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Final Year - ICSM PACES > Gastroenterology_Medicine & Surgery > Flashcards

Gastroenterology_Medicine & Surgery Flashcards

1
Q

Causes of hepatic decompensation in CLD? Key features of decompensation?

Dx & Mx of decompensated chronic liver disease?

A

Cause of hepatic decompensation in CLD:

  • Hypokalaemia
  • Constipation (given lactulose in hospital)
  • Alcohol
  • GI bleed (lots of protein (Hb) enters the bowel –>liver can’t cope)
  • HCC

Decompensated CLD –> Ascites, jaundice & encephalopathy

  • Severely scarred liver (cirrhosis) in CLD –> back pressure on portal vein –> PORTAL HTN = splenomegaly, ascites, varices - caput medusae, oesophageal & rectal

Ix:

  • Serum Ascites Albumin Gradient (SAAG) - serum albumin conc vs ascites conc - 11.1g/L
    • <11.1g/L = exudative cause - peritonitis (infection), peritoneal malignancy OR n_ephrotic syndrome_ (pee out albumin so low serum albumin)
    • Otherwise = transudative cause - cirrhosis, renal failure, HF
  • >250 neutrophils = spontaneous bacterial peritonitis (SBP) –> Tazocin/3rd gen cephalosporin
    • If protein conc <15g/L give prophylactic oral ciprofloxacin

Mx:

  • Paracentesis (ascitic drain) –> post-paracentesis circulatory dysfunction (drops BP) SO if >5L drained give human albumin solution (HAS) 8g/L drained
  • Spironolactone (2nd line - Furosemide) - to prevent fluid accumulation
  • (Salt restrict)
  • Hepatic encephalopathy (liver not dealing with toxins) - give Lactulose + Rifaximin to prevent
  • Coagulopathy - OGD (check for varices) + vit K (needed for clotting)
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2
Q

Chronic liver disease

  • Functions of liver? Outcome of failure?
  • Causes? Presentation? Ix?
  • Important complication?
  • Scoring?
A

Functions of the liver –> failure:

  • Albumin (plasma oncotic pressure) –> oedema
  • Bilirubin metabolism –> jaundice
  • Clotting factors –> coagulopathy
  • Detoxification –> encephalopathy

Causes:

  • Common - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis)
  • Less common - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson’s disease

Presentation:

  • Spider naevi (≥5, SVC distribution, flush inside to out), palmar erythema, gynecomastia, Dupuytren’s contracture (alcoholic liver disease), clubbing
  • Specific signs:
    • Needle marks/tattoos - hep C
    • Parotid swelling - alcohol-related liver disease
    • Bronzed complexion/insulin injection signs - haemochromatosis
    • Obesity/DM - non-alcoholic fatty liver disease
    • Xanthelasma - cholestatic disorder

Ix:

  • Alcohol history
  • Hep B/C serology
  • Ferritin, transferrin, A1AT, ceruloplasmin (Wilson’s)
  • Ig, auto-abs (ANA in AI hep, AMA in PBC)

Important complication = VARICES

  • Normal venous return: GI tract –hepatic portal vein –> liver –> hepatic vein –> systemic circulation
  • Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum
    • MEMORY AID: BUTT, GUT, CAPUT
  • Pathological process:
    • In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein –> reducing blood flow to the systemic circulation
    • Backflow of blood to the hepatic portal vein = increased –> backflow to hepatosystemic anastomoses:
      • Oesophagus –> Oesophageal varices
      • Spleen –> Splenomegaly
      • Umbilicus –> Caput Medusae
        • ​Only from portal HTN if running from below umbilicus up
      • Rectum –> Rectal varices

Score for prognosis & need for liver transplant = Child-pugh score (A = 5-6; B = 7-9; C = 10-15 –> C is most severe)

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3
Q

Jaundice breakdown & causes by type & Ix to differentiate

A

Pre-hepatic - unconjugated bilirubin comes from breakdown of RBCs

  • Haemolysis related-causes (excess prod) - AIHA, SCD, G6PD def, malaria
  • Ix:
    • Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it)
    • Urine: normal (unconjugated bilirubin is insoluble)
    • Stool: normal as liver functioning normally

Hepatic - bilirubin absorbed into liver –> conjugated –> excreted via biliary tract into duodenum

  • Liver disease related-causes - cirrhosis, hepatitis, Gilbert’s syndrome, drugs
  • Ix:
    • Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation)
    • Urine: dark (leaked conjugated bilirubin is soluble)
    • Stool: slightly pale (reduced conjugated bilirubin to GI tract)

Post-hepatic - conjugated bilirubin –> soluble urobilingogen (yellow): 1) Absorbed into circulation –> excreted via kidneys 2) Remaining –oxidised–> stercobilin (brown)

  • Biliary disease related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC
  • Ix:
    • Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can’t reach duodenum and instead leaks into blood)
    • Urine: dark (leaked conjugated bilirubin is soluble)
    • Stool: very pale (no conjugated bilirubin reaches GI tract –> no stercobilin generated)
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4
Q

Chronic diarrhoea - ddx? Sx? Distribution? Histology? Ix? Mx?

A

IBD

  • Crohn’s disease
    • Sx: RIF pain (terminal ileum), failure to thrive (incl. between attacks)
    • Distribution: mouth to anus (esp. terminal ileum), skip lesions
    • Histology: transmural, non-caseating granuloma (also in sarcoidosis)
    • Ix:
      • OGD/colonoscopy/capsule endoscopy
      • Gastografin follow-through
    • Mx:
      • Induction:
        • Steroids (induce remission)
        • 5-ASA (mesalazine)
      • Maintenance:
        • Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine)
        • Biologics e.g. Anti-TNF (infliximab)
    • Complications: strictures, obstruction, fistulae
  • Ulcerative colitis
    • Sx: gen. abdo pain, PR blood & mucus
    • Distribution: ONLY rectum & colon, continuous
    • Histology: mucosa & submucosa, mucosal ulcers, crypt abscesses
    • Ix:
      • Flexible sigmoidoscopy/colonoscopy
    • Mx:
      • Induction:
        • 5-ASA
        • Steroids
      • Maintenance:
        • 5-ASA (mesalazine)
        • Steroid-sparing agents (azathioprine)
        • Biologics (infliximab)
      • Surgery (proctocolectomy, IJ pouch)
    • Complications: toxic megacolon, colonic carcinoma, PSC
  • Extra-intestinal signs of IBD - A PIE SAC
    • Aphthous ulcers (crohn’s)
    • Pyoderma gangrenosum
    • Iritis, uveitis, episcleritis (Crohn’s)
    • Erythema nodosum
    • Sclerosing cholangitis (PSC in UC)
    • Arthritis
    • Clubbing fingers (CD > UC)
  • Truelove & Witts’ severity index = severity criteria for IBD

Coeliac disease

  • Def: inflammatory response to gluten (immune reaction to gliadin)
    • DQ2/8 (on HLA typing)
  • Sx: abdo Sx (steatorrhoea, diarrhoea, bloating), failure to thrive
    • Exam: blistering rash on both knees. aphthous mouth ulcers
    • Assoc: T1DM
  • Distribution: duodenum
  • Histology: subtotal villous atrophy with crypt hyperplasia
  • Ix: (maintain normal diet - eat gluten for 6wks before testing)
    • Haematinics - macrocytic anaemia, low Fe, B12/folate
    • Serological testing:
      • Screening: Anti-TTG & total IgA (check for selective IgA def in case this caused false ‘-ve’ anti-tTg abs)
      • If weakly +ve –> anti-endomysial abs (more sensitive & specific)
    • OGD & duodenal biopsy
      • Histology: sub-total villous atrophy with crypt hyperplasia
  • Mx: gluten avoidance

Irritable bowel syndrome - Dx of exclusion

  • Sx: bloating, related to stress, diarrhoea/constipation, relieved by defecation
    • “Pellet-like stools”
  • Ix: faecal calprotectin (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD)
  • Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants
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5
Q

Mesenteric ischemia:

  • What is the blood supply to the GI tract?
  • What area of GI tract is vulnerable to ischaemia?
  • Breakdown of mesenteric ischemia? Sx? Ix? Mx?

What is the difference between Mesenteric ischemia & ischemic colitis? Sx? Ix?

A

Blood supply

  • Coeliac axis - oesophagus, stomach, start of small intestine
  • Superior mesenteric artery (SMA) - most of the small intestines up to 2/3 transverse colon
  • Inferior mesenteric artery (IMA) - from 2/3 along transverse colon down to rectym
  • NOTE: area 2/3 along transverse colon @splenic flexure = WATERSHED ZONE (limited supply from superior & inferior mesenteric arteries) –> vulnerable to ischaemia!!

_​_Mesenteric ischemia

  • Acute - occlusion of SMA by thrombus/embolus
    • Sx: severe abdo pain, normal abdo exam, shock
    • Ix:
      • AXR (gasless abdo)
      • VBG (lactic acidosis)
      • CT abdo with contrast (if suspect mesenteric ischaemia)/CT angiogram (if LA)
        • If not primary surgery –> followed by mesenteric angiography (Dx non-occlusive mesenteric ischaemia)
    • Mx: resus + CCOT + NBM
      • Empirical abx
      • Bypass ± bowel resection
      • Heparin post-op
  • Chronic - narrowing of SMA by atherosclerosis (stable angina of bowel)
    • Sx: colicky post-prandial abdo pain (more work for bowel to do –> pain, just like in stable angina & exercise)
    • Ix: as above
    • Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery)

Ischemic colitis

  • Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus
  • Sx: abdo pain, PR bleeding
  • Ix: sigmoidoscopy/colonoscopy
  • Mx: seek GI & surgical input (can develop chr ulcerating IC)
    • Mild - conservative (IV abx, fluids, bowel rest, DM control)
      • Prophylactic LMWH
    • Segmental resection + stoma
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6
Q

Most common reason to do AXR? Most common causes of this reason by type?

AXR interpretation?

Key volvulus signs on AXR?

A

Reason to do AXR: worried about bowel obstruction (small/large bowel)

Small bowel obstruction on AXR:

  • valvulae conniventes (from one wall to other)
  • Central to image
  • >3cm distension
  • Causes: adhesions (surgery, sepsis), hernia, neoplasm, volvulus, IBD

Large bowel obstruction on AXR:

  • Haustra (Not full width of bowel)
  • Outsides of image
  • >6cm distension
  • Causes: neoplasm, diverticular disease, volvulus, faecal impaction

NOTE: 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm)

Volvulus signs (twisting of loop of bowel on mesentery –> balloon animal):

  • Coffee bean sign - sigmoid volvulus (large bowel just before rectum)
  • Embryo sign - caecal volvulus (large bowel just after small bowel)
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7
Q

At the end of abdo exam what do you offer to do? Exposure in abdo exam?

A

GOR(D)

  • external Genitalia
  • hernial Orificies
  • digital Rectal

Ideally nipples to knees but in this case, I will do nipples to the groin due to possible patient discomfort

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8
Q

Erythema nodosum is associated with which conditions?

A

IBD (also pyoderma gangrenosum),

Sarcoidosis

TB

Meds (OCP, sulphonamides, aspirin/NSAIDs)

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9
Q

Primary Sclerosis Cholangitis (PSC) vs Primary Biliary Cholangitis (PBC)

  • Associations? Ix? Tx?
A
  • PSC - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice)
    • Associations: UC (10% but 80% PSC have UC), Cholangiocarcinoma
    • Ix: MRCP, pANCA
      • ‘Beads on string’ on ERCP
    • Tx: supportive, liver transplant
  • PBC - intrahepatic only (benign condition - middle-aged female, intractable itching)
    • Associations: AI diseases (RA, Sjogren’s, hypothyroidism)
      • Sicca syndrome (70%) - dry eyes & mouth (like Sjogren’s syndrome)
      • Fat malabsorption w/ steatorrhoea (incl vitamins ADEK):
        • Low vit D can cause osteomalacia & proximal myopathy e.g. difficulty climbing stairs & pain in lower back
        • Low vit K can cause coagulopathy
    • Ix: ​anti-mitochondrial Ab (AMA), high cholesterol
    • Tx: ursodeoxycholic acid (prognostic benefit)
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10
Q

AI hepatitis - RFs? Ix? Mx? Complications?

A

RFs:

  • Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA)
  • Genetic predisposition:
    • For T1 AIH - HLA-DR3/4
    • For T2 AIH - HLA-DQB1/DRB1

Ix:

  • Anti-smooth muscle Ab (SMA), ANA
    • T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA
    • T2: anti-LKM1

Mx: high-dose prednisolone + long-term azathioprine

Complications:

  • Cirrhosis in 40%, relapse high if stop IS
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11
Q

How do you tell between spleen & kidney on examination?

A

Spleen (vs kidney):

  • Moves down with inspiration
  • You can’t get above it
  • Has a notch
  • Dull to percussion & not ballotable
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12
Q

Causes of hepatomegaly, splenomegaly & enlarged kidney(s)?

A

Hepatomegaly causes:

  • Hepatitis (infective and non-infective)
  • Hepatocellular carcinoma/hepatic mets
  • Wilson’s disease, Haemochromatosis
  • Primary biliary cirrhosis
  • Leukaemia, Myeloma, haemolytic anaemia
  • Glandular fever
  • Tricuspid regurgitation

Splenomegaly causes:

  • Portal HTN secondary to liver cirrhosis
  • Splenic mets
  • Haemolytic anaemia, Congestive HF, Glandular fever

Large kidney causes:

  • Bilaterally enlarged: polycystic kidney disease, amyloidosis
  • Unilaterally enlarged: renal tumour
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13
Q

Alcoholic liver disease - presentation? Bloods? Decompensated Mx?

A

Presentation: peripheral neuropathy, cerebellar, Wernicke’s, gout, parotitis, Dupuytren’s contracture

Bloods: AST > ALT (2:1)

Decompensated Mx:

  • Discrimination function calculated (PT/INR + bilirubin):
    • <32/Inf/upper GI bleed –> no steroids
    • Otherwise –> steroids
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14
Q

Upper GI bleed - scoring for need for intervention? Mx?

A

Blatchford score

Variceal bleed

  • Massive haemorrhage –> balloon tamponade
  • A-E assessment –> IV fluids, blood transfusion
    • F1 Essentials:
      • 2x large bore cannula
      • VBG
      • G&S/X-match
      • Bleep the bleed reg
  • Drugs with prognostic benefit:
    • IV Terlipressin (ADH analogue –> vasoconstriction)/Somatostatin (used for same reason)
    • Prophylactic abx - Ceftriaxone/Norfloxacin (abx)
  • Intervention (discuss with on-call bleed registrar) –> endoscopic band ligation
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15
Q

Peptic ulcer disease - RFs? Types? What artery is most likely to bleed in duodenal ulcer?

Presentation? Ix? Mx? Scoring to evaluate risk of re-bleed/death?

A

RFs:

  • H. pylori exposure
  • Aspirin/NSAID use

Types:

  • Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ NSAIDs
  • Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ H. pylori, worse by stress/at night –> radiates to back, put weight on, malaena
    • Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum –> likely cause of bleeding in PUD

Presentation:

  • Chr/recurrent upper abdo pain - related to eating & nocturnal
    • Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas
  • Pointing sign on exam - show where pain is with 1-finger
  • NOTE: ‘Coffee grounds’ vomiting = upper GI bleed (mostly due to PUD > gastric erosions)

Ix:

  • OGD endoscopy = gold-standard
    • Immediately if dyspepsia + upper GI bleed
    • Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain –> exclude malignancy
    • Repeat within 6-8wks to ensure ulcer healing/rule out malignancy
  • H. pylori stool antigen/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx)
  • Bloods - FBC

Mx: consider STOPPING NSAIDs

  • Active bleed:
    • Urgent evaluation (A-E + Blatchford score) + blood transfusion
    • OGD endoscopy (Dx & Tx) –> high-dose IV PPI afterwards (continue oral PPI for 6wks)
    • Rockall score (for risk of rebleed/death) –> if re-bleed –> repeat endoscopy & Tx endoscopically/emergency surgery
  • If H. pylori +ve:
    • H. pylori eradication - triple therapy for 7 days (PPI + 2 abx = Amox + clari/metro) –> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx)
      • If pen allergic –> PPI + Clari + Metro
    • If long-term NSAID/aspirin use:
      • Consider stopping NSAIDs/aspirin
      • Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks –> H. pylori eradication afterwards
  • If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist)
  • If recurrent/refractory ulcers –> long-term PPI/H2 antagonist
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16
Q
  • Joint pain in both knees, XR shows chondrocalcinosis
  • Wakes at night frequently to urinate, PMHx T2DM, low albumen on blood

Dx? Classification? Presentation? Ix? Mx?

A

Dx: haemochromatosis

  • Risk of HCC (hepatocellular carcinoma)

Classification:

  • Hereditary - AR, gene on chr6 (carried by 1:10 Europeans)
  • Secondary e.g. from frequent blood transfusions (SCD)

Presentation - from Fe-deposition in various tissues:

  • Arthritis (esp hands), bronze DM (tan), cirrhosis
    • Hypogonadism (accumulates in testis)
    • Dilated cardiomyopathy (accumulates in heart)
  • XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis

Ix:

  • Blood iron profile:
    • TF saturation high (>55% men, >50% women)
    • Ferritin normal/slightly high (>500)
    • Low TIBC (as all transferrin saturated)

Mx:

  • Venesection (until transferrin saturation normal)
  • Desferrioxamine (iron chelator to prevent recurring)
  • Monitoring ; TF saturation <50% & serum ferritin <50ug/l
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17
Q

What 2 things can make ALT go >1000? What are some more weird causes of slightly high ALT?

A

Ischaemic liver

Massive paracetamol overdose

Very rarely: fulminant hepatitis (B/C)

Weird causes of slightly raised ALT: Addison’s coeliac, anorexia

18
Q

Young female with unilateral leg tremor

  • Psychiatric issues
  • Exam: tremor, bradykinesia, dark circles round iris

Dx? Ix? Mx?

A

Dx: Wilson’s disease (AR)

  • Neuropsych issues + liver involvement (no increased risk of HCC unlike haemochromatosis)
  • Basal ganglia degeneration - movement disorders, dysarthria

Ix:

  • Conservative:
    • Urinalysis - elevated urinary copper
    • Kayser-Fleischer rings on slit-lamp exam
  • Bloods: hepatic bloods, reduced serum ceruloplasmin
  • Genetic testing (trinucleotide repeat) - condition appears earlier & earlier each generation

Mx: chelation w/ penicillamine

19
Q

Case:

  • 57yrs, burning pain after eating & lying flat, improved with cold drinks, high BMI, smokes, drinks alcohol, occasional bitter taste in back of the mouth
  • Difficulty swallowing in recent months

Dx? Presentation? Ix? Mx? Complication?

A

Dx: GORD

  • Decreased lower oesophageal sphincter (LOS) pressure:
    • Drugs - nitrates, CCBs (smooth muscle relaxation)
    • Alcohol, smoking
    • Hiatus hernia

Presentation: RFs (above), heartburn (worse lying down/at night), reflux incl bitter taste in mouth (after meals)

Ix:

  • 8wk PPI trial
  • If dyspepsia consider OGD for: anaemia, weight loss, dysphagia, >55yrs
  • Oesophageal pH study (<4 for >4% of time = GORD)

Mx:

  • Conservative: weight loss, smoking cessation, head of bed elevation/avoid eating late at night, reduce alcohol
  • Medical:
    • Standard-dose PPI (20mg omeprazole) - continued long-term (if Sx continue after stopping/erosive oesophagitis/Barrett’s oesophagus)
    • H2 antagonist (e.g. cimetidine)
  • Surgery (only if PPIs work but don’t want long-term medical Tx) e.g. laparoscopic fundoplication

Complication: Barrett’s oesophagus –> oesophageal adenocarcinoma

20
Q

Zollinger-Ellison syndrome - def? presentation?

Other causes of poorly healing peptic ulcers?

A

Gastrinoma (pancreatic islet-cell tumour)

  • Multiple peptic ulcers & relapses
  • Diarrhoea
  • NOTE: can be good for OSCE - PUD presentation + diarrhoea

ZE syndrome - is one cause of poorly healing gastric ulcers, others:

  • Crohn’s, gastric Ca
  • Bisphosphonates
  • TB, CMV
21
Q

Anal fissure - def? RFs? Presentation? Ix? Mx?

A

Def: tears of the squamous lining of the distal anal canal

  • <6 weeks = acute, ≥6wks = chronic
  • 90% @posterior midline

RFs: constipation, IBD, STIs (HIV, syphilis, herpes)

Presentation: painful, bright red, rectal bleeding

Ix: PR exam

Mx:

  • Acute <1wk:
    • Soften stool - high-fibre diet + high fluid intake, fybogel (2nd - lactulose)
    • Lubricants (for passing stool), topical anaesthetic, analgesia
  • Chronic: maintain above + topical GTN
    • After 8wks (if above not effective) –> GI referral for sphincterotomy (or botulinum toxin)
22
Q

Portal HTN - Def? Causes?

A

Portal hypertension - increase in the pressure within portal vein, which carries blood from the digestive organs to the liver

  • Hepatic venous pressure gradient (HPVG) = gold standard for assessing severity and a pressure > 5mmg

Causes:

  • Pre-hepatic – Portal/splenic vein thrombosis, congenital atresia of portal vein
  • Hepatic – Cirrhosis, Schistosomiasis, hepatic mets
  • Post-hepatic – Budd-Chiari Syndrome, Veno-occlusive disease, constrictive pericarditis
23
Q

Dysphagia DDx? Ix?

A

Dysphagia - difficulty swallowing

  • vs Odynophagia - painful swallowing
  • vs Globus sensation - lump in throat, no pain

Oropharyngeal - difficulty initiating swallowing (± cough, choking, aspirating, regurgitation) - pressure in throat

  • Oral:
    • mastication (CN 5,7,11) e.g. CVA
    • Low saliva e.g. Sjogren’s syndrome
  • Pharyngeal:
    • Neuromuscular - CVA, Myasthenia Gravis, Parkinson’s
    • Upper oesophageal sphincter - decreased relaxation

Oesophageal - difficulty after swallowing - pressure in chest

  • Solids & liquids - motor
    • Intermittent: oesophageal dysmotility
    • Progressive (solids –> both): achalasia (“birds beak”), systemic sclerosis
  • Solids only - obstructive
    • Non-progressive: lower oesophageal rings/webs, oesophagitis
    • Progressive: stricture, cancer

Ix:

  • Barium swallow - if a possible proximal oesophageal lesion
  • Upper endoscopy ± biopsy
  • If affects solids & liquids –> manometry
24
Q

Haemorrhoids - presentation, grading, Ix, Mx?

A

Presentation: rectal bleeding & perianal pain

Grading:

  • 1 - prominent BVs (no prolapse)
  • 2 - prolapse on bearing down + spontaneous reduction
  • 3 - manual reduction
  • 4 - can’t be manually reduced

Ix:

  • Bedside: Anoscopic exam, stool (occult haem)
  • Bloods: FBC
  • Imaging: Colonoscopy/flex sigmoidoscopy

Mx:

  • Conservative - fibre, fluids
  • Medical = G1 - topical CS
  • Surgical:
    • G2/3: band ligation
    • G4: surgical haemorrhoidectomy
25
Q

Acute abdomen sieve

A

ABC->P

  • Appendix
  • Bleeding/bowel obstruction/BV obstruction
    • GI bleed
    • Obstruction - small/large, mechanical/non-mechanical, complete/incomplete
    • Ischaemia/infarct
  • Cholecystitis/angiitis
  • Pancreatitis/Perforation (upper/lower GI)
26
Q

Hernia (surgery) - def? types? Mx?

A

Def: protrusion of a viscus through its wall

Types:

  • Incisional hernia - iatrogenic following surgery
  • Groin hernia - ASIS & pubic tubercle palpated:
    • Femoral (W>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation
    • Inguinal - above & medial to the pubic tubercle
      • Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring
      • Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring
      • Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear
    • Other groin lumps:
      • Lymphadenopathy - along inguinal ligament
      • Vascular - pulsatile varicose veins below inguinal ligament

Mx: surgical (mesh)

NOTE: hernias are safer the larger the defect as less likely to strangulate

27
Q

What are the borders of Hesselbach’s triangle?

28
Q

Abdominal scars

A
  • Midline sternotomy - AAA, laparotomy
  • Rooftop scar - liver transplant, Whipple’s procedure, gastric surgery, oesophagectomy
  • Kocher – open gallbladder surgery
  • Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick)
  • Lanz/McBurney’s = Appendicectomy
  • Pfannenstiel = C-section/prostatectomy/cystectomy
29
Q

Colorectal cancer - Presentation? Ix? Mx? Screen?

A

Presentation:

  • Bowel habit change
  • Palpable mass
  • IDA, PR bleed (clots, fresh)
  • Acute (obstruction, perforation)

Ix: colonoscopy

Mx: based on TNM staging post-CT

  • Colon cancer
    • T4 (local advancement) –> neoadjuvant Tx
    • Otherwise –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
  • Rectal cancer
    • T3-4 –> neoadjuvant Tx –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
    • T1-2NOMO –> transanal excision

Screen: 60-74yrs FIT testing (or FOB)

32
Q

Abdo pain ddx?

A

Upper:

  • RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis
  • Epigastric pain: PUD, GORD, pancreatitis

Middle:

  • Flank pain: pyelonephritis (loin to groin pain)
  • Umbilical pain - AAA (consider if >65yrs, HTN)

Lower:

  • RIF pain: appendicitis, ureteric colic, hernia, testicular torsion
  • Suprapubic pain: UTI
  • LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion
  • In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID
    • Ask about _P_ain, _P_regnancy, _P_V bleeding, _P_V discharge

NOTE: also consider psych cause of generalised abdo pain (esp in kids)

34
Q

Biliary anatomy?

A
  • Right and left hepatic ducts merge to form the common hepatic duct
  • Gallbladder - stores & concentrates bile and releases it to emulsify fats
  • Cystic duct connects gallbladder to the biliary tree
  • Cystic duct and common hepatic duct come together to form the common bile duct
  • Pancreatic duct feeds into the common bile duct - where it secretes exocrine hormones
  • All of the above feed through the Ampulla of Vater into the duodenum –> allowing secretion of bile into the intestines
35
Q

RFs? Types of stone? RUQ pain Ix?

Biliary colic - Def? Presentation?

Cholecystitis - Def? Presentation? Ix?

Ascending cholangitis - Def? Presentation? Acute Mx?

A

RFs (5Fs): Fat, Female, Fertile, Forty, Fair

Types of gallstone: mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous)

RUQ Pain Ix:

  • Abdo USS
  • Stone in CBD (common bile duct) –> ERCP
  • Deranged LFTs/dilated ducts –> MRCP
  • None of above –> cholecystectomy

Biliary colic:

  • Def: pain due to blockage of bile flow due to a gallstone
  • Presentation: RUQ pain, worse after fatty meals (stimulates gallbladder contraction –> bile release for fat emulsification)

Cholecystitis:

  • Def: inflammation of the gallbladder (typically in context of gallstones)
  • Presentation: RUQ pain (+ tenderness - Murphy’s sign), FEVER
    • ​Murphy’s only +ve if not present on the left as well
  • Ix:
    • Urine dip – infection, bHCG
    • Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen
    • Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum)

Ascending cholangitis:

  • Def: inf ascending the biliary tree, usually in the context of gallstone
  • Presentation (due to obstruction of Common Bile Duct - bile stagnates and becomes infected):
    • Charcot’s triad - RUQ pain, fever, JAUNDICE
    • Reynold’s pentad (severe) - above + shock + confusion
  • ​Surgical EMERGENCY - Mx via sepsis 6 protocol (abx = Tazocin) + drain obstruction:
    • Endoscopic retrograde cholangiopancreatography (ERCP) - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system
      • Complications: pancreatitis, bleeding (from dilation of AoV), perforation
    • Percutaneous transhepatic cholangiogram (PTC) - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree –> dislodge stone/alternative route for bile to flow - leave in cholecystostomy
    • Cholecystostomy - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy
    • Patients will likely require a later cholecystectomy (after dealing with the acute infection)
36
Q

Appendicitis - presentation? DDx? Scoring? Mx?

A

Presentation:

  • Acute umbilical to RIF pain (McBurney’s point)
  • Tenderness + guarding (if rigid abdo - perforated apendix)
  • N&V –> anorexia (not wanting to eat anything from nausea), change in bowel habit
  • Rovsig’s sign - pain in RIF on LIF palpation
  • Psoas sign & Obturator sign

DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction

Ix:

  • Urinalysis, bloods - FBC, U&E, CRP
  • USS abdo/pelvis –> consider contrast-enhanced CT-AP

Alvarado score - >4 = likely appendicitis

Mx:

  • A-E (incl. fluids)
  • Sepsis bundle - abx when Dx confirmed
  • Laparoscopic appendicectomy
  • Conservative only if uncomplicated appendicitis
38
Q

Bowel obstruction - immediate Mx, small vs large bowel obstruction - causes, features, Mx?

A

Immediate Mx:

  • NBM, Ryles tube (aspirate stomach contents)
  • IV fluids
  • AXR -> CT (identify transition point of obstruction)

Small bowel obstruction:

  • Causes: Adhesions (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian)
  • Features: central dilated loops of bowel, >3cm, valvulae coniventes
  • Mx: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative)

Large bowel obstruction:

  • Causes: tumour, volvulus
  • Features: peripheral dilated loops of bowel, >6cm, haustra
  • Mx: surgery, flatus tube (in sigmoid volvulus)

NOTE: 3/6/9 rule

39
Q

Right & left hemicolectomy - indications, process & what are you left with?

Panproctocolectomy - indications, process & what are you left with?

Total vs subtotal colectomy - process & what are you left with?

Hartmann procedure - indications, process & what are you left with?

Anterior vs AP resection - indications, process & what are you left with?

Urostomy (ileal conduit) - indications & process?

A

Right hemicolectomy - right colon

  • Indication: problems affecting the right side of the colon e.g. malignancy
  • Process: removing from ileocaecal valve to 1/3 the way along the transverse colon
  • What are you left with:
    • Primary anastomoses (ileum attached to the remaining colon)
    • Sometimes left with a stoma

Left hemicolectomy - left colon

  • Indication: problems affecting the descending colon e.g. tumour
  • Process: removing from 2/3 the way along the transverse colon to the sigmoid area
  • What are you left with: primary anastomoses from the transverse colon to the sigmoid colon

Panproctocolectomy - total colon & rectum e.g. UC

  • Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC
  • Process: remove full colon & rectum (from ileocaecal valve to the anus)
  • What are you left with: end ileostomy (loose end of ileum brought to the skin)

Total colectomy vs subtotal colectomy

  • Total colectomy:
    • Process: remove full colon but not the rectum
    • What are you left with: ileal-pouch anal anastomosis (loose end of ileum used to reform a rectum, don’t need a stoma)
  • Subtotal colectomy:
    • Process: remove colon except for the rectum and part of the sigmoid colon
    • What are you left with: end-ileostomy & rectal/sigmoid stump

Hartmann procedure - emergency sigmoid colon

  • Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don’t want to create anastomoses as unlikely to succeed)
  • Process: sigmoidectomy
  • What are you left with: end-colostomy and rectal stump –> at a future date can be reversed but many just stay with end-colostomy

Anterior vs AP resection - for rectal tumours (A higher; P lower)

  • Anterior:
    • Indication: higher rectal tumours
    • Process: removing sigmoid colon + top part of the rectum
    • What are you left with: end-colostomy/primary anastomoses ± defunctioning loop ileostomy
      • DLI - loop of ileum brought to surface, split so 2 lumens on surface –> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing
    • NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains)
  • AP (abdominoperineal):
    • Indication: low-lying rectal tumours
    • What are you left with: end-colostomy
    • Process: remove everything up to the top of the sigmoid colon

Colostomy (ileal conduit)

  • Indications:
    • Bladder cancer (had cystectomy)
    • Neurogenic bladder
      Radiation injury to the bladder
    • Chronic pelvic pain
  • Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch
40
Q

Stoma differentiation & examination

A

Colostomy - RIF, flushed, normal faecal matter

Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter

Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer

  • NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf)

Stoma examination:

  • Hands around stoma and ask to cough –> check for hernia + check for skin changes
  • Offer stoma rectal examination (finger into stoma)
41
Q

Splenectomy - indications? what is the problem? what is associated prophylaxis?

A

Indications:

  • Traumatic rupture
  • Idiopathic thrombocytopenia
  • Spherocytosis

Problem: increased risk from encapsulated bacteria e.g. strep pneumo

Prophylaxis:

  • Vaccines: Pneumococcus, Meningococcus, Haemophilus Influenzae Type B
  • Penicillin V
43
Q

Acute abdomen - def? immediate Tx & Ix?

A

Def: sudden, severe abdo pain that requires urgent medical/surgical attention

Immediate Tx & Ix:

  • Immediate Tx - NBM, IV fluids, analgesia
  • Bedside - urine dip
  • Bloods - basics, VBG (lactate), amylase, G&S, clotting
  • Imaging - errect CXR, AXR (bowel obstruction):
    • USS/MRCP/ERCP - gallstones
    • CT-KUB - renal stones
    • CT-AP - perforation/obstruction
    • CT-angiogram - ischaemic/bleed/AAA
47
Q

Oesophageal cancer - Presentation? Types? Mx?

A

Presentation: progressive dysphagia (solids –> then liquids) + FLAWS

Types:

  • Squamous cell carcinoma (SCC) - less common in UK, middle oesophagus, RFs: alcohol, smoking
  • Adenocarcinoma - most common in UK, lower oesophagus, assoc w/ GORD (long-term –> metaplasia - Barrett’s oesophagus –> eventually become dysplastic/ malignant)

Mx: SURGICAL

  • Ivor Lewis oesophagectomy - involves midline laparotomy + right thoracotomy (stomach is mobilised and pushed through oesophageal hiatus)
  • McKeown oesophagectomy - as above + left neck incision (oesophagus can be pulled up through neck incision)
50
Q

Acute pancreatitis - causes? Patterns of injury? Pathophysiology? Ix? Mx? Complications? Severity score?

A
  • Causes: alcohol, gallstones (GET SMASHED)
    • Duct obstruction: gallstones (50%), trauma, tumours
    • Metabolic/toxic: alcohol (33%), drugs, hypercalcaemia/hyperlipidaemia
    • Ischaemia: shock
    • Infection/inflammation: viruses (mumps), AI
  • Patterns of injury:
    • Periductal – cause: duct obstruction
      • Necrosis of acinar cells near ducts
    • Perilobular – cause: ischaemia (shock)
      • Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected
    • Panlobular – develops as ½ progress
  • Pathophysiology: vicious cycle - activated enzymes –> acinar necrosis –> enzyme release
    • Lipase release –> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits)
  • Ix:
    • Bloods – FBC, U&E, LFTs, CRP, Amylase
    • Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR
    • NOTE: Epigastric pain –> remember to do rectal exam (looking for melaena)
  • Mx - supportive (IV fluids + analgesia first)
    • Resus patient (IV fluids, analgesia, antiemetic, abx) –> ITU if glasgow score >3
    • VTE prophylaxis
  • Complications:
    • Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue –> can be infected –> abscess
    • Systemic: shock, hypoglycaemia, hypocalcaemia

Severity criteria = GLASGOW score (PANCREAS):

  • PaO2
  • Age
  • Neutrophils (WBC)
  • Ca
  • Renal funct (urea)
  • Enzymes (LDH)
  • Albumin
  • Sugar (glucose)
51
Q

Diverticulosis vs Diverticular disease vs Diverticulitis? Acute diverticulitis classification?

Presentation? Ix? Mx?

A

Diverticulosis: colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet)

Diverticular disease: above + Sx

Diverticulitis: infection & inflammation of diverticulum

  • Hinchey classification for acute diverticulitis:
    1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess <4cm
    2. Pelvic/interloop abscess/abscess >4cm
    3. Purulent peritonitis
    4. Faeculent peritonitis

Presentation:

  • RFs: >50yrs, low dietary fibre
  • LIF pain, raised WCC, fever, painless rectal bleed

Ix:

  • FBC, U&E, CRP, (BC, ABG & lactate if septic)
  • Contrast CT abdo (if suspected acute diverticulitis)
  • Other imaging:
    • CXR (rule out pneumoperitoneum)
    • Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia)
    • CT angiogram (if excess bleeding)

Mx:

  • Asymptomatic diverticulosis:
    • Increased fibre & fluids
    • Excercise, weight loss, stop smoking
    • Fybogel - if constipated
  • Symptomatic diverticular disease:
    • Above + paracetamol
    • PO Dicycloverine = anti-spasmodic (for abdo cramping)
  • Acute diverticulitis:
    • Uncomplicated:
      • Low-residue diet + Paracetamol + PO Dicycloverine
      • Oral abx (amoxicillin)
    • Complicated:
      • Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery)
      • Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx
    • Reccurent = open/laparoscopic resection
52
Q

Liver transplant - indications? Unsuitable group? Surgery scar? Post-transplant care?

A

Indications:

  • Acute liver failure - acute viral hep, paracetamol overdose
  • Chronic liver failure

Unsuitable for liver transplant:

  • Sign. co-morbidity (renal/heart failure)
  • Excess weight loss/malnutrition
  • Active hep B/C (other inf), end-stage HIV
  • Active alcohol - 6 months abstinence needed

Surgery: Rooftop/Mercedes Benz scar

Post-transplant care:

  • IS - steroids, azathioprine, tacrolimus (careful drug monitoring)
  • Conservative - no alcohol/smoking, monitor for disease recurrence, cancer, transplant rejection (fatigue, fever, jaundice, abn LFTs)
  • Tx opportunistic inf

Final Year - ICSM PACES (15 decks)

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