Dehydration and imbalance> Infection> Thrombosis> Liver failure> Vitamin Deficiencies
What is IBS?
Irritable bowel syndrome (IBS) is a chronic condition characterised by abdominal pain associated with bowel dysfunction.
What is Functional dyspepsia (FD)?
Functional dyspepsia (FD) is a chronic disorder of sensation and movement (peristalsis) in the upper digestive tract.
What are IBS and FD both classed as?
Functional Gastrointestinal Diseases
What is the epidemiology of IBS (and similarly FD)?
US- 10-15% of adults have itSlight predominance of females
What are the Risk Factors for IBS/ FD?
> Physical and Sexual abuse> Age under 50> Being female> Previous enteric infection> Family and Job stress
What are the signs and symptoms of IBS?
Abdominal discomfortAlteration of bowel habits and painAbdominal bloatingNormal abdo examMucus in stool
What investigations may you do for IBS?
Rule out inflammatory/ immube diseases:> Scoping> Anti tTG Ab (coeliac)> AXR> Faecal calprotectinRule out infection:> FBC> Stool studies> ScopesRockall IBS scoring may help with diagnosis
What is the treatment of IBS/ FD?
> Diet and lifestyle modifications> Laxatives or lubiprostone> Antispasmodics> Loperamide> SSRI/ TCA> CBT
What are the complications of these diseases?
DiverticulosisDamage to family and work relationships
How is prognosis for IBS?
Patients with IBS have an excellent prognosis in the sense that they have a normal life expectancy, and there are no long-term complications of their disease. However, the symptoms of the disease do tend to recur for much of adulthood, particularly at times of stress or emotional difficulty or dietary indiscretions.
What is diverticular disease?
Colonic diverticulosis refers to herniation of mucosa and submucosa through the muscular layer of the colonic wall and may be the result of colonic smooth muscle over-activity. (High pressure of the lumen vs wall weakness)
What are the risk factos for diverticular disease?
Low dietary fibreAge >50 years (decreased mechanical strength of colonic walls)Western dietObesityNSAIDS
WHAT IS THE EPIDEMIOLOGY OF DIVERTICULAR DISEASE?
Most patients are asymptomaticIncidence increases with age<10% in under 40’s50% by 50Up to 66% in over 80’sRight sided higher in asia due to meat consumption
What are the signs and symptoms of diverticular disease?
Left lower quadrant abdominal pain/ tenderness/ guardingRectal bleedingConstipationBloatingDiarrhoeaFeverLeukocytosisPelvic tenderness on DREPalpable abdominal mass
What investigations may you use to diagnose Diverticular disease?
FBCAXR/ CXRCT AbdoUS AbdoContrast EnemaColonoscopySigmoidoscopyAngiogramBlood culture
What may investigations show?
FBCPolymorphonuclear leukocytosisAbdo XrayPneumoperitoneumIleusSoft tissue densities Free air in bowel perforationCT abdoThickening of bowel wallMassAbscessStreaky mesenteric fatMay show gas in bladder in case of fistulaUS abdoSigns of abscess, perforation and obstructionCXRNormal or free air under diaphragm if perforation Contrast enemaDiverticuliAbscessPerforationObstructionFistulaColonoscopySingle, multiple, scattered diverticula InflammationAcute bleedsIschaemiaNeoplasmSigmoidoscopyMucosal pathology such as ischaemia, IBD, neoplasmAngiogramAetiology of bleeding identifiedBlood cultureG-ve rods Anaerobic bacteriaAdministration of antibiotics
What is the management plan for diverticular disease?
Fistula (Surgical repair)Colorectal neoplasm (Cancer treatment)Abscess (Bowel rest and broad spectrum AB/ surgery)Perforation (Surgery)Strictures, obstruction (Balloon dilation and stent placement)
What is the prognosis of diverticular disease?
Recurrence in 1/3 , associated with high mortality¼ of patients remain symptomatic after surgery
What are gallstones?
Cholelithiasis is the presence of solid concretions in the gallbladder. Gallstones form in the gallbladder but may exit into the bile ducts (choledocholithiasis).
What is biliary colic?
Sudden RUQ pain due to gallstone presence in a bile duct
Who gets gallstones and how often?
Cholelithiasis occurs in approximately 10% to 15% of adults in the US and Europe.Obese and older people are more likely to get it
What are the signs and symtpoms of gallstones?
RUQ pain > 30 minsPostprandial painNauseaJaundice
What are the risk factors of gallstones?
Common risk factors include older age, female sex and pregnancy, obesity, rapid weight loss, drugs, and a family history.
What investigations might you do for gallstones?
Bloods- FBC, LFTs, lipase/ amylase (rule out other conditions such as pancreatitis)Abdominal USMay consider MRCP, EUS, ERCP or Abdo CT
What is the management of gallstones?
CholecystectomyERCP with lithotripsy/ stent/ balloon dilationObservation
What are the complications of gallstones and their management?
ERCP related pancreatitis (bowel rest and analegsia)BD injuries (stent)Post sphincterotomy bleeding (Endoscopic haemostatic techniqures)Bouveret syndromeGallstone ileusCholecystitisAscending cholangitisAcute biliary pancreatitisMirizzi syndrome
What is the prognosis of gallstones?
Often a recurring problem
What is gastric cancer?
Stomach cancer is a neoplasm that can develop in any portion of the stomach and may spread to the lymph nodes and other organs.
What are the risk factors of gastric cancer?
> Pernicious anaemia> H Pylori> N-nitroso compounds> Less F/V> high salt> Smoking> Family history
What is the epidemiology of gastric cancer?
There are pronounced global epidemiological variations in gastric cancer, with a higher incidence in East Asia, Eastern Europe, and South America, compared with the rest of the world.
What are the signs and symptoms of gastric cancer?
Abdominal painWeight lossLymphadenopathyDysphagiaLower GI bleed
What are some investigations for gastric cancer?
OGD and biopsyeusCT CAPCXRLaparoscopy
What is GORD?
Symptoms or complications resulting from the reflux of gastric contents into the [o]esophagus or beyond, into the oral cavity (including larynx) or lung
What are the risk factors for GORD?
FHxAgeHiatus herniaObesityDrugsASthmaSmokingAlcoholDiet
What are the signs and symptoms of GORD?
Heart burn Acid regurgitationDysphagiaBloatingLaryngitisGlobusEnamel erosionHalitosisDyspepsia
What is the epidemiology of GORD?
GORD is a common condition that affects between 10% and 30% of people in developed countries
What investigations might you do for GORD?
PPI trialOGDAmbulatory pH monitoringOesophageal manometryCombined impedance pH testingBarium swallowOesophageal capsule endoscopy
What are the possible complications of GORD?
Oesophageal ulcerOesophageal StrictureBarrett’s oesophagusAdenocarcinoma
What is the prognosis for someone with GORD?
PPI treatment is pretty goodCancer has a bad prognosis
What is gastroenteritis?
Acute inflammation of the lining of the stomach and intestines caused by a pathogen.
What are the risk factors?
Contaminated foodClose contact with infectedPoor hygieneExtreme agesHIVOrgan transplantation Chronic illness
What is the epidemiology?
Common- leading cause of mortality worldwide
What are the signs and symptoms of gastroenteritis?
NauseaVomitingDiarrhoeaMalaiseVolume depletionAbdominal painAnorexiaFever
What investigations might you do for gastroenteritis?
Stool cultureRapid antigen testing (Rotavirus or calcivirus)PCR (Rotavirus, norovirus, astrovirus, adenovirus)Viral culture (Infection)Electron microscopy (Specific virus)Micro-organisms (Infection)Bloods (Infection)CT abdomen (Masses etc.)Basal metabolic profile (High Na/K, low Na, Metabolic acidosis)Renal function (Urea, creatinine or ratio may be elevated)
How would you manage gastroenteritis?
Oral rehydration therapyAnti diarrhoeal (like loperamide)Antiemetic (Like metoclopramide/ ondansetron)
What complications might you get from gastroenteritis?
Electrolyte imbalance (ORT)Renal failure (Acute) (ORT and dialysis)Food intolerance (Avoidance)
What is the prognosis?
Pretty good prognosisComplete recovery possible
What is GI perforation?
A GI perforation is a hole which has formed all the way through the wall of any part of the GI tract
What are the RFs for GI perforation?
Previous GI infectionUlcerGallstonesIBDCancerBlunt traumaDrugs such as NSAIDs or steroidsEndoscopy
What are the signs and symptoms of GI perforation?
Stomach painChillsFeverNauseaVomitingFatigue
What is the epidemiology of GI perforation?
Not very common spontaneously
What are the appropriate investigations for GI perforation?
Bloods- leuckocytosis, Anaemia, electrolyte imabalance, acid level imbalance, Kidney and liver dysfunctionCXRCT Abdo
What is the management plan for GI perforation?
Fix underlying issuesRemove foreing material from peritoneum (faeces, bile, food)Colectomy with colostomyAntibiotics
What are the complications of a GI perforation?
PeritonitisBleedingSepsisAbscesses Wound infectionBowel infarction
What is the prognosis of someone with a GI perforation?
Age, IBD and bleeding along with poor nutrition decrease prognosisPeritonitis decreases prognosis and so do steroids
What is haemochromatosis?
Haemochromatosis is a multisystem disorder of dysregulated dietary iron absorption and increased iron release from macrophages.
What are the risk factors of haemochromatosis?
White Middle ages FHxMaleSupplemental iron
What is the epidemiology of haemochromatosis?
The rare forms of haemochromatosis (types 2-4) have been reported worldwide. In contrast, the most common form, type 1 (HFE-related) haemochromatosis, occurs primarily in people of northern European descent.
What are the signs and symptoms of haemochromatosis?
FatigueWeaknessLethargyArthralgiaHepatomegalyDMImpotenceLoss of libidoSkin pigmentation
What are the investigations for haemochromatosis?
Serum transferrin saturation (> 45%)Serum ferritin (raised)MRI liver/ liver biopsy/ LFTs (damage)Fasting blood sugarEcho/ ECGtestosterone/ FSH/ LH assaysBone densitometry
What are haemorrhoids?
Haemorrhoidal cushions are normal anatomical structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.
What are the risk factors for haemorrhoids?
Age 45-65ConstipationPregnancy/ Space Occupying lesionHepatic insufficiencyAscites
What is the epidemiology of haemorrhoids?
Since the second half of the 20th century, there appears to be an unexplained decrease in the prevalence of symptomatic haemorrhoidal disease in both the US and England
What are the signs and symptoms of haemorrhoids?
Rectal bleedingPerianal pain and discomfortAnal pruritisTender palpable perianal lesionAnal mass
What investigations should you do for haemorrhoids?
DRE/ anoscopeColonoscopyFBCStool occult blood/ haem
How do you manage haemorrhoids?
Diet and lifestyle adviceTopical corticosteroidsRubber band ligationPhotocoagulationSurgical haemorrhoidectomy
What are the complications of haemorrhoids?
AnaemiaThrombosisIncarcerationFaecal incontinencePelvic sepsis Anal stenosis
What is the prognosis of haemorrhoids?
Good prognosis
What is a haemorrhoidectomy?
Surgical excision of haemorrhoids
What are the indications for a haemorrhoidectomy?
All patients having grade 4 internal, external or mixed haemorrhoidsThose who have failed to respond to previous treatments
What are the complications of a haemorrhoidectomy?
Anal fistula or fissure.Constipation.Excessive bleeding.Excessive discharge of fluid from the rectum.Fever of 101°F or higher.Inability to urinate or have a bowel movement.Pain
What is a hepatocellular carcinoma?
Hepatocellular carcinoma (HCC), also known as hepatoma, is a primary cancer arising from hepatocytes in predominantly cirrhotic liver.
What is the epidemiology of a hepatocellular carcinoma?
Worldwide, HCC is the sixth most common cause of cancer and the second leading cause of cancer-related death. The global incidence of HCC varies according to the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection.Majority of cases occurring in Asia
What are the risk factors for a hepatocellular carcinoma?
CirrhosisChronic Hep B/CChronic Heavy alcohol usediabetesobesityFHx of liver cancerAflatoxin
What are the signs and symptoms of a hepatocellular carcinoma?
Abdominal distensionOesophageal or gastric variceal bleedingRUQ painEarly satietyWeight lossHepatic encephalopathy CachexiaSplenomegalyPeripheral Stigmata:JaundiceAsterixisSpider naeviPalmar erythemaPeriumbilical collateral veins (caput medusae)Fetor hepaticusLeg oedema
What investigations might you do for a hepatocellular carcinoma?
Bloods> FBC (microcytic anaemia/ thrombocytopenia)> Metabolic panel> LFTs> INR and PT> Viral panel> Alpha fetoproteinLiver USContrast CT/ MRI Abdo
What is an umbilical hernia?
An umbilical hernia is a defect of the anterior abdominal wall fascia that occurs when the umbilical ring fails to close. The defect allows protrusion of a peritoneal sac that is covered by skin and may contain intra-abdominal contents, such as omentum or bowel.
What is an inguinal hernia?
An inguinal hernia is a protrusion of abdominal or pelvic contents through a dilated internal inguinal ring (indirect) or attenuated inguinal floor (direct) into the inguinal canal and out of the external inguinal ring, causing a visible or easily palpable bulge.
What is a femoral hernia?
A femoral hernia usually occurs when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh. It pushes through a weak spot in the surrounding muscle wall (abdominal wall) into an area called the femoral canal.
What is a hernia?
A protrusion of a viscus through an abnormal opening
What are the signs and symptoms of a hernia?
> bulge/ mass> Discomfort> Pain> Symptoms of bowel obstruction> Skin changes
What are the risk factors of an inguinal hernia?
> Male> Old> Smoking> AAA> Incision> Marfans/ Ehlers Danlos> Lathyrism
What are the risk factors of an umbilical hernia?
> Low birthweight> African ancestry
What is the epidemiology of hernias?
Inguinal- 0.14% of the population, 92% of whom were maleUmbilical- More common in kids, even in boys and girls
What is the management of a hernia?
> Hernia repair surgery (may need reduction first)> Prophylactic antibiotic therapy> Watchful waiting
What investigations would you do for a hernia?
Clinical diagnosis
What are the complications for a hernia?
Post operative wound infection/ haemorrhageRecurrence of herniaStrangulationRupturePeritonitis
What is the prognosis of a hernia?
Relatively good prognosis
What is a hiatus hernia?
Hiatus hernia is the protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm.
What is the epidemiology of a hiatus hernia?
Clinical estimates of the prevalence of hiatus hernia in western populations range up to 50%Related to GORD
What are the risk factors of a hiatus hernia?
ObesityMale Elevated intra abdominal pressureStructural abnormalityHerniaAdvanced age
What are the signs and symptoms of a hiatus hernia?
HeartburnRegurgitationObesityChest pain DysphagiaOdynophagiaHaematemesisSOBCoughWheeze Fever and chillsConfusion
What investigations might you fo dor a hiatus hernia?
CXROGDCT/MRI
What is the management of a hiatus hernia?
Surgical repairPPI and lifestyle changes
What are the complications of a hiatus hernia?
BloatingVolvulusObstructionHaemorrhageFundal necrosisInfectionRecurrenceBarrett’s oesophagus
What is the prognosis of a hiatus hernia?
Most patients with an uncomplicated sliding hiatus hernia will have adequate relief of symptoms (but not cure) with medical therapy.
What is intestinal ischaemia?
Intestinal ischemia occurs when the blood flow through the major arteries that supply blood to your intestines slows or stops.
What are the risk factors of intestinal ischaemia?
Old ageSmokingHypercoagulabilityAF
What is the epidemiology of intestinal ischaemia?
Acute mesenteric ischaemia accounts for approximately 0.1% of hospital admissionsOlder people are more likley to get it
What are the signs and symptoms of intestintal ischaemia?
PainCramps postprandiallyWeight lossDiarrhoeaNauseaBloatingAbdominal tendernessConfusion
What investigations do you request for intestinal ischaemia?
Bloods> FBC (anaemia)> Chemistry panel with serum lactate (raised)> Coagulation panel (prothrombotic disorder)>ABG for lactate>ECG> CXR> CT> Colonoscopy
What is intestinal obstruction?
Surgical emergency where a mechanical interruption (either complete or partial) occurs to the flow of intestinal contents, with multiple potential causes (e.g., malignant colorectal disease, colonic volvulus, benign stricture).
What are the risk factors for obstruction?
older agefemale genderinstitutionalisationmental illnessMegacolon
What is the epidemiology of obstruction?
Large bowel obstruction is a common symptom of colorectal cancer, with an incidence range of 15% to 29%.Common indication for surgery
What are the signs and symptoms of obstruction?
colicky abdominal painabdominal distentiontympanic abdomenchange in bowel habitstenesmusnausea and vomitingfeverAbdominal rigidityWeight lossconstipationPalpable mass
What are the appropriate investigations for intestinal obstruction?
Bloods> FBC (leukocytosis/ anaemia)> Serum electrolytes (deranged)> Renal Function (elevated creatinine/ urea)> Serum amylase/ lipase (elevated)> Coagulation studiesErect CXR (no pneumoperitoneum)AXR (Gas distension of large bowel, kidney bean shape volvulus)CT Abdo Pelvis
What are the complications of obstruction?
Bowel perforationSepsisDeath
What is the prognosis of a patient with obstruction?
Different causes result in different mortality and morbidity (e.g. cancer is bad, volvulus may reoccur)
What is the management of intestinal obstruction?
Supportive- oxygen, blood, NG decompensationSurgeryFlexi sig
What is laproscopic abdominal surgery?
Small incisions where tools are inserted and a camera in order to see into the abdomen without making a laparotomy incision
What are the indications for laprascopic abdominal surgery?
Cholecystectomy, weight loss procedures such as the Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band, Nissen fundoplication, Hellar myotomy, diagnostic laparoscopy, and staging laparoscopy.
What are the complications of laprascopic abdominal surgery?
bleeding and the potential need for a blood transfusion.infection.hernia.a risk of damage to internal structures, such as such as blood vessels, the stomach, bowel, bladder, or ureter.adverse reactions to anesthesia.abdominal inflammation or infection.blood clots
What is a liver abscess?
Liver abscesses are purulent collections in the liver parenchyma that result from bacterial, fungal, or parasitic infection.
What are the risk factors of a liver abscess?
Biliary tract diseaseAge >50underlying malignancyDMInterventional biliary or hepatic proceduresLiving in or visiting areas for amoebiasis
What is the epidemiology of a liver abscess?
Liver abscess is an uncommon disease. The annual incidence is approximately 3.6 per 100,000 in the US and the UK
What are the signs and symptoms of a liver abscess?
Fever/ chillsRUQ tendernessHepatomegalyWeight lossfatigueAbdominal painNausea and vomitingCough, SOB, chest pain
What investigations might you use for a liver abscess?
Bloods:> FBC (infection markers)> Serum LFTs (elevated alk phos, aminotransferases, BR and hypobilirubinaemia)> Blood Cultures> PT and aPTT (clotting)Liver USContrast enhanced CT Gram stain and culutre of abscess fluid aspirate
What is a liver cyst?
Liver cysts are fluid-filled sacs that form in the liver.
What are the risk factors of a liver cyst?
> Bile duct malformations> Parasite: echinococcus (food)> Polycystic liver disease
What is the epidemiology of liver cysts?
Affect about 5% of US population and 5% of those get symptoms
What are the signs and symptoms of a liver cyst?
Only if large> Bloating> Pain in RUQ> Palpable mass
What investigations do you do for liver cysts?
> Liver US> Liver CT> Bloods to rule out other causes/ anaemia
What is a Mallory Weiss Tear?
Mallory-Weiss tear (MWT), also known as Mallory-Weiss syndrome (MWS), is characterised by a tear or laceration often along the right border of, or near, the gastro-oesophageal junction.
What are the risk factors of a mallory weiss tear?
> Chronic Cough> Hiatus Hernia> Retching during endoscopy> Alcohol> Previous instrumentation
What is the epidemiology of a mallory weiss tear?
Admission to hospital for non-variceal upper gastrointestinal (GI) bleeding is common, with an incidence of about 50 to 150 per 100,000 people per year. Mortality ranges between 8% and 14%.
What are the signs and symptoms of a mallory weiss tear?
HaematemesisLight headednessPostural hypotensionDysphagiaOdynophagiaPainMalaenaHaematochezia
What investigations are appropriate for a mallory weiss tear?
FBC (anaemia)Urea (high if ongoing bleed)LFTs (normal)PT/ INR (normal)PTT (normal)CXR (normal)OGD (tear or laceration in mucosa)X match/ group
What is the management plan for a mallory weiss tear?
Fluids/ BloodEndoscopy with interventionAntigastric acid therapyAnti emeticSomatostatinErythromycinSurgical intervention
What are the complications of a mallory weiss tear?
vasopressin infusion-related abdominal painre-bleedingmyocardial ischaemia or infarctionadrenaline-related hypertensive emergencyadrenaline-related ventricular tachycardiahypovolaemic shock/deathoesophageal perforationgastric ischaemia or infarctmetabolic disturbance
What is the prognosis for a Mallory Weiss Tear?
For most patients, bleeding is self-limited, and will have stopped by the time of endoscopyRe-bleeding occurs in about 8% to 15% of patients. It usually occurs within the first 24 hours and most often in patients with high-risk factors for re-bleeding
What is an NG tube?
A nasogastric tube (NG tube) is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving a person extra calories.
What are the indications of an NG tube?
have neck or facial injurieshave had neck or facial surgeryneed a mechanical ventilator to breathehave an intestinal obstruction or blockageare comatose
What are the complications of an NG tube?
> aspiration> tissue trauma> abdominal cramping, abdominal swelling, diarrhea, nausea, vomiting, regurgitation of food or medicine> blocked, torn, or dislodged. > ulcers or infections to develop on the tissue of sinuses, throat, esophagus, or stomach.
What is NASH (or NAFLD)?
Non-alcoholic fatty liver disease (NAFLD) is a clinico-histopathological entity that includes a spectrum of conditions characterised histologically by macrovesicular hepatic steatosis in those who do not consume alcohol in amounts generally considered harmful to the liver.
What is the epidemiology of NASH?
It is estimated that NAFLD affects 20% to 40% of the Western world.
What are the risk factors of NASH?
> Obesity > Insulin resistance > Dyslipidaemia > Hypertension > Metabolic syndrome > Rapid weight loss > Hepatotoxic medications > Total parenteral Nutrition
What are the signs and symptoms of NASH?
> No alcohol> Fatigue/ Malaise> Hepatosplenomegaly> Truncal obesity> RUQ discomfort> Peripheral stigmata of liver disease
What are the appropriate investigations of NASH?
> AST and ALT (elevated)> BR (raised)> Alk Phos (raised)> GGT (raised)> FBC (anaemia/ thrombocytopenia)> Abnormal metabolic panel> Lipid panel (raised)> INR/ PT> Serum albumin> ANA> Iron studies
What is the managment of NASH?
> Diet/ exercise> Vitamin E> Weight loss> Roux-en- Y gastric bypass> Lipid lowering agents
What are the complications of NASH?
AscitesVariceal haemorrhagePortosystemic encephalopathyHepatocellular carcinomaHepatorenal syndromeHepatopulmonary syndromeDeath
What is the prognosis of NASH?
The natural history seems to be dependent on the histological subtype of NAFLD at the time of diagnosis. The overall prognosis in patients with bland steatosis (fatty liver without evidence of active inflammation) is considered to be good and a majority of patients will remain stable throughout their lifetime.
What is liver failure?
Acute liver failure (ALF) is a rare syndrome defined by a rapid decline in hepatic function characterised by jaundice, coagulopathy (INR >1.5), and hepatic encephalopathy in patients with no evidence of prior liver disease.
What are the risk factors of liver failure?
> Alcohol> Poor nutrition> Female> Age >40> Pregnancy> Chronic Hep B/C> Chronic pain and narcotic use> Hepatotoxicity
What is the epidemiology of liver failure?
ALF is a rare event. In the US it has an incidence of approximately 2000 cases annually, yet it accounts for up to 6% of all liver-related deaths
What are the signs and symptoms of liver failure?
> Jaundice> Hepatic encephalopathy> Abdominal pain> Nausea> Vomiting> Malaise> Cerebral oedema> RUQ tenderness> Hepatomegaly> Absence of Splenomegaly, palmar erythema, ascites
What are appropriate investigations for liver failure?
BloodsCXRAbdominal US with doppler
What are the complications of liver failure?
Rapidly progressing hepatic encephalopathyCoagulopathyInfectionRenal failure and haemodynamic changesMetabolic disordersCerebral oedemaGI bleeding
What is the prognosis of liver failure?
ALF carries a substantial risk of mortality and continues to be a major challenge to clinicians as strategies to improve outcomes are developed
What is oesophageal cancer?
Most oesophageal cancers are mucosal lesions that originate in the epithelial cells lining the oesophagus.
What are the risk factors of oesophageal cancer?
> Male> Tobacco> Alcohol> GORD/ Barrett’s oesophagus> Hiatus hernia> FHx> Low socioeconomic sttatus> Non white race> High temp> Low intake of fresh fruit and veg
What is the epidemiology of oesophageal cancer?
The annual incidence reported in Linxian Province in central China is 140 per 100,000. This compares with an average rate for Western countries of 3 per 100,000.
What are the signs and symptoms of oesophageal cancer?
DysphagiaOdynophagiaWeight loss HoarsenessHiccupsPostprandial cough
What investigations might you do for oesophageal cancer?
> OGD> metabolic profile> CT/ MRI CAP> Endo US with FNA> Bronchoscopy with FNA> Echo
What is open abdominal surgery?
Surgery which requires a large incision that exposes the inner organs, this may include a laparotomy ( a midline cut)
What are the indications for a laparotomy?
> Blunt abdominal trauma.>Hemorrhage/haemoperitoneum.>Perforated viscus.>Peritonitis.>Intestinal obstruction with hugely distended bowel loops, making a successful laparoscopic intervention unlikely.>Large specimen extraction>Multiple previous abdominal operations, making extensive adhesions likely>Obscure gastrointestinal bleeding that is not controlled by endoscopic intervention or embolisation
What are the complications of a laparotomy?
> Bleeding>Infection>Bruising>Seroma/ hematoma>Wound dehiscence>Necrosis>Incisional herniation>Chronic pain>Skin numbness>Fistulation with underlying structures>Raised intra-abdominal compartment pressure>Damage to underlying structures>Poor cosmesis
What is pancreatic cancer?
‘Pancreatic cancer’ refers to primary pancreatic ductal adenocarcinoma, which accounts for >85% of all pancreatic neoplasms
What are the risk factors of pancreatic cancer?
SmokingFHx Other hereditary cancer symptomsChronic sporadic pancreatitisDMObesityDiet
What is the epidemiology of pancreatic cancer?
Pancreatic cancer is a disease with a poor prognosis. In 2018, it is estimated there will be 55,440 new cases of pancreatic cancer in the US. An estimated 44,330 people will not survive the disease, which makes it the third most common cause of cancer-related death in the US.
What are the signs and symptoms of pancreatic cancer?
JaundiceUpper Abdo pain or discomfortWeight loss/ anorexiaAge 65-75SteatorrhoeaUrinary symptomsetc. (uncommon symptoms)
What investigations would you do for pancreatic cancer?
Abdo USPancreatic protocol CTLFTsCancer markers (CA 19-9)Amylase
What is acute pancreatitis?
Acute pancreatitis is a self-limiting and reversible pancreatic injury associated with mid-epigastric abdominal pain and elevated serum pancreatic enzymes
What is chronic pancreatitis?
Chronic pancreatitis is characterised by recurrent or persistent abdominal pain and progressive injury to the pancreas and surrounding structures, resulting in scarring and loss of function.
What are the risk factors for acute pancreatitis?
Middle aged womanYoung to middle aged menGallstonesAlcoholHypertriglyceridaemiaERCPTraumaSLESjorgen’s syndrome
What are the risk factors for chronic pancreatitis?
AlcoholSmokingFHxCoeliac disease
What is the epidemiology for chronic and acute pancreatitis?
Acute pancreatitis is a potentially lethal disease that is increasing in incidence. Incidence varies from 4.5 to 79.8 per 100,000 per year in different countries. Benign pancreatic disease, including chronic pancreatitis, affects 5 to 24 million people in the US and in 2004 accounted for 445,000 hospitalisations and 881,000 physician visits
What are the signs and symptoms of chronic pancreatitis?
Abdominal painsteatorrhoeaJaundiceWeight loss and malnutritionN and VSkin nodules, painful joints, low trauma, abdominal distension
What investigations would you do for acute pancreatitis?
Serum lipase or amylase (3x upper limit)AST and ALT (high)FBC (leukocytosis)CRP (Necrosis indicator)Hct (Necrosis indicator)ABG (hypoxaemia)AXR/ CXRTransabdominal US (pancreas inflammation)Ratio of serum lipase:amylase (>5)
What investigations would you do for chronic pancreatitis?
Blood glucoseCT scanAbdominal USAbdo X ray
How would you manage acute pancreatitis?
> IV fluids> Analgesia> Nutritional support> Supplemental oxygen> Anti emetic> Calcium and magnesium replacement therapy> (Insulin/ cholecystectomy)> Vitamins> ERCP> IV Abx
How would you manage chronic pancreatitis?
> Analgesia> Lifestyle changes- alcohol and cigarette cessation> Pancreatic enzymes plus PPI> Octreotide> Antioxidants> Decompression> ESWL> Distal pancreatectomy
What are the complications of acute pancreatitis?
Acute renal failureSepsisRetroperitoneal bleedingInfected pancreatic necrosisAcute lung injury/ ARDS
What are the complications of chronic pancreatitis?
Pancreatic exocrine insufficiencyDiabetes mellitusPancreatic calcificationsPancreatic duct obstructionLow trauma fracturePancreatic pseudocyst
What is the prognosis of acute and chronic pancreatitis?
Chronic:Generally, pain decreases or disappears over time, regardless of aetiologyTen-year survival after diagnosis is 20% to 30% lower than the general populationAcute:The majority of patients with acute pancreatitis will improve within 3 to 7 days of conservative management.Long-term prognosis is based on the aetiological factor and patient compliance to lifestyle modifications
What is peptic ulcer disease?
A break in the mucosal lining of the stomach or duodenum more than 5 mm in diameter, with depth to the submucosa. Ulcers smaller than this or without obvious depth are called erosions. Peptic ulcers result from an imbalance between factors promoting mucosal damage (gastric acid, pepsin, Helicobacter pylori infection, non-steroidal anti-inflammatory drug use) and those mechanisms promoting gastroduodenal defense (prostaglandins, mucus, bicarbonate, mucosal blood flow).
What are the risk factors of peptic ulcer disease?
H PyloriNSAIDsSmokingAgeFHx or personal Hx of peptic ulcer diseaseITU admission
What are the signs and symptoms of peptic ulcer disease?
Abdominal painPointing signEpigastric tendernessNausea or vomitingEarly satietyWeight loss or anorexiaDiarrhoeaAnaemiaGI bleedHypotensionSuccession splash
What is the epidemiology of peptic ulcer disease?
One systematic review of the literature reported an annual incidence of 0.10% to 0.19% for physician-diagnosed peptic ulcer disease and a 1-year prevalence of 0.12% to 1.50%.
What investigations might you do for peptic ulcer disease?
H Pylori breath or stool testUpper GI endoscopyFBC (anaemia, leukocytosis)
How do you manage peptic ulcer disease?
> Endoscopy and blood transfusion> PPI> Surgery or embolisation via interventional radiology> H2 antagonist> H Pylori eradication> Misoprostol
What are the complications of peptic ulcer disease?
> Penetration> Gastric outlet obstruction> Upper GI bleed> Perforation
What is the prognosis of peptic ulcer disease?
With proton-pump inhibitor (PPI) therapy, duodenal ulcers typically heal within 4 weeks and gastric ulcers within 8 weeks.
What is Gastritis?
Gastritis is defined as the histological presence of gastric mucosal inflammation.
What is the prognosis of gastritis?
Prognosis is dependent upon underlying aetiology and type of gastritis. (Phlegmonous gastritis is bad)
What are the risk factors of gastritis?
H PylorisNSAIDsToxinsPrevious gastric surgeryCritically ill patientsAutoimmune disease
What are the signs and symptoms of gastritis?
DyspepsiaAbsence of malignacyNausea, vomiting, loss of appetiteFeverAcute abdominal painAltered reflexesGlossitisCognitive impairment
What is the epidemiology of gastritis?
In the United States, dyspeptic symptoms affect up to 25% of the population; non-ulcer dyspepsia (including gastritis) contributes to the diagnosis in about 50% of patients referred for upper endoscopy.
What are the investigations you would do for gastritis?
H Pyloris breath or stool testFBC (anaemia)EndoscopyB12
What is the management of gastritis?
Anti-secretaory agentsH Pylori eradication therapyH2 antagonist or PPICyanocobalamin (autoimmune)
What is peritonitis?
Inflammation of the peritoneum.
What are the risk factors of peritonitis?
Ascites, stomach ulcers, pelvic inflammatory disease, decompensated hepatic stateE.Coli and S.Aureus
What are the signs and symptoms of peritonitis?
BloatingNauseaVomitingFeverDiarrhoeaDecreased urine outputPain/ tendernessSecondary peritonitis may cause more rigidity
What is the epidemiology of SBP?
SBP- 12% in patients with ascites from decompensated cirrhosis
What investigations may be important for peritonitis?
> BloodsFBCCrLFTINR/PTCultureABG-pH>Ascitic fluidNeutrophil countGram stainCultureLeukocyte esterasepH> UrineLeukocyte esterase strip
How do you manage peritonitis?
AntibioticsAlbuminLarge volume paracentesisSupportive therapy
What are the complications of peritonitis?
SepsisTense ascitesParacentesis- bleeding, perforation or leakageRenal failure
What is the prognosis of peritonitis?
High chance of recurrenceRenal dysfunction is prognosticLow mortality if treated
What is a perineal abscess?
A perineal abscess is an infection that causes a painful lump in the perineum
What is a perineal fistulae?
A perineal fistula is a type of anorectal malformation (ARM) that involves a misplaced anal passage that is often narrowed
Explain the aetiology / risk factors of perineal abscesses and fistulae
Absces: A blocked anal gland, a sexually transmitted infection (STI), or an infected anal fissure can cause anal abscesses. Some other risk factors include: Crohn’s disease or ulcerative colitis, which are inflammatory bowel diseases that cause the body to attack healthy tissue. diabetesFistulae: The causes of congenital anorectal malformations are unknown; however, environmental factors such as drug use during pregnancy may play a part.
Summarise the epidemiology of perineal abscesses and fistulae
The condition occurs in one out of every 5,000 births. Males are slightly more likely to develop the condition than females
What are the signs and symptoms of perineal abscesses and fistulae?
Abscess:constipationrectal discharge or bleedingswelling or tenderness of the skin surrounding the anusfatigueFistulae:Not passing stool the first day or two after birthPassing stool through a misplaced openingSwollen bellyMissing or misplaced anus
Identify appropriate investigations for perineal abscesses and fistulae and interpret the results
> Examination> Endoscope> MRI/ US> Blood test for Crohn’s
Generate a management plan for perineal abscesses and fistulae
Abscess:Drain the pusSurgerySitz bathFistulae:Surgery
Identify the possible complications of perineal abscesses and fistulae and its management
Fistulae (from abscess)BacteraemiaSepsisFaecal incontinencerecurrenceAnal stenosis
Summarise the prognosis for patients with perineal abscesses and fistulae
Abscesses and fistula require treatment or will greatly decrease QoL
What is a pilonidal sinus?
Pilonidal sinus is caused by the forceful insertion of hairs into the skin of the natal cleft in the sacrococcygeal area.
What are the risk factors of a pilonidal sinus?
> Male> Age 16-40> FHx> Stiff hair and hirsutism
What is the epidemiology of pilonidal sinuses?
Pilonidal sinus is common, with an estimated prevalence of 26 cases per 100,000 population in the US.
What are the signs and symptoms of a pilonidal sinus?
> Discharge > Pain and swelling> Sinus tracts> Skin maceration> Natal cleft pain and swelling> Fever or toxaemia
What investigations would you do for a pilonidal sinus?
Clinical
What is the management of a pilonidal sinus?
Hair removalLocal hygieneAntibiotic therapySurgical treatmentAnalgesia
What are the complications of a pilonidal sinus?
> suppurative, post-operative collection deep to sutures> Necrotising fasciitis
What is the prognosis of a pilonidal sinus?
Depending on the surgical technique chosen, recurrence rates are variable and average 6.9%. Recurrence is less likely to occur after healing by secondary intention compared with any type of primary wound closure, although off-midline closure confers an advantage over midline techniques
What is portal hypertension?
Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system.
What are the risk factors of portal hypertension?
> Cirrhosis (Alcohol use)> Hepatitis (IVDU, Tattoos, old blood) > Thrombosis in portal system> Schistosomiasis> focal nodular hyperplasia (HIV- unprotected sex, multiple partners)
What is the epidemiology of portal hypertension?
The incidence of portal hypertension is approximately 25,000 cases per 100,000 individuals with non-alcoholic fatty liver disease (NAFLD)The incidence of idiopathic portal hypertension is approximately 14,000-27,000 cases per 100,000 individuals with non-cirrhotic portal hypertension
What are the signs and symptoms of portal hypertension?
> GI bleeding symptoms (melaena, haematemesis, haematochezia)> Ascites> Encephalopathy> Reduced clotting ability > Leucopenia
What are the investigations for portal hypertension?
Abdo USCT AbdoEndscope
How do you manage portal hypertension?
> Lifestyle advice> eta blocjers> Diuretics (ascites)> Sclerotherapy
What are the complications of portal hypertension?
> Portal hypertensive gastropathy> TIPSS problems
What is the prognosis of patient with portal hypertension?
You can’t reverse damage caused by cirrhosis, but you can treat portal hypertension
What is primary biliary cirrhosis?
Primary biliary cholangitis (PBC) is a chronic disease of the small intrahepatic bile ducts that is characterised by progressive bile duct damage (and eventual loss) occurring in the context of chronic portal tract inflammation.
What are the risk factors of primary biliary cirrhosis?
> Female> 45-60> Smoking> UTI>FHx
What is the epidemiology of primary biliary cirrhosis?
The prevalence of primary biliary cholangitis (PBC) is up to 35/100,000 in US populations, with a distribution that is heavily skewed towards women (10:1 female-to-male distribution) and those over 45 years of age.
What are the signs and symptoms of primary biliary cirrhosis?
> Itch> Fatigue> Dry eyes and mouth> Sleep disturbance> Postural dizziness/ blackouts> Hepatomegaly> Weight loss and other metabolic features of mal-absorption> Memory/ Conc problems> Jaundice> Ascites> Splenomegaly> Skin pigmentation> Xanthelasmata
What investigations would you do for primary biliary cirrhosis?
BloodsAbdo USMRCPUpper GI endoscopyLiver biopsy
What bloods would you do for someone with primary biliary cirrhosis?
> Alk Phos> GGT> BR> ALT> Serum albumin> Anti-mitochondrial antibody immunofluorescence> ANA> Anti- pyruvate dehydrogenase complex E2-ELISA> Anti M2 ELISAAnti-glycoprotein-210 ELISA> Anti Sp100 ELISA
What is primary sclerosing cholangitis?
Primary sclerosing cholangitis (PSC) is a chronic progressive cholestatic liver disease, characterised by inflammation and fibrosis of the intrahepatic and/or extrahepatic bile ducts, resulting in diffuse, multi-focal stricture formation.
What are the risk factors for primary sclerosing cholangitis?
> Male> IBD> Genetic predisposition
What are the signs and symptoms of primary sclerosing cholangitis?
> Abdo pain> Pruritis> Fatigue> Weight loss> Fever> jaundice> Steatorrhoea> Splenomegaly> Ascites> Encephalopathy
What is the epidemiology of primary sclerosing cholangitis?
Prevalence:5.58 per 100,000 in the UK(relatively rare)
What investigations would you do for primary sclerosing cholangitis?
> serum alkaline phosphatase> serum gamma-GT> serum aminotransferases (aspartate aminotransferase, alanine aminotransferase)> serum total bilirubin> serum albumin> FBC> prothrombin time> atypical antineutrophil cytoplasmic auto-antibody (ANCA)> antimitochondrial antibody> abdominal ultrasound> MRCP> ERCP
What is rectal prolapse?
Rectal prolapse is when the rectum drops down towards or outside the anus. 3 types: Full thickness, Mucosal and internal
What are the signs and symptoms of rectal prolapse?
> External bulge> Red mass outside anal opening> Pain> Bleeding> leaking blood, mucus or faeces from anus
What are the risk factors of rectal prolapse?
> Pregnancy> Constipation> Diarrhoea> Lots of coughing> MS/ Spinal tumours/ Lumbar disc disease/ lower back injury
What is the epidemiology of rectal prolapse?
The annual incidence of rectal prolapse is 2.5 per 100 000 population.
What investigations would you do for rectal prolapse?
> DRE> Proctography> Colonoscopy> Endoanal US
What is ulcerative colitis?
An inflammatory bowel disease characterised by diffuse inflammation of the colonic mucosa and a relapsing remitting course. It normally involves the rectum and extends proximally to affect a variable length of colon.
What are the risk factors of UC?
Family historyHLA B27infectionNSAIDsNot smoking or former smoker
What is the epideiology of UC?
Incidence: 1-24 in 100,000 people per year (stable)Highest in Scandinavia and North EuropePrevalence: 1 in 1000 (increased recently)West > EastSlightly more common in men than womanaged 20-40 and 60 (uncommon <10)
What are the signs and symptoms of UC?
Rectal bleedingDiarrhoea Blood in stool Also: Abdominal pain, athritis/spondylitis, malnutrition, abdominal tendernessMaybe: fever, weight loss, constipation, skin rash, uveitis/ episcleritis, pallor
What investigations would you do for UC?
Stool- negative culture/ CDiff toxins, WBC present, elevated faecal calprotectinFBC- variable anaemia, leukocytosis, thrombocytosisMetabolic panel- hypokalaemic metabolic acidosis; elevated sodium and urea; elevated alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase; hypoalbuminaemiaESR- variable degree of elevation, although >30mm/hour is suggestive of a severe flare-upCRP- variable degree of elevationRadiograph (abdo)- dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to ≥6 cm in diameterflexible sigmoidoscope- findings are as in colonoscopy, but examination is limited to distal coloncolonoscopy- rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), normal terminal ileum (or mild ‘backwash’ ileitis in pancolitis)biopsies-continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing
What is the management of UC?
> Corticosteroids> Mesalazine> Infliximab> vedolizumab> tofacitinib> Ciclosporin> Colectomy
What are the complications of UC?
Toxic megacolonPerforationInfectionMassive GI bleed colonic adenocarcinomabenign strictureinflammatory pseudopolypsPSCDALM
What is the prognosis of UC?
Possible increased mortality but not confirmedIncreased mortality in surgical interventionToxic megacolon most common cause of death
What is viral hepatitis?
Inflammation of hepatocytes due to infection
What are the risk factors of viral hepatitis?
> Hep A virus from food or anal oral sex and IVDU> Hep B is an STD> Hep C is via needles and tattoos
What are the signs and symptoms of viral hepatitis?
diarrheafatigueloss of appetitemild fevermuscle or joint achesnauseaslight abdominal painvomitingweight lossjaundice
What is the epidemiology of viral hepatitis?
About 2.3 billion people of the world are infected with one or more of the hepatitis viruses. Viral hepatitis results in around 1.4 million deaths each year, HBV and HCV are responsible for about 90% of these fatalities, whilst the remaining 10% of fatalities are caused by other hepatitis viruses
What investigations would you use for viral hepatitis?
> Blood tests: These can detect whether the body is producing antibodies to fight the disease, and they can assess liver function by checking the levels of certain liver proteins and enzymes. > Nucleic acid tests: For hepatitis B and C, an HBV DNA or HCV RNA test can confirm the speed at which the virus is reproducing in the liver, and this will show how active the disease is.> A liver biopsy: This can measure the extent of liver damage and the possibility of cancer.> Paracentesis: Abdominal fluid is extracted and tested, to identify the cause of fluid accumulation.> Elastography: This measures the liver’s stiffness by emitting sound waves.> Surrogate markers: A type of blood test to assess the development of cirrhosis and fibrosis.
What are the complications of viral hepatitis?
Acute or subacute hepatic necrosis.Chronic active hepatitis.Chronic hepatitis.Cirrhosis.Hepatic failure.Hepatocellular carcinoma (HCC) in patients with HBV or HCV infection
What is the prognosis of viral hepatitis?
Unfortunately, not all patients with viral hepatitis recover completely. Five to 10 percent of patients with acute HBV infection and about 75% to 80% of patients with acute HCV infection develop chronic hepatitis. Patients (about 0.5% to 1%) that develop fulminant hepatitis have about an 80% fatality rate.
What is Vitamin deficiency?
A lack of a vitamin in the body.
How might you get a vitamin deficiency in general?
> Poor intake> Poor absorption> Overuse> Over removal
How do you get Vitamin A deficiency?
> Dietary > Iron deficiency> Fibrosis> Pancreatic insufficiency> IBD> Small bowel surgery
What is the epidemiology of Vitamin A deficiency?
It is common in poorer countries, especially among children and women of reproductive age, but rarely is seen in more developed countries
What are the signs and symptoms of Vitamin A deficiency?
> Night Blindness and xeropthalmia> Bitot’s spots> Imtiaz’s sign> Infection
What are the management of vitamin deficiency?
> Replacement > Diet modification> Dealing with associated problems
What investigations would you do for vitamin deficiency?
> Clinical diagnosis> Blood test
What is vitamin B?
There are 8 B vitamins:B1, B2, B3, B5, B6, B7, B9, B12. They play an important role in cell metabolism
What are the B vitamin deficiencies?
B1- Beriberi (nervous system disease)B2- Riboflavin deficiency (ariboflavinosis)B3- Pellagra (if also tryptophan deficiency)B5- Acne and parasthesiaB6- seborrhoeic dermatits like eruptions, pinkeye and neuro symptomsB7- Decrease hair and nail growthB9 (folate)- Macrocytic anaemiaB12- Macrocytic anaemia
What does Vitamin C deficiency cause?
Scurvy (uncommon in the developed world)
What are the symptoms of scurvy
Lassitude, weakness, irritability, weight loss, and vague myalgias and arthralgias may develop early.Swollen spongy gums (purple)Loosing teethInfectionPoor wound healing
What is the treatment for scurvy?
Ascorbic acid and diet modification
What are the symptoms of vitamin D deficiency?
> Fatigue and tiredness> poor immunity> Bone and back pain> Depression> Impaired wound healing> Bone loss> Hair loss> Muscle pain
What are some risk factors of vitamin D deficiency?
Having dark skin.Being elderly.Being overweight or obese.Not eating much fish or dairy.Living far from the equator where there is little sun year-round.Always using sunscreen when going out.Staying indoors.
What is the treatment of vitamin D deficiency?
ErgocalciferolDiet
What can Vitamin E deficiency cause?
Vitamin E deficiency can cause nerve and muscle damage that results in loss of feeling in the arms and legs, loss of body movement control, muscle weakness, and vision problems. Another sign of deficiency is a weakened immune system.
What are the risk factors for Vitamin E deficiency?
chronic pancreatitis.cholestasis.cystic fibrosis.primary biliary cirrhosis.Crohn’s disease.short bowel syndrome
What are the treatments for vitamin E deficiency?
Diet modificationHigh dose Vitamin E supplements
Who get’s vitamin K deficiency?
Infants
What are the symptoms of Vitamin K deficiency?
Easy bruising.Oozing from nose or gums.Excessive bleeding from wounds, punctures, and injection or surgical sites.Heavy menstrual periods.Bleeding from the gastrointestinal (GI) tract.Blood in the urine and/or stool
How do you treat Vitamin K deficiency?
> Phytonadione (Oral supplement or injection)
What is the prognosis of the vitamin deficiencies?
Pretty Good if supplemented appropriately
What is Vitamin B12 and folate deficiency?
Why is this a LO? its a nutrient deficiency?
How do you get Vitamin B12 and folate deficiency?
> Pernicious anaemia (B12) > Diet> Addisons disease/ vitiligo are RFs for pernicious anaemia> Gastrectomy> IBD> PPI> Malabsorption> Excessive peeing> Anticonvulsants> pregnancy> cancer
What are the signs and symptoms of B12 and folate deficiency?
> Symptoms related to anaemia> a pale yellow tinge to your skin> Glossitis> mouth ulcers> Parasthesia> disturbed vision> irritability> depression> Mental ability decline> Reduced sense of taste> Diarrhoea> Numbness and tingling in the feet and hands> muscle weakness> depression
What is the epidemiology of B12/ folate deficiency?
In the general population, some studies have shown that among patients with anemia, approximately 1% to 2% is due to B12 deficiencyThe prevalence of folate deficiency has decreased since many countries in the western hemisphere introduced a mandatory folic acid food fortification program starting in the late 1990s
What investigations would you do for B12/ folate deficiency?
Bloods> FBC (anaemia> B12 and folate
What is a volvulus?
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction.
What are the risk factors of a volvulus?
AgeFemaleMental illnessInstitutionalisationMegacolon
What is the epidemiology of volvulus?
For colonic volvulus, data from the US indicate an incidence of 1.47 per 100,000 per year, and 1.7 per 100,000 per year in the UK. Much higher incidences are reported from Africa (i.e., 12 per 100,000 per year).
What are the signs and symptoms of volvulus?
VomitingPainDistension/ tendernessWeight lossTympanic abdomenChange in bowel habitsAbnormal bowel sounds
What investigations would you use for volvulus?
Upper GI contrast SeriesCT abdomenAXR (coffee bean sign)FBCUS/ LGI contrast series/ ABG
What is Wilson’s disease?
Wilson’s disease is an autosomal-recessive disease of copper accumulation and copper toxicity caused by mutations in the ATP7B gene, which is part of the biliary excretion of copper pathway.
What are the risk factors of Wilson’s disease?
> ATP7B mutation> Non- veg diet
What are the signs and symptoms of Wilson’s disease?
> history of hepatitis> history of behavioural abnormalities> tremor> dysarthria> dystonia> incoordination> sloppy or small handwriting> dysdiadochokinesis> abnormal extraocular movements> normal sensation, muscular strength, and reflexes> Liver signs (e.g. jaundice, gynaecomastia)
What is the epidemiology of Wilson’s disease?
The worldwide incidence of Wilson’s disease is in the order of 30 cases per million
What investigations are important for Wilson’s disease?
> LFTs (abnormal)> FBC (leucopenia/ thrombocytopenia)> 24hr urine copper> blood free copper
