Gastrointestinal Flashcards
1
Q
IBD
Comparing Crohn’s and ulcerative colitis, comment on the following for Crohn’s…
i) location?
ii) inflammation area?
iii) continuous?
iv) smoking?
v) goblet cells?
vi) histology?
vii) enema finding?
A
i) Mouth>anus, favours terminal ileum
ii) Transmural
iii) No – skip lesions
iv) Risk factor
v) Present
vi) Granulomas, cobblestone appearance on colonoscopy
vii) Fistula = string sign of Kantor
2
Q
IBD
Comparing Crohn’s and ulcerative colitis, comment on the following for ulcerative colitis…
i) location?
ii) inflammation area?
iii) continuous?
iv) smoking?
v) goblet cells?
vi) histology?
vii) enema finding?
A
i) Colon only (never further than ileocaecal valve) + starts at rectum
ii) Mucosa only
iii) Yes
iv) Protective factor
v) Depletion
vi) Increased crypt abscesses, pseudopolyps
vii) Lead pipe colon = loss of haustrations
3
Q
IBD
What is the clinical presentation of Crohn’s disease?
What are some extra-intestinal findings more related to Crohn’s disease?
What are some complications of Crohn’s disease?
A
- Triad = abdominal pain (RLQ), diarrhoea (non-bloody) + weight loss
- Gallstones due to reduced bile salt reabsorption in terminal ileum
- Colorectal cancer, perianal disease (skin tags, fissures, abscesses, fistulas), strictures, bowel obstruction
4
Q
IBD
What is the clinical presentation of ulcerative colitis?
What are some extra-intestinal findings more related to ulcerative colitis?
What are some complications of ulcerative colitis?
A
- Triad = bloody diarrhoea, colicky LLQ pain + tenesmus
- Primary sclerosing cholangitis
- Toxic megacolon, colorectal cancer
5
Q
IBD
What are some extra-intestinal features that are present in both types of inflammatory bowel disease (IBD)?
A
- Arthritis
- Erythema nodosum
- Pyoderma gangrenosum
- Uveitis + episcleritis
- Finger clubbing
6
Q
IBD
What initial investigations would you do for IBD and what might they show?
A
- FBC = microcytic anaemia, raised WCC + platelets
- LFTs = low albumin (malabsorption)
- Raised ESR/CRP (inflammation)
- Stool MC&S to exclude infection
- Faecal calprotectin (released by intestines when inflamed, useful screen)
7
Q
IBD
What is the diagnostic investigation for IBD?
What other investigations would you do?
What investigations would you not do in acute ulcerative colitis, why and what could you do instead?
A
- Colonoscopy with biopsy
- Barium enema, CT/MRI to check complications
- Avoid barium enema/colonoscopy due to perforation risk, flexible sigmoidoscopy is preferred
8
Q
IBD
How would you induce remission in Crohn’s disease?
A
- Enteral feed 6–8w paeds if cautious of steroids
- PO prednisolone/IV hydrocortisone 1st line, ?add azathioprine or mercaptopurine
- Biologics like infliximab or adalimumab if fail to respond
9
Q
IBD
How do you maintain remission in Crohn’s disease?
What investigation would you order first?
A
- Azathioprine or mercaptopurine = 1st line, measure thiopurine methyltransferase (TPMT) activity first
- If not methotrexate
- Biologics infliximab, adalimumab
10
Q
IBD
What surgery might you consider in Crohn’s disease?
A
- Resections for complications (fistulae, abscess)
11
Q
IBD
How do you classify the severity of ulcerative colitis?
A
- Mild = <4 stools/day, small amount of blood
- Moderate = 4–6 stools/day, varying blood, no systemic upset
- Severe = >6 bloody stools/day + systemic upset (pyrexia, shock)
12
Q
IBD
How do you induce remission in mild-moderate ulcerative colitis?
What is a side effect of the first line management?
A
- First line = topical (PR) aminosalicylate (5-ASA) mesalazine if not PO
- Second line = PO prednisolone
- Sulfasalazine (lung fibrosis, anaemia), mesalazine (pancreatitis) + both (agranulocytosis)
13
Q
IBD
How do you induce remission in severe ulcerative colitis?
A
- Hospital admission
- IV steroids
- ?IV ciclosporin after 72h if still unwell
14
Q
IBD
How do you maintain remission in ulcerative colitis if…
i) mild-moderate?
ii) severe relapse or ≥2/year?
A
i) PR/PO 5-ASA
ii) PO azathioprine or mercaptopurine
15
Q
IBD
When would you consider surgery in ulcerative colitis and what’s the options?
A
- Medical therapy fails to induce remission
- Panproctocolectomy = curative as removes disease
- Either permanent ileostomy or ileo-anal anastomosis (J-pouch) where ileum is folded back on itself + fashioned into a large pouch that functions as a rectum as it attaches to the rectum
16
Q
COELIAC DISEASE
What is the pathophysiology of coeliac disease?
A
- Autoimmune condition where response to alpha-gliadin portion of the protein gluten causes inflammation in small intestine, particularly jejunum
- Autoantibodies in response to gluten exposure target intestinal epithelial cells leading to inflammation + atrophy of intestinal villi > malabsorption
17
Q
COELIAC DISEASE
What is the genetic association with coeliac disease?
What conditions are associated with coeliac disease and would prompt screening?
A
- HLA-DQ2 and HLA-DQ8
- T1DM, thyroid disease, Down’s syndrome, FHx
18
Q
COELIAC DISEASE
What is the clinical presentation of coeliac disease?
A
- Abnormal stools (smelly, floating, diarrhoea)
- Abdo pain, distension + buttock wasting
- Paeds = failure to thrive, weight loss
- Dermatitis herpetiformis = itchy blistering skin rash often on abdomen
19
Q
COELIAC DISEASE
What is crucial when investigating for coeliac disease?
What first line investigations would you do?
A
- Gluten-containing diet for 6w for accuracy
- IgA Ab = Anti-tissue transglutaminase (anti-TTG first line) and anti-endomysial as well as total IgA as deficiency can give false negative results
20
Q
COELIAC DISEASE
What is the diagnostic investigation for coeliac disease and what will it show?
A
- Endoscopic small intestinal biopsy
- Villous atrophy, crypt hyperplasia + increased intraepithelial lymphocytes
21
Q
COELIAC DISEASE
What are some complications of coeliac disease?
A
- Anaemia (iron/B12/folate)
- Osteoporosis
- Lymphoma (EATL)
- Hyposplenism
- Lactose intolerance
- Subfertility
22
Q
COELIAC DISEASE
What is the most important management in coeliac disease?
What other parts of the management is there?
A
- Lifelong gluten free diet curative under dietician
- ?Gluten challenge later if Dx <2y to ensure still intolerant
- PCV vaccine with booster every 5y due to hyposplenism
23
Q
OESOPHAGEAL CANCER
What are the two types of oesophageal cancer?
Where are they found?
What are the risk factors?
A
- Adenocarcinoma = most common type in UK/US, lower third oesophagus, RF = GORD, Barrett’s, smoking, obesity, achalasia
- Squamous cell = most common in developing world, upper two-thirds oesophagus, RF = smoking, alcohol, achalasia, Plummer-Vinson syndrome + nitrosamines (fish)
24
Q
OESOPHAGEAL CANCER
What is the clinical presentation of oesophageal cancer?
A
- Dysphagia = most common, often solids > liquids
- Anorexia, vomiting, weight loss
- Odynophagia, hoarseness
25
OESOPHAGEAL CANCER
What are the 2ww criteria for oesophageal cancer?
What is the first-line investigation?
- Dysphagia OR ≥55y with weight loss and any of: upper abdo pain, reflux or dyspepsia
- Upper GI endoscopy (OGD)
26
OESOPHAGEAL CANCER
| What other investigations would you do in oesophageal cancer?
- Staging CT chest, abdo + pelvis after endoscopy
| - Endoscopic USS preferred method for regional staging
27
OESOPHAGEAL CANCER
| What is Barrett's oesophagus and some risk factors?
- Intestinal metaplasia of lower oesophageal mucosa with the usual squamous epithelium being replaced by columnar
- GORD = #1, male, smoking, obesity
28
OESOPHAGEAL CANCER
| What is the management of Barrett's oesophagus?
- High dose PPI
- Endoscopic surveillance + biopsies if metaplasia every 3–5y
- Dysplasia detected of any grade = endoscopic mucosal resection or radiofrequency ablation
29
OESOPHAGEAL CANCER
What is the management of oesophageal cancer?
What is a complication of this?
- Surgical resection and adjuvant chemotherapy
| - Anastomotic leak > mediastinitis
30
GASTRIC CANCER
What are the two main types of gastric cancer and their different features?
What are the risk factors for gastric cancer?
- Intestinal type adenocarcinoma = lesser curvature
- Diffuse type adenocarcinoma = signet ring cells which high numbers are associated with worse prognosis
- Helicobacter pylori, atrophic gastritis, smoking + nitrosamines
31
GASTRIC CANCER
| What is the clinical presentation of gastric cancer?
- Epigastric pain, dyspepsia + progressive dysphagia
- Weight loss, N+V, early satiety
- Lymphatic spread = left supraclavicular (Virchow's node) and periumbilical (Sister Mary Joseph's node)
32
GASTRIC CANCER
| What are the investigations for gastric cancer?
- OGD + biopsy
| - CT/MRI for staging
33
GASTRIC CANCER
| What is the management of gastric cancer?
- Surgical = endoscopic mucosal resection, partial/total gastrectomy
- Chemotherapy
34
COLORECTAL CANCER
What are the two broad aetiological groups for colorectal cancer?
What are some risk factors?
- Sporadic (95%) and inherited autosomal dominant (5%)
| - FHx, IBD, increased age, high red meat diet, obesity, smoking, alcohol
35
COLORECTAL CANCER
| What are three inherited causes of colorectal cancer?
- Hereditary non-polyposis colorectal carcinoma (Lynch syndrome) = #1
- Familial adenomatous polyposis
- Peutz-Jeghers syndrome
36
COLORECTAL CANCER
What is the pathology of lynch syndrome?
What other condition are individuals at risk of?
- Mutation of mismatch repair genes
| - Endometrial cancer
37
COLORECTAL CANCER
What is the pathology of familial adenomatous polyposis?
What is the management?
- Mutation in APC gene > formation of hundreds of colonic polyps
- Panproctocolectomy
38
COLORECTAL CANCER
| What are the clinical features of Peutz-Jeghers syndrome?
- Pigmented lesions on lips, oral mucosa, palms
| - Multiple GI hamartomatous polyps
39
COLORECTAL CANCER
| What is the clinical presentation of colorectal cancer?
- Right sided = IDA + weight loss
- Left sided = PR bleeding, altered bowel habit + bowel obstruction
- Rectal = fresh bleeding, tenesmus, mass
40
COLORECTAL CANCER
| What are the 2ww criteria for colorectal cancer and what investigation do they get?
- ≥60 with change in bowel habit OR IDA
- ≥50 with unexplained rectal bleeding
- ≥40 with abdo pain AND unexplained weight loss
- Gastroscopy and colonoscopy
41
COLORECTAL CANCER
Explain the screening programme for colorectal cancer
What else can it be used for?
- Faecal immunochemical tests (FIT) for human Hb in stool replacing faecal occult blood test which gave false positives from blood in food
- Every 2 years those 60–74y (can request after 74y) and if abnormal > colonoscopy
- Also used if do not meet 2ww criteria
42
COLORECTAL CANCER
| What investigations are used in diagnosing colorectal cancer?
- Colonoscopy + biopsy = gold standard
- CT colonography with bowel prep if less fit for colonoscopy
- Staging CT with Dukes' classification
- Carcinoembryonic antigen (CEA) = tumour marker with role in monitoring/follow-up
43
COLORECTAL CANCER
| What are the stages in the Dukes' classification?
- A = confined to bowel mucosa
- B = extends through bowel wall
- C = local lymph node spread
- D = distant metastases
44
COLORECTAL CANCER
For the following colorectal cancer sites, state the type of resection and anastamosis...
i) caecal, ascending or proximal transverse colon?
ii) distal transverse or descending colon?
iii) sigmoid colon?
iv) upper rectum?
v) lower rectum?
vi) anal verge?
i) Right hemicolectomy = ileo-colic
ii) Left hemicolectomy = colo-colon
iii) High anterior resection = colo-rectal
iv) Anterior resection (total mesorectal excision, TME) = colo-rectal
v) Anterior resection (low TME) = colo-rectal ± defunctioning stoma
vi) Abdomino-perineal excision of rectum = none
45
COLORECTAL CANCER
| What are some complications of colorectal cancer surgery?
- Pain, infection and bleeding
- Anastomotic leak
- Post-op ileus
46
COLORECTAL CANCER
| In an emergency situation where the bowel has perforated, what is the management?
- Anastomosis risk so sigmoid colectomy with end colostomy which can be reversed later = Hartmann's
47
PEPTIC ULCER DISEASE
What is the pathophysiology of peptic ulcer disease (PUD)?
What are some risk factors?
- Breach in the mucosa due to breakdown of protective layer or increased acid
- Stress, alcohol, caffeine, smoking, spicy foods = increased acid
48
PEPTIC ULCER DISEASE
What is the most common cause of PUD?
What are some other causes?
- Helicobacter pylori (95% duodenal, 75% gastric)
- Drugs = NSAIDs, SSRIs, corticosteroids + bisphosphonates
- Zollinger-Ellison syndrome = rare gastrin-secreting tumour > excess gastrin
49
PEPTIC ULCER DISEASE
| What is the mechanism by which NSAIDs cause PUD?
- Reversible inhibitor of cyclo-oxygenase (COX1+2) > reduced prostaglandins = decreases mucus + bicarb secretion
50
PEPTIC ULCER DISEASE
| What is the clinical presentation of PUD?
- Epigastric pain with heartburn + nausea
- Duodenal = PAIN when HUNGRY + RELIEVED by EATING
- Gastric = PAIN when EATING + RELIEVED by HUNGER
- Haematemesis = "coffee ground" vomit + melaena
51
PEPTIC ULCER DISEASE
| What are some investigations for PUD?
- H. pylori urea breath test or stool antigen test = first line
- Endoscopy ± biopsies (gastric) ± rapid urease (CLO) test for H. pylori too
52
PEPTIC ULCER DISEASE
| What are some potential complications of PUD?
- Upper GI bleed = gastroduodenal artery
- Perforation = acute abdo + peritonitis = erect CXR (free air under diaphragm)
- Scarring and strictures > pyloric stenosis
53
PEPTIC ULCER DISEASE
What lifestyle advice would you give in PUD?
How do you manage H. pylori related PUD?
How do you manage H. pylori -ve PUD?
- Stop smoking, alcohol, avoid acidic foods + NSAIDs
- Triple eradication therapy = PO PPI + amoxicillin + metronidazole OR clarithromycin for 7d
- High-dose PPI for 4–8w
54
UPPER GI BLEED
| What are some causes of an upper GI bleed?
- Peptic ulceration
- Oesophageal varices (esp. if stigmata of liver disease)
- Mallory Weiss tear = brisk small-mod bright red blood, after straining)
- Malignancy
55
UPPER GI BLEED
| What is the clinical presentation of an upper GI bleed?
- Haematemesis = "coffee ground" vomit
- Melaena = black, tarry stools
- Shock
56
UPPER GI BLEED
| What initial investigations would you do in an upper GI bleed?
- FBC
- U&E (high urea due to protein meal of blood)
- LFTs and clotting
- Crossmatch 4–6 units (O -ve if emergency activating major haemorrhage protocol)
57
UPPER GI BLEED
What 2 risk assessments are used in acute upper GI bleeds?
What are the various parameters?
How are they applied clinically?
- Glasgow-Blatchford score at first assessment = Hb, urea, SBP + other parameters
- Rockall score can be pre/post-endoscopy = age, shock, co-morbidities, endoscopic findings
- For both >0 = inpatient OGD, 0 = urgent OP OGD
58
UPPER GI BLEED
| What is the initial emergency management of an acute upper GI bleed?
- A–E assessment
- 2x wide bore IV access, NBM, IV fluids + blood transfusion if Hb <70g/L
- Platelet transfusion if <50 + FFP in major haemorrhage
- Anticoagulant reversal (e.g., IV vitamin K + PCC)
59
UPPER GI BLEED
| What should be done after resuscitiation?
- OGD offered immediately if severe bleed
| - ALL patients should have OGD within 24h
60
UPPER GI BLEED
| What is the management of a non-variceal bleed?
- NICE do not recommend pre-endoscopy PPIs as can mask the bleed site
- If further bleeding > repeat endoscopy, interventional radiology + surgery
61
UPPER GI BLEED
| What is the management of a variceal bleed?
- Terlipressin + prophylactic Abx before endoscopy
- Endoscopic band ligation of varices
- Transjugular intrahepatic portosystemic shunts (TIPS) if variceal bleeding not controlled with above
- Uncontrolled variceal bleeding = ?Sengstaken-Blakemore tube
62
APPENDICITIS
| What is the pathophysiology of appendicitis?
- Faecolith causes obstruction of appendiceal lumen allowing gut organisms to invade the appendix wall > oedema, ischaemia ± perforation
63
APPENDICITIS
What is the classic presentation of appendicitis and why does it occur?
What other symptoms may the patient experience?
- Central abdo pain initially (appendix is midgut structure) which migrates to RIF (localised parietal peritoneal inflammation)
- Anorexia, N+V (often only 1–2x vomiting), fever
64
APPENDICITIS
| What are some signs of appendicitis?
- RIF tenderness
- Rovsing's sign
- Guarding
- Rebound/percussion tenderness
65
APPENDICITIS
| What initial investigations would you do in appendicitis?
- FBC (raised WCC, neutrophil dominant), VBG (lactate), U&E, LFTs, amylase, clotting, G&S for theatre + blood cultures if septic
- Urinalysis (leukocytes)
- Urine pregnancy test if childbearing age
66
APPENDICITIS
| What imaging might you consider in appendicitis?
- USS pelvis in women if ?gynae pathology
| - CT abdomen = most sensitive imaging to Dx but not routinely used
67
APPENDICITIS
| What are some potential complications of appendicitis
- Perforation > faecal contents in peritoneal cavity > peritonitis = copious abdominal lavage
- Local abscess
68
APPENDICITIS
| What is the management of appendicitis?
- Laparoscopic appendicectomy with prophylactic IV Abx prior
| - If appendix mass (omentum), broad spectrum Abx + interval appendicectomy
69
SEPSIS
| What is the difference between sepsis and septic shock?
- Sepsis = life-threatening organ dysfunction (confusion, hypoxia, oliguria, metabolic acidosis) due to a dysregulated host response to infection
- Septic shock = sepsis PLUS hypotension despite fluid resus or lactic acidosis
70
SEPSIS
| What is the clinical presentation of sepsis?
- Fever/sweats/chills, SOB, N+V, confusion
| - Signs = shock (tachycardic, hypotensive), pyrexia, CRT >2s, hypoxia, high RR
71
SEPSIS
| What is the initial management of sepsis
- ABCDE and sepsis 6 BUFALO
- Blood cultures + others (FBC, U&E, LFT, CRP, clotting)
- Urine output (catheter)
- Fluids IV crystalloids (if given 2L or pulmonary oedema = critical care)
- Abx IV broad-spectrum (e.g., co-amox, tazocin)
- Lactate (VBG/ABG)
- Oxygen (high flow for >94% or 88–92% if COPD)
72
SEPSIS
| What other investigations would you do in sepsis to figure out the source?
- Bedside = urinalysis + MC&S, pregnancy test, ECG, viral PCR
- Imaging = CXR, abdominal USS
- Lumbar puncture
73
BOWEL OBSTRUCTION
| What are the causes of small and large bowel obstruction?
- Small = adhesion (prev surgery) #1, hernias
| - Large = tumour #1 (may be initial presentation), volvulus, diverticular disease > strictures
74
BOWEL OBSTRUCTION
What is the clinical presentation of bowel obstruction?
How might this differ in small vs. large bowel obstruction?
- Abdominal pain + distension
- N+V = EARLY + bilious/faeculent in SBO, LATE in LBO
- Constipation (absolute = no flatus) = EARLY in LBO, LATE in SBO
- Tinkling bowel sounds on auscultation
75
BOWEL OBSTRUCTION
What investigations would you consider in bowel obstruction?
What is the first-line investigation you would request and what would you expect to see in bowel obstruction?
- FBC, U&E, CRP, VBG
- AXR (3-6-9 rule) = dilated loops of small bowel >3cm, large bowel >6cm + caecum >9cm diameter
- CT abdomen = high sensitivity + specificity as well as identifying the aetiology
76
BOWEL OBSTRUCTION
| What is the initial management of bowel obstruction?
- ABCDE
- NBM
- IV fluids
- NG tube with free drainage
- Avoid pro-kinetics like metoclopramide
77
BOWEL OBSTRUCTION
| What is the management of bowel obstruction?
- Can settle with conservative, if not surgery (majority of LBO will need surgery)
78
BOWEL OBSTRUCTION
What is a potential complication after bowel surgery?
How does it present?
How is it managed?
- Post-op (paralytic) ileus = reduced bowel peristalsis = pseudo-obstruction
- Presents as obstruction + deranged electrolytes can contribute
- NBM, NG tube if vomiting, IV fluids ± electrolyte correction
79
VOLVULUS
| What is a volvulus?
- Torsion of the colon around its mesenteric axis resulting in compromised blood flow + closed loop obstruction
80
VOLVULUS
| What are the two types of volvulus and how do they occur?
- Sigmoid (80%) = LBO as sigmoid colon twists on sigmoid mesocolon
- Caecal (20%) = retroperitoneal structure so not usually at risk of twisting but in minority there is failure of peritoneal fixation development
81
VOLVULUS
What are some associations with...
i) sigmoid volvulus?
ii) caecal volvulus?
i) Older, chronic constipation, neuro (Parkinson's)
| ii) All ages, adhesions, pregnancy
82
VOLVULUS
| What is the clinical presentation of volvulus?
- Abdominal pain + distension
- Constipation
- N+V
83
VOLVULUS
What initial investigation would you do in volvulus and what would it show?
What other investigation would you do?
- AXR – sigmoid volvulus = LBO + coffee bean sign, caecal volvulus = SBO may be seen
- CT abdomen = confirm Dx + identify any other pathology
84
VOLVULUS
What is the initial volvulus management?
How do you manage sigmoid volvulus?
How do you manage caecal volvulus?
- NBM, IV fluids, NG tube (drip and suck)
- Rigid sigmoidoscopy with rectal tube insertion
- Operative, may require right hemicolectomy
85
PERITONITIS
| What are some causes of peritonitis?
Perforation of hollow viscus –
- Boerhaave syndrome = perf oesophagus
- Peptic ulcer perf
- Bowel perf = appendicitis, diverticulitis, obstruction
Infection = SBP (infected ascites in liver disease)
86
PERITONITIS
| What is the clinical presentation of peritonitis
- Abdominal rigidity + guarding
- Rebound + percussion tenderness
- Shock, fever, vomiting
87
PERITONITIS
| What investigations would you do in peritonitis and what are you specifically looking for?
- FBC, U&E, LFT, CRP, amylase, clotting, ABG/VBG, group + save, blood cultures
- AXR = rigler's sign (pneumoperitoneum > double wall sign)
- ERECT CXR = air under the diaphragm (pneumoperitoneum)
88
PERITONITIS
| What is the management of peritonitis?
- ABCDE + alert senior
- NBM, IV fluids, NG tube
- IV Abx (cefotaxime in SBP)
- Laparotomy
89
HIATUS HERNIA
| What are the two types of hiatus hernia and how do they differ?
- Sliding (95%) = gastroesophageal junction moves above the diaphragm
- Rolling (paraoesophageal) = gastrooesophageal junction remains below diaphragm but separate part of stomach herniates through
90
HIATUS HERNIA
What are some risk factors for a hiatus hernia?
What is the clinical presentaiton?
- Obesity, increased intraabdominal pressure (ascites, multiparity)
- Heartburn, dysphagia, regurgitation, chest pain
91
HIATUS HERNIA
| What are the investigations for hiatus hernia?
- Barium swallow = Dx
| - Given nature of Sx often have endoscopy first
92
HIATUS HERNIA
| What is the management of hiatus hernia?
- Conservative = weight loss, avoid alcohol, smoking + acidic foods, avoid large meals before bed
- Medical = PPI for 4–8w then assess
- Surgery (Nissen's fundoplication) if above fail
93
INGUINAL HERNIA
| What are the two types of inguinal hernias and how they are different?
- Direct = protrudes directly through weakness in posterior wall of inguinal canal (older)
- Indirect = protrusion through deep ring > inguinal canal > superficial ring (paeds, patent processus vaginalis)
94
INGUINAL HERNIA
| What are the causes of inguinal hernias?
- Increased intra-abdominal pressure or abdominal muscle weakness = chronic cough, constipation, heavy lifting, obesity
95
INGUINAL HERNIA
| What is the clinical presentation of an inguinal hernia?
- Painless groin lump, superior + medial to pubic tubercle
- Indirect hernias may descend into scrotum
- Unable to get 'above' it on examination
96
INGUINAL HERNIA
| How can you differentiate direct and indirect inguinal hernias on clinical examination?
- Reduce hernia then pressure over deep ring (middle from ASIS-pubic tubercle)
- Prevents indirect reappearing, no effect on direct
97
INGUINAL HERNIA
How do you investigate an inguinal hernia?
What is the management of an inguinal hernia in adults and paeds?
- USS abdomen/scrotum to confirm diagnosis
- Open (unilateral) or laparoscopic (bilateral) mesh repair
- Paeds in first few months = risk of strangulation so urgent, >1y = elective
98
FEMORAL HERNIA
What is a femoral hernia?
Who is it more common in?
How does it present?
- Abdominal viscus passes into femoral canal
- Women
- Groin lump (inferolateral to pubic tubercle), may be irreducible
99
FEMORAL HERNIA
| What are some potential complications of femoral hernias?
- Incarceration = herniated tissue cannot be reduced
- Strangulation risk higher = tender, non-reducible > surgical emergency
- Bowel obstruction + ischaemia
100
FEMORAL HERNIA
| What is the management of a femoral hernia?
- Urgent surgical repair due to high risk of strangulation compared to inguinal
101
OTHER HERNIAS
What is an umbilical hernia?
What is it associated with?
How is it managed?
- Symmetrical bulge under umbilicus
- Paeds, Afro-Caribbean + down's syndrome
- No treatment + resolve by 3y, surgical mesh repair if large >1.5cm or if no closure by 4–5y
102
OTHER HERNIAS
What is an incisional hernia?
What are some causes?
- Hernia arises through a previously acquired defect
| - Obesity, surgical technique, incision type or increased intra-abdominal pressure (cough, straining)
103
GORD
What is gastro-oesophageal reflux disease (GORD)?
What are some risk factors?
- Reflux of gastric contents into oesophagus due to a defective lower oesophageal sphincter
- Obesity, alcohol, smoking, foods (coffee, spicy, citrus)
104
GORD
| What is the clinical presentation of GORD?
- Dyspepsia + sense of acid regurgitation
- Retrosternal chest pain
- Globus
- Nocturnal cough
105
GORD
What investigations would you do in GORD?
What are some potential complications?
- OGD > if -ve then ?24h oesophageal pH monitoring (gold standard)
- Oesophagitis, benign strictures, Barrett's oesophagus + oesophageal carcinoma
106
GORD
| What initial management would you trial in GORD?
- Lifestyle = weight loss, dietary changes, elevate head of bed, avoid late night food
- PPI (omeprazole) or H2 receptor antagonist (famotidine) to reduce stomach acid, antacids (Gaviscon) for symptomatic relief
107
GORD
| What are some potential adverse effects of PPIs?
- Low Na + Mg
- Osteoporosis
- C. difficile risk
108
GORD
| If medical therapy for GORD fails, what option is available?
- Nissen fundoplication
109
CONSTIPATION
What is the clinical presentation of constipation?
What are some risk factor?
- <3 bowel movements/week + often hard stool (type 1-2)
- Tenesmus + excessive straining
- Abdominal distension + masses
- Advanced age, inactivity, low fibre diet, opioids, females
110
CONSTIPATION
| What investigations would you consider in constipation?
- PR exam = hard stool or impaction
- AXR if concerned about obstruction
- Barium enema/colonoscopy for pathology
111
CONSTIPATION
| What are some complications with constipation?
- Anal fissures
- Haemorrhoids
- Overflow diarrhoea
112
CONSTIPATION
| What is the process by which overflow diarrhoea occurs in constipation?
- Prolonged faecal status = resorption of fluids = increase in size + consistency which can lead to rectal stretching + reduced sensation > overflow
113
CONSTIPATION
What lifestyle advice can you give in constipation?
What are the main types of laxatives?
- Increase dietary fibre, more water, increase exercise
- Stimulant (senna, bisacodyl)
- Osmostic (lactulose, macrogol)
- Stool softeners (docusate sodium, glycerol suppositories)
- Bulk-forming (ispaghula husk)
114
CONSTIPATION
What is the mechanism of...
i) stimulant laxatives?
ii) osmotic laxatives?
iii) stool softener laxatives?
iv) bulk forming laxatives?
i) Increase intestinal motility > can lead to abdominal cramp, avoid in bowel obstruction
ii) Increase water in large bowel
iii) Increased penetration of intestinal fluid into the faecal mass
iv) Small hard stools + cannot increase dietary fibre
115
CONSTIPATION
| In adults, how do you manage constipation?
- Bulk-forming laxatives initially (ensure adequate fluid intake)
- Stools remain hard add/switch to osmotic laxatives
- Stools soft but difficult to pass or tenesmus = stimulant laxatives
- Enemas if impaction present (sodium citrate)
116
CONSTIPATION
| In paediatrics, how do you manage constipation?
- First line = macrogols (e.g., Movicol)
- Second line = add/switch to stimulant laxatives
- Stools remain hard = lactulose or stool softener
117
GASTROENTERITIS
How is diarrhoea defined?
What two sub-types can diarrhoea be put into?
- ≥3 loose-watery stools within 24h
- Acute food poisoning = staph. aureus, bacillus cereus
- Traveller's diarrhoea = E. coli, cholera
118
GASTROENTERITIS
| What are some causes of acute and chronic diarrhoea?
- Acute <14d = gastroenteritis, diverticulitis, thyrotoxicosis
- Chronic >14d = IBS, IBD, colorectal cancer, coeliac
119
GASTROENTERITIS
| What are some bacterial causes of gastroenteritis?
- Escherichia coli = #1 traveller's diarrhoea
- Staph. aureus = eggs, dairy, meats
- Bacillus cereus = reheated rice
- Shigella = faeco-oral
- Campylobacter = raw poultry, associated with GBS
- Cholera (Vibrio cholerae) = faecal contaminated water
120
GASTROENTERITIS
What is the clinical presentation of gastroenteritis caused by...
i) E. coli?
ii) Staph. aureus?
iii) Bacillus cereus?
iv) Shigella?
i) Watery stools, abdo pain, E. Coli 0157 > HUS
ii) Severe vomiting with short incubation period
iii) Vomiting within 6h then diarrhoeal illness after 6h
iv) Bloody diarrhoea + vomiting, HUS
121
GASTROENTERITIS
What is the clinical presentation of gastroenteritis caused by...
i) campylobacter?
ii) cholera?
i) Flu-like prodrome, bloody diarrhoea, fever, abdo pain
| ii) Profuse, rice-water diarrhoea, severe dehydration
122
GASTROENTERITIS
| What are some viral causes of gastroenteritis and their unique features?
- Rotavirus = #1 in paeds, secretory D+V
| - Norovirus = #1 overall, risks = nursing homes, cruise ships, hospitals
123
GASTROENTERITIS
| What are some parasitic causes of gastroenteritis and their unique features?
- Giardiasis = resistant to chlorination so seen in swimming pools with fat malabsorption (greasy stools), prolonged
- Amoebiasis = gradual onset bloody diarrhoea can last weeks
124
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GASTROENTERITIS
What is Clostridium difficile?
What can cause it?
What are some risk factors?
How is it spread?
```
- Gram +ve spore-forming anaerobic rod
- C Abx = Cephalosporins, Clindamycin, Ciprofloxacin, Co-amoxiclav (penicillins)
- Elderly, hospital admissions, PPIs
- Faeco-oral from contaminated surfaces if people do not wash hands with soap + water
125
GASTROENTERITIS
What is the clinical presentation of C. diff?
What investigations would you do?
What is a key complication?
- Diarrhoea, pseudomembranous colitis, fever
- Raised WCC (>15 severe), CDT (toxin infection, antigen exposure)
- Toxic megacolon
126
GASTROENTERITIS
| What is the management of C. diff?
- PO vancomycin first line
- PO fidaxomicin second line (first-line if relapse <12w)
- PO vancomycin PLUS IV metronidazole if life-threatening
127
GASTROENTERITIS
| What general investigations would you do in diarrhoea?
- FBC, U&E, CRP, LFT, coeliac serology, stool MC&S and C. difficile toxin (CDT)
128
GASTROENTERITIS
| What are some post-gastroenteritis complications?
- Lactose intolerance
- IBS
- GBS
- Reactive arthritis
129
GASTROENTERITIS
What is the conservative management for gastroenteritis?
What is the management in paeds?
- Barrier nursing, strict handwashing with soap + warm water
| - 50ml/kg oral rehydration solution
130
GASTROENTERITIS
When would you consider antibiotics in gastroenteritis?
What antibiotics would you give for...
i) salmonella + shigella?
ii) campylobacter?
iii) cholera?
- Systemically unwell, immunocompromised or elderly
i) Ciprofloxacin
ii) Macrolide (clarithromycin)
iii Tetracycline like PO doxy but safe water + sanitation needed
131
DIVERTICULAR DISEASE
| What is a diverticulum?
- Herniation of colonic mucosa through the muscular wall, often between the taenia coli where vessels pierce the muscle to supply the mucosa
132
DIVERTICULAR DISEASE
What is meant by the following terms...
i) diverticulosis?
ii) diverticular disease?
iii) diverticulitis?
i) Presence of diverticular
ii) Symptomatic diverticulum
iii) Inflammation of diverticular
133
DIVERTICULAR DISEASE
What is the classic location where diverticular disease is seen?
What are some risk factors?
- Sigmoid colon
| - Old age, lack of dietary fibre + obesity
134
DIVERTICULAR DISEASE
| What is the clinical presentation of diverticular disease?
- Intermittent abdominal pain, usually LLQ
| - Often constipation ± PR bleeding
135
DIVERTICULAR DISEASE
| What is the clinical presentation of acute diverticulitis?
- Acute LLQ pain, tenderness + guarding
- Pyrexia, N+V, urinary Sx
- PR bleeding may occur
136
DIVERTICULAR DISEASE
| How would you diagnose diverticular disease?
- Often incidental finding on CT abdomen or colonoscopy
137
DIVERTICULAR DISEASE
| What investigations would you do in acute diverticulitis?
- FBC (raised WCC), raised CRP
- Erect CXR if ?perforation, AXR if ?obstruction
- CT abdomen = best modality in suspected abscesses
- Colonoscopy = avoid initially due to increased risk of perforation
138
DIVERTICULAR DISEASE
| What are some complications of diverticulitis?
- Abscess formation (drain CT/USS guided)
- Perforation > peritonitis
- Fistula formation e.g., colovesical > pneumaturia (bubbling) faecaluria + recurrent UTIs
139
DIVERTICULAR DISEASE
| What is the management of symptomatic diverticular disease?
- Increase dietary fibre + fluids
- Consider bulk-forming laxatives
- Simple analgesia = avoid NSAIDs/opioids as perforation risk
140
DIVERTICULAR DISEASE
What is the management of...
i) mild diverticulitis?
ii) severe or non-resolving diverticulitis?
iii) unresponsive to Abx or complications?
iv) recurrent severe diverticulitis?
i) PO co-amoxiclav + analgesia
ii) No improvement in <72h = NBM, IV Abx (cephalosporin + metronidazole) + IV fluids
iii) Surgery
iv) ?Elective colectomy
141
ACUTE MESENTERIC ISCHAEMIA
| What is the pathophysiology of acute mesenteric ischaemia?
- Thrombus/embolism results in sudden occlusion of an artery supplying the small bowel, usually superior mesenteric artery in patients with AF
142
ACUTE MESENTERIC ISCHAEMIA
| What are some risk factors for acute mesenteric ischaemia?
- Infective endocarditis
- Atherosclerosis
- Coagulopathy
143
ACUTE MESENTERIC ISCHAEMIA
| What is the clinical presentation of acute mesenteric ischaemia?
- Severe, sudden onset abdo pain out-of-keeping with physical examination
- PR bleeding + diarrhoea
- Shock + signs of sepsis
144
ACUTE MESENTERIC ISCHAEMIA
| What investigations would you do in acute mesenteric ischaemia and what would they show?
- FBC (high WCC), ABG (lactic acidosis)
| - CT angiography for diagnosis
145
ACUTE MESENTERIC ISCHAEMIA
| What is the management of acute mesenteric ischaemia?
- Immediate laparotomy esp. if signs of advanced ischaemia (peritonitis, sepsis)
146
CHRONIC MESENTERIC ISCHAEMIA
What is the pathophysiology of chronic mesenteric ischaemia?
What are some risk factors?
- 'Intestinal angina' result of mesenteric blood vessels affected by atherosclerosis where the blood supply cannot keep up with the demand
- CVD risk factors = age, FHx, smoking, DM, HTN, raised cholesterol
147
CHRONIC MESENTERIC ISCHAEMIA
| What is the clinical presentation of chronic mesenteric ischaemia?
- Central, colicky abdominal pain after eating
- Weight loss secondary to food avoidance
- Abdominal bruit on auscultation
148
CHRONIC MESENTERIC ISCHAEMIA
How is chronic mesenteric ischaemia diagnosed?
What conservative management would you offer?
- CT angiography
| - Reduce modifiable risk factors (stop smoking) + secondary prevention (statins)
149
CHRONIC MESENTERIC ISCHAEMIA
| What is the definitive management of chronic mesenteric ischaemia?
- Revascularisation either endovascular first line (percutaneous mesenteric artery stenting) or open surgery (endarterectomy, bypass grafting)
150
ISCHAEMIC COLITIS
What is ischaemic colitis?
Where is it likely to occur?
- Acute but transient compromise in the blood flow to the large bowel which can lead to inflammation, ulceration + haemorrhage
- Watershed areas such as splenic flexure
151
ISCHAEMIC COLITIS
What is the clinical presentation of ischaemia colitis?
What investigation might you consider?
What is the management?
- Transient abdo pain, PR bleeding, diarrhoea
- AXR = 'thumbprinting' due to mucosal oedema/haemorrhage
- Supportive, surgery in minority (peritonitis, perf, haemorrhage)
152
IRRITABLE BOWEL SYNDROME
| What is irritable bowel syndrome (IBS)?
- Functional bowel disorder thought to be related to neural gut-brain axis
153
IRRITABLE BOWEL SYNDROME
| What is the clinical presentation of IBS?
- Abdominal pain (relieved on opening bowels)
- Bloating
- Change in bowel habit
- Altered stool passage (straining, tenesmus) + PR mucus
- Worse symptoms after eating
154
IRRITABLE BOWEL SYNDROME
| What investigations would you do in suspected IBS and what would they show?
- Normal FBC, ESR + CRP
- Faecal calprotectin + coeliac serology both negative
- Exclude cancer if any red flags present
155
IRRITABLE BOWEL SYNDROME
| What is the lifestyle advice in IBS?
- Adequate fluid intake
- Low FODMAP diet
- Regular small meals
- Limit caffeine, alcohol + fresh fruit
156
IRRITABLE BOWEL SYNDROME
| What is the first line management of IBS?
- Loperamide if diarrhoea
- Laxatives if constipated (avoid lactulose > bloating)
- Antispasmodics (hyoscine butylbromide) if cramps
157
IRRITABLE BOWEL SYNDROME
| What other management options are their in IBS?
- Second line medical = TCA amitriptyline 5–10mg ON or if not SSRI
- ?CBT or other psychological therapy if poor medication response
158
HAEMORRHOIDS
| What is the pathophysiology of haemorrhoids?
- Anal cushions (3, 7 + 11 O'clock) expand + protrude outside the anal canal
- External = originate BELOW dentate line, prone to thrombosis + can be painful
- Internal = originate ABOVE dentate line, do NOT generally cause pain
159
HAEMORRHOIDS
| What is the clinical presentation of haemorrhoids?
- Painless bright red PR bleeding on toilet tissue #1
| - Pruritus, associated with constipation and straining
160
HAEMORRHOIDS
How do you fully visualise haemorrhoids?
How are they graded
- Proctoscopy
- Grade I = do NOT prolapse out of anal canal
- Grade II = prolapse on defecation but reduce spontaneously
- Grade III = manually reduced
- Grade IV = not manually reduced
161
HAEMORRHOIDS
What is a key complication of haemorrhoids?
How does it present?
- Thrombosed haemorrhoid
- Significant pain
- Exam = purple, oedematous, tender subcut perianal mass
162
HAEMORRHOIDS
| What is the management of a thrombosed haemorrhoid?
- Presents <72h = referral for ?excision
| - If not conservative = stool softeners, ice packs + analgesia
163
HAEMORRHOIDS
| What is the management for haemorrhoids?
- Conservative = soften stools (increased fibre + fluids)
- Topical local anaesthetics + steroids
- O/P = rubber band ligation preferred to injection sclerotherapy
- Surgery if large symptomatic which fail to respond to above
164
PILONIDAL DISEASE
| What is the pathophysiology of pilonidal disease?
- Sinuses + cysts form near the upper part of the natal cleft of the buttocks thought to be due to hair debris collecting in intergluteal pores
165
PILONIDAL DISEASE
What is the clinical presentation of pilonidal disease?
Epidemiology?
- Presents when acute inflammation occurs leading to an abscess
- Pain can be severe, purulent discharge + fluctuant swelling
- More common in males
166
PILONIDAL DISEASE
| What is the management of pilonidal disease?
- Asymptomatic = conservative, focus on local hygiene
- Symptomatic acute = incision + drainage allowing to close by secondary intention
- Symptomatic chronic/recurrent = excision of the pits + obliteration of underlying cavity
167
ANAL FISSURES
What is an anal fissure?
What are some risk factors?
- Tears of the squamous lining of the distal anal canal
| - Constipation, IBD, STIs (HIV, syphilis, herpes)
168
ANAL FISSURES
| What is the clinical presentation of anal fissures?
- Painful, bright red PR bleeding
| - 90% on posterior midline (if elsewhere ?IBD)
169
ANAL FISSURES
| What is the management of an acute anal fissure?
<1w =
- Soften stool = diet (high fibre + fluid) + bulk-forming laxatives (or lactulose)
- Lubricants (petroleum jelly) before defecation
- Topical anaesthetics + analgesia
170
ANAL FISSURES
| What is the management of a chronic anal fissure?
- Topical GTN = first-line
| - If not effective after 8w > secondary care referral to consider sphincterotomy or botulinum toxin
171
ANAL FISTULA
| What is an anal fistula?
- Abnormal connection between ano-rectal canal + skin often secondary to anorectal abscess or Crohn's
172
ANAL FISTULA
What is the clinical presentation of anal fistula?
What investigation would you do?
What is the management?
- Persistent anal discharge, pruritus ani + perianal pain
- MRI
- Fistulotomy + excision
173
ANORECTAL ABSCESS
What is an anorectal abscess?
What are some risk factors?
- Infection of one of the anal sinuses > inflammation + abscess formation
- Anal fistulae + Crohn's disease
174
ANORECTAL ABSCESS
| What is the clinical presentation of an anorectal abscess?
- Fluctuant tender peri-anal swelling
| - May have low grade pyrexia
175
ANORECTAL ABSCESS
| What is the management of anorectal abscess?
- Early incision + drainage to prevent infection spread
