Gastroenterology & GI Surgery Flashcards
Autosomal dominant
- Familial adenomatous polyposis
- Peutz Jeghers syndrome
Gilbert’s syndrome
Autosomal recessive
Liver damage enzymes
- ALT
- ALP
- AST
Liver function enzymes
- Bilirubin
- Albumin
Category 1 Colorectal cancer risk
Low 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
One 1st degree relative < 60 years at dx
OR
One 1st degree relative + > 1 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 + 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
Trousseau’s syndrome, also known as Trousseau’s sign of malignancy, is a medical condition characterized by recurrent and migratory thrombophlebitis (inflammation of the veins due to blood clots) associated with an underlying malignancy, often an adenocarcinoma. It was first described by Dr. Armand Trousseau in the 19th century.
- Association with Cancer: Trousseau’s syndrome is most commonly associated with cancers of the pancreas, lung, stomach, and colon. It can also be seen in other malignancies.
- Symptoms: Patients often present with episodes of blood clots in superficial veins that appear and disappear spontaneously, along with more generalized symptoms such as pain, swelling, and redness in the affected areas.
- Mechanism: The exact mechanism is not fully understood, but it is believed that cancer cells can produce substances that activate the coagulation system, leading to an increased tendency for blood clots.
- Diagnosis: Diagnosis involves a combination of clinical history, physical examination, imaging studies, and laboratory tests. Identifying the underlying malignancy is crucial.
- Treatment: Management includes treating the underlying cancer and using anticoagulants to prevent and treat blood clots. Low molecular weight heparin (LMWH) is often preferred.
Trousseau’s syndrome highlights the complex interplay between cancer and coagulation, necessitating a multidisciplinary approach for optimal management.
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
The combination of high INR, low calcium, and hypochromic microcytic anemia suggests a malabsorption syndrome due to the following reasons:
- High INR (International Normalized Ratio): This indicates a deficiency in vitamin K, which is essential for blood clotting. Vitamin K is absorbed in the small intestine, and malabsorption can lead to its deficiency, causing prolonged clotting times.
- Low Calcium: Calcium absorption primarily occurs in the small intestine. Malabsorption can result from conditions affecting the intestines, such as celiac disease, Crohn’s disease, or chronic pancreatitis, leading to hypocalcemia.
- Hypochromic Microcytic Anemia: This type of anemia is typically due to iron deficiency. Iron is absorbed in the duodenum and proximal jejunum. Malabsorption syndromes can impair iron absorption, resulting in this form of anemia.
These findings collectively suggest that the patient may have an underlying condition affecting the intestines’ ability to absorb essential nutrients, leading to deficiencies in vitamin K, calcium, and iron. Conditions like celiac disease, Crohn’s disease, or chronic pancreatitis should be considered and investigated.
malabsorption syndrome investigation
Anti-gliadin antibodies
Suspected ceoliac
Testing for anti-gliadin antibodies is a part of the diagnostic workup for malabsorption syndrome because it helps in diagnosing celiac disease, a common cause of malabsorption. Here’s why:
- Celiac Disease: This is an autoimmune disorder where the ingestion of gluten leads to damage in the small intestine. It is a significant cause of malabsorption syndrome, leading to deficiencies in various nutrients, including iron, calcium, and vitamins.
- Anti-Gliadin Antibodies: Gliadin is a component of gluten. In celiac disease, the immune system mistakenly targets gliadin, resulting in the production of anti-gliadin antibodies (IgA and IgG). Testing for these antibodies can help identify an abnormal immune response to gluten.
- Indicator of Gluten Sensitivity: The presence of anti-gliadin antibodies suggests that the body is reacting to gluten, which is a hallmark of celiac disease. This reaction can cause inflammation and damage to the intestinal lining, impairing the absorption of nutrients.
- Screening Tool: Anti-gliadin antibody tests are part of a panel of tests used to screen for celiac disease. Other tests include anti-tissue transglutaminase (tTG) antibodies and anti-endomysial antibodies (EMA), which are more specific to celiac disease. However, anti-gliadin antibodies are still used as part of the initial screening process, especially in children.
- Confirming Malabsorption Cause: Identifying celiac disease as the underlying cause of malabsorption allows for appropriate dietary modifications (gluten-free diet), which can lead to the healing of the intestinal mucosa and improvement of malabsorption symptoms.
In summary, testing for anti-gliadin antibodies is crucial in the investigation of malabsorption syndrome because it helps diagnose celiac disease, a common and treatable cause of malabsorption.
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
• tTG antibodies are more specific and sensitive for diagnosing celiac disease and are preferred for initial screening. • AGA antibodies have lower specificity and sensitivity and are less commonly used today, but can still be part of a diagnostic workup, especially in specific situations or when used alongside other tests.
In diagnosing celiac disease, tTG antibodies are typically the first choice due to their high accuracy, while AGA can provide additional information or be used in specific cases.
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)
A long history of vomiting after food and reduced appetite can suggest gastro-oesophageal reflux disease (GORD) due to the following reasons:
- Reflux Symptoms: GORD involves the backflow of stomach contents into the oesophagus, causing symptoms like heartburn, regurgitation, and sometimes vomiting. Persistent vomiting after meals can indicate that the stomach contents are frequently being refluxed into the oesophagus, leading to discomfort and the urge to vomit.
- Oesophageal Irritation: Chronic exposure of the oesophagus to stomach acid can cause inflammation (oesophagitis), leading to pain and discomfort after eating. This discomfort can reduce appetite over time as eating becomes associated with unpleasant symptoms.
- Vomiting: Reflux can trigger vomiting as a protective reflex to clear the oesophagus of irritating stomach contents. This can become a chronic issue if the reflux is severe or persistent.
- Reduced Appetite: Ongoing discomfort, nausea, and the anticipation of vomiting can significantly reduce a person’s desire to eat. Additionally, the inflammation and irritation caused by acid reflux can make swallowing painful, further reducing appetite.
- Diagnosis and Management: Identifying GORD involves taking a detailed patient history and may include diagnostic tests such as upper gastrointestinal endoscopy, pH monitoring, or manometry. Management typically includes lifestyle modifications (such as dietary changes and weight management), medications (like proton pump inhibitors or H2 receptor blockers), and in severe cases, surgical intervention.
According to the Royal Australian College of General Practitioners (RACGP) guidelines, the presence of chronic vomiting and reduced appetite warrants consideration of GORD among other differential diagnoses. The guidelines emphasize the importance of a thorough clinical evaluation to exclude other potential causes such as peptic ulcer disease, gastroparesis, or other gastrointestinal disorders. However, GORD is a common and likely cause, especially when the symptoms correlate with food intake and are alleviated by typical GORD treatments.
In summary, a long history of vomiting after food and reduced appetite is consistent with GORD because of the chronic irritation and inflammation caused by stomach acid reflux, leading to vomiting and a reduced desire to eat due to discomfort.
Most common complication of GORD
Oesophagitis
Gastro-oesophageal reflux disease (GORD) investigation
Initial: barium swallow
Intraoesophageally pH probe monitoring
diagnostic: oesophageal endoscopy with multiple biopsies only with
red flag 🚩
GORD management
Therapeutic trial of proton pump inhibitor
high age + progressive dysphagia + decreased contractions + increased tertiary wave activity
Presbyoesophagus
Presbyoesophagus refers to age-related changes in the esophagus that can affect its structure and function. This term is used to describe the altered motility and reduced efficiency of esophageal peristalsis commonly seen in elderly individuals.
- Decreased Peristalsis: The esophagus may exhibit weaker and less coordinated peristaltic waves, leading to difficulties in moving food from the throat to the stomach.
- Reduced Lower Esophageal Sphincter (LES) Pressure: The LES may not function as effectively, potentially contributing to gastro-oesophageal reflux disease (GORD) by allowing stomach contents to flow back into the esophagus.
- Altered Esophageal Contractions: There may be a higher prevalence of tertiary contractions (non-propulsive contractions), which do not help in moving food effectively down the esophagus.
- Dysphagia: Patients may experience difficulty swallowing (dysphagia), particularly with solid foods, due to the inefficient motility and clearance of the esophagus.
- Prolonged Transit Time: The time it takes for food and liquids to move through the esophagus may be longer, leading to symptoms such as a sensation of food sticking or delayed passage.
- Diagnosis: Diagnosis typically involves a combination of patient history, barium swallow radiography, esophageal manometry, and sometimes endoscopy to assess the structural and functional aspects of the esophagus.
- Symptoms: Symptoms of presbyoesophagus can include dysphagia, regurgitation, chest pain, and sometimes weight loss due to eating difficulties.
- Management: Treatment focuses on managing symptoms and may include dietary modifications (e.g., eating smaller, more frequent meals), ensuring proper hydration, and using medications such as prokinetics to improve esophageal motility. In some cases, addressing associated conditions like GORD with proton pump inhibitors may also be necessary.
While presbyoesophagus is related to normal aging, it is important to differentiate it from other esophageal disorders like achalasia, strictures, or malignancies that may require different treatments.
In summary, presbyoesophagus is a condition characterized by age-related changes in esophageal motility and function, leading to symptoms such as dysphagia and potential complications like GORD. Proper diagnosis and symptom management are crucial for improving the quality of life in affected individuals.
- 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
Heart burn is a late sign 🪧
Most important diagnostic feature of achalasia?
Dysphagia for both solids and liquids
Barrett’s oesophagus monitoring
2-years by endoscopy and biopsy depending on segment length JM
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
- Asymptomatic pancreatic pseudocyst AND either of the following:
Pseudocysts> 5cm, unchanged in size and morphology for more than 6 weeks
Diameter> 4cm and extrapancreatic complications in patients with chronic alcoholic pancreatitis
Suspected malignancy
Surgical drainage is the criterion standard against which all other interventions are measured in terms of success rate, mortality and recurrence rate. In recent years, however, endoscopic drainage has been introduced and can be applied provided that the cyst is near the stomach or duodenal wall:
size > 6cm ERCP
- Present for > 6 weeks
- Wall thickness for > 6 mm
Generally, patients with symptomatic pseudocysts should undergo interventional measures for pseudocyst drainage. The procedure of choice is endoscopic drainage. This cyst is 10 cm in size (>5cm) and amenable to endoscopic drainage either by endoscopic transmural or transpapillary drainage. Transpapillary drainage has the lowest complication rate of all the mentioned procedures and is the method of choice if the pseudocyst communicates with the pancreatic duct. Fortunately,
80% of pseudocysts communicate with the pancreatic duct.
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
Hepatic hydatid cyst USG
Hepatic hydatid cyst USG
Hepatic hydatid cyst CT
Hepatic hydatid cyst CT
