Gastrointestinal Flashcards
Features of coeliac
- Wheat intolerance –> villous atrophy and malabsorption
- Sx: Weight loss, offensive stools, diarrhoea, fatigue
- Ix: Anti-transglutaminase, biopsy
- Tx: gluten free diet
Causes of pancreatitis
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps/ Malignancy
- Autoimmune
- Scorpion/ spider bite
- Hypercalcaemia/thyroid/lipidaemia
- ERCP
- Drugs- azathioprine, oestrogens, thiazides, isoniazid, steroids, NSAIDs
Functional causes of bowel obstruction
- Paralytic ileus- post abdo surgery, pancreatits, spinal injury. NO BOWEL SOUNDS.
- Pseudo-obstruction- Ogilvies syndrome
Presentation of colorectal cancer
- Left sided- PR bleed, diarrhoea/constipation, mass on PR, tenesmus, ++ obstruction
- Right sided- Iron deficient anaemia, weight loss, abdo pain, fatigue
- Rectal- PR bleed, tenesmus
- General- Weight loss, loss of appetite, obstruction, perforation
What is Budd-Chiari syndrome?
Occlusion of hepatic vein Triad:
- Abdo pain
- Ascites
- Hepatomegaly
Jaundice- Post-hepatic causes
Conjugated
- Gallstone/ cholangitis
- External compression- PSC, pancreatic cancer, Mirrizi syndrome
- Drugs- flucloxacillin, fusidic acid, nitrofurantoin, sulfonylureas
Features of large bowel obstruction
- More gradual onset.
- Continual pain.
- Normal bowel sounds
- Metabolic acidosis
- AXR- Peripheral. Haustra partial width of bowel.
Psoas sign
Pain on extension of hip. (Appendicitis)
Pancreatic cancer 2 week wait criteria
- >40y with jaundice
- >60 years + weight loss and 1 of: diarrhoea, back pain, abdo pain, nausea, vomiting, constipation, new onset DM
Signs of chronic liver disease
- Hepatosplenomegaly
- Encephalopathy
- Constructional apraxia
- Jaundice
- Ascited
- Spider naevi (>5)
- Caput medusae
- Oesophageal
- Varices
- Palmar erythema/ Dupuytren’s
- Bruising
- Testicular atrophy
- Gynaecomastia
- Peripheral oedema
- Asterixis
- Clubbing
Definition of SBP
Neutrophils >250/mm3
Features and management of Wilson’s
- Copper in liver and CNS
- Sx: Liver failure, tremor, dysarthria, dyskinesias, parkinsonism, kayser-fleischer rings
- Ix: Urine 24h copper excretion, serum caeruloplasmin
- Tx: Penacillamine
Alcoholic liver disease bloods
- AST:ALT 2:1
- Normal Alk phos
- Raised GGT
- Macrocytic anaemia
- Raised IgA
Bacterial infections that cause gastroenteritis
- Campylobacter- milk, poultry, water
- Salmonella- meat, eggs, poultry
- E. Coli
- Shigella- ++ blood
- C. Diff- ABx, PPIs. Green watery stool. Risks: Perforation, toxic megacolon
Causes of small and large bowel obstruction
- Small- adhesions, hernias
- Large- Colon Ca, constipation, diverticular stricture, volvulus, caecal
Features of delirium tremens
- 2-3d later
- Hallucinations
- Seizures
- Confusion
Dyspepsia management
- lifestyle and stop high risk drugs
- PPI eg lansoprazole (risk C. Diff)
- H2 receptor antagonist eg ranitidine (X with CYP450)
- Antacids eg aluminium hydroxide
Appendicitis ABx
Metronidazole + cefuroxime
Conditions associated with IBD
APICES
- Apthos ulcers
- Pyoderma gangrenosum
- Iritis
- Clubbing
- Erythema nodosum
- Sclerosing cholangitis
Causes of acute liver failure
- Infection
- Metabolic eg Wilson’s, haemachromatosis
- Alcohol
- AI
- Fatty liver
- Pre-eclampsia/ HELLP
- Drugs
Features of duodenal ulcer
- 4x more common
- 50% ASx
- Sx- Epigastric pain RELIEVED by eating
- Ix- upper GI endoscopy
Features of Korsikoff’s
- Often after Wernicke’s
- Confabulation
- Amnesia
Features of chronic colonic ischaemia
- ‘Ischaemic colitis’
- Left lower abdominal pain +/- bloody diarrhoea
- Ix= Lower GI endoscopy
- Tx: IVT, ABx, surgical resection
Indications for stool sample in gastroenteritis
- Travel
- Institutional care
- ??Outbreak
Genetic RF for colorectal cancer
- Lynch syndrome (HNPCC)- small no. adenomas with rapid malignancy. Aspirin prophylaxis
- FAP- 1000s adenomas
Gastritis RF
- H. Pylori
- Alcohol
- NSAIDs
- Hiatus hernia
- CMV
- Crohn’s
- Sarcoidosis
Indication for upper GI endoscopy
- Dysphagia or >55y with persistent alarms symptoms
H. Pylori triple therapy
- PPI + 2x ABx
- Lansoprazole
- Amoxicillin (metronidazole if pen allergic)
- Clarithromicin
Treatment of ascities
- Bed rest
- Fluid and salt restriction
- Spironolactone
- Daily weights and U+Es
Presentation of pancreatic cancer
- Painless jaundice
- Weight loss + anorexia
- Steatorrhoea
- Epigastric pain –> back. Relieved by sitting forward
- ?Acute pancreatitis
- Epigastric mass
- Hepatosplenomegaly
- Lymphadenopathy
- Portal hypertension
- Hypercalcaemia
- Coirvoisier’s law- jaundice, palpable GB
- Thrombophlebitis migrans
What is GORD? Symptoms and RF.
- Gatroesophageal Ruflux Disease Reflux of stomach contents –> 2 or more heart burn episodes/ week.
- Sx- heartburn, belching, water brash, chronic cough
- RF- Hiatus hernia, pregnancy, obesity, alcohol, smoking, overeating, H. Pylori
Murphy’s sign
Hand on RUQ –> breath in –> sharp pain
Only +ve if -ve on left
Key features of UC
- Colon and rectum
- Diffuse.
- Mucous
- RF: non-smokers, 15-30y or >50y
- Sx- diarrhoea **BLOOD**, weight loss, tenesmus
- Complications- ++ Colorectal cancer, toxic megacolon, VTE, hypokalaemia
Features of inguinal and femoral hernias
- Indirect- through deep and superficial ring. Doesn’t come out if deep ring occluded. More common. Commonly into scrotum
- Direct- though superficial ring. Comes out when deep ring occluded. Rarely into scrotum.
- Femoral hernias- more in women. Most likely to strangulate.
Signs of peritonitis
- Fever +/- rigors
- Severe generalised abdo pain –> back/ shoulders.
- Worse with movement/ coughing
- Guarding and rigidity
- Septic
Jaundice- Pre-hepatic causes
- Unconjucated hyperbilirubinaemia
- Haemolysis- haemolytic anaemia, DIC, antimalarials
- Impaired hepatic uptake- contrast, RHF Impaired conjugation- Gilbert’s Physiological neonatal jaundice (combo of above)
Colorectal cancer 2 week wait referral
- >40y with unexplained weight loss and abdo pain
- >50y with unexplained rectal bleeding
- >60 with one of: Fe deficient anaemia, change in bowel habit, tenesmus, FOB
- ?Rectal/abdominal mass
- ?<50y with rectal bleeding and 1 of: abdo pain, change in bowel habit, weight loss, iron deficient anaemia
Features of gastric ulcer
- RF- H.Pylori, smoking, NSAIDs
- Sx- Epigastric pain made WORSE by meals and relieved by antacids
- Ix- upper GI endoscopy + biopsies. Repeat 6-8w to rule out malignancy
What is Barrett’s oesophagus?
Distal oesophagus epithelium from squamous –> collumnar. Metaplasia –> dysplasia –> neoplasia
Key features of Crohn’s
- Mouth to anus. Esp terminal ileum
- Patchy. Transmural.
- RF: smoking, esp 20-40y
- Sx: diarrhoea, abdo pain, weight loss, fever, lethargy, anorexia, mouth ulcer, perianal skin tags, arthritis
- Complications- SBO, fistulae
Pancreatic cancer Ix and Tx
- Ix: Bm, Ca19-9, USS, CT, ERCP
- Tx: Palliative, Whipples, CBD stent
2 week wait criteria for upper GI endoscopy
- Dysphagia
- >55y with weight loss and 1 of: upper abdo pain, reflux, dyspepsia
Antibiotics in gastroenteritis + their indication
Ciprofloxacin
Indications- unwell ++, elderly, immunosuppressed
Rovsing’s Sign
Pain in RIF when LIF pressed. Seen in appendicitis.
Features of IBS
- Recurrent abdo pain associated with at least 2 of:
- Relief by defecation
- Altered stool form
- Altered bowel frequency
- FLUCTUATING
- Doesn’t wake from sleep
Charcot’s triangle
= Cholangitis RUQ, fever, obstructive jaundice
Features of norovirus
- Fever
- Abdominal pain
- Diarrhoea
- Projectile vomiting- “winter vomiting illness”
Dyspepsia ALARMS symptoms
- Anaemia (iron deficient)
- Loss of weight
- Anorexia
- Recent/ progressive change
- Melaena/ haematemesis
- Swallowing difficulty
Presentation of acute liver failure
- Jaundice
- Hepatic encephalopathy- confusion, flap
- Fetor hepaticus
- Constructional apraxia
Liver cancer presentation
- Jaundice (late)
- Weight loss
- Anorexia
- Malaise
- Fever
- RUQ liver capsule pain
- Abdo mass Bruit
Grading and management of hepatic encephalopathy
- altered mood, sleep disturbance, dyspraxia
- drowsiness, confusion, inappropriate behaviour +/- flap
- Incoherent, stupor, liver flap
- coma. GCS<8
- Ix= ammonia
- Tx= lactulose +/- rifaxamin
Types of obstruction
- Simple
- Closed loops (2 points of obstruction) –> grossly distended with risk of perforation.
- Strangulated- blood supply compromised. ++pain, localised peritonism, Fever, high WCC.
Causes of acute lower GI bleed
- Anal fissure
- Haemorrhoids
- Polyps
- Diverticular disease
- IBD
- Colon cancer
- Ischaemic colitis
- Radiation proctitis
- Upper GI bleed
- Angiodysplasia
IBD investigations
- Bedside- NEWS, stool culture and faecal calprotectin
- Bloods- FBC, U+Es, LFTs, ESR, CRP, culture, coags, B12, folate
- Imaging- AXR, colonoscopy, MRI, USS
Features of Auto-immune hepatitis
- Markers: ANA/ASMA, IgG, raised ALT
- Any age any sex
- Ix: Biopsy
- Tx: immunosuppression- azathioprine, prednisolone
RF for acute mesenteric ischaemia
- !!! AF !!!
- Hypercoaguable state
- Poor cardiac output
- Renal failure
- Trauma
- Vasculitis
- Radiation
What is dysentry?
Diarrhoea with blood
Treatment of oesophageal varices
- ABCDE +/- IVT/ transfusion
- Tx based on Child-Pugh score- risk of variceal bleeding in cirrhossis
- Blachford score- guides acute management
- Rockall score= post-endoscopy prognosis
- Terlipressin + ABx Endoscopic banding
Causes of acute upper GI bleed
- Peptic ulcer
- Oesophageal varices
- Mallory-Weiss tear
- Oesophagitis
- Swallowed blood- epistaxis
- Upper GI cancer
- AVM
- Underlying coagulopathy
- High risk meds- NSAIDs, blood thinners, aspirin, steroids
Features and treatment of hepatorenal syndrome
- Cirrhosis + ascites + renal failure
- Tx: type 1= terlipressin, haemodialysis type 2= transjugular intrahepatic portosystemic shunt
Features of haemachromatosis
- Iron deposition in joints, liver, heart, pancreas, pituitary, adrenals, skin
- Sx: Tired, arthralgia, slate-grey pigmentation, cirrhosis, cardiomyopathy
- Tx: venesection
Features of Wernicke’s encephalopathy
Low thiamine Triad:
- Ophthalmoplegia
- Altered GCS
- Ataxia
Phlegmon
RUQ mass of inflamed omentum/ bowel
UC management
- ABCDE
- Mild- mesalazine, topical steroids
- Mod- PO prednisolone
- Severe- IVT, IV hydrocortisone, VTE prophylaxis
- Day 3-5 decline –> rescue therapy: ciclosporin, infliximab
- Immunomodulation- azathioprine if >2 steroids/ year. CHECK TPMT LEVELS
- All fail –> colectomy
Antibiotic treatment for peritonitis
Metronidazole + Cefuroxime
Features of primary sclerosis cholangitis
- Markers: ANCA, raised ALP
- Men>women. Esp IBD (UC)!!
- Sx: ASx, jaundice, RUQ pain, cholangitis?
- Ix: MRCP- beeding in large duct, Biopsy- onion skin in small duct
- Tx: Sx control, ERCP
Presentation of bowel obstruction
- Vomiting
- Nausea
- Anorexia
- Abdominal distention
- Constipation
- No flatus
Jaundice- Hepatic causes
- Mixed conjugated and unconjugated
- Infection- Hep A/B/C, CMV, EBV
- Drugs- paracetamol OD, isoniazid, rifampicin, MAOi, statins, sodium valproate
- Alcohol
- Cirrhosis
- Genetic- haemachromatosis, Wilson’s, alpha1 antitryptase AI hepatitis Budd-Chiari
Crohn’s management
- ABCDE
- Mild- Prednisolone PO
- Severe- IV hydrocortisone Immune modulation- azathioprine/ methotrexate
Causes of liver decompensation
- Sepsis
- Bleed
- Medication - new/ OD, paracetamol
- Constipation
- AKI
Presentation of gastric cancer
- Non-specific
- Early satiety
- Dyspepsia
- Weight loss
- Vomiting
- Dysphagia
- Anaemia
Liver screen bloods
- LFTs
- Coags/ PT
- Hep A/B/C serology
- EBV
- CMV
- AMA, ASMA, Anti-LKM, ANA, pANCA
- Immunoglobulins- IgM, IgG
- Alpha-1 antitrypsin
- Serum copper
- Ceruloplasmin
- Ferratin
- Paracetamol level
Management of acute upper GI bleed
- Ix: UO, ABG, bloods including X-match, OGD
- Tx: ABCDE + fluid/ transfusion. ??SHOCK
- NBM
- analgesia
- X anti-coags/ NSAIDs
- Endoscopy
- PPI post endoscopy
Symptoms and complications of diverticular disease
- Altered bowel habit
- L abdo pain relieved by defecation
- Nausea
- Flatulance
- PR bleed
- Complications- haemorrhage, perforation, fistulae, abscess
Colorectal cancer Ix
- FOB
- CEA
- Colonoscopy
- CT
Different presentations of gallstones
- Biliary cholic
- Cholecystitis
- Obstructive jaundice
- Cholangitis
- Pancreatitis
- Mucocoele/empyema
- Coirvoisier’s law- GB small, shrunken, not palpable
- Gallstone Ileus
Features of alpha1-antitrypsin
- Affects lungs and liver
- Sx: SOB, cirrhosis, cholestatis jaundice
- Ix: liver biopsy
- Tx: transplant?
Acute liver failure diagnostic criteria
- Raised PT by 4-6s
- Encephalopathy In a patient with no pre-existing disease
Features of Primary biliary cholangitis
- Markers: AMA, raised ALP, raised IGM
- Middle aged women
- Sx: liver disease, jaundice, cholestatis LFTs
- Tx: Ursodeoxycholic acid, fibrates, obeticholic acid, transplant?
Features of chronic mesenteric ischaemia
- ‘Abdominal angina’
- Sx: weight loss, abdo pain (esp post-prandial), upper abdominal bruit
- Ix: CT, MR angiography
- Tx: revascularisation and stent
Presentation of oesophageal cancer
- Dysphagia
- Weight loss
- Anaemia
- Chest pain
- Mass
- Horse voice/ mass
- Vomiting
Management of obesity
- lifestyle
- Orlistat + lifestyle. BMI>28 + complications or BMI>30
- Bariatric surgery- banding/ bypass. BMI35-40 + complications or BMI >40
Indications that gastroenteritis is bacterial
- More unwell
- Higher fever
- Blood/ mucus in stool
- Abdominal pain
Assessing UC severity
Truelove and Witts Severe:
- >6 motions/ day
- Large rectal bleeding
- Temp >37.8
- >90bpm
- Hb <105g/L
- ESR >30
Signs of liver decompensation
- Jaundice
- Ascites
- Encephalopathy
- Renal impairment
- Sepsis
Presentation of pancreatitis
- Epigastric pain –> back
- Fever
- Guarding/ rigidity
- Vomiting ++
- Dehydration
- Ecchymosis: Cullen’s (umbilical), Grey Turner’s
Symptoms of Cholecystitis
- Epigastric/RUQ pain –> R shoulder
- Phlegmon
- Murphy’s
- Anorexia, vomiting
- Local peritonism
- Fever
Features of small bowel obstruction
- Presents quicker
- Pain higher in abdomen
- Tingling bowel sounds
- Metabolic alkalosis
- AXR- central. valvulae coniventes across whole width.
HCC screening
6 monthly USS and AFP in those at risk: Cirrhosis (esp HBV), FHx, African, Asian
Types of laxatives and examples
- Bulk forming- ispaghula husk
- Osmotic- Macrogol, lactulose
- Stimulant- senna, bisacodyl
- Stool softeners- docusate, liquid paraffin
Investigations and management of diverticular disease
- Ix: Obs, bloods, CT
- Tx: High fibre diet, IVT, NBM, analgesia, ?ABx, antispasmodics- mebevarine
Causes of constipation
- General- diet, elderly, IBS, environmental
- Anorectal disease eg fissures
- Bowel obstruction
- **colorectal cancer**
- Metabolic- hypercalcaemia, hypothyroidism, hypokalaemia
- Drugs- Iron, opiates, diuretics, CCB, TCAs Neuromuscular eg spinal injury
Acute mesenteric ischaemia Ix and Tx
- Bedside- NEWS
- Bloods- FBC, amylase, ABG/lactate
- Imaging- AXR, CT, MR angiography
- Tx: Piptaz, LMWH, surgical resection
Presentation of acute mesenteric ischaemia
Triad:
- No/minimal abdo signs
- Acute, severe abdominal pain
- Rapid hypovolaemia/ shock
What is achalasia and its symptoms, Ix and Tx?
- Lower oesophageal sphincter fails to relax due to degeneration of myenteric plexus
- Sx: Dysphagia or solids and fluids, regurgitation, weight loss, heart burn
- Ix- CXR fluid level, barium swallow
- Tx- Balloon dilatation
Markers of synthetic liver function
- Albumin
- Bilirubin
- PTT
- Glucose
Obturator/ Cope’s sign
- Pain on flexion and internal rotation of hip. (Appendicitis)
What is Mirizzi’s Syndrome?
Obstructive Jaundice from CBD compression by gallstone impacted on cystic duct. Associated with cholangitis.
Presentation, Ix and Tx of testicular torsion
- = Spermatic cord twists –> ischaemia. RF= undescended testes.
- Presentation-
- Sudden onset, severe, unilateral abdominal/groin/testicular pain –> always examine testes!
- N+V
- Fever
- Swollen testicle - rapid
- No cremasteric reflex
- Preh’s -ve (lifting testis doesn’t relieve pain)
- Ix- Doppler USS, urgent senior r/v
- Tx- Emergency surgical exploration with bilateral fixation within 6h
