Gastrointestinal Flashcards
How do you induce remission in someone with Crohn’s?
Rx for mild + severe
Mild: 30mg Prednisolone PO
Severe: 100mg Hydrocortisone IV QDS
Hydrocortisone in saline PR
Methotrexate weekly
How do you induce remission in Crohn’s that is refractory to steroid treatment?
Infliximab (TNF antibody)
Which drugs maintain (not induce) remission in Crohns?
Azathioprine (a purine synthesis inhibitor)
/mercaptopurine
/infliximab (TNF)
Causes of GI clubbing?
Crohns/ Ulcerative colitis
Cirrhosis/ Liver diease
Coeliac disease/ Malabsorption
Weight loss and non caseating granulomas found in a persistent ulcer. Diagnosis?
Crohns
Ulcerative colitis only effects the distal gi tract
Tb would be caseating
Which type of herpes virus causes vesicles, seventh nerve palsy, vertigo, hearing loss etc?
Zoster- ramsay hunt
What part of the ear would produce mucoid discharge if you were trying to identify the site of infection?
Middle ear, outer ear doesn’t produce mucoid discharge
For children with very severe sleep apnoea, dropping saturations down to 80% how would you manage them?
Adenotonsillectomy- removing adenoids and tonsils
2 year old, temperature 39 degrees, purulent otorrhoea, pinna is laterally and inferiorly displaced. Diadnosis?
Mastoiditis-since the ear is displaced
Recurrent sinus problem with facial pain and rhinorrhoea. Antibiotics do not help. Maxillary sinus has a round opacity, mixed density mass. Likely diagnosis?
Fungal overgrowth- ie. Aspergillus may form a ball
In plummer vincent syndrome, anaemia induced oesophageal web occurs where?
Post cricoid (upper oesophagus)
36 year old with intermittent vertigo, hearing loss and tinnutis lasting 12 hours
Diagnosis, treatment?
Menieres disease
Endolymph where it should not be
Betahistine- histamine receptor antagonist
Dilates vessels in inner ear, relieving pressure and increasing neurotransmitter release to stimulate nerve endings
Child is playing with a toy and then starts coughing and the toy is gone. Where is it most likely to go?
Into the bronchus
Often find a unilateral wheeze, may be misdiagnosed as asthma
Imaging modality for subperiosteal abscess in the orbit?
CT scan
MRI would not show bony defects
Ultrasound wouldn’t extend far enough in, to visualise medial orbit
Xray wouldn’t image abscess
23 year old with left sided frontal headache, bilateral purelent nasal discharge, soft lump on forehead. Diagnosis or rare condition?
Pott’s puffy tumour
Non-neoplastic complication of acute sinusitis causing osteomyelitis or subperiosteal abscess
Rx ladder for Crohns in children?
Induce remission: Enteral nutrition + Pred ± 5-ASA
2nd (Rx resistant, early relapse): Azathioprine, Methotrexate
3rd: Infliximab, surgery
How is UC managed in children?
Induce: sulphasalazine + pred + 5-ASA (can use topical)
Maintain: sulphasalazine + 5-ASA
2nd: Azathioprine
3rd: Surgery, cyclosporin
What is the difference between UC and Crohns management?
Induce: UC uses sulfasalazine + 5-ASA, both use steroids
Maintain: all UC- sulphasalazine/ 5-ASA
2nd: both- azathioprine, Crohns + methorexate
3rd: both- surgery, Crohns infliximab
Patient has severe epigastric pain and vomiting for the last few hours, which digestive enzymes would be likely to be raised in pancreatitis?
Serum lipase (more specific)
Amylase
Trypsinogen activated peptide
Elevation of which enzyme is more specific for pancreatitis?
Lipase
Moreso than amylase
Eccymoses around the periumbilical region and flank are known as what signs and are associated with what?
GrAy Turner- flaNk
CUllens- periUmbilical
= retroperitoneal bleeding associated with pancreatitis
What does choledocholithiasis mean?
Chol = bile Doch = duct Lith = stone Iasis = condition
What is Courvoisier’s law regarding the gall bladder?
A palpable distended gallbladder is more likely to be due to neoplasm than stones.
Chronic stones cause fibrosis of the gallbladder which becomes shrunken and impalpable (however if impalpable it cannot be assumed to be stones as distended gallbladders may not be palpable)
Dilated small bowel in the epigastrium is known as the ‘sentinel sign’ characteristic of which cause of an acute abdomen?
Acute pancreatitis
= a focal area of adynamic ileus close to an intra-abdominal inflammatory process
In the Right lower quadrant, it is associated with appendicitis
Left-sided appendicitis (complex with rebound tenderness) in a 60 year old is most likely to be??
Diverticulitis
Why might there be absent bowel sounds on examination?
Diffuse peritonitis (+ shock = perforated bowel, + fever = appendicitis) Intestinal obstruction Paralytic ileus
What do calcium levels indicate in pancreatitis?
Low calcium is a poor prognostic sign as it precipitates in the abdomen as intraperitoneal fat necroses (digested by the pancreas enzymes)
What’s more common, gastric cancer or duodenal cancer?
Gastric
A lady with pigmented lesions around her lips comes in with her fifth episode of haematamesis. Likely cause of blood?
Peutz-Jeghers syndrome
Bleeding is due to vascular malformations
Increased predisposition to cancer of the lung, pancreas, liver, breast, ovaries etc
What are the two main complications of Meckel’s diverticulum?
Ectopic gastric tissue secreting acid may lead to ileal ulceration or intestinal obstruction (from volvulus or intussusception)
How is mild cognitive impairment different from dementia?
Interference with ADL = dementia
Crypt abscesses in colon suggest?
Ulcerative colitis
A patient in his 50s has Whipple’s disease, what are the typical features?
Gram +ve Tropheryma whippelii
Abdo pain, steatorrhoea + diffuse pigmentation
PAS +ve particles on duodenal biopsy
IHx needed in suspected Whipple’s disease
Steatorrhoea, abdo pain + diffuse pigmentation in someone middle-aged
Duodenal biopsy = PAS +ve macrophages
PAS stains carb macromolecules like proetoglycans
What BMI is a criteria of anorexia nervosa?
17.5
In HIV what is the cause of oral hairy leukoplakia?
EBV
When would you consider biopsy-ing a mouth ulcer?
If it has not healed after 3 weeks (to exclude malignancy)
Rx for oral candida?
Antifungals
Nystatin suspension (swill and swallow)
Amphoteracin lozenges
How does the treatment for candidiasis differ if it is for the tongue or the oropharynx?
Oropharynx, consider fluconazole
Tongue- nystatin/amphoteracin
Deficiency in which vitamins causes angular stomatitis?
Iron or Vitamin B2 (riboflavin)
Which drugs cause gum hypertrophy?
(pen, spoon + knife)
Phenytoin
Ciclosporin (immunosupressant)
Nifedipine (Ca2+ antagonist)
Which white blood cell cancer is associated with gum inflammation and hypertrophy?
Acute myeloid leukaemia (get in 50s, find auer rods)
What is the differential of a small tight mouth?
Systemic sclerosis (diffuse = Scl70, limited = anti-centromere) Burns Epidermolysis bullosa (rare inherited blistering condition of skin)
Which deficiencies cause glossitis?
Smooth red sore tongue
Iron, folate, B12
Whereas stomatitis was B2 or iron
What is the different drainage of lymph from the thirds of the tongue?
Ant 1/3 = submental
Middle 1/3 = submandibular
Post 1/3 = deep cervical
Cause of corkscrew oesophagus on barium swallow?
Diffuse oesophageal spasm (can cause intermittent difficulty swallowing)
What causes achalasia?
Degeneration of the myenteric plexus causes failure of the lower oesophagus to relax
PC: non-progressive dysphagia (for fluids and solids)
IHx findings for achalasia?
CXR: fluid level in dilated oesophagus
Barium swallow: Dilated tapering oesophagus
Vomiting that occurs an hour after food is characteristic of what gastro conditions?
Gastroparesis (diabetic mellitus, degeneration of autonomics)
What are the ‘ALARMS’ symptoms of indigestion (dyspepsia)?
Anaemia (iron deficiency) Loss of weight Anorexia Recent onset/progressive Melaena Swallowing difficulty
In those with dyspepsia under 55 years, what test should you do?
- Try lifestyle changes, antacids, stop antagonising drugs
- 13 C breath test to look for H Pylori
If +ve Rx with:
PPI + metronidazole + clarithromycin
If over 55 with new dyspepsia how should they be managed?
If haven't recently started NSAIDs Urgent endoscopy (if persisting for 4 weeks +)
How much more common is a duodenal ulcer than a gastric ulcer?
4 times
Which drugs increase your risk of duodenal ulcer?
NSAIDs
SSRIs
Steroids
Characteristically what is the difference in symptoms between dudodenal ulcers and gastric ulcers?
Duodenal ulcers are relieved by eating (or drinking milk)
Gastric ulcers are worsened with meals
For diagnosis of a duodenal ulcer by upper endoscopy, when do you need to stop taking PPIs?
2 weeks before
How long do you give PPIs for if someone has a gastric ulcer compared to a duodenal ulcer?
Gastric ulcer- 8 weeks
Duodenal ulcer- 4 weeks
Can use H2 antagonists also (ranitidine) for 8 weeks
In someone
Try PPIs (omeprazole) or H2 blockers (ranitidine) for 4 weeks
What effect do PPIs and ranitidine have on a C13 breath test for H Pylori?
Can cause a false -ve
How many heart burn episodes a week constitutes GORD?
At least 2
Or if you get a complication (oesophagitis, ulcer, benign stricture, iron deficiency)
What is the difference between dyspepsia and GORD?
Dyspepsia = bloating, belching, nausea
From ulcers, H pylori, function, gastritis etc
GORD = retrosternal pain, acid brash (regurg)
From hiatus hernia, obesity, overeating etc
What change in cell type occurs in barrett’s oesophagus?
Squamous to columnar
Increases adenocarcinoma risk
Endoscopy is normal, what else can you do to try to diagnose GORD?
24 hour oesophageal pH monitoring
± manometry (measures pressure)
Rx for GORD?
Antacids- magnesium trisilicate
Alginates- Gaviscon advance
Oesophagitis- PPI
Los Angeles 4 stages of GORD?
1- mucosal breaks 5mm long, between 2 mucosal folds
3- mucosal break over 2 mucosal folds, 75% of oesophageal circumference
What is the difference between a rolling and sliding hiatus hernia?
Sliding: gastro-oesophaeal junction slides into the chest (more gastric reflux)
Rolling: gastro-oesophageal junction remains under the diaphragm but another portion of stomach herniates into the chest (less gastrix reflux)
Best test to diagnose hiatus hernia?
Barium swallow, NOT upper GI endoscopy
Infectious causes of bloody diarrhoea?
Salmonella shigella campylobacter Invasive E Coli amoebiasis C Difficile (pseudomembranous colitis)
Common antibiotics causing C Difficile infection?
Broad-coverage Abs especially: Fluoroquinolones Cephalosporins Clindamycin Penicillins
How does an infection of the large bowl present differently to the small bowl?
Pain is relieved on deification- large bowel
Not in small bowel + pain is higher, periumbilical rather than pelvic pain
What are the 3 factors which predict fulminant C diff colitis?
Girota’s triad:
- Increasing abdominal pain/distension + diarrhoea
- Leukocytosis >18,000
- Haemodynamic instability
(Typically occurs in over 70s, those with previous C Diff infection + use of anti-peristaltic drugs)
Rx of moderate to severe C Diff infection?
Moderate/symptomatic: metronidazole
Severe: Vancomycin QDS
What are the indications for investigation in someone with constipation?
> 40
Change in bowel habit
Reduced weight, tenesmus
Anaemia, PR mucus or blood
Type of laxatives to avoid in intestinal obstruction?
Stimulants (cause it all to be compounded)
Ie. Senna, bisacodyl, docusate, glycerol
Laxative that is useful for treating constipation associated with painful anal fissures etc?
Stool softeners- parrafin, arachis oil
Good for impacted faeces
What level of bilirubin produces visible jaundice?
> 60umol/L
What does level of urobilinogen in the urine tell you?
Urobilinogen is formed when the liver breaks down bilirubin, excretes it into the intestines, where it is converted to urobilinogen and reabsorbed and then excreted by the kidneys.
As long as the path from liver to intestine is open (Aka not post-hepatic/obstructive cause) there will be urobilinogen in urine.
If no urobilinogen in stool = pale
If more conjugated bilirubin in urine (hasn’t been converted to urobilinogen) = dark
What does cholestasis mean?
Impaired hepatic excretion of bilirubin
Obstructive/post-hepatic cause of jaundice
In acute serious upper GI bleed, what drug can you give IV continuous?
Omeprazole, as a bolus dose then continuous
Prevents rebleeding
Which position of an ulcer is most at risk of re-bleeding?
Posterior duodenal ulcer- closest to the gastroduodenal artery
What factors contribute to a pre-endoscopy Rockall score for upper GI bleeds?
Age: 60-79 (1), 80+ (2)
BP + HR: HR over 100 (1), BP
On endoscopy, what findings suggest high risk of rebleeding without intervention?
Active arterial bleeding
Visible vessel
Adherent clots
What U+Es finding might suggest a recent bleed?
High urea compared to creatinine (suggests protein meal)
How soon should upper GI bleeds receive endoscopy visualisation and in what circumstances?
Variceal bleeds- 4 hours
Ongoing bleeding- within 24 hours of admission
Acute deterioration- urgently asap
Pathogenesis of oesophageal varices?
Liver fibrosis + nodules produce contractile elements in liver’s vascular bed.
Portal hypertension > splanchnic circulation dilation
More cardiac output, salt + water retention
Increased portal flow, varices form
What primary preventions can stop cirrhotic varices from bleeding?
Propranolol BD
Endoscopic banding ligation
Secondary prevention: transjugular intrahepatic port-systemic shunt if resistant to banding
IV drug to give for an acute upper gI bleed due to varices?
Terlipressin
An analogue of vasopressin- ADH which are vasoactive
How does the typical bowel prep differ for sigmoidoscopy compared to colonoscopy?
Sigmoidoscopy- phosphate enema (osmotic)
Colonoscopy- sodium picosulphate (Stimulant)
What are the route options for taking a liver biopsy and how do you decide between them?
Percutaneous is INR is okay
Transjugular with fresh frozen plasma if not
What is the risk of doing a colonoscopy when someone has diverticulitis?
Higher risk of perforation
What is the difference between hyperacute liver failure and acute liver failure?
Hyperacute: encephalopathy within 7 days of jaundice onset
Acute: encephalopathy within 8-28 days of jaundice onset
Subacute: encephalopathy within 5-26 weeks of jaundice
What findings on an ascitic tap suggest spontaneous bacterial peritonitis?
Neutrophils >250/mm
What is the pathology of fulminant liver failure?
Syndrome resulting from massive necrosis of liver cells leading to severely impaired function of the liver
Rx of cerebral oedema secondary to liver failure?
Cerebral oedema occurs as ammonia builds up gets converted to glutamine by astrocytes in the brain clearing it and resulting in a disruption to the osmotic balance
On ITU- 20% mannitol IV + hyperventilation
Rx of encephalopathy in liver failure?
Lactulose TDS to reduce numbers of nitrogen forming bacteria
Aim for 2-4 soft stools a day
(If very severe, ultimately a liver transplant)
What factors indicate a worse prognosis in liver failure?
Age > 40
Grade 3/4 encephalopathy
Drug induced liver failure
Albumin
Name some liver toxic drugs best avoided in liver failure?
TAMPON
Tetracycline (UTI, acne) Azathioprine Methotrexate (rheumatoid arthritis) Paracetamol Oestrogens aspiriN
What’s the difference between stage I, II, III and IV of hepatic encephalopathy?
All involve a behaviour/mood/personality change
I- reversed sleep pattern + poor arithmetic
II- more drowsy, confusion, slurred speech
III- incoherent, restless, stupor, liver flap
IV- coma
What three things comprise hepatorenal syndrome?
Cirrhosis
Ascites
Rena failure (where other causes have been excluded)
Abnormal circulation changes cause renal vasoconstriction, despite splanchnic dilation
What are King’s criteria for liver transplant in paracetamol-induced liver failure?
Arterial pH 100
Creatinine >300umol
Grade III or IV encephalopathy (incoherent, restless or coma)
What criteria for liver transplant are in the King’s criteria for non-paracetamol liver failure?
Prothrombin time >100
Or 3 of: Prothrombin time >50s Bilirubin >300 Drug-induced liver failure Age 40 More than a week between jaundice onset and encephalopathy
Rx to help pruritis in cirrhosis?
Cholestyramine- sequesters bile acid
How often should AFP + ultrasound be considered in those with cirrhosis and why?
3 months, look for hepatocellular cancer
Which types of cancer metastasize to the liver typically?
Breast
Bronchus
And Bowel
Which primary liver cancer presents with jaundice early on?
Cholangiocarcinoma- biliary tree cancer blocks the bile duct
In someone with suspected tongue cancer, which lymph nodes drain the different thirds of the tongue?
Ant third- submental nodes
Middle third- submandibular nodes
Post third- deep cervical nodes
How can you distinguish whether a patient has oropharyngeal dysphagia or oesophageal dysphagia?
(Difficulty swallowing)
Oropharyngeal- difficulty in initiating swallow, may cough/choke/aspirate
Oesophageal- sense of food getting stuck, difficulty comes a few seconds after initiation
IHx for someone with oesophageal dysphagia?
1st: endoscopy
2nd: barium swallow
(unless you suspect pharyngeal pouch or a stricture in the upper oesophagus from a radiotherapy stricture that might perforate, then use barium swallow first)
THEN: If motility disorder suspected- motility testing
(ie achalasia, oesophageal spasm, sclerosis, neurological)
Match the barium swallow finding with the condition:
Corkscrew oesophagus
Tapering oesophagus
- Diffuse oesophageal spasm
2. Achalasia (degeneration of myenteric plexus= fails to relax) or benign oesophageal stricture
Rx of achalasia and benign oesophageal stricture?
Endoscopic balloon dilatation
Achalasia- PPIs, Botox
= degeneration of myenteric plexus, so oesophagus doesn’t relax
Diabetic patient complains of vomiting an hour after eating, likely diagnosis?
Gastroparesis (gastric stasis)
Due to autonomic nerve degeneration
1st line IHx in patient vomiting, with suspected bowel obstruction?
Abdo Xray
Anti-emetics to avoid in bowel obstruction?
Pro-kinetic D2 antagonist:
Metoclopramide
Domperidone
Haloperidol
What are the conditions for referring a patient with dyspepsia for an upper GI endoscopy?
(Fullness after meals, early satiety, epigastric burning)
Over 55 and:
not taking NSAIDS
lasted 4 weeks
Or ALARMS:
Anaemia, loss of weight, anorexia, recent onset, malaena/haematemesis, swallow difficulty
45 year old patient feels very full after meals and gets burning in his epigastrium with eating. No alarm features. Management?
If someone gets a duodenal ulcer, what is the cause in 90% of cases?
H Pylori
Rx: full dose PPI, amoxicillin, clarithryomycin
Rx for H Pylori -ve patient with dyspepsia (under 55, no ALARMS)?
PPI or H2 blockers for 4 weeks
What do you need to advise a patient if you are going to do an endoscopy to determine if they have duodenal ulcers?
Stop PPIs 2 weeks before
When would you re-test to see if H pylori was eradicated following Rx?
If symptoms persist.
If H Pylori has gone > endoscopy
Someone with GORD is found to have intestinal metaplasia on histology when their stomach is biopsied, what follow up do they require?
Intestinal metaplasia = epithelium producing enzymes with a brush border (like the intestines do)
Surveillance every 2 years
IHx for GORD?
Same indications as ‘dyspepsia’- over 55, ALARMS, Rx-resistant, lasting 4 weeks etc
1st: endoscopy
2nd: if normal then 24hr oesophageal pH monitoring
2 common causes of steatorrhoea?
Giardiasis
Coeliac disease
3 causes of passing mucus with stools?
IBS
Colorectal cancer
Polyps
Passing frank pus with stools (not mucus) suggests what 3 causes?
IBD
Diverticulitis
Fistula/abscess
What is the risk of giving antiperistaltic agents: loperamide or codeine phosphate to someone with diarrhoea caused by colitis (UC or microscopic colitis or C Diff)?
Colitis + loperamide may precipitate
Toxic megacolon
What is Girotra’s triad predicting fulminant C Diff infection?
- Over 70
- Leukocytosis > 18000
- Haemodynamic instability
Or use loperamide/codeine (CAUSES TOXIC MEGACOLON)
Constipation + menorrhagia is likely to be due to:
Hypothyroidism
For people with constipation and faecal impaction, which type of laxative do you not want to use?
Bulking agents
Stool softeners can help
If you suspect myeloma, what three tests should you do as screening?
ESR
Blood film- rouleaux formation (RBCs stacked on top of each other)
Urine/serum electrophoresis
How do you diagnose c diff?
C diff toxin in the stool
Elisa + pcr
Why biopsy gastric ulcers?
Incase underlying it is a tumour rather than H Pylori or Ibuprofen related
Why type of cancers do you tend to get in the stomach?
Adenocarcinoma (glandular)
Or Lymphoma
Diarrhoea and a biopsy report that says intraepithelial lymphocytosis, what is the diagnosis?
Coeliac disease
Do you get granulomas in Crohns or Ulcerative Colitis?
Crohns
Which hand signs suggest chronic liver disease?
Clubbing (also coeliac, Crohns)
Leuconychia (no albumin)
Dupytren’s contractures (EtoH)
Palmar erythema
In an abdominal exam what does signs of excoriation point you towards?
Cholestasis
Patient has signs of chronic liver disease, what 4 signs should you look out for to identify the cause?
Tattoos/needle marks - hepatitis
Grey pigmentation- haemochromatosis
Cachexia- malignancy
Mid-line sternotomy- CCF
What three A’s on examination suggest decompensation of chronic liver disease?
Ascites: Shifting dullness
Asterix (high urea affecting cerebellar centres)
Altered consciousness (hepatic encephalopathy)
Causes of hepatomegaly: 3 C’s and 3 I’s
Cirrhosis
Carcinoma (secondaries)
CCF
Infections- Hep B + C
Immune- PSC, PBC, autoimmune hepatitis
Infiltrative- amyloid + myeloproliferative
To determine autoimmune causes of chronic liver failure (PBC, autoimmune hepatitis, PSC) which autoantibodies should be tested for?
Anti-mitochondrial antibodies (PBC)
Anti-smooth muscle antibodies (autoimmune hepatitis)
ERCP is used to exclude which cause of chronic liver disease?
Primary sclerosing cholangitis
PBC won’t be seen injecting dye there
When investigating cirrhosis, which blood test should be included to investigate haemochromotosis and wilson’s disease?
Iron studies- haemochromatosis (excess iron absorption)
= high ferritin + reduced TIBC*
Low caeruloplasmin- Wilson’s (binds copper to carry in the blood, which is low if the liver can’t incorporate copper into it due to mutation, and less is excreted into bile)
*total iron binding capacity
3 C’s: causes of ascites
Cirrhosis
CCF
Carcinomatosis (widespread dissemination)
Same as hepatomegaly
Causes of palmar erythema:
Resp- polycythaemia
Rheum- rheumatoid arthritis
Abdo- cirrhosis
Endo- hyperthyroidism
Pregnancy
Causes of gynaecomastia:
Kleinfelter's (XXY) Cirrhosis Drugs: spironolactone, digoxin Testicular tumour or orchidectomy Endo: Hyper or hypo thyroidism, Addison's
Liver failure and diabetes, what should you be thinking of?
Haemochromotosis- bronze diabetes
Excess iron absorption
HFE gene mutation, autosomal recessive chromosome 6
Raised ferritin
Treatment for Haemochromotosis?
Regular venesection- 1 unit a week until iron deficient
Then 3/4 times a year
Avoid alcohol
Surveillance for HCC
What is the main risk if someone with haemochromotosis develops cirrhosis?
Hepaocellular carcinoma
200x increased risk if cirrhotic
A patient has splenomegaly, what should be looked for to illicit cause?
Lymphadenopathy- haem or infective causes
(CML, myelofibrosis, EBV, infective hepatitis)
Chronic liver disease- cirrhosis + portal hypertension
Splinter haemorrhages, murmur- infective endocarditis
Rheumatoid hands- Felty’s syndrome (+neutropenia)
Indications for splenectomy?
Rupture- trauma
Haem- ITP or hereditary spherocytosis
How does anal fissure present?
Severe, sharp pain during defaecation
‘Like passing glass’
Often on inspection, can’t digitate it as too sore
Where do anal fissures most commonly occur along the anal canal?
80% Posterior (at 6 o clock- closest to the floor)
20% Anterior
What features of a fissure indicate it’s chronic?
Lasting more than 2 weeks
Use proctoscope:
Sentinel pile
Fibrosis
Fibres of internal anal sphincter
Simple measures for anal fissure?
Laxatives/stool softeners
High fibre diet
Salt bath
Topical creams:
Lignocaine
GTN cream (SE headache, which improves with time)
Calcium antagonists (diltiazem, GTN)
Why is GTN and diltiazem thought to reduce pain and help with anal fissure healing?
It is thought that the muscle pressure is too high, restricting arterial flow for healing of the fissure, so GTN helps to relax muscles (as botox does)
Chronic anal fissure Rx:
1st: GTN topical
2nd: diltiazem topical
3rd: Botox
4th: surgery (incontinence risk)- lateral internal sphincterotomy
What are the positions of the vascular cushions on the anal canal?
3, 7 and 11 o clock
Become haemorrhoids if enlarged
Which two symptoms are indications for surgery in haemorroids?
Bleeding
Prolapse
Sx associated, but not indications:
Pruritis (leakage or mucus), pain if ischaemic
Outpatient surgical treatments for haemorrhoids?
Rubber band ligation
Injected sclerotherapy
Infrared ligation
(Not definitive often, may come back)
Why doesn’t the haemorrhoid surgical treatment require much pain relief for the procedure?
The haemorrhoids originate above the dentate line, so there’s visceral innervation, non-specific
Why is metronidazole a good antibiotic option for gut surgery like haemorrhoid surgery?
It stays within the gut and is anti-inflammatory
Side effects of haemorrhoid surgical treatments?
Initial- bleeding, infection, urinary retention (from pain)
Late- anal stenosis, reoccurance, incontinence
Define a fistula:
An abnormal connection between two epithelial surfaces
A patient has multiple abscesses in their perianal region, with fever and a painful lump. What might be the underlying cause?
An anal fistula, forming as anal glands become infected, suppurate and channels form to allow the pus to drain.
Imaging to look for anal fistula?
MRI
Transanal ultrasound
Fistulography
How does the site of the opening of a perianal fistula indicate the pathway it runs in to get from the anal canal to the opening hole on the skin?
If anterior skin hole (top half nearest the head) it runs direct/oblique
If posterior skin hole (bottom half of the anus) it runs at 12 o clock down before curving round to opening
Where are most colorectal tumours found within the colon?
Descending colon- 30%
Rectum- 40%
When would you be more likely to do a flexible sigmoidoscopy compared to a colonoscopy?
Flexible sig if left sided bleeding symptoms- rectal symptoms (urgency, tenesmus) or bright bleeding
Colonscopy needs a total clear out- dehydration, electrolyte changes, fluid shifts, less safe if co-morbidities, whereas flexi-sig only needs enema on the day.
Tumour marker for colorectal cancer?
CEA
Carcinoembryonic antigen
Common sites of metastases in colorectal cancer?
Liver and lung
Patient identified to have a colorectal cancer, what imaging will be needed and why?
CT chest abdo pelvis- staging
MRI- planning operation, determining if pre or post-op chemo is needed
Difference between abdomino-perineal resection and anterior resection?
Anterior resection- go through rectum, keep rectum
Anterior perineal resection- go through abdomen, end up with a stoma
How does the site of diverticular disease differ with ethnicity?
In Far East get it in the right side, in Westernised culture, get it in the left side
If you suspect acute diverticular disease would it be better to do a CT or colonscopy?
CT- faster, less fluid shifts and will exclude differentials
What is Hartmann’s procedure for diverticulitis?
End colostomy
Removal of sigmoid colon
Ideally should be reversed but often isn’t.
How do you know if a stoma is viable?
Inspect
Use green needle
Proctoscope- see if mucosa looks viable
Finger (take bag off, should feel warmer than finger)
Difference between GORD and dyspepsia?
GORD- reflux
Dyspepsia- pain after eating, feeling full (endoscopy if over 55 + ALARM)
Drugs causing dyspepsia:
Bisphosphonates (bone strength)
NSAIDs
Calcium channel antagonists
What is the definition of toxic megacolon?
Megacolon
On xray, transverse colon >6cm
Loss of haustra
Toxic
3 of: Fever, HR>120, Neutrophils >10.5, anaemia
+ 1 of dehydration, electrolyte, disturbance, hypotension, confusion
Which criteria allows classification of ulcerative colitis severity?
Truelove Witt score
Why do a flexible sigmoidoscopy before giving steroids for ulcerative colitis?
May have CMV co-infection so may need ganciclovir before immunosuppression
How does your choice of investigation differ if you suspect Crohns in adults compared to children?
Colonscopy up to caecum has come back normal.
In children would consider upper GI endoscopy as common to get Crohns that high in the bowel.
In adults would do MRI small bowel (look for thickening, rosethorn ulcers)
Screening antibody for coeliac now?
Anti-endomysial antibody
Good dietary treatment for IBS/gluten intolerance:
FODMAP diet
If a patient has an acute pancreatitis, what might suggest gallstones over alcohol as a cause?
Transaminitis (raised ALT) or perhaps a high bilirubin suggests gallstones = obstructive picture
What sequalae may arise in acute pancreatitis?
Walled off necrosis
Pancreatic pseudocyst
ARDS
Autoantibody for Primary Biliary Cholangitis?
Anti-mitochondrial Abs
Anti-smooth muscle is autoimmune hepatitis
Why isn’t the gallbladder enlarged with gallstones?
It fibroses and shrinks down, rather than being enlarged and palpable (pancreatic cancer distally)
How can you tell from the bloods if a cirrhotic patient has portal hypertension?
Drop in platelets suggests blood backing up is leading to hypersplenism and sequestration of platelets there.
Patient has become jaundiced after a business trip to South America, would he have Hep B or Hep C?
Hep B = acute
Hep C = chronic
How is acute liver failure defined?
Onset or coagulopathy and encephalopathy within 12 weeks of onset of jaundice with no previous diagnosed liver disease
4 common causes of occult blood loss leading to iron deficiency anaemia in the GI system?
Aspirin/NSAIDs
Cancer- colon or gastric
Angiodysplasia
Benign gastric ulcer
