Gastroenterology & GI Surgery Flashcards
Autosomal dominant
- Familial adenomatous polyposis
- Peutz Jeghers syndrome
Autosomal recessive
Gilbert’s syndrome
Liver damage enzymes
- ALT
- ALP
- AST
Liver function enzymes
- Bilirubin
- Albumin
Category 1 Colorectal cancer risk
- Near average risk if they have no family history of colorectal cancer
- Above-average risk 1 1st degree relative > 60 years at dx
Category 1 Colorectal cancer screening
- iFOBT every 2 years after 45 years to 74
- low-dose (100 mg) aspirin daily should be considered from age 45 to 70
Category 2 Colorectal cancer risk
Moderate risk
2x-4x higher than average risk
One 1st degree relative < 60 years at dx
OR
One 1st degree relative AND >One 2nd degree diagnosed at any range
OR
Two 1st degree relatives diagnosed at any age
Category 2 Colorectal cancer screening
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis in 1st degree relative
OR age 50, whichever is earlier, to age 74.
- CT colonography if clinically indicated
- Low dose aspirin (100mg)
- Update history
Category 3 Colorectal cancer risk
High risk
Two 1st degree relatives AND One 2nd degree relative diagnosed < 50
OR
Two 1st degree relatives + > Two 2nd degree relative diagnosed at ANY age
OR
> Three 1st degree relatives diagnosed at ANY age
Category 3 Colorectal cancer screening
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative
OR
age 40, whichever is earlier, to age 74. - CT colonography if clinically indicated
- Low dose aspirin (100mg)
- Update history
migratory superficial thrombophlebitis + deep vein
thrombosis
Trousseau’s syndrome
hix of gastric bypass + discomfort, including nausea, vomiting, cramps, and diarrhea
Dumping syndrome
Dumping syndrome management
- Diet modification (high fibre + protein)
- -Hydrogen breath test positive
- Barium fluoroscopy
- radionuclide scintigraphy reoperation if diet fails
Trousseau’s syndrome associated tumours
1-Pancreas 24%
2-Lung 20%
3-Prostate 13%
4-Stomach12%
5-Acute leukaemia 9%
6-Colon 5%
Small bowel obstruction investigation
initial: Abdominal X-ray
Best: CT abdomen/gastograffin meal (dx & tx)
Elective non-cardiac surgery following PCI
Defer surgery for 6 weeks - 3 months
Elective surgery with history of drug eluding stents
Defer for 12 months
emergency surgery with history of rug eluding stents
Withhold clopidogrel for 5-7 days
- continue aspirin
most common cause of large bowel obstruction
Colon cancer
upper GIT endoscopy 🚩’s
▪ anaemia (new onset)
▪ dysphagia (difficulty swallowing)
▪ odynophagia (painful swallowing)
▪ haematemesis or melaena
▪ unexplained weight loss >10%
▪ vomiting older age >50 yrs
▪ chronic NSAID use
▪ severe frequent symptoms including hiccoughs, hoarseness
▪ family history of upper GIT or colorectal cancer
▪ short history of symptoms
▪ neurological symptoms and signs
Oropharyngeal dysphagia causes
Neuro-muscular disease:
* Stroke
* Parkinson’s disease
* Brain stem tumour
* Degenerative conditions: ALS
MS
* Myasthenia gravis
* Peripheral neuropathy
Obstructive lesion:
* Tumour
* Inflammatory masses: abscess
* Pharyngeal pouch (Zenkers)
* Anterior mediastinal mass
Oesophageal dysphagia causes
Neuro-muscular disease:
* Achalasia
* Scleroderma
* GORD
Obstructive lesion:
* Tumour
* Strictures:
Peptic (reflux oesophagitis)
Radiation
Chemical (caustic Ingestion)
Medication
* Oesophageal webs (Plummer
Vinson)
* Foreign Bodies
Extrinsic Structural Lesions:
* Vascular compression (enlarged or Left Atrium)
* Mediastinal masses:
lymphadenopathy or retrosternal
thyroid.
Iron deficiency anaemia in elderly
colon cancer
high INR + low calcium + hypochromic microcytic anaemia
malabsorption syndrome
malabsorption syndrome investigation
Anti-gliadin antibodies
Coeliac disease Symptoms:
Chronic diarrhoea
Steatorrhoea
Weight loss
Anorexia
Abdominal distension
Nutritional deficiency: folate, calcium, zinc or iron (in particular)
Grouped blisters around the knees, elbows and buttocks (dermatitis herpetiformis)
Hair loss
Mouth ulcers
Coeliac vitamin deficiencies
- iron (most common)
- B12
- ADEK
Coeliac disease investigation
Serum transglutaminase antibodies
conditions is associated with an increased risk of coeliac disease
- Type I diabetes mellitus
- Hashimoto’s thyroiditis
- autoimmune diseases
- Down’s syndrome
- Turner’s syndrome
- IgA deficiency
long hx of vomiting after food + reduced appetite
Gastro-oesophageal reflux disease (GORD)
Most common complication of GORD
Oesophagitis
Gastro-oesophageal reflux disease (GORD) investigation
Initial: Intraoesophageally pH probe monitoring
diagnostic: oesophageal endoscopy with multiple biopsies
GORD management
Therapeutic trial of proton pump inhibitor
high age + progressive dysphagia + decreased contractions + increased tertiary wave activity
Presbyoesophagus
- Dysphagia to solids and liquids
- Heartburn unresponsive to a trial of proton pump inhibitor therapy for 4weeks
- Retained food in the oesophagus on upper endoscopy
- Unusually increased resistance to passage of an endoscope through the oesophagogastric junction
achalasia
Most important diagnostic feature of achalasia?
Dysphagia for both solids and liquids
Barrett’s oesophagus monitoring
2-5 years by endoscopy and biopsy depending on segment length
bariatric surgery indications
– BMI above 40 with no co-morbidities
– BMI above 35 with co-morbidities such as hypertension
– BMI above 30 with poorly controlled type 2 diabetes
– BMI above 30 with increased cardiovascular risk due to multiple risk factors such as hypertension, hyperlipidemia, strong family history of cardiovascular disease at a young age
bariatric surgery contraindications
– Irreversible end-organ dysfunction.
– Cirrhosis with portal hypertension.
– Medical problems precluding general anaesthesia.
– Centrally mediated obesity syndromes such as Prader-Willi syndrome or Craniopharyngioma.
PUD risk factors
-Male sex.
-Family history of peptic ulcer disease.
-Smoking.
-Stress.
-NSAIDs.
-H.pylori.
H. Pylori
Gram -ve
- corkscrew-shaped, motile bacillus with three to seven flagella
- rapid urease test
- Eradication with colloidal bismuth (Pepto-Bismol), an antibiotic (amoxicillin or ampicillin), and a nitroimi-dazole such as metronidazole.
Left supraclavicular lymph node cancer
- abdominal or pelvic
Acute pancreatitis investigation
- serum lipase (elevated)
acute pancreatitis surgery indications
- Uncertainty of clinical diagnosis
- Worsening clinical condition despite optimal supportive car2
- Infected pseudocysts
- Gallstone-associated pancreatitis
Pancreatic pseudocyst management
- size > 6cm ERCP
- Present for > 6 weeks
- Wall thickness for > 6 mm
NOTE: if ERCP fails, then move on to laporotomy
Pancreatic cancer risks
-Smoking.
-Long-standing diabetes mellitus.
-Chronic pancreatitis.
-Obesity.
-Inactivity (high cholesterol/obesity?
-Non–O blood group
freckling + gastrointestinal polyposis (polyps in small bowel) + intussusception + pigmented macules (1–5mm) on lips, buccal mucosa and fingers
Peutz Jeghers Syndrome
Peutz Jegers Syndrome complications
high risk of specific cancers:
intestine
colon
pancreas
breasts
cervix
ovaries
testes
Diverticultis highest mortality rate complication
Perforation 20%
- Bleeding especially in elderly
– Intra-abdominal abscess.
– Peritonitis.
– Fistula formation.
– Intestinal obstruction.
Meckel diverticulum investigation
- painless large-volume intestinal hemorrhage
Technetium-99m pertechnetate scintigraphic study
– Severe colicky epigastric and periumbilical pain
– Absolute constipation.
– Nausea and vomiting.
– Abdominal distension
small bowel obstruction
jaundice, dark urine, and pale stool + palpable gall bladder
Periampullary tumor
GI bleed with weight loss and decreased appetite
colon adenocarcinoma
5 F’s of cholecystitis
- Fair
- Fat
- Female
- Fertile
- Forty
infective cholecystitis pathogen
E. Coli
hx of cholecystectomy + abdominal pain + dyspepsia + increased liver enzymes abd cholesterol
post-cholecystectomy syndrome
post-cholecystectomy syndrome investigation
Perform ERCP
gall stone investigation
initial:
diagnostic: US/ERCP
Gallstone surgery indication
size > 3 cm
- calcified/porcelain gallbladder
abdominal surgical interventions
D1. iffuse peritonitis(localized peritonitis is not always an indication).
2-Severe or increasing localized tenderness.
3-Progressive abdominal distension.
4-Tender mass with fever or hypotension (abscess).
5-Septicemia and abdominal findings.
7-Bleeding and abdominal findings.
8-Suspected bowel ischemia (acidosis,fever,tachycardia).
9-Massive bowel dilatation more than 12cm.
diarrhoea + abdominal pain + bloating + belching + flatus + nausea and vomiting
Giardiasis
Giardiasis investigation
stool examination for ova and cyst
most common cause of constipation
Dietary
dysphagia + hoarseness + hx of achalasia + thoracic inlet mass
Oesophageal cancer
dysphagia + chest discomfort +
weight loss ± hiccoughs
oesophageal cancer
oesophageal malignant lesions surgical contraindication
- Invasion of tracheobronchial tree
- Invasion of great vessels
- lesion more than 10 cm
hoarseness + dysphagia + neck mass
Laryngeal cancer
paraesophageal/hiatus hernia investigation
Diagnostic: Barium swallow
fever + jaundice, + pain in the right upper quadrant + chills
Acute cholangitis
Harcot’s triad
Acute cholangitis poor prognostic determinants
1- Age more than 70.
2- Female gender.
3- Failure to respond to conservative management.
4- Concurrent medical conditions:
- liver abscess
- cirrhosis
- hypoalbuminaemia
- thrombocytopenia
- IBD
- malignant strictures
abdominal pain + diarrhoea + Tenderness on DRE
Acute appendicitis
Left iliac fossa pain + Fever + Tenderness and rebound tenderness + Guarding + Per rectal bleeding + hypotension
Acute diverticulitis
hx of ascites+ fever + altered mental status + increased WBC + abdominal pain/discomfort
spontaneous bacterial peritonitis
Splenectomy measures
- Vaccination against:
streptococcus pneumoniae
meningococcus
H. influenza - Antibiotics (Penicillin) from 6 months - 2 years
- target cells (deformed RBCs)
Peritonitis investigation
- Ascitic analysis
(fluid neutrophil count more than 250 cells/mm3)
Malignant cells in ascites will spread to
Left supraclavicular lymph nodes
spontaneous bacterial peritonitis transmission
Bacterial translocation from gut to mesenteric lymph node Bacterial translocation from gut to mesenteric lymph node
bacterial peritonitis treatment
Cefotaxime and albumin
- albumin to reduce the rate of renal failure
screening for hepatoma or primary liver cancers with chronic hepatitis
Alpha fetoprotein
Hepatic hydatid cyst pathogen
Echinococcus tape worm
Hepatic hydatid cyst investigation
Initial: USG
Best: Triphasic abdominal CT (confirmatory)
- Cyst aspiration
Hepatic hydatid cyst USG
Hepatic hydatid cyst USG
Hepatic hydatid cyst CT
Hepatic hydatid cyst CT
Hepatic hydatid cyst management
Albendazole
Surgery
Praziquantel followed by albendazole if spilled cyst
autoimmune hepatitis predictor of poor clinical response to therapy
Anti-liver-kidney microsomal antibody (Anti-LKM antibody)
Elevated liver enzymes with normal bilirubin
Ischemic hepatitis
Indicator for chronic liver disease
- Alanine aminotransferase
- Aspartate aminotransferase
Child-Pugh classification
The severity of portal hypertension
1-Increased total bilirubin.
2-Prolonged INR.
3-Low serum albumin.
4-Presence of hepatic encephalopathy.
5-Presence of ascites.
Best predictor of patient livelihood
Hypoalbumin
- decrease in osmotic pressure, therefore ANSARCA that leads to CHF
Best indicator for chronic liver disease
Albumin
Longstanding cirrhosis or Hep C
Form hepatocellular carcinioma
Cirrhosis findings
PE: spider naevi, palmar erythema, gynecomastia and splenomegaly
LAB:
- Thrombocytopenia
Abnormal coagulation studies including INR and PT
Hypoalbuminemia
Pilonidal sinus prevention
1-Keep the area clean and dry.
2-Avoid sitting for a long time on hard surfaces.
3-Remove hair from the area
Acute confusion post surgery
Atelectasis, PR, chest infection
- check pulse oximetry
Encephalopathy grades
Grade-I involves altered mood/behaviour, sleep disturbance including reversal of sleep cycle.
Grade-II involves increasing drowsiness, confusion and slurred speech
Grade-III involves stupor, incoherence, restlessness and significant confusion
Grade IV is an
ultimate coma
Dilated abdominal veins flowing towards head + hepatomegaly
Inferior Vena Cava Obstruction
Dilated abdominal veins flowing towards legs+ hepatomegaly
Caput medusae from cirrhosis and portal hypertension
History of recent myocardial infarction. + acute onset of abdominal pain + Metabolic
acidosis.
mesenteric ischemia
chronic gastrointestinal bleeding prevention
BB (Propranolol or nadolol)
most likely to strangulate hernia
indirect inguinal hernia
least likely to strangulate hernia
Direct inguinal hernia
gastroenteritis in Australia?
Norovirus
Repeated unconjugated hyperbilirubinemia + No evidence of haemolysis, with normal findings on complete blood count, reticulocyte count, and blood smear. + Normal liver function tests except for the bilirubin.
Gilbert’s syndrome
most common gastrointestinal complication seen after cholecystectomy
Diarrhoea
infliximab for inflammatory bowel disease
Crohn’s disease with perianal fistulas
erythematous + well define + fluctuant mass at the anal orifice
Perianal abscess
sulfasazine side effects
- agranulocytosis
- haemolytic anaemia
rash -
presence of eosinophils + dysphagia
eosinophilic esophagitis
eosinophilic esophagitis management
- PPI
- Swallowed budesonide
- Systemic corticosteroids
CEA
glycoprotein found in colon - cancer
- CEA assay is a sensitive serologic tool for identifying recurrent disease
infant + volvulus + duodenal obstruction + intermittent or chronic + abdominal pain
malrotation
hernia that follows the path of the spermatic cord within the cremaster muscle
Indirect inguinal
hernia passes directly beneath the inguinal
ligament at a point medial to the femoral vessels
femoral
hernia passes through a weakness in the floor of the inguinal canal medial to the inferior epigastric
artery
direct inguinal
hernia that protrude through an anatomic defect that can occur along the lateral border of
the rectus muscle at its junction with the linea semilunaris
Spigelian
thiazide diuretic + beta
blocker
hypokalemia
haemorrhoiids investigation
Proctoscopy
Recurrent pneumonia + dysphagia + undigested food regurgitation
Zenker diverticulum (pharyngeal puch)
Zenker diverticulum investigation (pharyngeal puch)
Initial: Contrast esophagography
Best: Upper gastrointestinal endoscopy
Zenker diverticulum management (pharyngeal puch)
Surgery: cricopharyngeal myotomy ± diverticulectomy
dysphagia + coughing and choking + recurrent aspiration pneumonia + stroke
Oropharyngeal dysphagia
Oropharyngeal dysphagia investigation
Videofluoroscopic modified barium swallow study
middle-aged women + hyperlipidemia + fatigue + pruritus + elevated alkaline phosphatase
cholestasis
constipation + fecal ncontinence + hematochezia + hx of pelvic radiation therapy
Radiation proctitis
Acute pancreatitis worse prognosis
Blood urea nitrogen level
- reflect intravascular volume depletion
Ursodeoxycholic acid is used to treat
Primary biliary cirrhosis
- increases bile acid output and bile flow while reducing
cholesterol absorption
primary lymphoma predisposing factors
Celiac disease
solids dysphagia + breathlessness, cough +
heartburn + wheezing
Congenital anomaly of the aortic arch
- presses against the oesophagus causing dysphagic, compression isn’t too harsh as liquids can still pass through
long hx of constipation + sudden cut-off + dilated proximal colon + abdominal distension + empty rectum on DRE
sigmoid volvulus
sigmoid volvulus investigation
diagnostic: CT abdomen
NOTE: barium if perforation is suspected
mild tenderness on rectal exam + pain localized in the pelvis
pelvic appendicitis
Disease with strongest association with colorectal cancer
Familial adenomatous polyposis
- cancer can develop as early as 20
Somalian + anal fissure predisposing factor
Rectal schistosomiasis
most common cause of treatment failure in PUD
metronidazole/clarithromycin resistance
dyspepsia + belching + abdominal pain + post cholesytectomy
Post- cholecystectomy syndrome (PCS)
Most common cause of post-cholecystectomy syndrome (PCS)
Choledocholithiasis
Radiologic study of choice for oesophagus
Barium swallow
Radiologic study of choice for oesophagus + stomach + duodenum
Barium meal
Radiologic study of choice for oesophagus + stomach + duodenum + small intestine
Barium follow-through
Radiologic study of choice for colon
Barium enema
Radiologic study of choice for suspected perforations/ volvulus/ bowel obstructions
Gastrogaffin
Oesophagogastroduodenoscopy
(OGD) indications
Haematemesis or Melena
Colonoscopy indications
- Diarrhoea
- Dark red blood in rectal bleeding
OGD + colonoscopy indications
Iron deficiency anaemia
flexible sigmoidoscopy indications
Rectal bleeding bright red blood
