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FINALS > GASTROENTEROLOGY + GEN SURGERY > Flashcards

GASTROENTEROLOGY + GEN SURGERY Flashcards

1
Q

What are some causes of dysphagia?

A
  1. Inflammatory = tonsilitis, pharyngitis, oesophagitis, oral candidiasis, aphthous ulcers
  2. Neuro/motility disorders = achalasia, diffuse oesophageal spasm, bulbar/pseudobulbar palsy, systemic sclerosis, MG
  3. Mechanical = foreign body, benign stricture, oesophageal web, malignant stricture, pharyngeal pouch, hiatus hernia (rolling), lung cancer
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2
Q

What is the crucial investigation required in pts presenting with dysphagia?

A

ENDOSCOPY

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3
Q

What are the ALARMS symptoms?

A 
A - anaemia (IDA)
L - loss of weight
A - anorexia
R - recent onset/progressive onset
M - malaena/haematemesis 
S - swallowing problems
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4
Q

What are the symptoms of oesophageal cancer?

A
  • progressive dysphagia
  • initially solids, progressing to liquids
  • odynophagia
  • retrosternal chest pain
  • hoarseness
  • occassional cough
    WEIGHT LOSS
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5
Q

How do you investigate someone with suspected oesophageal cancer?

A
  1. OGD with biopsy - mucosal lesion, adenocarcinoma/SCC
  2. Comprehensive metabolic profile
    - Hypokalaemia
    - Raised creatinine
    - Raised serum urea/nitrogen
  3. CT Thorax + abdomen for staging
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6
Q

What are the clinical features of an oesophageal web?

A
  • intermittent solid food dysphagia

- associated odynophagia

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7
Q

How do you manage oesophageal webs?

A

Dilatation of the webs

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8
Q

What is a benign oesophageal stricture? How does it present?

A

Occurs when stomach acid + other irritants damage lining of oesophagus over time. Leading to inflammation + scar tissue formation.

  • progressive dysphagia to solids
  • associated with chronic GORD
  • may be hx of corrosive indigestion, radiation exposure or trauma
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9
Q

What are the clinical features of pharyngeal pouch?

A

5x more common in men

  • odynophagia
  • regurgitation
  • chronic cough
  • aspiration
  • neck swelling which gurgles on palpation
  • halitosis
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10
Q

What oesophageal disorder is commonly misdiagnosed as ACS?

A

OESOPHAGEAL SPASM

- as has spontaneous intermittent chest pain + dysphagia

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11
Q

How is oesophageal spasm diagnosed + managed?

A

Barium swallow shows abnormal contractions e.g. corkscrew contractions
- managed with CCBs e.g. nifedipine

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12
Q

What are the clinical features of achalasia?

A
  • dysphagia to solids AND liquids from the start
  • regurgitation
  • gradual weight loss
  • retrosternal pressure/pain
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13
Q

How do you investigate suspected achalasia?

A
  1. Upper GI endoscopy
  2. Barium swallow
    - loss of peristalsis + delayed oesophageal emptying
    - beak-like gastro-oesophageal junction
  3. Oesophageal manometry
    - incomplete relaxation of LES + aperistalsis
  4. CXR - fluid level in dilated oesophagus (absence of gastric gas bubble)
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14
Q

How is achalasia managed?

A
  1. Endoscopic pneumatic dilatation or heller’s cardiomyotomy
  2. CCBs to manage symptoms while waiting for surgery
  3. Botulinum toxin can be injected if not suitable for surgery
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15
Q

What are the typical clinical features of oesophageal candidiasis?

A
  • dysphagia
  • odynophagia
  • hx of HIV or steroid inhaler use
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16
Q

How do you manage oesophageal candidiasis?

A
  1. Fluconazole

2. Itraconazole

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17
Q

What are some common differentials for pts presenting with dypepsia?

A
  • functional dyspepsia
  • h.pylori infection
  • GORD + oesphagitis
  • PUD
  • Gastroparesis
  • Gastritis + duodenitis
  • UGI malignancy
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18
Q

What are the 2ww rules for people with suspected UGI cancer?

A 
Urgent upper GI endoscopy in those with
- Dysphagia 
OR 
- Aged 55 or over with weight loss + any one of:
> upper abdo pain
> reflux
> dyspepsia
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19
Q

What are risk factors for developing peptic ulcer disease?

A
  • h.pylori infection
  • steroid use
  • NSAIDs
  • SSRIs
  • Smoking
  • Hx/FHx
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20
Q

What investigations should be performed in suspected peptic ulcer disease?

A
  1. H.pylori urea breath test or stool antigen test (if under 55)
  2. Upper GI endoscopy - PPI must be stopped for 2 wks before
  3. CLO test (rapid urease test) - test for h.pylori via endoscopy
  4. FBC - indication as to presence of UGI bleed
  5. Fasting serum gastrin level - hypergastrinaemia in Zollinger-Ellison
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21
Q

How do you manage PUD in patients with no red flag symptoms?

A
  1. Detect + treat H.pylori
  2. Advise to STOP smoking, NSAIDs, alcohol, drug abuse + aspirin
  3. Use PPI/H2 for 4-8wks, consider for longer until ulcer has resolved
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22
Q

When is triple therapy for h/pylori eradication indicated? What is used?

A

Under 55y + tested +ve or over 55y with confirmed gastric ulcer
Use:
- clarithromycin
- amoxicillin (metronidazole if penicillin allergic)
- PPI

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23
Q

What are some causes of upper GI bleed?

A

COMMON:

  • oesophageal varices
  • peptic ulcers
  • Mallory-weiss tear
  • Gastritis/erosions
  • drugs
  • cancer of stomach/duodenum
  • oesophagitis

RARE:
- bleeding disorders, portal hypertensive gastropathy, Boerhaave syndrome, angiodysplasia, meckel’s diverticulum, peutz-jeghers syndrome

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24
Q

What is the Glasgow Blatchford score? What is it used for?

A

Assess the likelihood that a person with UGI bleed will need medical intervention e.g. blood transfusion or endoscopic intervention
- score of more than 0 suggests need e.g. transfusion, endoscopy, biopsy etc

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25
Q

What is the management of an acute UGI bleed? (HINT: ABATED)

A 
A - ABCDE + rhesus 
B - Bloods
- FBC: IDA, platelets 
- U+E: raised urea
- LFT: ?liver disease
- Clotting
- Crossmatch 2 units blood 
A - Access with 2-large bore cannulae
T - Transfuse
E - Endoscopy - URGENT w/in 24h
D - Drugs: IV PPI, stop anticoagulants + NSAIDs
- In variceal bleeds also give terlipressin + prophylactic broad spectrum Abx
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26
Q

What is the definitive management/investigations for UGI bleed?

A
  1. ENDOSCOPY
    - within 4h for variceal haemorrhage
    - within 24h for all others
    - will help estimate risk of re-bleed + identify bleeding sites
  2. Treatment options
    - depends on cause
    - sclerotherapy, variceal banding, argon plasma coagulation
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27
Q

What are some causes of oesophageal varices?

A

PRE-HEPATIC
- thrombosis (portal or splenic vein)
HEPATIC
- cirrhosis, schistosomiasis, sarcoid, myeloproliferative disease, congenital hepatic fibrosis
POST-HEPATIC
- Budd-Chiari syndrome, RHF, Constrictive pericarditis, veno-occlusive disease

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28
Q

When would you suspect varices as a cause of UGI bleed?

A
  1. Alcohol abuse
  2. Cirrhosis present
  3. Signs of chronic liver disease
    - encephalopathy, splenomegaly, ascites, hyponatraemia, coagulopathy, thrombocytopenia
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29
Q

What primary + secondary prophylactic management can be given for oesophageal varices?

A

PRIMARY (cirrhosis present)

  • propranolol 40-80mg BD
  • endoscopic band ligation

SECONDARY (after 1st bleed)

  • propranolol 40-80mg BD
  • endoscopic band ligation
  • transjugular intrahepatic porto-systemic shunt (TIPS)
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30
Q

How do you manage bleeding peptic ulcers?

A
  1. Control initially with adrenaline injection
  2. Diathermy, laser coagulation or heat probe
  3. Surgery in severe haemorrhage/re-bleeding
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31
Q

What are some conditions which can pre-dispose patients to Mallory-Weiss tear?

A
  • alcoholism
  • bulimia nervosa
  • GORD
  • hiatal hernia
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32
Q

How do you manage a Mallory-Weiss tear?

A
  1. If bleeding stops spontaneously, conservative treatment sufficient
  2. Control precipitating factors e.g. PPI in GORD
  3. Treat haemodynamic instability if present
  4. Surgical intervention if actively bleeding lesion
    - adrenaline injection
    - electrocoagulation
    - endoscopic band ligation
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33
Q

What are the typical triad of features in Boerhaaves?

A
  1. Vomiting/retching
  2. Severe retrosternal pain - often radiates to back
  3. Subcutaneous or mediastinal emphysema
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34
Q

How do you manage Boarhaaves?

A
  1. Nil by mouth
  2. Broad spectrum Abx
  3. IV PPI
  4. Surgical repair
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35
Q

What are the red flags for a change in bowel habit?

A
  1. Aged over 60y
  2. Unexplained anaemia
  3. Weight loss
  4. Rectal bleeding
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36
Q

What are the 2ww rules for suspected colorectal cancer?

A
  1. Aged 40 or over with weight loss + abdo pain
  2. Aged 50 or over with unexplained rectal bleeding
  3. Aged 60 or over with IDA OR change in bowel habit
  4. FOB
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37
Q

What are some causes of gastroenteritis? Who do each type tend to affect?

A 
NOROVIRUS = most common in adults
ROTAVIRUS = most common in kids 
E.COLI = travellers, watery stool
GIARDIASIS = prolonged non-bloody
CAMPYLOBACTER = bloody diarrhoea, flu-like prodrome, risks GBS
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38
Q

What investigations should be done in patients with gastroenteritis?

A
  1. Clinical examination
  2. U+E - raised Na + urea (dehydration)
  3. Blood glucose - required before starting fluids
  4. Stool MC+S if:
    - recent travel abroad
    - blood or mucus
    - immunocompromised
    - no improvement by day 7
    - suspected septicaemia
  5. Blood culture - if starting Abx
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39
Q

How do you manage gastroenteritis?

A
  1. Attempt fluid challenge
  2. ORS or IV fluids
  3. Loperamide/Metoclopramide
  4. Abx if bacterial
    - campylobacter = erythromycin
    - c.difficile = metronidazole + vancomycin
  5. AVOID work/school for 48h after symptoms resolve
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40
Q

What patients should be tested for coeliacs disease even if they have no typical symptoms?

A

All newly diagnosed T1DM

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41
Q

What are the clinical features of ischaemic colitis?

A
  • lower left sided abdominal pain

- bloody diarrhoea

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42
Q

What investigations are performed in suspected ischaemic colitis?

A
  1. CT
  2. Colonoscopy with biopsy = GOLD STANDARD
  3. Barium enema - thumbprinting of submucosal swelling
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43
Q

How do you manage ischaemic colitis?

A
  1. Fluid replacement
  2. Abx
    - strictures are common!
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44
Q

What are the signs + symptoms of Crohns disease?

A

SYMPTOMS
- abdominal pain (diffuse or RUQ), non-bloody diarrhoea, nocturnal diarrhoea, perianal lesions

SIGNS:

  • aphthous ulcers
  • perianal abscess, fistula, skin tags
  • anal stricture
  • clubbing, arthritis, episcleritis/uveitis
  • pyoderma gangrenosum, erythema nodosum
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45
Q

What investigations should you perform in suspected Crohn’s disease?

A
  1. FBC - anaemia
  2. Faecal calprotectin
  3. Iron studies
  4. Serum B12
  5. CRP/ESR
  6. Stool testing - r/o c.diff
  7. Abdo x-ray
  8. CT abdomen
  9. Colonoscopy (+biopsy) = definitive.
    - skip lesions, cobblestoning, deep ulcers
  10. OGD (affects whole GI tract)
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46
Q

How do you manage Crohns? (How to induce remission + maintain)

A 
MUST STOP SMOKING!
INDUCING REMISSION:
1. Steroids (oral prednisolone, IV hydrocortisone)
2. Azathioprine
3. Methotrexate

MAINTENANCE:

  1. Azathioprine
  2. Methotrexate
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47
Q

Where does UC affect?

A

Always starts at rectum + never spreads beyond ileocaecal valve
- disease is also continuous

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48
Q

What are the symptoms + signs of Ulcerative Colitis?

A

SYMPTOMS:

  • episodic/chronic diarrhoea (blood + mucus)
  • crampy abdo pain (LLQ)
  • Increased frequency + urgency of motions
  • Blood in stool
  • Tenesmus

SIGNS:

  • clubbing
  • arthritis/spondylitis
  • erythema nodosum
  • episcleritis/uveitis
  • pyoderma gangrenosum
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49
Q

What investigations should be performed in suspected ulcerative colitis?

A
  1. Bloods - FBC, U+E, LFT, ESR, CRP
    - LFT should be done every 6-12 months to detect PSC
    - U+E = hypokalaemic metabolic acidosis from diarrhoea
  2. Faecal calprotectin
  3. Stool MC+S - r/o c.diff
  4. AXR - toxic megacolon if colon more than 6cm
  5. Colonoscopy/Flexi sig - rectal involvement, continuous, loss of vascular markings
  6. Biopsy - no inflammation beyond submucosa!, crypt abscesses, reduced goblet cells
  7. Barium enema (only if mild UC) = drainpipe colon
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50
Q

What is used to determine severity of UC? Describe mild, moderate + severe,

A

Truelove + Witts Severity Assessment

(i) MILD = 4 or less motions/day
(ii) MODERATE = 4-6 motions/day
(iii) SEVERE = 6 or more motions/day + fever + blood + raised ESR + tachycardia + anaemia

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51
Q

How do you induce remission in UC?

A

MILD-MODERATE:

  1. Aminosalicylate (topical mesalazine)
  2. Topical steroid/oral mesalazine
  3. Oral steroids or tacrolimus

SEVERE

  1. IV hydrocortisone
  2. IV ciclosporin
  3. Colectomy
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52
Q

How do you maintain remission in UC?

A
  1. Oral + topical mesalazine
  2. Azathioprine

Surgery indicated in perforation, massive haemorrhage, toxic dilatation, failed medical therapy

  • 1st = proctocolectomy + terminal ileostomy
  • followed by colectomy + ileo-anal pouch (J pouch)
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53
Q

What are some causes of rectal bleeding?

A
  1. Haemorrhoids - most common
  2. Colorectal cancer - most serious
  3. Anal fissure
  4. Gastroenteritis
  5. IBD
  6. Diverticular disease
  7. Angiodysplasia
  8. UGI bleed
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54
Q

What are risk factors for developing anal fissures?

A
  • constipation
  • IBD
  • STI: HIV, syphillis, herpes
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55
Q

How do you manage anal fissures? Both acute + chronic.

A

ACUTE (less than 6 wks)

  1. High-fibre diet + fluid intake
  2. Bulk forming laxative (methylcellulose), then lactulose
  3. Lubricants
  4. Topical anaesthesics

CHRONIC

  1. Lactulose
  2. Topical GTN or diltiazem
  3. 2ndary care referral after 8 wks for IVA + botox
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56
Q

What is the most common type of colorectal cancer?

A

adenocarcinoma

57
Q

What are the typical clinical features of colorectal carcinoma?

A
  • change in bowels
  • PR bleeding
  • weight loss
  • tenesmus
  • IDA
  • bowel obstruction
  • abdominal mass
58
Q

What tests should be done in suspected colorectal cancer?

A
  1. FBC - microcytic anaemia
  2. FOB - used for screening
  3. Colonoscopy with biopsy = GOLD STANDARD
  4. CT colonography - considered in pts not fit for scope
  5. Staging CT TAP
  6. CEA
59
Q

What is Dukes classification for colorectal cancer?

A

A - confined to mucosa + part of muscle bowel wall
B - extending through muscle of bowel wall
C - lymph node involvement
D - metastatic disease

60
Q

How is colorectal cancer managed?

A

MDT APPROACH - all varies depending on stage, general health + pts wishes etc.

  1. Surgical resection
  2. Chemotherapy
  3. Radiotherapy
  4. Palliation
61
Q

What is a temporary loop ileostomy?

A

Temporary = ileostomy created to protect distal anastomosis
- 6-8 week period allows for healing of anastomosis, after this time it is reversed

Loop = both ends of section of small bowel brought to skin. The proximal, functioning end is turned inside-put to form a spout which protects surrounding skin

Usually found on lower right side of abdomen

62
Q

What is the follow-up timelines for patients following curative colorectal cancer resections?

A
  • CT TAP @ 1, 2 and 3 years
  • Colonoscopy @ 1 and 5 years
  • CEA 6-monthly for 3 years
63
Q

What are the clinical features of diverticular disease?

A
  • altered bowel habit
  • blood mixed in stool
  • abdominal pain (typically LLQ)
64
Q

How is diverticular disease diagnosed?

A
  1. Common incidental findings found on colonoscopy
  2. Barium enema
  3. CT abdomen is best for diverticulitis (enema or colonoscopy risk perforation in acute setting)
65
Q

How is diverticular disease managed?

A
  1. Advice re weight loss + high-fibre diet

2. Can use mebeverine for spasms

66
Q

What are the clinical features of diverticulitis?

A
  • LLQ pain + tenderness
  • Fever
  • Change in bowel habit
  • Bleeding mixed in with stool
  • N+V
67
Q

What investigations should be performed in a pt presenting with suspected diverticulitis?

A
  1. FBC - raised WCC
  2. CRP raised
  3. Erect CXR - r/o bowel perforation
  4. CT with contrast
    - use water soluble enema = gastrograffin
  5. Colonoscopy - once stabilised
68
Q

How do you manage diverticulitis?

A

MILD attacks = treat at home with bowel rest (fluids only) + Abx (co-amoxiclav) with follow-up after 48h

If unwell or complications e.g. rectal bleeding, then admission required.

  1. NBM + IV fluids
  2. IV Abx
  3. Analgesia
  4. Surgery determined by degree of infective complications
69
Q

When do haemorrhoids become painful?

A

When they thrombose

  • this happens when they protrude through the anal sphincter + venous return is blocked
  • appear as purple, very tender, swollen lumps around anus
  • PR exam impossible due to pain
70
Q

What investigations should be performed in suspected haemorrhoids?

A

Like in all cases of rectal bleeding, do:

  1. PR exam
  2. Proctoscopy - to visualise internal haemorrhoids
  3. Abdominal exam to r/o other DDx
  4. Sigmoidoscopy - to visualise rectal pathology higher up
71
Q

What are the types of anal prolapse? (HINT 1-4)

A 
1 = no prolapse
2 = prolapse on straining, returns on relaxing
3 = prolapse when straining, has to be pushed back in
4 = prolapsed permanently
72
Q

How do you manage haemorrhoids?

A

1st DEGREE:

  • increase fluid + fibre
  • topical analgesics
  • stool softener
  • topical steroid short-course

2nd + 3rd DEGREE or 1st IF ABOVE FAILS:

  • rubber band ligation
  • sclerosants

4th DEGREE:
- surgery = excisional haemorrhoidectomy

73
Q

What investigations should be performed in suspected toxic megacolon?

A
  1. FBC: raised WCC, reduced Hct
  2. U+E: low K + Mg due to volume loss
  3. CRP: raised
  4. Serum albumin: low
  5. Lactate: raised
  6. Stool studies
  7. CT abdo/pelvis
  8. AXR: colonic dilatation over 6cm, absence of haustra
  9. Erect CXR: ?perforation
  10. Sigmoidoscopy
74
Q

How should you manage toxic megacolon?

A
  1. ABCDE + resus!
  2. Broad spectrum Abx = metronidazole + ciprofloxacin
  3. NG decompression
  4. IV corticosteroid if IBD
  5. Surgery - if no improvement after 72h of medical therapy
    - abdominal colectomy with end ileostomy
75
Q

What is the triad of symptoms in Budd-Chiari syndrome?

A

= Hepatic Vein Thrombosis

  1. abdominal pain: sudden onset, severe
  2. ascites → abdominal distension
  3. tender hepatomegaly
76
Q

What investigation is used to diagnose Budd-Chiari?

A

Ultrasound with doppler flow studies should be first investigation

77
Q

What should you repeatedly monitor/assess for in pts with Acute Liver Failure?

A
  • Hypoglycaemia
  • Hyperkalaemia
  • Renal failure
  • Bacterial/fungal infection
  • Cerebral oedema + raised ICP
  • Metabolic acidosis
78
Q

What are some causes of Acute Liver Failure?

A
  1. DRUGS/TOXINS
    - paracetamol OD
    - anti-TB drugs
    - halothane, ecstasy, carbon tetrachloride
  2. INFECTION
    - acute viral hepatitis, CMV, EBV
  3. VASCULAR
    - shock/ischaemic hepatitis, Budd-Chiari syndrome
  4. OTHER
    - Wilson’s disease, autoimmune hepatitis
    - Acute fatty liver, pregnancy
    - extensive malignant infiltration
79
Q

When should you suspect alcoholic hepatitis?

A

Pts who drink over 40units/week
OR
Develop withdrawal symptoms after 24-48h in hospital

80
Q

What are the common features of acute liver failure?

A
  • Jaundice
  • Coagulopathy (INR over 1.5)
  • Hepatic encephalopathy
81
Q

What are the complications that can occur from acute liver failure?

A
  1. Cerebral oedema
    - mannitol + hyperventilate
  2. Ascites
    - fluid restrict, low-salt diet, diuretics
  3. Bleeding - Vit K, platelets, FFP
82
Q

What investigations do you perform in suspected cirrhosis?

A
  1. LFTs
  2. Albumin: low
  3. U+E: hyponatraemia common
  4. Clotting: PT prolonged, raised INR
  5. FBC: low WCC in hypersplenism
  6. FIBROSCAN CONFIRMS DIAGNOSIS
    - tests to locate cause: iron studies, ANA, AMA, serum caeruloplasmin, alpha-1 antitrypsin
83
Q

What treatment is given in SBP?

A

Cefotaxime

84
Q

What investigation confirms hepatic steatosis?

A

USS

85
Q

What are the clinical features of hereditary haemochromatosis?

A
  1. early symptoms = fatigue, erectile dysfunction + arthralgia (often hands)
  2. ‘bronze’ skin pigmentation
  3. diabetes mellitus
  4. LIVER: stigmata of chronic liver disease, hepatomegaly, cirrhosis, hepatocellular deposition)
  5. CARDIAC failure (2nd to dilated cardiomyopathy)
  6. hypogonadism
  7. arthritis (especially of the hands)
86
Q

How do you investigate hereditary haemochromatosis?

A
  1. LFTs deranged
  2. Iron studies
    - raised serum ferritin + transferrin saturation
    - low TIBC
  3. Genetic testing - CONFIRMS DIAGNOSIS (HFE mutation)
  4. Imaging
    - Xray = chondrocalcinosis
    - MRI = deposits in liver
  5. Liver biopsy = Perl’s stain
  6. ECG/Echo if dilated cardiomyopathy suspected
87
Q

What are the triad of features in wilson’s disease?

A
  1. hepatic problems - 40%
    - hepatitis + cirrhosis
  2. CNS problems = 50%
    - dysathria, dystonia, parkinsonism
  3. Psychiatric problems - 10%
    - depression, psychosis, dementia
88
Q

What is used to treat Wilson’s disease

A
  1. Penicillamine
  2. Zinc therapy
  3. Trientine
89
Q

How do you manage Hepatitis A?

A
  1. Supportive - analgesia
    - typical resolution in 1-3 months
  2. AVOID alcohol
  3. Interferon alpha if fulminant disease (RARE)
90
Q

Who is at risk of Hepatitis B?

A
  • IVDU + their partners
  • Healthcare workers
  • Haemophiliacs
  • Dialysis pts
  • Sexually promiscuous
  • Babies from HBsAg +ve mothers
91
Q

What does all of the following mean?

(i) HBsAg
(ii) Anti- HBs
(iii) Anti-HBc
(iv) HBeAg

A

(i) HBsAg = implies infectivity
- acute if less than 6 months
(ii) Anti- HBs = implies immunity
- resolved infection OR vaccination
(iii) Anti-HBc = past or current infection
- IgM remains for 4-6 months
- IgG = chronic infection
(iv) HBeAg = marker of infectivity

92
Q

Can hep B be spread by breast feeding?

A

NO

93
Q

What is the (i) screening + (ii) diagnostic test for Hepatitis C?

A

(i) hepatitis C antibody (anti-HCV) = screening

(ii) HCV RNA (PCR) = diagnostic

94
Q

What antibodies are associated with autoimmune hepatitis?

A

ANA
Anti-smooth muscle
LKM-1

95
Q

How do you treat autoimmune hepatitis?

A
  1. Steroids or azathiprine

2. Liver transplant

96
Q

What condition is commonly associated with PBC?

A

Sjogrens syndrome (80%)

others = RA, systemic sclerosis, thyroid disease

97
Q

What is the treatment for PBC?

A
  1. Cholestyramine for pruritus
  2. Fat-soluble vitamin supplementation
  3. Ursodeoxycholic acid
  4. Liver transplant
  5. Steroids
98
Q

What is the gold standard test to diagnose PSC?

A

MRCP

- also ANCA+ve

99
Q

How is PSC managed?

A
  1. ERCP can dilate + stent any strictures
  2. Ursodeoxycholic acid may protect against colorectal cancer
  3. Cholestyramine for pruritus
  4. Liver transplant if advanced disease
100
Q

What are the USS findings in acute cholecystitis?

A
  • thickened GB wall
  • stones/sludge in Gb
  • fluid around GB
  • stones in duct
  • duct dilatation (6mm plus 1mm for every decade over 60)
101
Q

How do you distinguish between acute cholecystitis + ascending cholangitis?

A

Ascending cholangitis is RUQ pain, fever/raised WCC + jaundice
Acute cholecystitis there is no jaundice

102
Q

How do you manage acute cholecystitis?

A
  1. NBM
  2. Fluids
  3. Analgesia - diclofenac or morphine
  4. Abx - cefuroxime IV
  5. Laparoscopic cholecytectomy
103
Q

What are the 2ww criteria for suspected pancreatic cancer?

A
  1. Aged over 40 with jaundice
  2. Consider if aged over 60 with weight loss + any of:
    - diarrhoea
    - constipation
    - back pain
    - abdominal pain
    - new-onset DM
    - nausea or vomiting
104
Q

What investigations are performed in suspected pancreatic cancer?

A
  1. Endoscopic USS with biopsy
  2. CT TAP
  3. CA19-9
105
Q

What is the surgery used for pancreatic cancer?

A

only used in less than 20%
WHIPPLES RESECTION = pancreaticoduodenectomy
- removes head of pancreas, GB, duodenum + pylorus

106
Q

How does hereditary spherocytosis present? How is it treated?

A

Jaundice, splenomegaly, gallstones + aplastic crisis in the presence of parovirus
- treated with folate supplementation + splenectomy. May also require cholecystectomy

107
Q

How is G6PD inherited?

A

X-linked recessive

108
Q

How does G6Pd deficiency present?

A

Jaundice (typically in neonatal period), gallstones, anaemia, splenomegaly
+ Heinz bodies on blood film
Diagnosed by doing G6PD enzyme assay

109
Q

How is AIHA managed?

A
  1. Blood transfusions
  2. prednisolone
  3. rituximab
  4. Splenectomy
110
Q

What is the diagnostic test for sickle cell anaemia?

A

Hb electrophoresis

111
Q

What are general management you should advise pts of with sickle cell anaemia?

A
  1. AVOID dehydration + other triggers of crisis
  2. Ensure vaccines up to date
  3. Abx prophylaxis = phenoxymethylpenicillin
  4. Hydroxycarbamide = stimulates production of foetal Hb
  5. Blood transfusion for severe anaemia
  6. Bone marrow transplant can be curative
112
Q

What are the 4 main types of sickle cell crises? Describe VERY briefly/

A
  1. VASO-OCCLUSIVE CRISIS (painful crisis)
    - block capillaries causing ischaemia
    - can cause priapism in men
  2. SPLENIC SEQUESTRIAN CRISIS
    - RBCs blocking flow to spleen
    - severe anaemia + shock
  3. APLASTIC CRISIS
    - caused by parovirus B19
    - loss of creation of new cells (temporary)
  4. ACUTE CHEST SYNDROME
    - can be from infection (pneumonia/bronchiolitis) or non-infective (fat emboli)
113
Q

What is the initial generic management of the acute abdomen?

A
  1. ABCDE to prioritise resuscitation
  2. NBM
  3. IV access
  4. IV Fluids
  5. IV Abx if evidence of infection
  6. Analgesia + anti-emetics
  7. NG tube if vomiting/evidence of obstruction
  8. Catheterise for fluid balance monitoring
  9. Consent
  10. Escalate care
114
Q

What should a pt with AF + abdominal pain make you think of?

A

Mesenteric ischaemia

115
Q

What are the clinical features of mesenteric ischaemia?

A

Acute severe abdominal pain
- central + constant, or around the RIF
Degree of illness out of proportion to clinical signs (no abdominal signs)
Rapid hypovolaemia + shock

116
Q

What investigations should you perform in suspected mesenteric ischaemia?

A
  1. FBC - raised Hb due to plasma loss, raised WCC
  2. ABG - metabolic acidosis
  3. Lactate raised
  4. AXR - gasless abdomen
  5. CT/MRI angiography
  6. Laparotomy
117
Q

How do you manage mesenteric ischaemia?

A
  1. Fluid resuscitation
  2. Thrombolysis with HEPARIN
  3. Abx - gentamicin + metronidazole
  4. Laparotomy to resect necrotic bowel
118
Q

What are the causes of acute pancreatitis? (HINT: GET SMASHED)

A 
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion venom
H - hyperlipidaemia/hypothermia/hypercalcaemia
E - ERCP
D - drugs
119
Q

What is (i) Cullen’s sign (ii) Grey-Turners sign?

A

(i) Cullens = periumbilical discolouration

(ii) Grey-turners = Flank discolouration

120
Q

What investigations should you perform in acute pancreatitis?

A
  1. Amylase - 3x upper limit of normal
  2. Lipase
  3. ABG - raised lactate
  4. LFT - raised AST
  5. CRP raised
  6. AXR
  7. Erect CXR - r/o perforatoin
  8. CT = gold standard
  9. USS if gallstones + raised AST
  10. ERCP - if LFTs worsen
121
Q

How is pancreatitis managed? What scoring system is used to determine management?

A

Modified Glasgow Score

  1. NBM - likely need NG tube to decrease pancreatic stimulation
  2. IV fluids
  3. Analgesia - pethidine, morphine
  4. Hourly obs + bloods
  5. May require Abx
  6. Address cause
122
Q

What is the main cause of chronic pancreatitis?

A

Alcohol

123
Q

What are the clinical features of chronic pancreatitis?

A
  • upper abdo pain worse 15-30 mins following meal
  • steatorrhoea
  • DM usually 20y after onset of symptoms
124
Q

What test can be used to assess endocrine function of pancreas?

A

Faecal elastase

125
Q

How do you manage chronic pancreatitis?

A
  1. Pancreatic enzyme supplementation
  2. Analgesia
  3. Antioxidants
126
Q

What is the gold standard test to diagnose appendicitis?

A

CT

127
Q

What Abx can be given pre-op for appendicitis?

A

Cefuroxime + metronidazole

128
Q

What are the 3 main causes of bowel obstruction?

A
  1. Adhesions
  2. Hernias
  3. Malignancy
    (also volvulus, ischaemia)
129
Q

What is the initial management + tests for bowel obstruction?

A

DRIP + SUCK
- NBM, IV fluids, NG tube on free drainage

  1. AXR
  2. CT confirms diagnosis (use gastrograffin as contrast)
  3. Bloods: Amylase, FBC, U+E, lactate
130
Q

What is the most common type of volvulus?

A

Sigmoid volvulus (80%)

131
Q

What is the classical sign of sigmoid volvulus on AXR?

A

Coffee bean sign

132
Q

How do you manage sigmoid volvulus?

A
  1. Right sigmoidoscopy + rectal tube insertion

2. Sigmoid colectomy sometimes required

133
Q

What is paralytic ileus? When does it tend to occur?

A

Bowel goes to ‘sleep’ temporarily causing pseudo-obstruction
= very common post-abdominal surgery
- lasts 2-4 days

134
Q

How should paralytic ileus be managed?

A
  1. NBM + IV hydration
  2. Reduce opioid analgesia + replace with non-opioid
  3. NG decompression
  4. Consider parenteral nutrition if more than 3 days without food
135
Q

What is the best test to diagnose hiatus hernia?

A

Barium swallow

136
Q

What are the 3 main causes of large bowel obstruction?

A
  1. Adhesions
  2. Hernias
  3. Malignancy
137
Q

What is paralytic ileus?

A

Adynamic bowel due to the absence of normal peristaltic contractions.
Contributing factors include = abdominal surgery, pancreatitis (or any localised peritonitis), spinal injury, hypokalaemia, hyponatraemia, uraemia, peritoneal sepsis & drugs (e.g. TCAs)
- common post surgery + lasts 2-4 days

138
Q

What are the classic triad of features in chronic mesenteric ischaemia?

A
  1. Colicky post-prandial abdominal pain
  2. Weight loss (eating hurts)
  3. Upper abdominal bruit and/or PR bleeding
139
Q

How do you diagnose + manage chronic mesenteric ischaemia?

A

CT angiogram

- percutaneous transluminal angioplasty + stent insertion

FINALS (14 decks)

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