Gastrointestinal Flashcards
(266 cards)
1
Q
What is Wilson’s disease
A
It is an autosomal recessive disorder characterised by a reduced biliary excretion of copper and thus, accumulation of copper in the liver and brain. ATP7B Mutations
2
Q
Who is usually affected by Wilson’s disease
A
Liver disease usually presents in children
Neurological disease usually presents in young adults
3
Q
What are the signs and symptoms of Wilson’s disease
A
Liver
- Jaundice
- Easy bruising
- Variceal bleeding
- Encephalopathy
- Hepatosplenomegaly
- Ascites/Oedema
- Gynaecomastia
Neurological (6Ds)
- Drooling
- Dementia
- Dystonia
- Dysarthria
- Dysphagia
- Dyskinesis
- Ataxia
- Rigidity
- Tremor
Psychiatric
- Conduct disorder
- Personality change
- Psychosis
Eyes
- KF Rings
4
Q
What are the appropriate investigations for Wilson’s disease
A
LFTs - Abnormal
Serum Copper - Elevated
24hr Urine Copper - Elevated
Liver biopsy - Increased copper content
Genetic analysis
5
Q
What is a Volvulus
A
Rotation of a loop of small bowel around the axis of its mesentery causing bowel obstruction and potential ischaemia
65% Sigmoid
30% Caecum
6
Q
What are risk factors for Volvulus
A
Long sigmoid
Long mesentery
Mobile caecum
Chronic constipation
Adhesions
Chagas disease
Parasitic infection
7
Q
What are the signs and symptoms of Volvulus
A
Severe colicky pain & swelling & tenderness
Absolute constipation
Vomiting
Hx of transient attacks in which spontaneous reduction of the volvulus has occurred
Absent or tinkling bowel sounds
Fever
Tachycardia
Signs of dehydration
8
Q
How is Volvulus investigated
A
AXR
Erect CXR - If perforation is suspected
Water soluble contrast enema - Shows site of obstruction
CT scan
9
Q
What are the risk factors for Rectal prolapse
A
Straining
Abnormal rectal anatomy or physiology
Constipation
Cystic fibrosis
Previous trauma to the anus/perineum
Neurological conditions
Biphasic distribution
10
Q
What are signs and symptoms of Rectal prolapse
A
Initially associated with defecation
Faecal incontinence
PR mucus or bleeding
Strangulating emergency
Reduced anal sphincter tone
11
Q
What are the appropriate investigations in Rectal prolapse
A
Imaging: Proctosigmoidoscopy + Defacting proctogram or barium enema
Anal sphincter manometry
Pudendal nerve studies
12
Q
Define the 4 main types of Viral Hepatitis
A
Hep A & E: Can only cause acute infection
Hep B & D: Can cause acute and chronic disease with D only being able to infect when B is present
Hep C: Can cause an acute course and in most cases progresses to a chronic course
13
Q
Describe the causes and distribution of HAV and HEV
A
HAV is caused by picornavirus
HEV is caused by calicivirus
They are both transmitted faecal-orally
HAV is endemic in the developing world and infection often occurs sub-clinically - Acquired by travellers
HEV is endemic in Asia, africa and central America - Causes fulminant hepatitis in pregnancy
14
Q
Describe the causes and distribution of HCV
A
This is an ss-RNA virus. Many genotypes
It is transmitted parenterally (Sexual transmission, Childbirth, IDUs, Exposure to needles)
Different genotypes have different geographical prevalences
15
Q
Describe the causes and distribution of HBV and HDV
A
HBV is a ds-DNA virus
HDV is a ss-RNA virus
HBV is transmitted parenterally (Sexual transmission, Childbirth, IDUs, Exposure to needles)
Common in South east Asia, Africa and the mediterranean
16
Q
What are the signs and symptoms of HAV and HEV
A
Incubation period of 2-6 weeks
Malaise
Fever
Anorexia
N&V
- Dark Urine (High CB & UBG)
- Acholic stools
- Jaundice lasting 3 weeks
- Pruritus
- RUQ pain
- Hepatosplenomegaly
- Arthralgia and skin rash
- No stigmata of chronic liver disease
17
Q
What are investigative findings of HAV and HEV
A
Bloods
LFTs: High ALT, AST, ALP & Bilirubin + Low Albumin
FBC: High platelets
Serology
HAV:
- IgM - During acute illness (Present 3-4 weeks after exposure and Disappears after 3-6 months)
- IgG - Recovery phase and life-long persistence (Sign of previous infection or vaccination)
HEV:
- IgM - During acute illness (Present 1-4 weeks after exposure)
- IgG - Recovery phase and life-long persistence (Sign of previous infection)
Urinalysis
Bilirubin and UBG
18
Q
How is HAV and HEV managed
A
No specific management it is just supportive.
Anti-pyretics, Anti-emetics, Cholestyramine (Foe pruritus)
19
Q
What are complication of HAV and HEV
A
- Cholestatic hepatitis - Pruritus, Diarrhoea, Weight loss, Malabsorption
- Fulminant hepatitis
- Relapsing HAV
- Post-hepatitis syndrome
20
Q
What are the signs and symptoms of HCV
A
90% of acute infections are asymptomatic
10% become jaundiced with
21
Q
What are investigative findings of HCV
A
a
22
Q
How is HCV managed
A
a
23
Q
What are the complications of HCV
A
a
24
Q
What are the signs and symptoms of HBV and HDV
A
a
25
What are investigative findings of HBV and HDV
a
26
How is HBV and HDV managed
a
27
What are the complications of HBV and HDV
a
28
What is a Pilonidal sinus
This is an epithelium-lined tract filled with hair that opens onto the skin surface - Commonly in the natal cleft
29
What causes the formation of a Pilonidal sinus
It caused by shed or sheared hairs penetrating the skin and inciting an inflammatory reaction
RFs include:
- Hirsutism
- Spending a long time siting down
- Occupational
- Diabetics
30
What are the signs and symptoms of Pilonidal sinuses
Painful natal cleft
Discharging swelling- Hair
Tender if infected
31
How is a Pilonidal sinus treated
Acute - Incision and drainage
Chronic - Excision under GA with exploration
Prevention - Good hygiene + Shaving
32
What is a Perineal abscess and fistula
Perineal abscess: A pus collection in the perineal region
Perineal fistula: An abnormal connection between the epithelial surface of the outer and inner anus
Fistula develop as a complication of an abscess
33
What are risk factors for Perineal abscess and fistulae
Crohn's disease - Pepper pot perineum
IBD
DM
Malignancy
34
What are the signs and symptoms of Perineal abscess and fistulae
- Constant throbbing pain in the perineum - Tender
- Intermittent discharge (Mucus/feacal staining) near he anal region
- FHx/Hx IBD
- Small skin lesion near the opening of the anus
DRE - Thickened area over the abscess/fistula
Goodsall's Law
- Anterior <3cm will run directly into the anal canal
- Posterior or >3cm will follow a curved path and open in the posterior midline
35
How would the Perineal abscess and fistulae be imaged without surgical exploration
CT/MRI
36
How are Perineal abscess and fistulae treated
Surgical treatment
Open drainage of abscess
Laying open of fistula
- Superficial fistula can be managed by Fistulotomy avoiding the anal sphincter or Placement of Seton
- Deep fistula only placement of a Seton is an option
Antibiotics are also given
37
What are Peptic ulcer disease and gastritis
Ulceration of areas of the GI tract. More commonly in the stomach or duodenum
38
What are the causes of Peptic ulcer disease and gastritis
Imbalance between the damaging action of acid and pepsin secretions and the protective mechanisms of mucosal secretion.
H. Pylori
NSAIDs
Rare: Zollinger-Ellison syndrome (a syndrome of gastric acid hypersecretion NET)
39
What are the signs and symptoms of Peptic ulcer disease and gastritis
- Epigastric pain - Relieved by antacids
- Worse after eating (Gastric sooner than duodenal)
- Haematemesis
- Malaena
- Microcytic Anaemia
40
What are the investigative findings of Peptic ulcer disease and gastritis
```
Serum amylase (Exclude pancreatitis)
Secretin test (IV secretin will cause a rise in serum gastrin in Zollinger-Ellison)
```
OGD (First test if >55) - Biopsy rule out malignancy (Duodenal no biopsy)
Rockall scoring:
Scores the severity after a GI bleed
Score <3 carries good prognosis
>8 carries high risk of mortality
Testing for H. Pylori (First test if <55)
- C-13 Urea breath test: Radiolabelled urea taken mouth - C13 Detected in expelled air
- Serology - IgG against H. Pylori confirms exposure but not eradication
41
How are Peptic ulcer disease and gastritis treated
H pylori negative:
1st - Treat underlying cause + PPI
2nd - H2 antagonist (Ranitidine) or sucralfate or misoprostol
H pylori positive:
1st - Eradication triple therapy (PPI + Clarithromycin + Amoxicillin/Metronidazole)
2nd - Try alternative regime
3rd - PPI
Active bleed
1st - Endoscopy (Injection sclerotherapy, Laser coagulation, Electrocoagulation) + Blood transfusion
+ PPI
2nd - Surgery or embolisation via interventional radiology
42
What is Crohn's disease
This is chronic granulomatous inflammatory disease that can affect any part of the GI tract
Usually affects the ileum and colon or just the ileum
RF: Ashkenazi Jewish people
43
What are signs and symptoms of Crohn's disease
```
Crampy abdominal pain
Diarrhoea
Bloody/steatorrhoea stool
Fever, malaise, weight loss
RIF pain if ileum affected
```
Clubbing
Anaemia
Mouth ulcers
Perianal skin tags, fistulae and abscesses
Extra intestinal: Uveitis, Erythema nodosum, Pyoderma gangrenous
44
What are the investigative findings in Crohn's disease
FBC - Anaemia, High platelets, High WCC
ESR - Raised
Stool MC - Exclude infective colitis
AXR - Assess severity
Contrast radiology - Strictures, Deep ulcers (Through the submucosa - Mucosa to serosa), Cobblestone mucosa
OGD/Colonscopy + Biopsy- Definitive
Shows mucosal oedema
Fistulae/Abscesses
Transmural inflammation
Faecal calprotectin - Elevated
45
What is the treatment for Crohn's disease
Acute:
- Fluid restrict
- Corticosteroids
- 5-ASA analgoues (Mesalazine)
- Analgesia
- Parenteral nutrition
- Monitor markers of disease activity
Chronic:
- Corticosteroids for episodes
- 5-ASA analogues decreased relapse frequency (Useful for mild to moderate, better in UC)
- Immunosuppression - Azathioprine, 6-Mercaptopurine, Methotrexate
- Anti-TNF agents (Infliximab) - Very effective at inducing and maintaining remission
Surgery - Risk of reccurence due to skips
46
What are the complications of Crohn's disease
GI:
- Haemorrhage
- Strictures
- Perforation
- Fistulae (between bowel, bladder, vagina)
- Perianal fistulae and abscesses
- GI cancer
- Malabsorption
Extraintestinal Features:
- Uveitis
- Episcleritis
- Gallstones
- Kidney stones
- Arthropathy
- Sacroiliitis
- Ankylosing spondylitis
- Erythema nodosum
- Pyoderma gangrenosum
- Amyloidosis
47
What is Ulcerative colitis (UC)
Chronic relapsing and remitting inflammatory disease affecting the large bowel
Associated with pANCA and Primary sclerosing cholangitis
Ashkenazi jews
48
What are the signs and symptoms of UC
- Bloody or mucous diarrhoea (Frequency coincides with severity)
- Tenesmus and urgency
- Crampy abdominal pain before passing stool
- Weight loss
- Fever
Extra articular: Uveitis, scleritis, erythema nodosum and pyoderma gangrenosum
- Anaemia
- Dehydration
- Clubbing
- Abdominal tenderness
- Tachycardia
- DRE - Blood mucous
49
What are the investigative findings in UC
FBC - Anaemia, High WCC
ESR - High
Low albumin
Stool culture - Faecal calprotectin elevated. Eliminated infectious colitis
AXR
Colonoscopy + Biopsy - Diagnostic
Determines severity
Histological confirmation
Detection of dysplasia
Barium enema - Narrow colon, Ulcers - May be dangerous during exacerbation
50
How is UC treated
Acute
- IV rehydration
- Corticosteroids
- Antibiotics
- Parenteral feeding may be necessary
- DVT prophylaxis
Mild
Oral or rectal 5-ASA (-Alazine) and/or rectal steroids
```
Severe
Oral steroids
Oral 5-ASA
Immunosuppression - Azothioprine, 6-Mercaptopurine, Cyclosporine
Anti-TNF - Infliximab
```
Surgical - Resection
- Ileostomy bag from protocolectomy
- Ileo-anal pouch
51
What are the complication of UC
GI:
- Haemorrhage
- Toxic megacolon
- Perforation
- Colonic carcinoma
- Gallstones
- Primary sclerosing cholangitis
Extraintestinal Features:
- Uveitis
- Kidney stones
- Arthropathy
- Sacroiliitis
- Ankylosing spondylitis
- Erythema nodosum
- Pyoderma gangrenosum
- Amyloidosis
- Osteoporosis
52
What is portal hypertension
This is abnormally high pressure in the hepatic portal vein
Hepatic venous pressure gradient >10mmHg
53
What are causes of portal hypertension
Pre-hepatic:
- Congenital stenosis
- Portal vein thrombosis
- Splenic vein thrombosis
- Extrinsic compression
Hepatic:
- Cirrhosis
- Chronic hepatitis
- Schistosomiasis
- Myeloproliferatice disease
Post-Hepatic
- Budd-Chiari syndrome (Hepatic vein obstruction)
- Constrictive pericarditis
- RHF
54
What are signs and symptoms of Portal hypertension
- Haematemesis or melaena
- Lethargy, irritability, changes in sleep
- Abdominal distension
- Abdominal pain and fever
- Pulmonary involvement
- Caput medusa
- Splenomegaly
- Ascites
55
What are the investigative findings of Portal hypertension
- Abdominal US check Liver and spleen size
- Doppler US - Assess direction of blood flow in vessels
- CT/MRI - If other imaging methods are inconclusive
- OGD check for oesophageal varices
- Measure hepatic venous pressure gradient
56
How is Portal hypertension treated
Difficult to treat portal hypertension specifically
Mainly treating underlying cause
BB or Terlipressin - Reduce portal venous pressure
Transjugular intrahepatic portosystemic shunt
Liver transplant
57
What are the complications of portal hypertension
- Bleeding oesophageal varices
- Ascites + Complications of ascites (Spontaneous bacterial peritonitis, hepatorenal syndrome, hepatic hydrothorax)
- Pulmonary complication (Hepatopulmonary syndrome: Hepatic dysfunction, hypoxaemia, Extreme vasodilation)
- Liver failure
- Encephalopathy
- Cirrhotic cardiomyopathy
58
What is Peritonitis
This is inflammation of the peritoneal lining or the abdominal cavity
Localised or generalised
59
What are the different examples and causes of Peritonitis
Localised:
- Appendicitis
- Cholecystitis
- Diverticulitis
- Salpingitis
Primary generalised:
- Bacterial infection of the peritoneal cavity without an obvious source (RFs: Ascites, Nephrotic syndrome) - Ascending UTI in adolescent females
Secondary generalised:
- Caused by bacterial translocation from a localised focus
- It could also be non-bacterial due to spillage of bowel contents
60
What are signs and symptoms of Peritonitis
Inflammation of the parietal peritoneum is usually continuous, sharp and localised, exacerbated by movement and coughing
Localised:
- Tenderness
- Guarding
- Rebound tenderness
Generalised:
- Very unwell
- Systemic signs of toxaemia or sepsis
- Patient lying still
- Shallow breathing
- Rigid abdomen
- Generalised abdomen tenderness
- Reduced bowel sounds
- DRE may show anterior tenderness
61
What are the investigative finding in Peritonitis
- FBC - Low Hb, High WCC
- Ascitic tap - Hazy/Cloudy/Bloody, >250 Neutrophil count, Gram-stained bacteria, Growth in culture, Leukocyte esterase reagent strip testing of ascitic fluid -ve rules out SBP
Imaging - Erect CXR for pneumoperitoneum
AXR - Check for bowel obstruction
62
How is Peritonitis treated
Localised - Depends on cause. May be surgical may be antibiotics
Generalised:
- IV fluids
- IV antibiotics
- Urinary catheter
- NG tube
- Central venous line (to monitor fluid balance)
- Laparotomy - Remove the infected or necrotic tissue, treat cause, peritoneal lavage
- Primary peritonitis - Antibiotics
SBP:
Quinolone antibiotics or cefuroxime + metronidazole
63
What are the complications of Peritonitis
```
Septic shock
Respiratory failure
Multiorgan failure
Paralytic ileum
Wound infection
Abscesses
Incisional hernia
Adhesions
```
64
What is Non-alcoholic steatohepatitis (NASH)
Build up of fat in the liver due to causes other than excessive alcohol consumption
65
What are causes of Non-alcoholic steatohepatitis (NASH)
```
Obesity
T2DM
HTN
Hypercholesterolemia
Age >50
Smoking
```
(Cardiac risk factors)
NASH is the most common liver disorder in the developed world
66
What are the signs and symptoms of Non-alcoholic steatohepatitis (NASH)
In early stages no symptoms
Incidental finding
```
Possible:
RUQ aching pain
Fatigue
Weight loss
Weakness
Advanced = Signs of cirrhosis
```
67
What are the investigative findings in Non-alcoholic steatohepatitis (NASH)
LFTs = Raised AST, ALT, ALP, Bilirubin
| Liver US = Steatosis
68
How is Non-alcoholic steatohepatitis (NASH) managed
All conservative to prevent or slow progression to cirrhosis
```
BP
DM
Cholesterol
Smoking cessation
Weight Loss
Exercise
Reduced alcohol consumption
```
69
What are the complications of Non-alcoholic steatohepatitis (NASH)
Cirrhosis
- Ascites
- Oesophageal varices
- Hepatic encephalopathy
- Hepatocellular carcinoma
- End-stage liver failure
70
What is Mallory–Weiss tear
This is a tear in the lining of the oesophagus around the junction with stomach. Usually as a result of violent vomitting or straining of the oesophagus
71
What are risk factors of Mallory–Weiss tear
Chronic alcohol abuse
Bulimia
Trauma, intese coughing, gastritis
72
What are the signs and symptoms of Mallory–Weiss tear
Most cases do not cause any symptoms
```
Potential:
Abdominal pain
Severe vomiting prior
Haematemesis
Involuntary retching
Black tarry stools - Melaena
```
73
How is Mallory–Weiss tear investigated
OGD - Tear
| Bloods - Anaemia?
74
How is Mallory–Weiss tear treated
Most of the time the bleeding will stop on its own
If not:
Surgery - Injection scleropathy, Coagulation therapy, Arteriography
75
What is a complication of Mallory–Weiss tear
Boerhaave's perforation
76
What is Liver failure
This is sever liver dysfunction leading to:
Jaundice
Encephalopathy &
Coagulopathy
It is classified based on time interval between the onset of jaundice and the development of the hepatic encephalopathy
Hyperacute <1w, Acute 1-4w, Subacute >4w
77
What are causes of Liver failure
Viral: Hep ABCDE
Drugs: Paracetamol overdose (50% in UK), idiosyncratic drug reactions
Less common causes:
- Autoimmune Hepatitis
- Budd-Chiari syndrome
- Pregnancy
- Malignancy
- Haemochromatosis
- Mushroom poisoning
- Wilson's disease
78
What are the signs and symptoms of Liver failure
Fever, Nausea, Jaundice
```
Encephalopathy
Asterixis
Fetor hepaticus
Ascites and splenomegaly (Less common if acute or hyperacute)
Bruising or bleeding
Pyrexia
```
79
What are the investigative findings in Liver failure
Identify the cause:
- Viral serology
- Paracetamol levels
- Autoantibodies (ASM, Anti-LKM)
- Ferritin
- Caeruloplasmin and urinary copper
LFTs: Elevated AST, ALT, ALP, Bilirubin, GGT. Low Albumin
Liver US/CT
Ascitic tap - MC&S + ANC >250/mm3 = SBP
Doppler scan of hepatic or portal vein
EEG - Monitors encephalopathy
80
How is Liver failure treated
Resuscitation
Treat cause if possible: N-acetylcysteine - Paracetamol overdose
- Monitor
- Manage encephalopathy - Lactulose and phosphate enemas
- Antibiotic and anti fungal prophylaxis
- Hypoglycaemia treatment
- Coagulopathy treatment - IV vitamin K, FFP, Platelet infusions
- Gastric mucosa protection - PPIs or sucralfate
- Avoid sedatives or drugs metabolised by the liver
- Cerebral oedema decreased ICP with mannitol
Surgical - Transplant
81
What are complications of Liver failure
```
Infection
Cerebral oedema
Haemorrhage
AKI
Respiratory failure
```
82
What are the different classifications for Intestinal obstruction
- Small or large bowel
- Partial or complete obstruction
- Simple or strangulated
83
What are the causes of Intestinal obstruction
- Extramural - Hernia, Adhesions, Bands, Volvulus
- Intramural - Tumours, Inflammatory strictures
- Intraluminal - Pedunculated tumours, foreign body
84
What are the signs and symptoms of Intestinal obstruction
- Severe colicky pain with periods of ease
- Abdominal distension
- Frequent vomiting
- Absolute constipation
- Generalised tenderness
- Tinkling bowel sounds
- Peritonitis
- Hernias
85
What are the investigative findings in Intestinal obstruction
AXR
- Large bowel - Peripheral, Presence of haustration
- Small bowel - Central, Jejunum: Vulvulae conniventae, Ileum: may appear tubeless, No gas
Water soluble contrast enema
Barium follow through
86
How is Intestinal obstruction treated
- Gastric aspiration via NG tube if the patient is vomiting
- IV fluids
- Electrolyte replacement
- Monitor vital signs, fluid balance and urine output
- Surgical - Emergency laparotomy in acute obstruction
87
What are the complication of Intestinal obstruction
```
Dehydration
Bowel perforation
Peritonitis
Toxaemia
Gangrene of ischaemic bowel wall
```
88
What are the different types of Hiatus hernia
- Congenital - Asymptomatic
- Sliding
- Paraoesophageal (Rolling)
- Mixed - Sliding and paraoesophageal
- Upside down stomach
89
What are risk factors for Hiatus hernias
```
Obesity
Low-fibre
Chronic oesophagitis
Ascites
Pregnancy
```
90
What are the signs and symptoms of Hiatus hernias
Most are asymptomatic
Sliding hernias are more likely to cause symptoms
Symptoms of GORD - Heartburn and waterbrash
91
How are Hiatus hernias investigated
CXR - Gastric air bubble above diaphragm
Barium swallow
OGD
92
How are Hiatus hernias treated
Medical - Weight loss + PPI
Surgical - Nissen fundoplication (The fundus of the stomach is wrapped around the oesophagus 360)
- Belsey mark IV fundoplication - 270 degree wrap
- Hill repair - Gastric cardia is anchored to the posterior abdominal wall
93
What are the complications of Hiatus hernias
Oesophageal
- Intermittent bleeding
- Oesophagitis
- Erosions
- Barrett's oesophagus
- Oesophageal strictures
Non-oesophageal
- Incarceration of hiatus hernia (Rolling hernia)
- This can lead to strangulation and perforation
94
What are Haemorrhoids
This is when the anal vascular cushions become enlarged and engorged with tendency to protrude, bleed and prolapse in the anal canal
95
How are Haemorrhoids classified and graded
They can be internal or external
Internal: Arise from a superior haemorrhoids plexus above dentate line
External: Lie below dentate line
4 Degrees of severity:
1: Do not prolapse
2: Prolapse with defecation but reduce spontaneously
3: Prolapse and require manual reduction
4: Prolapse and irreducible
96
What are causes of Haemorrhoids
Exact cause is disputed
| RFs: Constipation, Prolonged straining, derangement in internal anal sphincter, Pregnancy, Portal hypertension
97
What are the signs and symptoms of Haemorrhoids
Usually asymptomatic
- Bleeding: Bright red on toilet paper and in pan - Not mixed in
- Absence of red flag symptoms
- Itching, Anal lumps, Prolapsing tissue
98
What are investigative findings of Haemorrhoids
DRE - Felt if thrombosed
Proctoscopy - Visualised
Rigid or flexible sigmoidoscopy - Important to exclude other causes of bleeds further upstream
99
How are Haemorrhoids treated?
Conservative
- High fibre
- Increased fluid intake
- Bulk laxatives
- Topical creams (Local anaesthetic)
Injection sclerotherapy
Banding - Higher cure rate than injection sclerotherapy but more painful
Surgery
- Reserved for symptomatic 3rd and 4th degree haemorrhoids
100
What are complications of Haemorrhoids
Bleeding
Prolapse
Thrombosis
Gangrene
101
What are causes of gastrointestinal perforation
Large bowel: Diverticulitis, Colorectal cancer, Appendicitis
Gastroduodenal: Ulcer, Gastric cancer
Small bowel (Rare): Trauma, Infection (TB), Crohn's disease
Oesophageal: Boerhaave's perforation - Forceful profuse vomiting
RFs: NSAIDs, Steroids, Bisphosphonates
102
What are the signs and symptoms of Gastrointestinal perforation
Large bowel:
- Peritonitic abdominal pain
- Important to rule out AAA
Gastroduodenal:
- Sudden-onset severe epigastric pain - Worse on movement
- Pain becomes generalised
- Gastric malignancy may have accompanying weight loss
Oesophageal:
- Severe pain following an episode of violent vomiting
- Neck/chest pain and dysphagia develop soon afterwards
```
Very unwell patients
Signs of shock
Fever
Pallor
Dehydration
Signs of peritonitis (Gaurding, rigidity, rebound tenderness, absent bowel sounds)
Loss of liver dullness
```
103
What are the investigative findings in Gastrointestinal perforation
CXR - Pneumoperitoneum
AXR - Abnormal gas shadowing
Gastrograffin swallow - Suspected oesophageal perforations
104
How is Gastrointestinal perforation treated
Resuscitation: IV antibiotics + Correct electrolytes and fluids
Surgery
Pleural lavage + Somethings
105
What are the complications of Gastrointestinal perforation
Large and Small Bowel: Peritonitis
Oesophageal: Mediastinitis, shock, overwhelming sepsis and death
106
What is Gastro-oesophageal reflux disease (GORD)
This is inflammation of the oesophagus caused by reflux of gastric acid and/or bile
107
What are the causes of GORD
Disruption of mechanisms that prevent reflux:
- Lower oesophageal sphincter
- Acute angle of junction
- Mucosal rosette
- Intra-abdominal portion of oesophagus
- Prolonged acid clearance - 50%
BMI
Alcohol
Smoking
108
What are the symptoms of GORD
- Heartburn - Burning discomfort (Lying down, Bending, Large meals, Alcohol)
- Acid regurgitation
- Dysphagia
- Bloating
- Aspiration - Hoarness, laryngitis, nocturnal cough
Relieved by antacids
Potential:
Wheeze and tenderness
109
What are the appropriate investigations for GORD
Clinical diagnosis with further confirmation by PPI trial
- OGD - Exclude malignancy, oesophagitis
- Barium swallow - Hiatus hernia, Peptic stricture, extrinsic compression of the oesophagus
- Ambulatory pH monitoring
110
How is GORD treated
Conservative:
- Weight loss
- Elevating head of bed
- Lower fat meals
- Avoid large meals late in the evening
Medical:
- Antacids
- Alginates
- H2 antagonists (Ranitidine)
- PPIs
Annual endoscopic surveillance - Barrett's
Refractory surgery/Nissen fundoplication
111
What are the complications of GORD
```
Barrett's
Adenocarcinoma
Oesophageal ulceration
Anaemia
Associated asthma and chronic laryngitis
```
112
What is Biliary colic
This is pain resulting from obstruction of the gall bladder or CBD usually by a stone
113
What are risk factors for Biliary colic
The pain is due to the contraction of the biliary tree against the stone
```
6Fs
Fair - White
Fat
Fertile - Pregnancy + Exogenous oestrogen
Forty - Increasing age
Female
FHx
```
114
What are the signs and symptoms of Biliary colic
RUQ/Epigastric pain + tenderness
N&V
Postprandial pain
115
What are the investigative findings in Biliary colic
LFTs - Elevated ALT, ALP, Bilirubin
Lipase and amylase - Elevated 3 times in acute pancreatitis
Abdominal US - Diagnostic
ERCP - High risk - Also diagnostic
116
How is Biliary colic treated
Symptomatic:
Cholecystectomy
Choledocholithiasis
1. ERCP
A Lithotripsy, balloon dilation, stenting
2. Laproscopic CBD exploration
Asymptomatic:
Observational unless risk of cancer or complications
117
What are complications of Biliary colic
```
ERCP - Pancreatitis
Iatrogenic bile duct injury
Cholecystitis
Ascending cholangitis
Acute biliary pancreatitis
```
118
What is Cholecystitis
This is gallbladder inflammation and is one of the major complications of cholelithiasis
10% of symptomatic gallstones
119
What are the different types of gallstones
Mixed stones 80% - Cholesterol, Calcium bilirubinate, Phosphate, Protein
Pure cholesterol stones 10%
Pigment stones 10% - Black stones made from calcium bilirubinate - Increased Bilirubin
120
What are risk factors for Cholecystitis
```
Forty
Female
Fat + DM
Fertile - High oestrogen states + Octreotide
Fair - White
FHx
```
Pigment stones - Haemolytic disorders e.g. sickle cell anaemia
121
What are the signs and symptoms of Cholecystitis
Systemically unwell
Fever
Prolonged abdominal pain (Referred to right shoulder)
```
Tachycardia
Fever
RUQ pain
Guarding or rebound tenderness
Murphy's sign +ve
```
122
What are the appropriate investigations for Cholecystitis
FBC - Elevated WCC
CRP - Elevated
LFTs - Elevated ALT, ALP, GGT, Bilirubin
RUQ US - Pericholecystic fluid + Thickened and distended gallbladder
Murphy's sign positive
123
How is Cholecystitis treated
Supportive: IV fluids, NBM, NSAIDs
IV Antibiotics - Cefuroxime or ciprofloxacin and metronidazole
Early LC only by skilled surgeon
124
What are complications of Cholecystitis
```
Perforation
Suppurative Cholecystitis
Gangrenous Cholecystitis
BD injury
Gallstone ileus
```
125
What is Acute cholangitis
This is infection of the biliary tree
126
What are causes of Acute cholangitis
Cholelithiasis leading to choledocholithiasis leading to obstruction
Iatrogenic biliary injury during Cholecystectomy or ERCP
Benign stricture - Chronic pancreatitis, Radiation induced, Chemotherapy
Malignant stricture
Sclerosis Cholangitis - 2nd Leading cause
Parasitic infection of the bile duct (Ascariasis)
127
Who is typically affected by Acute cholangitis
Age 50 - 60
1% of cholelithiasis
Latin Americans and American Indians
128
What are signs and symptoms of Acute cholangitis
Charcots triad:
RUQ pain
Fever
Jaundice
Reynolds pentad (Severe):
Hypotension
Altered mental status
Acholic stools
Pruritus
129
What are the investigative findings in Acute cholangitis
```
FBC - High WCC
U&ES - High urea and creatinine
LFTs - High ALT, AST, ALP, Bilirubin
Coag panel
CRP - Elevated
Blood culture
```
Abdominal US
ERCP
130
How is Acute cholangitis treated
1. IV antibiotics - Cefepime & metronidazole
+ decompression - ERCP/PTC
A - lithotripsy - Large stone
A - Analgesia - Opiods
2. Surgical decompression -
IV antibiotics + Opiods
131
What are the complications of Acute cholangitis
Acute pancreatitis
Hepatic Abscess
Inadequate drainage
132
What are prognostic factors in Acute cholangitis
High bilirubin, Fever, WCC, Age
| or Low Albumin
133
What is Alcohol withdrawal and what causes it
Patients with alcohol dependance with sudden drop in consumption of alcohol.
Occurs 4-12hrs after stopping
Caused by over active SNS due to NMDA up regulation and GABA down regulation
134
What are the signs and symptoms of Alcohol withdrawal
Mild:
- HTN
- N&V
- Fine tremore
Moderate:
- Agitation
- Coarse tremor
Severe:
- Delirium
- Tonic-clonic seizures
- Hallucinations
- Hyperthermia
135
What are the appropriate investigations in Alcohol withdrawal
U&Es - Metabolic acidosis +/- Hypokalaemia
LFTs - Potential additional diagnosis of alcoholic hepatitis
Ethanol - If ethanol levels are still high during withdrawal then there may be risk of severe AWS
CT head - Exclude IC causes
CXR - Exclude cardiopulmonary causes
136
How is Alcohol withdrawal treated
1st Line: Benzodiazepine (Diazepam) or clomethiazole
+ Supportive
A - Phenobarbital - Severe
A - Vitamin supplementation - Thiamine, Folic acid, Mg sulphate
Severe + ICU:
A - Dexmedetomidine - Makes Benzos more effective
Benzo resistant + ICU:
A - Propofol
137
What are complications of Alcohol withdrawal
```
Over sedation
Delirium tremens 5%
AW seizures
Status epilepticus <3%
Mortality
```
Usually persistent insomnia for 6 months
50% remain abstinent for a year
138
How does one get Alcoholic hepatitis
Drinking a lot!
Women 20-40g/day
Men 40-80g/day
For 10-12 years!
This leads to Alcoholic hepatitis or liver cirrhosis
The less severe form is Alcoholic fatty liver
Females + Obesity
139
What is the CAGE questionnaire
The CAGE questionnaire is commonly used as an alcohol misuse screening tool because it is fast, easy, and effective:
C: Have you ever felt you needed to CUT down on your drinking?
A: Have people ANNOYED you by criticising your drinking?
G: Have you ever felt GUILTY about drinking?
E: Have you ever felt you needed a drink first thing in the morning (EYE-OPENER) to steady your nerves or get rid of a hangover?
140
What are symptoms of Alcoholic hepatitis
Fatigue
N+V
Anorexia
Weight loss
Jaundice
Fever
RUQ discomfort
141
What are signs of Alcoholic hepatitis
Face: Telangiectasia, Parotid enlargement
Hands: Palmar erythema, Dupuytren's contracture, Clubbing
Hormonal: Gynaecomastia, testicular atrophy
Organomegaly: Hepatomegaly, Splenomegaly
General: Spider naevi, Easy bruising, Malnourished, Ascites, Encephalopathy, Jaundice, Fever
142
What are appropriate investigations for Alcoholic hepatitis
FBC - Elevated WCC, Low Hb, Platelets, High MCV
LFTs - High AST, ALT, ALP, GGT, Bilirubin, Low Albumin
U&Es - Normal or low Na, K, Mg, Phosphate. Normal or high Urea, Creatinine
Coagulation profile - PT and INR Elevated
Hepatic US - Hepatomegaly, Fatty liver, Portal hypertension
OGD - Varices
Biopsy
143
How is Alcoholic hepatitis treated
1. Abstinence + withdrawal management
+ Weight reduction + smoking cessation
+ Nutritional supplementation + multivitamins
+ Immunisations
A - Corticosteroids
A - Sodium restriction
A - Pentoxifylline - Prophylactic reduce risk of Hepatorenal syndrome
144
What are complications of Alcoholic hepatitis
```
Portal hypertension
Hepatic encephalopathy
Hepatorenal syndrome
Renal failure
Coagulopathy
GI bleeding
Sepsis
HCC
```
145
What is an anal fissure
This is a split in the distal anal canal characterised by pain on defecation and PR bleeding
146
What are causes of Anal fissures
Hard stool
Constipation (Opiates)
Ischaemia - Anterior/POsterior midline deficiency in NO
147
What are signs and symptoms of Anal fissure
Pain of defecation
Burning after initial sharp pain
PR bleeding on wiping or fresh in bowel
Posterior midline cut
Anal ulcer - Crohns, TB, syphilis, HIV, Anal cancer
148
How are Anal fissures treated
1st line: Conservative - High fibre, more water, sitz baths and topical analgesia. Stool softeners
A - Topical GTN - Promotes healing
A - Topical Diltiazem - No headache side effects
Recurrent
1st: Botulinum toxin
1st: Surgical sphincterotomy
2nd: Anal advancement flap
149
What is the prognosis of Anal fissures
60% heal 6-8 weeks
| 20% after diltiazem
150
What are the symptoms of Appendicitis
```
Periumbilical pain that moves to the right iliac fossa
Anorexia
Vomiting
Constipation
Diarrhoea
```
151
What are the signs of Appendicitis
```
Tachycardia
Fever
Furred tongue
Lying still
Coughing hurts
Foetor with/without flushing
Shallow breaths
```
RIF:
PR Pain on right side
Guarding
Rebound and percussion tenderness
Special signs:
Rovsing's - Palpation of LIF causes pain in RIF
Psoas - pain of hip extension - Retrocaecal appendix
Cope - Pain on flexion and internal rotation of hip - Close to obturator internus
Retrocaecal/peritoneal appendix can cause flank pain or RUQ pain
152
What are the investigative findings in Appendicitis
Bloods - Elevated WCC & CRP
CT - High sensitivity
Pregnancy test - Not ectopic
153
How is Appendicitis treated
Prompt appendicectomy
Antibiotics: Cefuroxime and metronidazole
154
What are complications of Appendicitis
Perforation
Generalised peritonitis
Abscess
155
What is Achalasia
Loss of LOS closer
Loss of coordinated peristalsis
Due to oesophageal smooth muscle fibres failing to relax
156
What causes Achalasia
Progressive degeneration of the ganglion cells in myenteric plexus within the oesophageal wall (Smooth muscle).
```
Primary achalsia (Most common)
- No known underlying cause
```
Secondary achalasia
- Oesophageal cancer
- Chagas disease - Protozoan infection due to Trypanosoma Cruzi leads to loss of intramural ganglion cells and therefore incomplete LOS relaxation and aperistalsis (Central & South America)
157
What are the signs and symptoms of Achalasia
Insidious onset and gradual progression
- Dysphagia with solids and liquids
- Reguritation
- Heartburn - Unresponsive to PPIs
- Chest pain - Retrosternal
- Difficulty belching
- Hiccups
- Weight loss
- Aspiration of food - Aspiration Pneumonia
158
What are the investigative findings in Achalasia
Endoscopy
- Excludes malignancy
- May show retained food
Barium swallow x-ray and continuous fluroscopy
- Dilated oesophagus (Double right heart border) which smoothly tapers down to sphincter (Bird-beak appearance)
- Air-fluid margin over barium column due to lack of peristalsis. Abscence of normal gastric air buble.
Manometry - Diagnostic
- Elevated resting LOS pressure (Greater than 45mmHg)
- Incomplete LOS relaxation
- Aperistalsis in the distal oesophagus
Maybe serology for antibodies against Trypanosoma Cruzi if Chagas disease is suggested
159
What is Autoimmune hepatitis
This is chronic inflammatory disease of the liver
Characterised by:
Auto-antibodies
Hyperglobulinaemia
A favourable response to immunosuppressive treatment
160
What are the causes of Autoimmune hepatitis
HLA-DR3/4 association
Complex interaction between:
1. Genetic predisposition
2. Environmental triggering agents
3. Auto-antigens
4. Dysfunction of immunoregulatory mechanisms
Classifications
Type 1: ANA, ASMA, pANCA, Anti-SLA
Type 2: Anti-LKM1, Anti-LC1
Type 1 occurs in all ages but mainly young women
Types 2 essentially only affects girls and young women
161
What are the signs and symptoms of Autoimmune hepatitis
```
Fatigue + Malaise + Lethargy
Anorexia
Nausea
Abdominal discomfort
Mild pruritus
Arthralgia of small joints
```
Rarely: Fever, oligomenorrhoea, encephalopathy, GI bleeding
Sign: Hepatomegaly, Jaundice, Splenomegaly, Spider Naevi
162
How is Autoimmune hepatitis diagnosed
Bloods
LFTs - Raised AST, ALT, Bilirubin, GGT and ALP, Raised globulin, Low Albumin
Coagulation Profile - Prolonged PT
Imaging
Abdominal ultrasound - Diagnose hepatic biliary obstuction
Liver Biopsy but after treatment is being prescribed
```
Other
ANA
SMA
Alpha-1 antitrypsin
Loads of other antibodies
```
163
What are Liver abscesses and cysts
Abscesses: Liver infection resulting in a walled off collection of pus
Cysts: Liver infection resulting in a walled off collection of cyst fluid
164
What are causes of Liver abscesses and cysts
```
Pyogenic - Pus - Most common in industrialised
- E. coli
- Klebisiella
- Enterococcus
- Bacteriodes
- Streptococci
- Staphylococci
60% are caused by biliary tract disease
15% have unknown causes
```
Amoebic abscess - Entamoeba histolytica - Most common worldwide
Hydatid cyst - Tapeworm - Common in sheep-rearing countries
165
What are the symptoms of Liver abscesses and cysts
```
Fever
Malaise
Nausea
Anorexia
Night sweats
Weight loss
RUQ/Epigastric pain - Tender
Jaundice
Diarrhoea
```
Ask foreign travel!!
Right side: Reactive Pleural Effusion
166
How are Liver abscesses and cysts diagnosed
Bloods
FBCs - Leukocytosis, elevated neutrophil count, Anaemia
LFTs - Elevated ALP, Mildly ALT & AST & Bilirubin, Hypoalbuminaemia
Cultures - Pyogenic potentially
US - Variably echoic lesion
Contrast-enhanced CT - Hypodense liver lesion
Gram stain and culture of aspirated abscess fluid
Pyogenic potentially
Other
CXR
Serum antibody test
167
What is Barrett’s oesophagus
Change in the normal squamous epithelium of the oesophagus to the specialised intestinal metaplasia (simple columnar epithelium, goblet cells - Usaully found in the lower GI tract)
This is a premalignant condition.
168
What are causes of Barrett’s oesophagus
The primary aetological factor is gastro-oesophageal reflux (GORD). There is evidence that bile reflux is also involved.
Chronic acid exposure causes reflux esophagitis and therefore metaplastic change.
Squamous epithelium to Simple Columnar epithelium
```
Risk Factors
Acid/bile reflux/GORD
Age - Older more likely
White
Male (2 times more likely)
Hiatus Hernia
```
Obesity
Family history
Smoking
169
What the signs and symptoms of Barrett’s oesophagus
Symptoms of GORD are the key feature:
- Heartburn
- Regurgitation
- Nausea
- Water-brash
Many patients are asymptomatic
Atypical Symptoms
- Chest Pain
- Voice Changes
- Respiratory symptoms (Dyspnoea or Wheezing)
- Dysphagia
170
How is Barrett’s oesophagus diagnosed
OGD with biopsy - Abnormal epithelium characteristic of Barrett's Oesophagus. The Z line boundary is migrated proximally
Barium Oesophagogram - May be intial test if there is dysphagia
Identifies Hiatus Hernia and reflux
171
How is Barrett's oesophagus treated
Non-dysplatic
1 - PPI + Surveillance
A - Radiofrequency ablation if high risk of progression (Older white men)
2 - Anti reflux surgery + Surveillance
Low grade
1 - Radiofrequency ablation with or without endoscopic mucosal resection
High grade
1 - Radiofrequency ablation with or without endoscopic mucosal resection
+ PPI
2 - Oesophagectomy
172
What is Liver cirrhosis
This is end stage chronic liver disease
- Fibrosis
- Normal liver architecture to structurally abnormal nodules known as regenerative nodules
173
What are the causes of Liver cirrhosis
Cirrhosis can be derived from chronic liver disease - The primary event is hepatic fibrosis due to over activation of the hepatic stellate cells which are the major source of extracellular matrix
Alcoholic liver disease: Most common UK cause
Worldwide the most common causes are chronic hepatitis C followed by non-alcoholic fatty liver disease (steatohepatitis) and chronic hepatitis B
Drugs: Methotexate, Hepatotoxic drugs
Inherited: alpha 1-Antitrypsin deficiency, Haemochromatosis, Wilson's disease, Galactosaemia, Cystic Fibrosis
Vascular: Budd-Chiari syndrome or hepatic venous congestion
Chronic biliary disease: PBC, PSC, biliary atresia
Cryptogenic is idopathic - 5-10%
Risk Factors
- Alcohol misuse
- IV drug use
- Unprotected intercourse
- Obesity
- Blood transfusion
- Tattooing
174
What are the symptoms of Liver cirrhosis
```
Symptoms:
Fatigue
Weakness
Anorexia + Weight loss
Nausea
```
Decreased liver synthetic function:
- Easy bruising
- Abnormal swelling
- Ankle oedema
Reduced detoxification function:
- Jaundice
- Encephalopathy
- Amenorrhoea
- Galactorrhoea
Portal hypertension:
- Abdominal swelling - Ascites
- Haematemesis - Oesophageal Varices
- PR bleeding or melaena
Decompensated if complicated by any of:
- Ascites
- Jaundice
- Encephalopathy
- GI bleed
175
What are the signs of Liver cirrhosis
General - Jaundice
Hands and Nails - Leukonychia, Palmar erythema, Spider Naevi, Clubbing, Dupuytren's contracture
Facial - Telangiectsia, Bruising, Rhinophyma, Parotid swelling, Paper-dollar skin, Seborrhoeic Dermatitis, Jaundiced sclerae, Xanthelasma
Chest - Gynaecomastia & Loss of secondary sexual hair in men, breast atrophy in women, Spider Naevi
Abdominal - Ascites, hepatomegaly, splenomegaly, Abdominal distension, Hepatic bruit, Loss of secondary sexual hair and testicular atrophy in men, Caput medusae
Lower extremity swelling
176
How is Liver cirrhosis diagnosed
Bloods
- LFTs - Deranged! Raised AST and ALT, Raised GGT, Normal or Raised Bilirubin, Reduced Albumin, Prolonged PT
- FBC - Reduced Platelet count,
- Electrolytes - Reduced Sodium
- Viral Serology - Antibodies to Hep B/C may or may not be present
Other
- Iron studies - Raise total Iron, Reduced TIBC, Raised transferrin saturation and ferritin in haemochromatosis.
- Anti-self antibodies (ANA, ASMA, AMA) - Autoimmune hep
- Alpha 1 anti-trypsin
- Ceruloplasmin - Wilson's disease
Ascitic tap:
- MC&S - Signs of infection
Liver Biopsy - Most sensitive diagnostic
Abdominal US, CT, MRI - Ascites, splenomegaly, collateral circulation
OGD - Varices
```
Child-Pugh grading:
- Class A is score 5-6
- Class B is score 7-9
- Class C is score 10-15
It is based on: 1s are as follows
- Albumin >35, 35-28, <28
- Bilirubin <2, 2-3, >3
- PT <4, 4-6, >6
- Ascites None, Mild, Moderate
- Encephalopathy None, Grade 1-2, Grade 3-4
```
177
How is Liver cirrhosis treated
1st Line - Treatment of underlying cause of CLD and prevention of superimposed hepatic insult
+ Monitoring for complications
- Portal HTN, Hepatorenal syndrome, HCC
- Encepathopathy
- SBP - Antibiotics: Cefuroxime and metronidazole. Prophylaxis against SBP with ciprofloxacin
A - Sodium restriction and diuretic therapy for ascites
- Spironolactone and or Furosemide
- Avoid alcohol and NSAID due to their hepatotoxicity
2nd Line - Liver transplant (Especially if decompensated)
178
What is the most lethal complication of Liver cirrhosis
Gastro-oesophageal varices
| 20% mortality after 6 weeks
179
What is Coeliac disease
This is a systemic autoimmune disease triggered by dietary gluten peptides causing chronic intestinal malabsorption
180
What causes Coeliac disease
Sensitivity to Gliadin component of gluten
HLA-B8/DR3/DQW2
Rare in East Asia
FHx component
181
What are the signs and symptoms of Coeliac disease
May be asymptomatic
```
Diarrhoea
Bloating
Abdominal pain
Fatigue
Weight loss
Intese itchy blisters - Dermatitis herpetiformis
Failure to thrive in children
```
```
Signs of anaemia
Signs of malnutrition:
- Short stature
- Abdominal distension
- Wasted buttocks in children
- Triceps skin fold thickness gives indication of fat stores
Signs of vitamin/mineral deficiencies:
- Osteomalacia
- Easy bruising
```
182
How is Coeliac disease diagnosed
Bloods
FBC - Low Hb
Serology
- Immunoglobulin A-tissue transglutaminase (IgA-tTG) - Titre above normal range for lab - 1st Line investigation
- Endomysial Antibody (EMA) - Elevated titre
- IgG DGP - Elevated titre
- IgG-tTG - Elevated titre
Histology - Diagnostic test
Presence of intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia - Gold standard diagnostic
Endoscopy
Atrophy, Scalloping of folds, Nodularity
Other
HLA typing - HLA-DQ2 or DQ8
Skin bipsy for dermatitis herpetiformis
Gluten challenge
183
How is Coeliac disease treated
1st Line - Gluten-free diet
Plus - Calcium and Vitamin D supplementation +/- Iron
Refractory
1st Line - Gluten-free diet
Plus - Calcium and Vitamin D supplementation +/- Iron
Plus - Referral to dietician or gastroenterologist
Crisis
1st Line - Gluten-free diet
Plus - Calcium and Vitamin D supplementation +/- Iron
Plus - Rehydration + Correction of electrolyte abnormalities
Adjunct - Corticosteroid - Short course
184
What are the complications of Coeliac disease
```
Iron, B12, Folate deficiency
Osteomalacia
Ulcerative jejunoileitis
GI lymphoma (T-cell)
Bacterial Overgrowth
Cerebellar ataxia
```
185
What are the different stages of Diverticular disease
Diverticulosis is the herniation/out-pouching of the mucosa and submocusa through the muscle layer of the colonic wall.
Diverticular disease is the presence of diverticulosis associated with symptoms. These include, haemorrhage, infection and fistulae
Diverticulitis is the acute inflammation and infection of the colonic diverticulae
Classifications
- Asymptomatic diverticulosis
- Symptomatic uncomplicated diverticular disease
- Complicated diverticular disease
Hinchey's Classification of Acute Diverticulitis
Stage I - Small/confined mesenteric abscess
Stage II - Large paracolic abscess
Stage III - Perforated diverticulitis with purulent peritonitis
Stage IV - Perforated diverticulitis with faecal peritonitis
186
What are risk factors for Diverticular disease
```
Low dietary fibre
Increasing age
Western diet
Obesity
NSAIDs
```
Ehler's-Danlos syndrome/Herniosis - Saint's triad (Hiatus hernia, Diverticulosis, Gallstones)
187
What are the signs and symptoms of Diverticular disease
90% Asymptomatic
```
Reccurent LIF pain
Fever
Bloating
Constipation
Diarrhoea
```
```
PR bleeding
Diverticulitis - LIF and fever
Diverticular fistula - Pneumaturia, faecaluria and recurrent UTIs
Pelvic tenderness on DRE
Rebound tenderness and Guarding
```
188
How is Diverticular disease diagnosed
Bloods
- FBC - polymorphonuclear leukocytosis - Acute
- CRP - Raised
Barium enema - Diagnostic but not in acute setting because there is a high risk of perforation
Flexible sigmoidoscopy - Diagnostic visualisation
In acute setting: CT AP may be used look for evidence of diverticular disease and complications
189
How is Diverticular disease treated
GI bleed: PR bleeding is often managed conservatively with nil by mouth, IV
rehydration, antibiotics, blood transfusion if necessary.
Diverticulitis: Nil by mouth, IV antibiotics (cephalosporin and metronidazole)
and IV fluid rehydration.
Chronic: High-fibre diet with bulking agent (e.g. methylcellulose). Laxatives
may be required if constipation is severe. Encourage high fluid intake.
Surgery: May be necessary with recurrent attacks or when complications develop,
e.g. severe bleeding or infection.
Sigmoid colectomy, Hartmann’s procedure,
fistulectomy or drainage of pericolic abscesses are some operations performed.
190
What is Primary biliary cirrhosis (PBC)
Chronic inflammation liver disease involving progressive destruction of intrahepatic bile ducts leading to cholestasis and ultimately cirrhosis
Autoimmune
191
Who is affected by PBC
Middle-aged women 9:1
192
What are signs and symptoms of PBC
Asymptomatic
```
Fatigue
Pruritus preceding jaundice
Xanthomas
Skin pigmentation
Hepatomegaly
Ascites
Signs of chronic liver disease
```
Other autoimmunity: Sjogren's syndrome, RA, Raynaud's
193
How is PBC diagnosed
Bloods
LFTs: Increased ALT, AST, ALP, GGT, Bilirubin. Decreased Albumin. Prolonged PT
(Transaminases normal until later disease)
AMA (Anti-Mitochondrial Antibodies)
High IgM
High Cholesterol
ANA
US scan: Obstructive duct lesions must always be excluded radiologically before the diagnosis of PBC is made
Biopsy: Not usually needed anymore
194
What is Primary sclerosing cholangitis (PSC)
Primary sclerosing cholangitis is inflammation and fibrosis of the intrahepatic and/or extra hepatic bile ducts resulting in diffuse, multi focal stricture formation
195
Who is usually affected by PSC
Males with IBD
4% of people with UC have it
80% of people with PSC have UC
196
What are the signs and symptoms of PSC
```
RUQ pain
Pruritus
Fatigue
Fever
Jaundice
```
197
How is PSC diagnosed
LFTs - first line - GGT elevated
MRCP - Diagnostic - Beading
AMA antibodies should be negative
ANCA - May be present
198
What are risk factors for Pancreatic cancer
```
Age
Smoking
DM
Chronic pancreatitis
Dietary (Low intake of fresh fruit and vegetables)
2x Male
```
199
What are signs and symptoms of Pancreatic cancer
Initial nonspecific
Weight loss
Anorexia
Painless Jaundice and a palpable gallbladder (Courvoisier's law)
Epigastric tenderness or mass
Met-Hepatomegaly
Trousseau's sign of malignancy - Superficial thrombophlebitis
200
How is Pancreatic cancer diagnosed
Bloods
- CA19-9
- CEA is also elevated
- Obstructive jaundice - High bilirubin, ALP and deranged clotting
Imaging
US
CT +/- biopsy (Diagnostic)
ERCP = May allow biopsy
201
What are the 2 types of Oesophageal cancer
Squamous cell carcinoma
| Adenocarcinoma
202
What causes each type of Oesophageal cancer
Squamous cell (Most common worldwide)
- Alcohol
- Achalasia
- Scleroderma
- Coeliac disease
- Plummer-Vinson syndrome
- Dietary toxins
Adenocarcinoma (Most common western)
- GORD
- Barrett's oesophagus
3x Men
203
What are the signs and symptoms of Oesophageal cancer
- Progressive dysphagia (Initially worse with solids)
- Odynophagia
- Weight loss
- Hoarseness
- Hiccups
Mets - Liver and lungs
204
How is Oesophageal cancer diagnosed
OGD with biopsy - Diagnostic
205
What are causes of Intestinal ischaemia
Embolus (60%)
Thrombosis (40%)
Volvulus
Intussusception
Bowel strangulation
Failed surgical resection
RFs:
AF
Endocarditis can throw emboli
Arterial thrombosis: Hypercholesterolaemia, HTN, DM, smoking
Venous thrombosis: Portal HTN, splenectomy, septic thrombophlebitis, OCP, thrombophilia
206
What are the signs and symptoms of Intestinal ischaemia
- Severe colicky pain + Tenderness
- Vomiting
- Rectal bleeding
- Hx of chronic mesenteric artery insufficiency - Gross weight loss + Post prandial abdominal pain
- Hx heart or liver disease
Distension
Mass
Bowel sounds absent
207
How is Intestinal ischaemia diagnosed
Diagnosis is based on clinical suspicion or after laparotomy
AXR - Thickening of the small bowel folds and signs of obstruction
ABG - Lactic acidosis
Mesenteric angio is stable
208
What are associated risk factors for Hepatocellular carcinoma
Chronic liver disease: ALD, HEP C, Autoimmune Hep
Metabolic disease: Haemochromatosis
Aflatoxins: Cereals contaminated with fungi
209
What are the signs and symptoms of Hepatocellular carcinoma
Malaise
Weight loss
Loss of appetite
```
Distension
Jaundice
Hepatomegaly
Ascites
Bruits over liver
Lymphadenopathy
```
210
How is Hepatocellular carcinoma diagnosed
Bloods -
FBC - Microcytic anaemia and thrombocytopenia
LFTs - Elevated ALT, AST, ALP, Bilirubine, Low albumin
U&Es - Hyponatraemia and high urea
Alpha-fetoprotein - Elevated (60%)
Imaging
Abdominal US
CT - Gold standard staging
211
What are the different types of Gastric cancer
Adenocarcinoma
Lymphoma
Leiomyoscarcoma
Stromal tumours
212
What are risk factors for Gastric cancer
```
Smoked and processed foods
Smoking
Alcohol
H. Pylori
Atrophic gastritis
Pernicious anaemia
Partial gastrectomy
Gastric polyps
```
Highest incidence in Japan
213
What are the signs and symptoms of Gastric cancer
```
Early satiety
Epigastric discomfort
Systemic symptoms: weight loss, anorexia
Dysphagia
Met - Liver
Anaemia
```
Virchows node
Sister Mary Joseph Nodule (Metastatic node on the umbilicus)
Krukenberg's tumour (Ovarian metastases)
214
How is Gastric cancer diagnosed
OGD
Endoscopic US (EUS) - After diagnosis - Assess depth of gastric invasion and lymph node involvement
CT - Aid with mets
215
What is Haemochromatosis
This is a multisystem genetic disorder of dysregulated dietary iron absorption and increased iron release from macrophages - Autosomal recessive (HFE gene)
216
Who is usually affected by Haemochromatosis
Middle aged
White
Men
FHx
217
What are the signs and symptoms of Haemochromatosis
Asymptomatic until the last stage of the disease
```
Fatigue
Weakness
Lethargy
Arthalgias
Impotence
Loss of libido
```
```
Skin pigmentation
Hepatomegaly + Cirrhosis
Congestive heart failure
Porphyria cutanea tarda
Diabetes mellitus
```
218
What are the investigative findings in Haemochromatosis
Serum ferritin
Bloods
Iron studies - Ferritin raised, Transferrin Low, Transferrin saturation raised, TIBC Low
CRP - Inflammation
LFTs - ALT raised in liver necrosis
Other liver tests
HFE mutation analysis
Liver biopsy
219
What is Amyloidosis
This is heterogenous group of diseases characterized by extracellular deposition of amyloid fibrils
Any histological tissue specimen that binds the cotton wool dye, Congo red, and demonstrates green birefringence when viewed under polarised light is an amyloid deposit.
Deposition may be localised in tissue or part of a systemic process
220
What are the different types of Amyloidosis
There are 3 types of Amyloidosis:
- Primary amyloidosis (Immunoglobin light chain amyloidosis - AL)
- Secondary amyloidosis (Non familial or familial periodic fever syndrome - AA)
- Inherited forms (AF)
```
AL
Potential predisposing conditions:
- Multiple myeloma,
- Waldenstroms macroglobulinaemia
- B-cell lymphoma
- MGUS
```
AA
- Chronic inflammatory diseases (RA, Seronegative arthritides, Crohn's disease, familial mediterranean fever)
- Chronic infections (TB, bronchiectasis, osteomyelitis)
- Malignancy (Hodgkin's disease, renal cancer)
AF
Autosomal dominantly transmitted mutations in the gene for transthyretin
221
What are risk factors for Amyloidosis
- Monoclonal gammopathy of undetermined significance
- Inflammatory polyarthropathy - Rheumatoid arthritis, juvenile arthritis, psoriatic arthritis, Ankylosing spondylitis
- Chronic infections - Bronchiectasis, Subcutaneous injections of illicit drugs, decubitis ulcers, chronic UTIs and osteomyelitis
- IBDs - Crohn's
- Familial periodic fever syndromes - Familial Mediterranean fever and TNF receptor associated
- Castleman's disease
222
What are signs and symptoms of Amyloidosis
AL is associated with restrictive cardiomyopathy and peripheral neuropathy
AA is associated with nephrotic syndrome and hepatosplenomegaly
Symptoms:
- Weight loss
- Fatigue
- Dyspnoea
- Paraesthesias
Signs:
- Lower extremity oedema
- Elevated JVP
- Periobital amyloid purpura
- Eyelid petechiae
- Macroglossia
- Enlargement of submandibular salivary glands
- Palpable hepatomegaly, splenomegaly
- Shoulder pad sign
- Diffuse muscle weakness
- Amyloid peripheral neuropathy
223
How is Amyloidosis diagnosed
Initial:
- Serum Immunofixation - Prescence of monoclonal protein - 60% - AL
- Urine Immunofixation - 80% -AL
- Immunoglobulin free light chain assay - Extremely high sensitivity for AL
- Bone marrow biopsy - AL
Diagnostic - Tissue biopsy to prove the tissue stains positive for Congo red. Apple-green birefringence is seen when Congo red stained material is viewed under polarised light
Immunohistological studies of amyloid deposits - To distinguish the type of Amyloidosis
224
What are risk factors for Cholangiocarcinoma
Chronic liver disease due to hepatitis B or C leading to cirrhosis, alcoholic liver disease, non-specific cirrhosis, bile duct diseases, choledocholithiasis, cholecystolithiasis, UC and HIV. Primary sclerosing cholangitis
- Age >50
- Diabetes
- Cigarrette smoking
- Exposure to toxins/medicines - PCBs, isoniazid, oral contraceptives, chronic typhoid carriers
225
What are the signs and symptoms of Cholangiocarcinoma
```
Obstructive jaundice
Acholic stools
Dark urine
Pruritus
Abdominal pain or fullness
Systemic symptoms of malignancy: Weight loss, malaise, Anorexia
```
Palpable gallbladder - Courvoisier's Law - Presence of a non-tender palpable gallbladder and jaundice is unlikely to be due to gallstones
Epigastric/RUQ
Hepatomegaly
226
How is Cholangiocarcinoma diagnosed
LFTs - Elevated ALP, Bilirubin, GGT
PT Prolonged
Cancer markers: CA19-9, CEA
serum CA 19-9 + (40 times CEA) Equation used to calculate the likelihood of tumour progression. PPV of 100%, CA-125 Dectable in up to 65% of patients
Abdominal US - Malignancy vs Benign
ERCP - Tissue diagnosis and therapeutic
227
What is the distribution of Colorectal carcinomas
60% - Rectum and sigmoid
30% - Descending colon
10% - Rest of colon
228
What are risk factors for Colorectal carcinoma
- Western diet (Red meat, alcohol)
- Colorectal polyps
- Previous colorectal cancer
- FHx
- IBD
Familial forms:
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC)
229
What are the signs and symptoms of Colorectal carcinoma
Left-sided colon:
- Change in bowel habit
- Rectal bleeding (blood or mucus mixed with the stools)
- Tenesmus (due to a space-occupying tumour in the rectum)
Right-sided colon:
- Presents later
- Anaemia symptoms (lethargy)
- Weight loss
- Non-specific malaise
- Lower abdominal pain (rare)
20% of the tumours present as an emergency with pain and distension due to:
- Large bowel obstruction
- Haemorrhage or peritonitis due to perforation
Abdominal mass
Met - Hepatomegaly + Ascites
Low-lying rectal tumours may be palpable on DRE
230
How is Colorectal carcinoma diagnosed
FBC - Anaemia
LFT - Deranged with met
Renal function - Just in case pelvic tumour is compressing on ureter
Colonoscopy requires full bowel preparation with oral laxatives - Multiple biopsies required
Double contrast Barium Enema - May show 'apple core' strictures
Contrast CT - Duke's staging
231
What is Irritable bowel syndrome (IBS)
This is a chronic condition characterised by abdominal pain associated with bowel dysfunction. There are recurrent episodes of abdominal pain/discomfort for >6 months of the previous year, associated with 2 of the following:
- Altered stool passage
- Abdominal bloating
- Symptoms made worse by eating
- Passage of mucous
232
What are risk factors of IBS
```
Physical and sexual abuse
Age <50 years
Female sex
Previous enteric infection
Family and job stress
Food intolerance (Lactose)
```
233
What are the signs and symptoms of IBS
- Abdominal pain/discomfort
- Altered bowel habits
- Pain relieved by defecation
- Abdominal bloating
- Passage of mucus with stools
- Sensation of incomplete evacuation following a bowel movement
Carnett test (Pain on tightening the abdomen = abdominal wall, Less pain on tightening = intraperitoneal pain)
234
How is IBS investigated
Bloods
FBC - Normal though anaemia suggests non-IBS disease
Stool studies
Stools - Normal though WBCs in stools or parasites suggest non-IBS diseasea
Antibodies
- Anti-endomysial antibodies - Negative though positive in coeliac disease
- Anti-tTG antibodies - Negative though raised in coeliac disease
Imaging
- Plain abdominal x-ray - Normal, abnormal bowel position suggests obstruction
Endoscopy
- Flexible sigmoidoscopy - Normal, abnormal mucosa suggests IBD
- Colonscopy - Normal, Muscosal inflammation or ulceration suggests IBD
Other
- Hydrogen breath test - Lactase deficiency
- Faecal calprotectin - Lower than 40micrograms IBD unlikely
- Serum CRP - Lower than 0.5mg/L IBD unlikely
235
How is IBS treated
Advice: Dietary modification
Medical: Depends on the main symptoms affecting the patient
- Antispasmodics (e.g. buscopan)
- Prokinetic agents (e.g. domperidone, metaclopramide)
- Anti-‐diarrhoeals (e.g. loperamide)
- Laxatives (e.g. Senna, movicol, lactulose)
- Low-‐dose tricyclic antidepressants (may reduce visceral awareness)
Psychological therapy:
- CBT
- Relaxation and psychotherapy
236
What is Gastroenteritis/Infectious colitis
This is acute inflammation of the lining of the GI tract manifested by N+V, Diarrhoea and Abdominal discomfort
237
What are causes of Gastroenteritis/Infectious colitis
Can be caused by viruses, bacteria, protozoa or toxins contained in contaminated food or water
(Incubation/Duration)
Viral:
- Rotavirus (Young) (1d/7d),
- Norovirus (Adults) (1d/4d),
- Enteric adenovirus 40+41 (3-10d/9d)
```
Bacterial:
- Camplyobacter Jejuni
- E Coli (0157 - Enterohaemorrhagic)
- Salmonella
- Shigella
Vibrio cholerae
Listeria
Yersinia enterocolitica
```
Protozoal:
- Entamoeba histolytica
- Cryptosporidium parvum
- Giardia lamblia
```
Toxins:
Staphylococcus aureus
Clostridium botulinum
Clostridium perfringens
Bacillus cereus
Mushrooms
Heavy metals
Seafood
```
Commonly contaminated food: - Meat (S. aureus, C, Perfringens)
- Old rice (B. cereus, S. aureus)
- Eggs and poultry (Salmonella)
- Milk and cheeses (Listeria, Campylobacter)
- Canned food (Botulism)
- Travel generally - E. coli causes traveller's diarrhoea
- Travel to Asia, Africa and South America - Rotavirus
- Travel to Asia or Central America - Vibrio Cholera
- Travel to developing countries - Giardia, Aeromonas, Cryptosporidium (Water)
- Recent Antibiotics (C Dif)
- Daycare - Rota
- Homosexual men - Shigella, Campylobacter, Salmonella
238
What are the signs and symptoms of Gastroenteritis/Infectious colitis
Sudden N+V and anorexia
- Diarrhoea
- Abdominal pain or discomfort
- Increased bowel sounds
- Dehydration
Fever and malaise
Time onset:
Toxins - Early within a day
Microorganism = 12hrs+
Botulinum = Paralysis
Mushrooms can cause fits renal or liver failure
239
How is Gastroenteritis/Infectious colitis investigated
FBC/blood culture/U&Es/dehydration assessment
CXR/AXR: colitis 'thumbprinting' of submucosal swelling
Stool culture: Sortibtol MacConkey agar (E.coli O157:H7),
240
How is Gastroenteritis/Infectious colitis treated
- Bed rest
- Fluid and electrolyte replacement with oral rehydration solution (contains glucose and salt)
- IV rehydration may be necessary in those with severe vomiting
- Most infections are self-limiting (so will go away with time)
- Antibiotic treatment is only used if severe or if infective agent has been identified
- NOTE: if botulism is present (due to Clostridium botulinum) treat with botulinum antitoxin (IM) and manage in ITU
- NOTE: this is often a notifiable disease and is an important public health issue
241
What are complications of Gastroenteritis/Infectious colitis
```
Dehydration
Electrolyte imbalance
Sepsis and shock
]Haemolytic uraemia syndrome associated with toxins from E. coli O157
GBS weeks after campylobacter
Botulinum may cause paralysis
```
242
What is a Hernia
The abnormal protrusion of peritoneal sac through a weakness of the abdominal wall in the inguinal region
243
What are the main types of Hernias
Direct inguinal:
- Protrusion of the hernial sac directly through a weakness in the transversals fascia and posterior wall of the inguinal canal
- Arises medial to the the inferior epigastric vessels
- Appear through Hesselbach's triangle (Lateral border of rectus abdominal, inferior epigastric vessel, Inguinal ligament)
Indirect inguinal:
- Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal
Femoral:
- Occur just below the inguinal ligament when abdominal contents pass though a naturally occurring weakness in the abdominal wall called the femoral canal
Umbilical: Women during and after pregnancy and overweight people
244
What are causes of Hernias
Congenital: Abdominal contents enter the inguinal canal through a patent processes vaginalis
Acquires - Due to increased IAP along with muscles and transversals fascia weakness
```
RFs:
Male
Prematurity
Age
Obesity
Constipation
Bladder outflow obstruction
Intraperitoneal fluid
Heavy lifting
```
Female (Femoral)
245
What are the signs and symptoms of Hernias
Asymptomatic
Lump in groin
May cause discomfort or pain
May be irreducible
Tender is strangulated
Auscultation there may be bowel sounds over the hernia
Cough impulse
246
How are Hernias diagnosed
Clinical diagnosis
Diagnostic uncertainty: US
CT - Contrast: Very obese
247
How are hernias treated
Surgical
- Usually elective repair of uncomplicated hernia
- Hernia reduced and a mesh is inserted to reinforce the defect in the transversals fascia
Emergency
- If obstructed or strangulated
- Laparotomy with bowel resection may be indicated if the bowel is gangrenous
248
What are the complications of Hernias
Incarceration
Strangulation
Bowel obstruction
Maydl's hernia - W loop
x
249
What is Acute pancreatitis
Acute inflammation of the pancreas with variable involvement of other regional tissues
Mild: Minimal organ dysfunction and uneventful recovery
Severe: Organ failure and/or local complications such as necrosis, abscesses and pseudocysts
250
What are causes of Acute pancreatitis
GET SMASHED
```
Gallstones
Ethanol
Trauma
Steroids
Mumps/HIV/Coxsackie
Autoimmune
Scorpion venom
Hypercalcaemia/Hypertryglceridaemia
ERCP
Drugs (Valproate, Steroids, thiazides, azathioprine)
```
251
What are the signs and symptoms of Acute pancreatitis
Severe Epigastric pain and tenderness radiating to the back - Relieved by sitting forward and aggravated by movement
Fever
Shock
Decreased bowel sounds
Severe:
- Cullen's sign (Periumbilical bruising)
- Grey-Turner signs (Flank bruising)
252
How is Acute pancreatitis diagnosed
Serum amylase/lipase (3x upper limit)
FBC
LFTs
MRCP
US
Gold standard: CT scan with contrast
253
What are the scoring systems used in Acute pancreatitis
Glasgow score, APACHE II score and ransom score used to assess severity
Poor prognosis:
Glasgow >3
APACHE >8
Ranson >8
```
Glasgow
PaO2 - <8kPa
Age - >55
Neutrophils, WCC - >15
Calcium - <2
Renal, Urea - >16
Enzymes, LDH >600 or AST >200
Albumin <32
Sugar, Glucose >10
```
254
How is Acute pancreatitis treated
Medical:
- Fluid and electrolyte resuscitation
- Urinary catheter and NG tube if vomiting
- Analgesia
- Blood glucose control
- HDU and ITU support if necessary
- Prophylactic antibiotics may be useful in reducing mortality
ERCP and sphincterotomy:
Used for gallstones in the presence of cholangitis.
If there is gallstones with no cholangitis a cholecystectomy is preferred.
Surgical:
If there is a sterile pancreatic necrosis then catheter drainage or a necrosectomy can be performed
If it is infected then IV antibiotic should be given before drainage or necrosectomy
255
What are complications of Acute pancreatitis
```
Pancreatic necrosis
Pseudocyst
Abscess
Ascites
VT
```
```
Multiorgan failue
Sepsis
Renal failure
ARD
DIC
Hypocalcaemia
Diabetes
```
256
What is Chronic Pancreatitis
Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain
257
What are the causes of Chronic pancreatitis
Alcohol - 70%
Idiopathic - 20%
Rare: Recurrent acute pancreatitis, ductal obstruction, pancreas divisor, hereditary pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism
258
What are the signs and symptoms of Chronic pancreatitis
Recurrent severe epigastric pain and tenderness radiating to the back relieved by sitting forward
Aggravated by eating or drinking alcohol
Over year:
Weight loss
Bloating
Steatorrhoea
259
How is Chronic pancreatitis diagnosed
Bloods:
High glucose
Faecal elastase-1 - Low
Abdo US
ERCP - Gold standard
260
How is Chronic pancreatitis treated
General:
- Treatment is mainly symptomatic and supportive (e.g. dietary advice, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia)
- Chronic pain management may need specialist input
Endoscopy Therapy:
- Sphincterotomy
- Stone extraction
- Dilatation and stenting of strictures
- Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal
Surgical:
- May be indicated if medical management fails
- Lateral pancreaticojejunal drainage (modified Puestow procedure)
- Pancreatic resection (pancreaticoduodenectomy or Whipple's procedure)
- Limited resection of pancreatic head (Beger procedure)
- Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)
261
Outline Vitamin A deficiency
Fat soluble - Absorbed in the small intestine
Found in Liver, Milk and eggs (Protein generally)
Deficiency due to malnutrition, poor conversion from carotene to vitamin A or reduced absorption
S+S: Night blindness then as the diseases progresses, the cornea becomes hazy and can develop erosions which can lead to its destruction and eventually complete blindness.
Can also get drying, scaling and follicular thickening of the skin due to keratinisation of skin
Respiratory infections due to keratinisation of mucous membranes in respiratory tract.
T: Daily oral vitamin A supplements/Dietary intake
262
Outline Vitamin B1 (Thiamine) deficiency
Absorbed in small intestine
Beri-beri and Werincke's encephalopathy
Wet Beriberi - There is heart failure with general oedema
Dry Beriberi - Neuropathy
RFs:
- Diets consisting of high levels of milled rice and raw freshwater fish
- High consumption of tea, coffee and betel nuts
- Alcoholic state
- Starvation state
- Prolonged vomiting
- Gastric bypass surgery – due to limited caloric intake post surgery
- Parental nutrition without adequate thiamine supplementation
S+S: Wet: palpitations, SOB, leg swelling, tachycardia
Dry: Numbness of peripheries, confusion, trouble moving legs, pain
T: Thiamine (Pabrinex) I, Oral supplementation to continue after IV
263
Outline Vitamin B3 (Niacin) deficiency
Pellagra
Niacin found in beans, milk and eggs
Dementia
Diarrhoea
Dermatitis
```
S+S:
Loss of appetite
Generalised weakness
Irritability and aggression
Abdominal pain
Vomiting
Stomatitis.
Bright red glossitis.
Vaginitis.
Oesophagitis.
Dermatitis - classically, a pigmented, scaly rash prominent in sun-exposed skin
```
T: Oral supplementation
264
Outline Vitamin C deficiency
Scurvy
Important for wound healing
265
Outline Vitamin E deficiency
Fat soluble
266
Outline Vitamine K deficiency
Fat soluble
