Gastroenterology Flashcards
1
Q
What is gastro-oesophageal reflux disease?
A
Symptoms or complications resulting from reflux of gastric contents into the oesophagus or beyond
2
Q
Why might GORD symptoms be worse at night?
A
Because of vagal stimulation causing upper oesophageal relaxation
3
Q
What condition can predispose to GORD?
A
Hiatus hernia
4
Q
What cancer can GORD predisposed to and why is this?
A
Oesophageal cancer either Adenocarcinoma or squamous cell
because the gastric contents of the damages the mucosal epithelial cells and causes oesophagitis
5
Q
What are risk factors of GORD?
A
Family history of heartburn
obesity
increased age
hiatus hernia
6
Q
What are the symptoms of GORD?
name the red flag symptoms of GORD?
A
Heartburn tightness in chest regurgitation asthma -like symptoms with cough burping
dysphasia
bloating
early satiety
7
Q
what is the initial investigation of GORD?
A
A PPI trial of eight weeks and then check for improvement
8
Q
Following a PPI trial there is no improvement in the patient’s GORD symptoms, what is the next line investigation?
when else would you want to order this investigation for GORD?
A
OGD endoscopy
if there are any red flag symptoms
9
Q
What sign may you see on endoscopy that is a precursor to oesophageal cancer?
A
Barrett’s oesophagus showing cellular metaplasia
10
Q
What is the management plan with GORD?
A
Continue PPI (up to x2 doses a day)or have surgery if that is possible
if there is a nocturnal component ranitidine H2 agonist can be used
11
Q
what is oesophageal cancer?
A
Mucosal lesions originating in the epithelial cells lining the oesophagus either adenocarcinoma or squamous cell carcinoma
12
Q
What other two main causes of oesophageal cancer?
A
Gastro-oesophageal reflux disease and Barrett’s oesophagus
high BMI with an unclear mechanism
13
Q
What are the risk factors associated with oesophageal cancer?
A
GORD High BMI male Tobacco use excess alcohol use family history diet low in fibre
14
Q
What is the main presentation of oesophageal cancer?
A
Dysphasia it is usually a late presentation with two thirds of the oesophagus occluded
painful swallow and weight loss
15
Q
What investigation is required to diagnose oesophageal cancer?
what other investigations useful?
A
OGD with biopsy
and metabolic profile since cancers are usually advanced
16
Q
What other cancers can cause dysphasia?
A
Mediastinal cancers :
lung
lymphatic inc. non-Hodgkin’s lymphoma
thymoma
17
Q
What is oesophageal achalasia?
A
A disorder of unknown aetiology characterised by aspirations and insufficient lower oesophageal sphincter relaxation due to loss of neurons in the oesophageal myenteric plexus - aucherbach plexus
18
Q
What is the presentation of oesophageal achalasia?
A
Aspirations when eating
dysphasia
changing posture when swallowing to help
retro sternal pain and pressure with regurgitation
a gradual weight loss - rapid weight loss indicates malignancy and is a red flag
heartburn is not usually present!
19
Q
What investigations would you use for oesophageal achalasia?
A
Upper GI endoscopy + barium swallow
oesophageal manometry
20
Q
What would you see on an upper GI endoscopy for oesophageal achalasia?
A
Retained saliva with frothy appearance
21
Q
What would barium swallow show for oesophageal achalasia?
A
Delayed swallow with a tapered dilated appearance
22
Q
What is the management of oesophageal achalasia?
A
Surgical or pharmacological with Botox and possibly gastrostomy
pharmacological therapy = isorbatide denigrate or CCB (nifiedepine)
23
Q
What is systemic scleroderma?
A
Systemic scleroderma is a multisystem autoimmune disease characterised by functional and structural abnormalities of small blood vessels fibrosis of the skin and internal organs as well as the production of autoantibodies
24
Q
Describe the pathophysiology of systemic scleroderma?
A
Has a strong genetic component and immunological components (ANA positive in 90%)
immune system activation leading to endothelial cell activation and damage of the endothelium
fibroblasts because increased collagen deposition
activated T cells promote disease by making for pro fibrotic cytokines and down regulating the inhibitory cytokines
25
What is the presentation of systemic scleroderma in the hands and feet?
Hand and feet swelling
skin thickening
functional loss
26
What is the presentation of systemic scleroderma in the GI tract?
Heartburn
reflux
bloating
faecal incontinence
27
What is the presentation of systemic scleroderma in the respiratory system?
dysnopea
| dry crackles at bases of lungs
28
What is the presentation of systemic scleroderma in the vascular system?
Raynaud's disease
| pits and ulcers at the tips of fingers from ischaemia
29
What investigations are required in oesophageal scleroderma?
Serum antibodies:
ANA - most common 90%
anti-SCL
anti- rna polymerase
```
U+E (renal involvement)
urine microscopy (to check the renal crisis, proteinuria)
```
ESR and CRP are usually normal
pulmonary function tests (interstitial lung disease)
chest x-ray (interstitial lung disease)
ECG (arrhythmias which show cardiac involvement)
echocardiogram (yearly test for pulmonary hypertension)
barium swallow ( decreased peristalsis)
30
What is the management of oesophageal scleroderma?
Manage any heartburn symptoms with PPI
| increased motility using erythromycin or domperidone (pro kinetics)
31
What is a common complication of oesophageal scleroderma?
what is the treatment?
Bacterial overgrowth is causing diarrhoea and weight loss
treat with cephalexin and metronidazole
32
What is classed as a peptic ulcer
A breakdown in the mucosal lining of the stomach and duodenum reaching the submucosa
an ulcer is classed at 5 mm anything smaller or more shallow is considered an erosion
33
What are the protective factors of the stomach for peptic ulcer disease?
Prostaglandins
mucus
HCO3
mucosal blood flow
34
What are the damaging factors of stomach for peptic ulcer disease?
Gastric acid
Patsy
H. pylori
NSAIDs
35
What are the symptoms of peptic ulcer disease?
Upper epigastric pain exacerbated by eating (gastric) or 2 to 3 hours after eating (duodenal)
then maybe posterior radiation of pain indicating penetration to the pancreas
epigastric tenderness
36
what would be your first line investigations for peptic ulcer disease?
Urea breath test or stool antigen test for H pylori
but in those >55y you may consider going straight to endoscopy
FBC - check for blood loss (microcytic anaemia)
37
what is the management of an active bleeding peptic ulcer?
Stop any NSAIDs
| endoscopy to stop the bleeding plus PPIs
38
What is the management of pt with peptic ulcer which has no bleeding but is positive for H. pylori?
Triple therapy of omeprazole clarithromycin and metronidazole
39
what would you do if the H pylori Cannot be eradicated?
Long-term acid suppression with PPI and H2 antagonists if needed
40
How to manage patient which has a peptic ulcer with no bleeding and negative H. pylori?
Treat the underlying cause and give PPIs treatment usually lasts 4 to 8 weeks
41
what is the management of peptic ulcer if it isInduced by NSAIDs?
Misoprostol
42
What all gastro-oesophageal varicies?
Related collateral blood vessels that develop as a consequence of portal hypertension usually due to cirrhosis
43
What is the pathophysiology behind gastro-oesophageal varices?
Increased hepatic vein pressure occurs as liver function deteriorates (usually due to alcohol or hepatitis B) causing the dilation of blood vessels
44
what conditions can indicate a presence of gastro-oesophageal varices?
Alcoholic hepatitis
hepatitis B or C
cirrhosis
hepatic encephalopathy
45
What are the symptoms of gastro-oesophageal varices?
```
Symptoms of cirrhosis:
ascites
jaundice
spider angiomas and caput medusa
haemoptysis or haematochezia
```
46
What investigations would you do to diagnose varices?
And OGD
47
What investigations should you run on someone who has gastro-oesophageal varices?
full blood count (check for bleeding and thrombocytopenia indicate portal hypertension and splenomegaly)
coagulation profile (assesses function of liver but also risk a bleed)
hepatic venous pressure gradient (assesses portal hypertension)
blood type and crossmatch (in case of life-threatening bleed)
you should also attempt to find the cause of the cirrhosis of this has not been established:
serum LFTs ( AST ALT Alk Phos Billi all ++)
hepatitis B antigen – HBsAg
Hepatitis C Ig - HCV IgG
48
How would you treat an acute haemorrhage caused by rupture of gastro-oesophageal varices?
Supportive therapy ABCDE
and vasoactive drugs (vasopressin or another pressin)
endoscopic therapy
consider using BBlocker propranolol as adjunct
49
What procedure should be performed in anyone who has an acute haemorrhage caused by gastro-oesophageal varices and is high risk of getting it again?
Trans-jugular intrahepatic Porto systemic shunt aka tips
50
How would you treat large varices which are not bleeding?
Binding and ligation with a non-selective beta-blocker
51
how would you treat small varices which are not bleeding?
Beta-blocker and endoscopic surveillance
52
How would you treat someone who has portal hypertension but has not yet developed varicies?
Endoscopic surveillance and vasoactive drugs
53
how would you treat someone Who has cirrhosis but has not yet developed varices or portal hypertension?
Endoscopic surveillance
54
What is a Mallory Weiss tear?
A tear or laceration in the oesophagus caused by a sudden increase in the pressure gradient
it is usually spontaneous and self-limiting
55
What is the most common location for a Mallory Weiss tear?
Near the gastro-oesophageal junction
56
What are the risk factors for Mallory Weiss tear?
```
Conditions predisposing to vomiting
retching
straining including from coughing
chronic cough
hiatal hernia
endoscopy
alcohol with excessive vomiting
```
57
what investigations are required in a Mallory Weiss tear?
Full blood counts
OGD
if severe crossmatch and save
plus...
urea and creatinine – monitoring severity please
a T assessing for liver disease
PT/INR consider anticoagulation
chest x-ray normal in an uncomplicated Mallory Weiss tear
58
How would you manage a Mallory Weiss tear?
ABCDE management
when giving fluids make sure bilateral IV
if severe intubate and give phytomenadione IV aka Vit K
endoscopic clip placement +/- adrenaline - always before 24h even if not severe
plus...
pantoprazole and promethazine (antiemetic)and erythromycin (contracts stomach) pre surgery
59
What is gastritis?
The histological presence of gastric mucosal inflammation
60
What is gastropathy?
Lesions characterised by minimal or no inflammation
61
What are the causes of gastritis?
H. pylori (causes acute or chronic non-erosive gastritis)
erosive (NSAIDs or alcohol induced)
stress induced (in the critically ill on mechanical ventilation> 48 hours or coagulopathy)
autoimmune
phlegomonus (S. aureus, strep, e coli)
62
What are symptoms of gastritis?
Dyspepsia
epigastric discomfort
nausea and vomiting
loss of appetite
lack of red flags
63
What is the management of gastritis caused by H. pylori?
Triple therapy of lansoprazole clarithromycin and metronidazole
64
What is the management of gastritis caused by erosive causes?
Discontinue exposure use PPI or H2 antagonist
65
What could you give to someone who is at risk of gastritis?
Ranitidine
| misoprostol
66
What type of cancer is stomach cancer?
adenocarcinoma
67
What are some risk factors for developing stomach cancer?
```
NHS anaemia
H. pylori
50 to 70 years
family history
smoking
```
68
What are symptoms of stomach cancer?
```
Epigastric pain – an early symptom
lymphadenopathy – see virchows node
nausea
dysphagia
lower GI bleeding and Melina
```
69
What investigations are necessary for stomach cancer?
Endoscopy and biopsy
70
What is the management of stomach cancer?
Pre-and post op chemotherapy or radiotherapy
surgery
consider immunotherapy
71
What is viral gastroenteritis?
Acute inflammation of the lining of the stomach and intestines caused by an enteropathic virus
72
What viruses cause gastroenteritis?
norovirus
rotavirus
cytomegalovirus – significant in immunocompromised groups
73
What risk factors are associated with viral gastroenteritis?
Exposure to contaminants or close contact with someone infected
living in close quarters such as care homes
Poor hygiene
extremities age – causes more severe dehydration
comorbidities
immunocompromised groups
74
when would you need to investigate viral gastroenteritis?
If there is severe volume depletion
75
What investigations would you perform for viral gastroenteritis?
Full blood count - is the white cell count elevated indicating a bacterial or parasitic infection are the signs of anaemia indicating a chronic cause such as IBD
U+E- check renal function
consider a stool sample for culture
76
When would you perform a stool culture for patients with viral gastroenteritis?
```
Blood or pus installs
high fever
diarrhoea lasting two weeks
history of foreign travel
persistent antibiotic use
```
77
What is management of viral gastroenteritis?
Dehydration is mild-to-moderate: oral rehydration salts severe: IV fluids
antiemetics may be used but antidiarrhoeal should not routinely be used
78
What is IBS?
A chronic condition characterised by abdominal pain and bowel dysfunction without the presence of structural abnormalities
79
What are risk factors for developing IBS?
Female
previous enteric infection
history of physical or sexual abuse
80
What symptoms does IBS carry?
```
Cramping abdominal pain
pain in lower/middle abdomen
mild/severe pain
altered bowel habit
relief of symptoms on defecation
abdominal bloating/distension
mucus-y stool
```
81
How would you diagnose IBS?
IBS would be a diagnosis of exclusion, a history of typical symptoms is suggestive of IBS
differentiate from coeliac and IBD
stool cultures will be negative
82
What tests differentiate IBS from coeliac disease?
Anti-endomyseal +ve in coeliac
| Anti- tTG antibodies +ve in coeliac
83
what tests would differentiate from IBD?
Faecal calprotectin
| flexible sigmoidoscopy or colonoscopies
84
How do you treat IBS?
Management must be symptomatic
if constipated - lactulose
if diarrhoea – loperamide (antidiarrhoeal)
pain or bloating – dicycloverine (antispasmodic)
CBT or hypnotherapy is also useful
high-fibre diets and eliminating triggers
SSRIS such as citalopram
85
What is Crohn's disease?
and inflammatory bowel disease causing transmural inflammation of the GI tract which can involve any or all of the GI tract
86
What histopathological findings would you find for crohns disease?
Transmural inflammation
skip lesions
can be anywhere in the GI tract
87
where Is most common for Crohn's disease to occur?
Terminal ileum and peri-anus
88
What is the presentation of Crohn's disease?
```
Abdominal pain
prolonged diarrhoea
perianal lesions
fatigue
weight loss
abdominal tenderness
```
can have some mucous blood and purse install but this is not a typical presentation
fever from inflammation or as a complication
89
What are perianal lesions?
Skin tags
| fistula
90
What are the more common complications of Crohn's disease?
Obstruction – from fibrosis
| perforations and fistula – due to sinus tracts caused by inflammation
91
What investigation is diagnostic for Crohn's disease?
Flexible sigmoidoscopy (colonoscopies) with biopsy and histological examination
92
A patient presents with symptoms of IBD disease what are the first line investigations you would do as a GP?
FBC – may find anaemia and increased white cell count
iron studies, B12, folate
comprehensive metabolic panel albumin, calcium, magnesium, phosphate all reduced
CRP, ESR
Faecal calprotectin - raised, marker of bowel inflammation
you may want to do a stool test
you may consider imaging from:
x-ray (obstruction)
CT or MRI (lesions, bowel thickening, accesses/fistulae)
93
How would you manage crohns ?
Budesonide (steroid) or 5 ASA therapy
Azothioprine + CS
methotrexate and folic acid
biologics and CS reduction
94
What is ulcerative colitis?
an inflammatory bowel disorder characterised by its involvement of the rectum and extending approximately
95
What are the risk factors forInflammatory bowel disease?
Ages 15 – 40 or 60 – 80
family history
white ancestry
96
What are the symptoms of ulcerative colitis?
Most common symptom is rectal bleeding and blood in stool
diarrhoea abdominal pain malnutrition and weight loss are more common in Crohn's disease
97
What vitamin deficiencies occur in ulcerative colitis?
Vitamins ACD he
beta-carotene, magnesium, zinc
98
What would imaging show for Crohn's disease?
x-ray (obstruction)
| CT or MRI (lesions, bowel thickening, accesses/fistulae)
99
What would imaging show for ulcerative colitis?
dilatoed loops with air or fluid,
| free air suggests a perforation dilation of loops over 6 cm suggests toxic megacolon
100
What are the histopathological findings of ulcerative colitis?
```
Only rectal involvement with continuous and uniform diffuse erythema
biopsy shows :
mucosal involvement
mucosal depletion
absence of granulomata
anal sparing
```
101
What is the management for ulcerative colitis?
mesalazine (mainstay for remission)
hydrocortisone or pred +/- tacrolimus
IV hydrocortisone (in acute flare)
In recurrent disease:
Thiopurines (azothioprine)
Biologics/TNF a inhibitor (infliximab)
colectomy
102
What is fulminant ulcerative colitis?
Sudden and extensive inflammation which can be life-threatening
103
What are symptoms of fulminant ulcerative colitis?
6+ bloody stools daily
evidence of toxicity:
- fever
- tachycardia
- anemia
- ++ESR
104
what is the management of fulminant ulcerative colitis?
Investigate with ultrasound and emergency colonoscopies
IV corticosteroids and IV fluids
a stable enough start infliximab and cyclosporin if not rush for a colectomy
105
What is toxic megacolon?
A potentially lethal complication of acute colitis with total or segmental non-obstructive chronic distension associated with systemic toxicity
106
What are the risk factors for toxic megacolon?
```
Inflammatory bowel disease
infected colitis
immunosuppression
discontinuation of IBD medication
anti-motility agents
```
107
How does toxic megacolon present?
Fever tachycardia hypotension
abdominal pain tenderness and dissension
diarrhoea
mental status changes
108
What investigations should you perform?
Abdominal x-ray – die rotation of over 6 cm
stool studies
full blood count (+white cell count - haemacrit)
serum electrolytes (- magnesium and potassium due to volume loss)
serum albumin (- due to volume last)
serum lactic acid if ischaemic
109
What is the initial management of toxic megacolon?
ABCDE
Nil by mouth IV fluid recess
broad-spectrum antibiotics
NG decompression
rancour myosin – if presumed CDF
IV hydrocortisone – history of inflammatory colitis
surgery if no improvement after 72 hours
110
What is mesenteric ischaemia?
An umbrella term for disorders which cause a decrease in blood flow to the GI tract
it can be acute or chronic, occlusive or non-occlusive, transient or fulminant
111
What are the risk factors for mesenteric ischaemia?
```
Old-age
smoking history
however quite liberal state
atrial fibrillation
myocardial infarction
structural heart disease
history of vasculitis
```
112
What is a presentation of mesenteric ischaemia?
```
Abdominal pain
Melena – due to mucosal sloughing
diarrhoea
abdominal tenderness
weight loss
```
abdominal bruit may be heard
113
What is a first-line diagnostic test for mesenteric ischaemia?
CT
114
What would a CT show for mesenteric ischaemia?
Thickening
dilatation
pneumatosis intestinalis
thumbprint sign – showing mucosal oedema or haemorrhage
115
which artery does mesenteric ischaemia usually affect?
Superior mesenteric artery
116
What is diverticular disease?
A herniation of the mucosa and submucosa through the muscular layer
it is any clinical state caused by symptoms relating to colonic diverticula
symptoms ranging from asymptomatic to severe uncomplicated
117
What is the most common complication of diverticular disease?
Diverticulitis
118
What is diverticulitis?
Inflammation of a diverticulum which may be caused by infection
119
What are complications of diverticular disease?
(Diverticulitis)
```
segmental colitis
lower GI bleed
abscess
perforation and peritonitis
fistula
obstruction
```
120
What are risk factors of diverticular disease?
Low dietary fibre
| anyone over the age of 50
121
What is the presentation of diverticular disease?
It is usually asymptomatic until there's diverticulitis
| but may have some IBS type symptoms of bloating and constipation
122
What are the symptoms of diverticulitis?
Lower quadrant abdominal pain
fever
guarding
leucocytosis
123
What are the diagnostic tests for diverticular disease?
Contrast anime shows diverticulitis abscesses
if unclear go to sigmoidoscopy
124
how would you Diagnose acute diverticulitis?
CT with contrast
125
How would you treat diverticular disease?
If asymptomatic no treatment
if symptomatic:
high fibre diet and supplements
any symptoms of bacterial infection require broad-spectrum antibiotics
126
How would you manage symptomatic diverticulitis?
```
Analgesia
oral antibiotics (moved to IV if not getting better)
```
127
What is appendicitis?
An acute inflammation of the veniform form appendix most likely caused by obstruction of the lumen of the appendix
128
what causes the obstruction in appendicitis?
faecolith
stool
infection
lymph drainage
129
What are the risk factors for acute appendicitis?
There are no real risk factors however:
child/teen
low dietary fibre
smoking
130
What is the presentation of appendicitis?
```
Constant made abdominal pain that moves to the right quadrant
pain worse on coughing and movement
tenderness at McBurney's point
rebound tenderness may be present
anorexia
```
nausea fever decreased bowel sounds on the right side
be aware of tachycardia as it's a sign of perforation
131
What does tachycardia in a patient with suspected appendicitis indicate?
Perforation
132
What is the diagnostic test of appendicitis?
CT
133
What is the management of an uncomplicated appendicitis?
Appendectomy (adjunct IV antibiotics)
| antibiotic only therapy for patients who wish not to have surgery
134
what is the management of Appendicitis complicated by perforation or abscess?
IV antibiotics appendectomy and supportive care
| drainage may be necessary if there is an abscess
135
What are the three main types of hernia?
Umbilical
inguinal
hiatus
136
what is an umbilical hernia?
A defect of the interior wall fascia occurring when the umbilical ring fails to close and the peritoneal sack protrudes
137
What are the risk factors for an umbilical hernia?
Low birthweight
| African or African-American ethnicity
138
What is the presentation of an umbilical hernia?
Presents at birth with a bolt at the umbilicus
becoming larger or tense during movement or crying
stretched skin
139
What features would you find on examination for an umbilical hernia?
easily reducible
| on examination the ring of the fascia can be felt around the defect
140
If an umbilical hernia presents as a tender abdominal mass what does this mean?
It's incarcerated
141
What is the management of an umbilical hernia?
First attempt reduction
asymptomatic and small:
observe and offer elective outpatient surgical repair otherwise move to ASAP surgical repair
142
What is an inguinal hernia?
The most common type of hernia
it is a protrusion of abdominal or pelvic contents through her dilated internal inguinal ring to the external inguinal ring
143
What is the presentation of an inguinal hernia?
Easily visible and palpable bulge
groin discomfort or pain if the hernia is bulging
groin mass
may be confused with pathologies of the testicles
144
If a patient presents the tender distended abdomen with absent bowel sounds who has had a past history of groin pain what could this be?
Strangulated hernia causing an acute abdomen
145
What investigations are necessary for an inguinal hernia?
Usually the diagnosis is clinical if you are uncertain and ultrasound scan of the groin or CT
146
What is the management of a strangulated inguinal hernia?
Surgery with IV/IM cephalexin prophylaxis if open repair
147
What is the management of a large or symptomatic hernia
Surgery unless a patient is nonsurgical then a truss can be worn (device that compresses over inguinal canal)
148
What is the management of a small asymptomatic inguinal hernia?
Observation
149
What is a hiatus hernia?
Protrusion of intra abdominal contents through an enlarged oesophageal hiatus of the diaphragm most commonly containing a portion of stomach
150
What are the risk factors for a hiatus hernia?
Anyone over the age of 50
obesity
previous GI procedure
intra-abdominal pressure increases
151
What is the presentation of a hiatus hernia?
Heartburn
regurgitation
GORD like
152
How do you diagnose a hiatus hernia?
A barium swallow
| endoscopy
153
How do you treat a hiatus hernia?
PPI and lifestyle changes
surgical repair
if there's obstruction resus and urgent surgical repair
154
What is large bowel obstruction?
Mechanical interaction occurring to the flow of the intentional contents it is a surgical emergency
155
What can cause large bowel obstruction?
Colorectal cancer
colonic Volvos
benign structure such as diverticular disease
foreign body
156
What are risk factors for large bowel obstruction?
```
older age
female
institutionalisation
mental illness
Megacolon
```
157
What is the presentation of large bowel obstruction?
Colicky abdominal pain
abdominal distension
tympanic handling
change in bowel habits no or very little faeces or flatus
rectal bleeding - indicates malignancy
abnormal bowel sounds can be increased frequency or absent in advanced disease
158
what does hard faeces on DRE in the context of large bowel obstruction mean?
Faecal impaction
159
What does an empty rectum mean in the context of a DRE in large bowel obstruction?
Proximal obstruction
160
Why should you perform a faecal occult blood in the context of large bowel obstruction?
To exclude barrel malignancy
161
what are symptoms of a Large bowel perforation?
Constant pain which is worsening
worse on movement or coughing or deep breathing
fever
abdominal rigidity – peritonitis secondary to perforation
162
What is a diagnostic test for a large bowl obstruction?
Plain abdominal x-ray
163
What is the first test you should do if you suspect perforation in large bowel obstruction
Erect chest x-ray
164
Apart from imaging what other tests are useful in large bowel obstruction?
Full blood count – WCC for infection anaemia in malignancy
serum electrolytes and renal function – check renal function
serum amylase – raised in intra abdominal events
165
you suspect abdominal perforation what investigations are indicated?
Chest X ray (USS abdominal if in unstable situation)
Septic screen
FBC, LFT and U+E
166
What is the management of large bowel obstruction?
```
ABCDE - consider blood products if theres coagulopathy
catheter monitoring urinary output
broad-spectrum antibiotics presurgery
NG decompression!
surgery
```
NO OPIATES
167
What is volvulus?
A loop of interesting twists around itself and its mesentery
causing a bowel obstruction
168
Where are volvulus common?
In the sigmoid or coecal
169
What classic sign is found on CT/x-ray for a volvulus?
a coffee or kidney bean shape
170
What are risk factors for a volvulus?
intestinal malrotation
enlarged colon
hirsprungs
adhesions form prev. surgery
171
What is a small bowl obstruction?
Mechanical disruption in the patency of the GI tract resulting in vomiting which may be pillars absolute constipation and abdominal pain
172
What are common causes in adults for small Bowel obstruction?
```
Previous surgery
inguinal hernia – other hernias
Crohn's disease
intestinal malignancy
appendicitis
```
173
what are common causes for children for small bowel Obstruction?
Appendicitis
inrucusseption
intestinal atresia
volvulus
174
What is the presentation of small bowel obstruction?
```
Failure to pass glasses or stool
abdominal pain
vomiting
abdominal tenderness and distension
if there's perforation peritonitis
```
there may be fever tachycardia and lethargy from inflammation and dehydration
175
What is the diagnostic investigation for small bowel obstruction?
CT abdominal
176
What is the gas distribution you would see on imaging in the bowels in a partial small-bowel obstruction?
Gas throughout the abdomen
177
What is the gas distribution you would see on imaging in the bowels in a complete small-bowel obstruction?
No distal gas and staggered air - fluid
178
What is the gas distribution you would see on imaging in the bowels in a complicated small-bowel obstruction?
Complicated by a perforation will be free air under the diagram
if complicated by ischaemia there will be thumb printing sign
179
What is the management of partial small-bowel obstruction?
```
Fluid recuss
NG decompression
antiemetic (ondesatron)
antispasmodic (loperamide) if a more severe partial
opiate analgesia
```
surgery if no change after 48 to 72 hours
180
What is the management of a complete small-bowel obstruction?
NG decompression
morphine analgesia
perioperative antibiotics
Laparotomy
if the candidate is nonsurgical then treat as a partial obstruction
181
what is an ileus?
The slowing of GI motility accompanied by distension in the absence of mechanical obstruction
182
What causes ileus?
```
It is something which occurs in response to physiological stress such as:
surgery
sepsis
metabolic derangements
GI diseases
```
183
What risk factors are associated with developing an ileus?
```
Abdominal surgery
acute or systemic illness:
sepsis
MI
pneumonia
trauma
metabolic derrangements
```
184
What is the presentation of an ileus?
Similar to that of obstruction but without its clinical features on examination
```
nausea and vomiting
abdominal distension
constipation
discomforts
abdominal cramping
decreased or hypoactive bowel sounds
```
BUT.. no features of mechanical obstruction such as peritoneal inflammation, hernias, rebound tenderness
185
What is the diagnosis of an ileus?
what other investigation may you like to perform?
It is a diagnosis of exclusion of obstruction
abdominal x-ray is diagnostic (showing no specific gas pattern and diffuse distension)
Full blood count - rule out infection
186
What differences would you see on x-ray for an obstructed bowel versus an ileus?
Obstructed bowel will have little to no air distal to the obstruction whereas an ileus will have a diffuse non-specific gas pattern
187
What is the management of an ileus?
Nil by mouth and IV fluids
NG decompression if there is significant vomiting or distension
parenteral nutrition if symptoms lasting more than three days
188
What is peritonitis?
inflammation of the peritoneum
189
What can cause peritonitis?
Perforation of the GI tract - most common
local or systemic infection
leakage of non-infectious bodily fluids- blood gastric juice pancreatic enzymes (pancreatitis)
190
What is spontaneous bacterial peritonitis?
Inflammation of the peritoneum caused by leakage of infected ascitic fluid due to end stage cihrossis
191
What are the symptoms of peritonitis?
```
Abdominal pain
Guarding
rigidity
rebound tenderness
fever
tachycardia
altered mental state
```
192
What features does spontaneous bacterial peritonitis have that peritonitis does not have?
Spontaneous bacterial peritonitis Has all the same symptoms as normal peritonitis but with additional signs of ascites cirrhosis and diarrhoea caused by intestinal hyper mobility
193
What is the management of peritonitis?
Broad-spectrum antibiotics e.g. cephalexin or laparotomy
194
What investigations is it important to carry out in spontaneous bacterial peritonitis?
Check LFT And PT/INR
Ascitic fluid analysis gram staining culture – diagnostic
blood cultures may also be useful
195
What is the management of spontaneous bacterial peritonitis?
Broad-spectrum antibiotics IV
if there is a hypo renal syndrome (renal impairment) – IV albumin
large-volume paracentesis may be given
196
Is antibiotic prophylaxis indicated for people who have had spontaneous bacterial peritonitis?
Yes and a beta-blocker may also be added
197
What is the definition of obesity?
A chronic adverse condition due to excess body fat mainly determined by BMI
BMI over 30
198
What is classed as underweight (BMI)?
<18.5
199
What is classed as normal weight (BMI)?
18.5-24.9
200
What is classed as overweight (BMI)?
25-29.9
201
What is classed as obese (BMI)?
30-39.9
202
What is classed as extremely obese (BMI)?
>/= 40
203
How do you calculate BMI?
Weight (KG) / [height(m)]^2
204
What are some Hormonal causes of obesity?
PCOS
hypothyroidism
hyper- cortical-ism
insulinoma
205
What are some behavioural causes of obesity?
Sedimentary
large portions
habits
206
What is the physiology of leptin?
| What role does leptin have in satiety?
An increase in ad oppose causes leptin to be released
leptin reduces appetite
adipose is used up
207
How is leptin affected in obesity?
There is leptin resistance
208
What is the physiology of ghrelin?
| What role does ghrelin have in satiety?
Secreted by a stomach acting by the vagus nerve
| acts centrally on the hypothalamus to increase appetite
209
What role does endocannabinoids have in satiety?
Increase appetite by affecting the central nervous system a.k.a. the hypothalamus
210
What role does T3 have in satiety? and how?
Increases appetite
| hypothyroidism causes excess energy expenditure causing weight loss
211
What role do peptins have in satiety?
Decrease appetite and food intake centrally and on GI organs like the pancreas
212
What role does insulin have in satiety?
Decreases appetite centrally
213
What role does cholecystokinin have in satiety?
Decreases appetite centrally
214
What investigations may want to undertake in an obese individual?
SBC
lipid levels
LFT – check liver dysfunction caused by fatty liver
TFTs
ECG – check for heart disease
abdominal ultrasound scan – check for fatty liver disease
215
What pharmacological management can you offer an individual with obesity?
Orlistat - inhibits fat absorption
2ry = liraglutide - peptide like agonist
216
what are the criteria to be eligible for bariatric surgery?
BMI ≥ 40,
| BMI ≥ 35 and at least one or more obesity-related co-morbidities
217
What type of cancer is colorectal cancer?
Majority are adenocarcinomas from epithelial cells
218
What is the most common location for large bowel cancer?
The:
219
What risk factors are associated with large bowel cancer/colorectal cancer?
```
Age- very rare under 40
APC gene mutation -a Polly process syndrome
IBD
obesity
low fibre diet
```
220
What is the presentation of colorectal cancer?
```
Rectal bleeding
change in bowel habits - increase frequency and loose stools
hard mass on DRE
anaemia
weight loss
```
221
What is diagnostic for colorectal cancer?
What other tests should be performed?
CT colonography or colonoscopies with biopsy
-barium enema can also be used but it is less sensitive
in FBC showing anaemia is a red flag especially in older men or postmenopausal women
222
Describe the screening process for colorectal cancer?
Starts at 60 years old until 74
F IT testing done yearly
screening starts at 50 years if there is a positive family history of two first-degree relatives
223
In patients with IBD what is the process for screening for colorectal cancer?
Perform colonoscopy 10 years after diagnosis and then every five, three, one year depending on their level of risk
224
Who should you refer to 2 week wait in regards to colorectal cancer?
>40 with unexplained weight loss or abdominal pain
>50 with unexplained rectal bleeding
>60 unexplained iron deficiency anaemia or changes in bowel habits
anyone with a positive FIT +/- Sx depending on age
anyone with a rectal or abdominal mass
```
anyone under the age of 50 with rectal bleeding and one other finding of:
abdominal pain
change in bowel habits
weight loss
iron deficiency anaemia
```
225
What are the causes of dietary diarrhoea?
```
Sugars
dairy
FODMAP
gluten
fatty foods
Spicy foods
caffeine
```
226
How do sugars cause diarrhoea?
stimulate water movement into the bowels causing loose stool
227
How does dairy cause diarrhoea?
Lactose can cause difficulty on digestions as an intolerance
228
What is the criteria for travellers diarrhoea?
Three or more unformed stools in 24 hours
plus one or more of:
- fever nausea vomiting cramps or bloody stools
during a trip abroad
229
What common pathogens cause travellers diarrhoea?
E. coli
Shigella
Campylobacter Jejuni
Salmonella
230
What are the differences in presentation between a bacterial and parasitic infection?
Parasitic infections cause persistent symptomsOver two weeks
| bacterial usually lasts 3 to 5 days
231
What are the risk factors for contracting travellers diarrhoea?
```
<30y
Prior travellers diarrhoea
chronic disease
immunocompromised
travelling in hot and wet climates and endemic areas
```
232
What are indications for antibiotics in travellers diarrhoea?
Blood and fever
233
When would you do further testing for travellers diarrhoea?
If symptoms are severe or if antibiotics haven't worked
234
What tests could you perform for travellers diarrhoea?
stool culture and sensitivity
+stool occult blood
+PCR
stool ova and parasite examination
235
What is the management for travellers diarrhoea?
Loperamide is used as long as there is no blood or fever which is an anti-motility drug to help cramping and diarrhoea
rehydration therapy
if symptoms are severe then use azithromycin
236
What commonly gives you travellers diarrhoea in terms of Food & Drink?
```
Ice and tapwater
salad
previously peeled fruits
raw food
unpackaged sauces and condiments
Street vendors and buffets
```
237
When would prophylactic antibiotics be given for travellers diarrhoea?
For short-term critical trips or critically ill/immunocompromised patients with trips lasting less than three weeks
238
Why would you want to give fluids over 48 hours and replace sodium if hyponatraemic?
To avoid cerebrally oedema
239
What is a classic symptom of an E. coli infection?
Profuse diarrhoea
240
What symptom would not be present in viral/parasytic induced travellers diarrhoea?
Bloody stool
241
What is a classic symptom of a campylobacter infection?
Severe abdominal pain
242
What are classic symptoms of a shigella infection?
High fever with person blood in stool
243
What pathogen is cholera caused by?
vibris cholerae
244
What is the pathophysiology of cholera?
cholera endotoxin leads to continued activation of adenylate cyclase in the intestinal epithelial cells
this causes secretion of water and salt into the gut lumen
245
Which demographic does cholera usually affect?
children under five living in Endemic countries
246
What is the presentation of cholera?
Watery diarrhoea with rice water appearance
Diarrhoea of more than 1 L per hour for a sustained period of time
```
evidence of severe water depletion:
sunken eyes
dry mucous membrane
irritability
significant postural hypotension
a decrease in skin turgor
Cap Refill of over two seconds
```
247
what investigations should you perform for cholera if available?
rapid dipstick test – diagnostic
FBC- + WCC and haemocrit (+ in vol. depletion)
serum electrolytes- check K+
urea and creatinine
ABG- acidosis if severe
ECG- low K+ causes prolonged PR and flattened T wave. Bradycardia = v bad sin
248
What is the management of cholera?
Aurore therapy aggressive rehydration for two – four hours followed by maintenance fluids until diarrhoea is absent
doxycycline
zinc and vitamin A supplementation children
IV rehydration can used in severe cases
249
is there a vaccine for cholera?
Yes it is an oral vaccine used in endemic countries
250
What is coeliac disease?
As systemic autoimmune diseases triggered by dietary gluten peptides
251
what is the pathophysiology of coeliac's disease?
Immune activation of the small intestine is caused by gluten peptides
this leads to villous atrophy hypertrophy of intestinal crips and increases the number of lymphocytes in the epithelium and lamina propria
this causes malabsorption and systemic effects
252
What's HLA does coeliac carry?
HLA DQ2
| HLA DQ8
253
What is the purpose of the HLA proteins?
causes the gluten peptides to be presented to T cells in a manner which activates them and being in response
254
What antibodies are present in coeliac disease?
anti-gliadin
| anti-tTG
255
What is the presentation of coeliac disease?
Diarrhoea
bloating
abdominal pain/discomfort
anaemic symptoms and failure to thrive in children
256
what investigation allows for DEFINITIVE DIAGNOSIS of coeliac?
Small-bowel histology is diagnostic
| and gluten challenge
257
What blood tests would you want to run for coeliac disease?
anti TTG
EMA antibody (endomyseal antibody)
FBC + blood smear - microcytic
258
what histological findings would you find in coeliac disease?
Intraepithelial lymphocytes villus atrophy and crypt hyperplasia
259
How do you diagnose coeliac disease in children?
IgA tTG + EMA + HLA DG2/ HLA DG8
260
What is the management of coeliac disease?
Gluten-free diet
calcium and vitamin D supplements (ergocalciferol + calcium carbonate)
Do a bone mineral density scan one year after a gluten-free diet
iron supplements if anaemic
261
What is the management of a coeliac crisis?
Rehydration therapy with electrolyte corrections and adjunct corticosteroids if severe enough
262
Where can small bowel cancer occur?
Duodenum
jejunum
ileum
+ appendix
263
what is the most common type of small bowel cancer Of the duodenum?
adenocarcinoma
264
What is most common type of small bowel cancer of the appendix or ileum?
neuroendocrine A.k.a. carcinoid
265
What are risk factors for small bowel cancer?
```
Increasing age
familial polyposis
Crohn's
coeliac
diets rich in smoked foods red meats or very high fibre
```
266
What is the presentation of small bowel cancer?
```
Abdominal pain
abdominal rash
weight loss
feeling or being sick
Melina
obstruction symptoms
anaemia and associated symptoms
```
267
What investigations would you perform for small bowel cancer?
Endoscopy with histological sample
| can consider ultrasound scan or CT
268
What is gastroparesis?
Delayed emptying of solids by the stomach in the absence of any mechanical obstruction
269
What risk factors are associated with gastroparesis?
Diabetes
previous gastric and pancreatic surgery
achalasia
270
What is the presentation of gastroparesis?
```
Post-prandial nausea
vomiting
early satiety
epigastric pain
fullness and bloating
weight loss
```
271
What is important to roll out in gastroparesis?
Obstruction with abdominal x-ray
| pancreatitis using serum amylase and lipase
272
Why is it important to check white cell count and gastroparesis?
White cell count elevation suggests a viral infection which can temporally cause gastroparesis
273
what is the management of gastroparesis?
Pro kinetic agent such as Metoclopramide or retro myosin
| antiemetic
274
What is eosinophilic oesophagitis?
Oesophageal dysfunction caused by an immune/allergic mediated reaction causing eosinophil infiltration
275
What risk factors are associated with eosinophilic oesophagitis?
Family history of atopy
atopy
children and young adults
276
What other symptoms of eosinophilic oesophagitis?
GORD type
| can have dysphagia and failure to thrive
277
How would you diagnose eosinophilic oesophagitis?
OGD with biopsy showing using Ophelia
| OGD will have narrowing with white plaques
278
What is the management of eosinophilic oesophagitis?
Corticosteroid such as budesenone
279
What is dyssenergic defication?
Dysfunction of the pelvic floor muscles and nerves causing failure of contemporary relaxation for defication
280
What risk factors are associated with dyssenergic defication?
Previous pregnancy and childbirth
chronic constipation
previous surgery in pelvic floor
281
What are the symptoms of dyssenergic defication?
```
Access training
feeling of incomplete evacuation
positive hard stool
lesson three movements per week
the use of digital manoeuvres to pass stool
```
282
What is important to rule out in dyssenergic defication?
and how would you diagnose dyssenergic defication?
obstruction - use X ray
sigmoidoscopy
283
What is the management for dyssenergic defication?
Improving toilet habits
increasing fibre intake
laxatives
284
What is hirsprungs disease?
Also all complete colonial functional obstruction associated with the absence of ganglion cells
this causes luminal obstruction
285
what part of the GI tract does hirsprungs disease affect?
The distal part of the colon
286
What nerve plexus is affected in hirsprungs disease?
The mesenteric nerve plexus
287
What conditions is hirsprungs disease heavily associated with?
downs syndrome
288
What is the presentation of hirsprungs disease?
```
Vomiting
abdominal distension
delayed meconium passage
lack of desiccation
explosive passage of liquid and foul stool on DRE
presenting <1y
```
289
What complications can occur due to hirsprungs disease?
and why?
Enterocolitis and sepsis
stasis leads to bacterial overgrowth and secretory diarrhoea
290
How do you diagnose hirsprungs disease?
Contrast enema
abdominal x-ray is non-specific in young children
291
What is the management of hirsprungs disease?
Bowel irrigation and surgery
292
how do you manage hirsprungs disease complicated by hirsprungs disease?
Add antibiotics and IV fluids and decompression via colostomy before surgery
293
what is chronic diarrhoea?
The presence of 3+ loose stools in a day for four weeks
294
How do you assess chronic diarrhoea?
Determine the duration frequency pattern and severity of symptoms
ask about red flags such as bleeding weight loss anaemia
look for red flags such as masses raised inflammatory markers
check hydration status
look for potential causes in history such as foreign travel laxative use antibiotic use or other drugs
295
What other potential causes of chronic diarrhoea?
Ulcerative colitis
Crohn's colitis
viral bacterial parasitic enteropathy's
ibs
296
If you suspect malabsorption what tests should you run?
```
FBC- anaemia
folate and B12 ferratin
serum albumin may be low
serum electrolytes such as magnesium potassium calcium
zinc
check INR which can be deranged
can also do vitamin screen
```
297
What is tropical sprue?
An infectious malabsorption condition caused by long-term stay in specific endemic areas in the tropics
298
What is the presentation of tropicals sprue?
Low-grade fever
abdominal cramping and diarrhoea
hair loss and. oedema - due to low protein/albumin
signs of vitamin B12 and folate deficiency such as parlour angular chelitis
299
What investigations should you perform in tropical sprue?
Malabsorption screen
| endoscopy with biopsy
300
how do you manage Topical sprue?
Folic acid plus antibiotics like tetracycline
| and B12 supplements
301
What is Whipple's disease?
Rare infection caused by tropheryma whipplei
302
What is the presentation of Whipple's disease?
```
Diarrhoea weight loss
arthralgia
lymphadenopathy and fever
steatorrhea
anaemia
skin darkening
```
303
How do you diagnose Whipple's disease?
Upper GI endoscopy with biopsy and PCR
304
What is giardiasis?
An enteric infection caused by a protozoan Guardia lamblia
305
what risk factors are associated with giardiasis?
Contaminated food and water
| domestic animals living in the house
306
What is the presentation of giardiasis?
```
Diarrhoea
frequent belching
abdominal bloating and discomfort
weight loss
nausea and vomiting
```
307
How do you diagnose giardiasis?
Store microscopy
308
how do you treat giardiasis?
Anti-protozoan therapy – metronidazole
309
what is the pathophysiology of lactase deficiency?
There is reduced lactase in the mucosal brush border
lactase is broken down and passes into the:
the unbroken lactose increases osmolality of the colon
it then gets broken down by bacteria in the colon
causing symptoms of diarrhoea and gas
310
In children what can cause a temporary lactose intolerance?
Viral (usually) enteritis/gastroenteritis
311
How do you diagnose lactase deficiency?
There should be no signs of malabsorption
| the trial of dairy elimination
312
What is the management of lactase deficiency?
Dietary modification with calcium and vitamin D supplements
in infants give oral lactase as well as appropriate formula
313
What is a short bowel syndrome?
A substantial portion of the small intestine is absent either due to congenital or surgical causes
314
What is the pathophysiology of short bowel syndrome?
There is a loss of surface area causing disturbances and fluid nutrients and medication absorption
315
What are problems associated with short bowel syndrome?
Inability to maintain a protein energy fluid electrolytes or micronutrients balance when eating a normal diet
316
What is the presentation of short bowel syndrome?
Fatigue
fractures
dysuria or renal colic due to the formation of kidney stones (if there is significant fluid loss)
abnormal neurological exam a due to low vitamin a and B12
jaundice or pruritus from liver failure in consequence to long-term intestinal failure
317
What is the management of short bowel syndrome
Electrolyte vitamin and micronutrient replacement which may require PN feeding
318
What are the investigations required for short bowel syndrome?
malabsorption screen
LFT + INR
U+E
ultrasound scan and CT for kidney stones or gallstones
319
What are haemorrhoids?
vascular rich connective tissue cushions /structures located within the anal canal however as they enlarge they can protrude outside the anal canal causing symptoms
320
What are the risk factors associated with haemorrhoids?
45 to 65 years old
constipation
pregnancy
321
what is the presentation of haemorrhoids?
bright red blood on defecation
perianal pain or discomfort
if the haemorrhoid is thrombosed then pain and discomfort is worse
322
On DRE what would you find for haemorrhoids?
Tender palpable lesion
323
What investigations can you perform for haemorrhoids?
Anus copy exam
colonoscopies suspecting malignancy
FBC for anaemia
324
What is the management of haemorrhoids?
Lifestyle modification and dietary modification
topical corticosteroids
Rubber band ligation
325
What are anal fissures?
A split in the skin of the distal anal canal
326
What are the symptoms of anal fissures?
Pain on defecation very severe feels like passing shards of glass or tearing sensation
and rectal bleeding
327
How do you diagnose anal fissures?
Clinical diagnosis unless it has been caused by a previous treatment (anal manometry) or you suspect an anal sphincter defect then anal USS
328
what is the management ofAn anal fissure?
Conservative management with high fibre diets and increasing fluids
a severe surgery may be considered
329
What is pilondial disease?
The forceful insertion of hairs into the skin of the natal cleft above the bum
prompts of chronic inflammatory reaction and forms multiple communicated sinuses or an abscess
330
who is affected by pilondial disease?
Young men who tend to be more hairy
331
What is the presentation of pilondial disease?
Discharge pain and swelling around that area
332
how do you diagnose pilondial disease?
On examination you find several connecting sinus tracts and possibly an abscess
333
How do you manage pilondial disease?
Hair removal and local hygiene and if infected give ABx
pain relief if there's an abscess
334
What type of cancer is anal carcinoma?
squamous cell
335
what usually causes anal carcinoma?
HPV - 16 and -18
336
what are the risk factors for anal carcinoma?
HIV
men who have sex with men
repeated anal trauma
exposure to those with HPV
337
what is the presentation of anal carcinoma?
rectal bleeding and pain
mass palpable
lymphadenopathy in more advanced
338
how do you diagnose anal carcinoma?
anoscopy and biopsy
but can view initially with USS - anal
339
what is rectal prolapse?
When the rectal wall slides out through the anus
340
Why does rectal prolapse occur?
Usually when the intra-abdominal pressure increases (coughing or desiccation) and due to the weakening of muscles and ligaments prolapse occurs
341
What are the symptoms of rectal prolapse?
mass palpable outside the rectum
342
What does it mean if a rectal prolapse is painful and swollen?
That it is strangulated
343
What is the management of rectal prolapse?
lifestyle management to decrease training if it is very severe than surgery
344
What medication causes constipation?
```
Opioids
anticholinergics
antispasmodic
tricyclic antidepressants
calcium channel blockers
levodopa and other Parkinson's drugs
diuretics
iron supplements
calcium supplements
antidiarrhoeal's
NSAIDs
```
345
What is laxative abuse?
The repeated use of laxatives to purge calories or food
346
What does laxative abuse leads to?
Dehydration
electrolyte disturbances
mineral deficiencies
constipation- due to XS stimulation causing nerve damage and thus constipation
347
What is angiodysphasia of the colon?
A degenerative vascular malformation of the GI tract characterised by fragile leaky blood vessels
348
what is the presentation of angiodysphasia of the colon?
Chronic painless low-grade and intermittent bleeding
colour of blood depends on the level of malformation:
fresh red blood – lower GI
Melena – upper GI
anaemia Sx
Rarely present with massive haemorrhage
349
what investigations should you perform for angiodysphasia of the colon?
Colonoscopy / endoscopy / both– diagnostic
| FBC - assess anaemia
350
How do you treat angiodysphasia of the colon?
Interventional endoscopy with the supportive care
351
What is paediatric GORD?
Reflux leading to inadequate intake or tolerance to fluids in children>1y
352
Why does paediatric GORD occur?
Inappropriate relaxation of the lower oesophageal sphincter due to functional immaturity
353
What are risk factors for developing paediatric GORD?
Prematurity
IUGR
under one years old
developmental delay (e.g. cerebral palsy)
short intra-abdominal oesophagus or other anatomical abnormalities of the upper GI tract
354
What is a presentation for paediatric GORD?
Stressful mealtimes with the feed time over 30 minutes
regurgitation and vomiting
abdominal pain/colic
irritability or lethargy at meals
355
What's important to note in the history of a patient with paediatric GORD?
Abnormal perinatal events such as prolonged time to pass meconium
abnormal feeding patterns
an increased volume of feed
356
How does the presentation of paediatric GORD differ in very young/premature infants?
may present as:
apnoea
desaturation
bradycardia
357
How do you diagnose paediatric GORD?
```
Mainly through response to treatment however if you are concerned about any DD such as:
obstruction
aspirations
pyloric stenosis
oesophageal atresia
```
you will need to do further testing
358
What is the management of paediatric GORD?
Education and reassurance – advised to lie prone or laterally while awake
give feed thickening is or anti-regurgitation formula
failure to respond should prompt a trial of cows milk protein free formula
if paediatric GORD is unresponsive to nonpharmacological treatment then give PPI
359
What is pyloric stenosis?
The hypertrophy of the pyloric sphincter resulting in a narrowed pyloric canal
the most common cause of gastric outlet obstruction in those 2w-12w
360
What is a presentation of pyloric stenosis?
Numberless projectile vomiting occurring soon after feeding
peristaltic waves moving from left to right across the stomach
features of dehydration irritability failure to thrive patient
361
what may you feel on abdominal examination of a patient with pyloric stenosis?
An upper abdominal mass/hollow shape
362
How do you diagnose pyloric stenosis?
Abdominal ultrasound scan
| check U+E
363
what electrolyte abnormalities may be present in pyloric stenosis?
hypochloremic acidosis with hypokalaemia
| classic vomiting derangement
364
What is the management for pyloric stenosis?
IV fluids and resus
| surgery
365
What commonly causes viral gastroenteritis in children?
Rotavirus
366
What risk factors are associated with viral gastroenteritis in children?
Younger than five
daycare attendance
poor personal hygiene
Winter
367
what is an inguinal hernia (paediatric)?
A protrusion of abdominal or pelvic contents caused indirectly by patent processus vaginalis
368
What are risk factors associated with paediatric inguinal hernias?
Premature
| mail
369
How does an inguinal hernia present in paediatrics?
Intermittent swelling in groin or scrotum and crying or straining
inguinal swelling
irritable and vomiting
370
Are you able to reduce paediatric inguinal hernias?
No unless opioid analgesia is used
| a truly irreducible hernia requires surgery ASAP
371
what is the management of an inguinal hernia?
Try and reduce the hernia
| wait 24-48h to resolve oedema then proceed to surgery
372
What are inguinal hernias associated with?
Undescended testes
373
What is marasmus?
Severe protein and energy malnutrition
374
What is the weight to height ratio in marasmus?
Abnormal
375
What is the presentation of marasmus?
low made arm circumference
reduced skinfold thickness
withdrawn and apathetic
376
What is Kwashiorkor?
Protein malnutrition
377
What is the weight to height ratio in Kwashiorkor?
normal (due to increased fluid)
378
What is the presentation of Kwashiorkor?
```
Oedema with distended abdomen
severe wasting
desquamation of the skin and hyper keratosis
angular estimate hoses
diarrhoea
hypotension and bradycardia
hypothermia
```
379
What are causes of paediatric malnutrition?
```
IBD
coeliac
cholestatic liver disease
short bowel syndrome
exocrine pancreatic dysfunction
```
380
What is the management of paediatric malnutrition?
Glucose and dextrose
fluids
replace electrolytes especially sodium potassium in chlorine
give micronutrients especially vitamins ADEK
small and often feeds
381
What is intusucception?
A common cause of intestinal obstruction in young children caused by prolapse of one part of the lumen into the adjoining part
382
Where is the most common location for intussusception?
Ileocecal
383
What risk factors are associated with intussusception?
Male
| aged 6 to 12 months
384
What is the presentation of intussusception?
Colicky abdominal pain with flexing of the legs
normal behaviour in between episodes
vomiting
Lethargy and irritability between waves of pain
redcurrant jelly store
fever
pallor
385
What do you need to be careful of in intussusception?
It can cause hypovolaemic shock if perforated ischaemic or necrotic
386
On abdominal examination what might you feel in a child with intussusception?
RUQ or epigastric mass
387
How do you diagnose intussusception?
Contrast enema or ultrasound scan
if you suspect obstruction or perforation then Abdominal X Ray
388
What would a contrast enema show in Intussusception?
Meniscus sign- the round apex of the intussusception coiled spring sign- the oedematous mucosal folds
389
What are contraindications to a contrast enema?
Shock
suspected perforation
peritonitis
evidence of necrosis
390
What is the acute management of intussusception?
ABCD approach
fluid resuscitation and contrast enema reduction
give broad-spectrum antibiotics (clindamycin gentamicin)
if the reduction doesn't work or the enema is contraindicated then surgical resection is used
391
What is the ongoing management of Intussusception?
Only really used if there are three or more occurrences
do a CT
if possible reduce it but otherwise surgical resection is needed
392
what causesIntussusception to occur?
Lymph-node thin payers patches often are the first part of an intussusception
a pathological lead to point (first part) can be because by cystic fibrosis and HSP if they cause bowel wall abnormalities
393
What is meckles diverticulum?
Common congenital malformation of the small bowel
394
what is the pathophysiology of meckles diverticulum?
A true diverticulum resulting from failure of embryonic tissue (vitelline duct) to obliterated in the fifth week of gestation
395
How does meckles diverticulum present ?
Commonly is asymptomatic, if symptoms present it is usually before two years
acute episodic painless passage of maroon blood
constipation
nausea and vomiting
abdominal cramps
396
How can meckles diverticulum show in adults?
Lower abdominal pain caused by diverticulitis
397
What is the diagnostic test for meckles diverticulum?
Technetium 99 pertechnetate scan
| or CT
398
What complications or differential diagnoses are associated with meckles diverticulum?
and how would you manage these?
Intussusception
diverticulitis
bowel obstruction - surgery + abc (cefotaxime and metronidazole )
399
What would a full blood count show in meckles diverticulum?
Anaemia
| increased white cell count in inflammation
400
What is the management of meckles diverticulum?
If asymptomatic:
no treatment is required
if symptomatic:
excision of the diverticulum
401
What is toddlers diarrhoea?
A chronic non-specific diarrhoea causing the passage of stools of varying consistency
it is very common
402
What is the pathophysiology behind toddlers diarrhoea?
Occurs due to an underlying delay in maturation of the intestine leading to intestinal hurry
403
Is there any malnutrition or failure to thrive associated with toddlers diarrhoea?
no
404
How do you manage toddlers diarrhoea
Start a high fibre diet
405
are any investigations required in toddlers diarrhoea?
Not really
check the toddlers awaits their growth charts and assess any signs of malnutrition
if you have any doubts do a full blood screen
406
What is the definition of recurrent abdominal pain?
pain severe enough to disrupt daily activities for >3m
407
how would you diagnose recurrent abdominal pain?
it is a diagnosis of exclusion
you want a full examination (including genital and peri anal area - GU causes and IBD signs)
and include some imagine (X Ray/less commonly CT)
also an USS to check for gallstones/obstruction
+urine cultures and dipstick
408
How would you manage recurrent abdominal pain?
the same as wit IBS
reassure and educate on diet
small frequent feeds
low fat and high fibre diet
can try probiotics
laxatives (fibrogel)
antispasmodics (cimetropium)
409
What is colic?
a symptom complex occurring within the first few months of life
410
What is the presentation of colic?
paroxysmal inconsolable crying with drawing of knees
XS flatulance
worse in evenings
411
what are the risks of colic?
in itself nothing but...
increases risk of:
postnatal depression
parental stress
increased risk of domestic abuse
412
what is the management of colic?
no real remedies
reassurance and lots of support
usually resolves by 4m
413
what could persistent (after 4m) colic indicate?
GORD
| cows milk protein allergy
414
what is the definition of childhood obesity?
BMI>95th centile
415
what BMI is defines ad severely obese in children?
BMI>99th centile
416
what BMI is defined as overweight in children?
BMI>85th centile
417
What are non-environmental causes of childhood obesity?
```
hypothyroidism
prader willi
pseudohypoparathyroidism
bushings
injury/abnormality of the hypothalamus and pituitary
```
418
what are measurements of a Childs weight?
mid arm circumference
waist to hip ratio
skinfold thickness
419
what should always be checked in a child with obesity?
BP ?hypertension
420
what are risk factors associated with childhood obesity?
obese parents
rapid weight gain in infancy and early childhood
poor SE status
sedentary
421
What investigations should you perform in a child with obesity?
Fasting blood glucose
serum lipids
LFT (non-alcoholic fatty liver disease)
422
What is the management of childhood obesity?
Lifestyle modifications with counselling
the aim of management is not on losing weight but rather not gaining weight and allowing a child to grow into their current weight
if severely obese orlistat can be used and if old enough surgery is very rarely offered
423
What is a diagrammatic hernia?
Herniation of the abdominal contents through foreign men in the diaphragm
424
How is a diaphragmatic hernia diagnosed in infants?
Usually on antenatal ultrasound
| Dan confirmed once born with chest and abdominal x-ray
425
What is the management of a diagrammatic hernia in infants?
NG tube + suction to prevent distension
after stabilisation surgical repair
426
What is the most common complication with a diagrammatic hernia in infants?
pulmonary hypoplasia due to their compression en utero
427
What is necrotising enterocolitis?
A bacterial invasion of ischaemic bowel wall upon bowel death
428
What is the pathophysiology of necrotising enterocolitis?
The bowel and immune system are immature allowing for bacterial invasions of the gut
causes inflammation and can lead to perforation
causing further bacterial invasion
eventually leads to necrosis
429
How does necrotising enterocolitis present?
```
Feeding intolerance
abdominal pain and distension
shiny skin on abdomen
bloody stools
bile stained vomit
shock
```
430
What word an x-ray show in necrotising enterocolitis?
Dilated and distended bowel loops
thickened bowel walls
intramural gas, gas under the diaphragm and in biliary tree
431
Apart from x-ray what other quick test can show necrotising enterocolitis?
Abdominal trans-illumination
432
How do you manage necrotising enterocolitis?
Nil by mouth start PTN
antibiotics
ventilation and surgery
433
What complications are associated with necrotising enterocolitis later in life?
Strictures
| malabsorption
434
What is gastroschisis?
Congenital defect of the abdominal wall resulting in herniation from the abdominal cavity
435
what is the difference between gastroschisis and omphalocele?
an abdominal sac covers the contents of an ompahloele whereas it isn't present in gastroschisis
436
what are the risk factors for gastroschiasis/ompahlocele?
smoking
maternal age 20< (gastroschiaisis)
maternal age >40 (omphalocele)
437
Which congenital abnormalities is ompahlocele associated with?
trisomy 13, 18, 21
438
what other condition is usually present if theres gastroschiasis/omphalocele?
and why?
intestinal atresia
due to constriction of the mesenteric blood supply causing decreased perfusion
439
how are gastroschiasis/ompahlocele detected?
antenatal USS in 2nd trimester
440
what compound is elevated in gastroschiasis/ompahlocele?
alpha-feto protein
441
what test should you offer after detecting gastroschiasis/ompahlocele?
amniocentesis at 15-20w
CVS at 10-12w
442
what is the management of gastroschiasis/ompahlocele?
Emergancy
ABCDE
fluid resus, temperature measurements and support, bowel protection until surgery
after surgery PTN/NG feed
443
what does gastroschiasis/ompahlocele cause that makes it a medical Emergancy?
massive fluid and heat loss
444
why is recovery longer in gastroschiasis than ompahlocele?
because the lack of sac means that theres development of a thick inflammatory film over the bowels
445
what is intestinal atresia?
any congenital malformation resulting in bowel obstruction - either misconnection, narrowing or total block
446
what are the classifications of intestinal atresia?
```
complete
incomplete
mesenteric gap
blind end complete
apple peel syndrome
multiple blockages
```
447
where does intestinal usually occur?
SI namely the ileum and jejunum because duodenal atresia is its own diagnosis
448
what causes intestinal atresia?
a vascular event en utero causing a decrease in perfusion and death of bowel
449
what is the presentation of intestinal atresia?
vomiting +/- bile
swollen soft abdomen
no meconium passage
450
how is intestinal atresia diagnosed?
fetal USS
+ contrast Xray after birth to confirm
usually not necessary is laparoscopy however can be used if unclear
451
What sign in pregnancy indicated intestinal atresia?
polyhydramnious
452
what is the management of intestinal atresia?
laparoscopic surgery
+stoma to allow healing
IV fluids and NG feeds
