Gastrointestinal Flashcards
1
Q
What is gastro-oesophageal reflux disease?
A
Reflux of stomach contents (acid and bile) causes troublesome symptoms such as heartburn
2
Q
What can prolonged GORD cause? (3)
A
1) Oesophagitis
2) Benign oesophageal strictures
3) Barrett’s oesophagus
3
Q
Give 4 causes of GORD
A
- ) Lower oesophageal sphincter hypotension
- ) Hiatus hernia
- ) Oesophageal dysmotility
- ) Obesity
- ) Gastric acid hypersecretion
- ) Delayed gastric emptying
- ) Smoking
- ) Alcohol
- ) Pregnancy
- ) Drugs (nitrates)
4
Q
Give 3 oesophageal symptoms of GORD
A
- ) Heartburn
- ) Belching
- ) Acid brash (acid/bile regurgitation)
- ) Waterbrash (increased salivation)
- ) Odynophagic (painful swallowing)
5
Q
Give 3 extra-oesophageal symptoms of GORD
A
- ) Nocturnal asthma
- ) Chronic cough
- ) Laryngitis
- ) Sinusitis
6
Q
What can GORD lead to that could lead to cancer?
A
Barrett’s oesophagus
7
Q
What is the histological change in Barrett’s oesophagus?
A
Distal oesophageal epithelium undergoes metaplasia from squamous to columnar
8
Q
What tests can we do for GORD? (3)
A
1) Endoscopy
2) Barium swallow
3) 24 hours of oesophageal monitoring and manometry
9
Q
When do we do an endoscopy in GORD? (2)
A
1) Symptoms >4 weeks
2) >55 with alarm symptoms
10
Q
What is the treatment for GORD? (4)
A
- ) Lifestyle changes
- ) Drugs (antacids alginates, PPI)
- ) Avoid nitrates, antcholinergics, calcium channel blockers, NSAIDs, bisphosphonates
- ) Surgery to increase sphincter pressure
11
Q
Give an example of a PPI
A
Lanzoprazole
12
Q
Give the lifestyle changes for GORD
A
- ) Weight loss
- ) Smoking cessation
- ) Small regular meals
- ) Reduce hot drinks
- ) Alcohol
- ) Citrus fruits, tomatoes, onions
- ) Fizzy drinks
- ) Spicy foods
- ) Caffeine, chocolate
- ) Avoid eating <3hr before bed
- ) Raised bed head
13
Q
Give 3 symptoms of peptic ulcer disease
A
- ) Epigastric pain often related to hunger, specific foods, time of day
- ) Bloating
- ) Fullness after meals
- ) Heartburn
- ) Tender epigastrium
- ) ALARM symptoms
14
Q
What are the ALARMS symptoms?
A
Anaemia Loss of weight Anorexia Recent onset Melena (or haematemesis) Swallowing problems
15
Q
What do we test for if the patient is <55 with peptic ulcer disease?
A
H. pylori
16
Q
How do we treat a H. pylori infection?
A
PAC
PPI
Amoxicillin
Clarithromycin
17
Q
What should we do if a patient is >55 and has new dyspepsia or ALARM symptoms?
A
Urgent endoscopy
18
Q
What drugs can cause peptic ulcer disease?
A
NSAIDs
19
Q
How can a duodenal ulcer cause pancreatitis?
A
It erodes through to the pancreas
20
Q
Where do ulcers erode into to cause haemorrhaging?
A
Arteries
21
Q
Where do ulcers erode into to cause peritonitis
A
Layers of stomach/duodenal wall
22
Q
Is H. pylori gram negative or positive?
A
Negative
23
Q
Are duodenal or gastric ulcers more common?
A
Duodenal
24
Q
Give 2 minor risk factors for duodenal ulcers
A
- ) Increased gastric secretion
- ) Increased gastric emptying (decreased duodenal pH)
- ) Smoking
25
What test do we do in peptic ulcer disease to diagnose?
Upper GI endoscopy
26
On which curve of the stomach do gastric ulcers usually occur?
Lesser curve
27
Give 3 risk factors for gastric ulcers
- ) H. pylori
- ) Smoking
- ) NSAIDs
- ) Reflux
- ) Delayed emptying
- ) Stress
28
What are the 4 parts of peptic ulcer disease treatment?
1) Lifestyle (decrease alcohol and tobacco)
2) H. pylori eradication
3) Drugs to reduce acid
4) Drug induced ulcers (stop drug if possible)
29
What drugs can we give to reduce acid in peptic ulcer disease? (2)
1) PPIs - lansoprazole
| 2) H2 blockers - ranitidine
30
What is gastritis?
Inflammation of the lining of the stomach
31
What are the 3 pathophysiological causes of gastritis?
1) Mucosal ischaemia (less mucin made)
2) Increased acid
3) Helicobacter infection (live in mucus layer)
32
Give 4 causes of gastritis
- ) Alcohol
- ) NSAIDs
- ) H. pylori
- ) Reflux/hiatus hernia
- ) Atrophic gastritis
- ) Granulomas
- ) CMV (cytomegalovirus)
33
What are the symptoms of gastritis? (2)
Epigastric pain
| Vomiting
34
How do we diagnose gastritis?
Upper GI endoscopy
35
How do we prevent gastritis when taking NSAIDs?
PPI
36
What is malabsorption?
Where we do not absorb enough food/nutrients from our diet
37
What are the 3 most common causes of gastrointestinal malabsorption in the UK?
1) Coeliac disease
2) Chronic pancreatitis
3) Crohn's disease
38
Give 4 more rare causes of malabsorption
- ) Decreased bile
- ) Pancreatic insufficiency
- ) Small bowel mucosa
- ) Bacterial overgrowth
- ) Infection
- ) Intestinal hurry
39
What 2 drugs can cause malabsorption?
Alcohol, metformin
40
Give 5 symptoms of malabsorption
- ) Diarrhoea
- ) Weight loss
- ) Lethargy
- ) Steatorrhoea
- ) Bloating
41
Give 4 signs of malabsorption
- ) Anaemia
- ) Bleeding disorders
- ) Oedema
- ) Metabolic bone disease
- ) Neurological features
42
What decreases in anaemia in malabsorption? (3)
Fe, B12, folate
43
What decreases in bleeding disorders in malabsorption?
Vitamin K
44
What decreases in oedema in malabsorption?
Protein
45
What decreases in metabolic bone disease in malabsorption?
Vitamin D
46
What are we looking for in a blood test for malabsorption? (8)
- ) FBC (micro/macrocytic anaemia)
- ) Low Ca2+
- ) Low Fe
- ) Low B12
- ) Low folate
- ) Lipid profile
- ) High INR
- ) Coeliac tests
47
What are we looking for in a stool test for malabsorption?
Fat globules, microscopy, elastase
48
What do we do for bacterial overgrowth testing in malabsorption?
Breath hydrogen analysis
49
What are the results of breath hydrogen analysis if there is bacterial overgrowth?
Increased exhaled hydrogen after giving glucose
50
Give an organism that can cause infectious malabsorption
Giardia lamblia
51
What physical test can we do for malabsorption?
Endoscopy and small bowel biopsy
52
What is coeliac disease?
T cell responses to gluten in the small bowel causing villous atrophy and malabsorption
53
What gene is associated with 95% of cases of coeliac disease?
HLA DQ2
54
What gene is associated with 5% of cases of coeliac disease?
HLA DQ8
55
What is coeliac disease associated with? (2)
1) Autoimmune disease
| 2) Dermatitis herpetiformis
56
What are the 2 peaks of prevalence of coeliac disease?
Childhood and 50-60 yrs
57
What should we suspect in patients with diarrhoea, weight loss and anaemia?
Coeliac disease
58
Give 6 presenting features of coeliac disease
- ) Bad smelling stools/steatorrhoea
- ) Diarrhoea
- ) Abdominal pain
- ) Bloating
- ) Nausea and vomiting
- ) Aphthous ulcers
- ) Angular stomatitis
- ) Weight loss
- ) Fatigue
- ) Weakness
- ) Osteomalacia
- ) Failure to thrive
59
What main antibodies are found in coeliac disease? (3)
1) Anti-transglutaminsae (IgA)
2) Anti-endomysial
3) Deamidated gliadin peptide
60
What do blood tests show in coeliac disease? (4)
- ) Decreased Hb
- ) Increased red cell distribution width
- ) Low B12
- ) Low ferritin
61
What is the treatment for coeliac disease?
Lifelong gluten free diet
62
Give 3 complications of coeliac disease
- ) Anaemia
- ) Dermatitis herpetiformis
- ) Osteopenia/osteoporosis
- ) Hyposplenism
- ) GI T cell lymphoma
- ) Increased risk of malignancy
- ) Neuropathies
- ) Secondary lactose intolerance
63
What is irritable bowel syndrome? (IBS)
A group of mixed abdominal symptoms for which no organic cause can be found
64
What are most IBSs though to be due to? (3)
Disorders of intestinal motility, enhanced visceral perception, microbial dysbiosis
65
How do we diagnose IBS?
Recurrent abdominal pain/discomfort with at least 2 of:
- ) Relief by defecation
- ) Altered stool form
- ) Altered bowel frequency
66
Give 3 other features of IBS
- ) Urgency
- ) Incomplete evacuation
- ) Abdominal bloating/distension
- ) Mucous PR
- ) Worsening of symptoms after food
- ) Nausea, bladder symptoms, backache
67
What the the chronic symptoms of IBS often exacerbated by? (3)
- ) Stress
- ) Menstruation
- ) Gastroenteritis
68
What drug do we give for constipation?
Lactulose
69
What drug do we give for diarrhoea?
Loperamide
70
What drugs do we give for bloating/colic in IBS?
Antispamodics
71
What non medical treatment is given in IBS
CBT and hypnotherapy
72
What do we need to diagnose IBS if the history is classic? (4)
FBC, ESR, CRP, coeliac serology
73
What is ulcerative colitis?
A relapsing and remitting inflammatory disorder of the colonic mucosa
74
Where does UC not spread past?
Ileocaecal valve
75
What is UC in the rectum named?
Proctitis
76
What is UC in the left part of the colon named?
Left-sided colitis
77
What is US in the entire colon named?
Pancolitis
78
What is the cause of UC?
Inappropriate immune response against possibly abnormal colonic flora in genetically susceptible individuals
79
What is the difference in lesions between UC and Crohn's?
UC has distinct cut off line, Crohn's has skip lesions
80
Is UC or Crohn's more common in non-smokers?
UC
81
What is the pathological appearance in UC? (2)
1) Hyperaemic/haemorrhagic colic mucosa +/- pseudo polyps formed by inflammation
2) Punctate ulcers may extend deep into lamina propria
82
Give 3 GI symptoms of UC
- ) Episodic/chronic diarrhoea (+/- blood and mucus)
- ) Crampy abdominal discomfort
- ) Bowel frequency relates to severity
- ) Urgency/tenesmus = proctitis
83
Give 3 systemic symptoms of a UC attack
Fever, malaise, anorexia, weight loss
84
Give 3 signs of acute severe UC
Fever, tachycardia, tender distended abdomen
85
Give 4 extra intestinal signs of UC
- ) Clubbing
- ) Aphthous oral ulcers
- ) Erythema nodosum
- ) Conjunctivitis
- ) Episcleritis
- ) Iritis
- ) Large joint arthritis
- ) Sacroilitis
- ) Anklosing spondylitis
- ) Primary sclerosing cholingitis
- ) Nutritional deficits
86
What 5 tests do we do for UC?
- ) Blood
- ) Stool MC&S/CDT
- ) Faecal calprotectin
- ) AXR
- ) Lower GI endoscopy
87
What does MC&S stand for?
Microbiology culture & sensitivity
88
What does CDT stand for?
Carbohydrate deficient transferrin test
89
What 3 things does an AXR show in UC?
- ) No faecal shadows
- ) Mucosal thickening/islands
- ) Colonic dilatation
90
Give 2 acute complications of UC
- ) Toxic dilatation of colon with risk of perforation
- ) Venous thromboembolism
- ) Decreased K+
91
Give a chronic complication of UC
Colonic cancer
92
What do we treat mild UC with?
5-amino salicylic acid (mesalazine)
93
What do we treat moderate UC with? (2)
- ) Prednisolone
| - ) Then maintain on 5-ASA (mesalazine)
94
What do we treat severe UC with?
Admit by nil by mouth with:
- ) IV hydration
- ) IV steroids (hydrocortisone)
- ) Thromboembolism prophylaxis
- ) Daily tests
95
What do we give if they improve on severe UC treatment?
Prednisolone
96
What do we give if they don't improve on severe UC treatment?
Colectomy
97
What do we give in UC if there is no remission with steroids?
Immunomodulation (azathioprine)
98
What are UC and Crohn's both types of?
Inflammatory bowel disease - IBD
99
What is Crohn's disease?
A chronic inflammatory disease characterised by transmural granulomatouss inflammation affecting any part of the gut from the mouth to anus
100
Where does Crohn's especially occur?
Terminal ileum and proximal colon
101
What causes Crohn's disease?
Inappropriate immune response against possibly abnormal gut flora in genetically susceptible individuals
102
Does UC or Crohn's have skip lesions?
Crohn's
103
What drugs may exacerbate Crohn's
NSAIDs
104
Give 3 GI symptoms of Crohn's
- ) Diarrhoea
- ) Abdominal pain
- ) Weight loss/failure to thrive
105
Give 3 systemic symptoms of Crohn's
- ) Fatigue
- ) Fever
- ) Malaise
- ) Anorexia
106
Give 3 GI signs of Crohn's
- ) Bowel ulceration
- ) Abdominal tenderness/mass
- ) Perianal abscess/ fistulae/ skin tags
- ) Anal strictures
107
Give 2 extra intestinal signs of Crohn's
- ) Clubbing
| - ) Skin, joint and eye problems
108
Give 4 complications of Crohn's
- ) Small bowel obstruction
- ) Toxic dilatation
- ) Abscess formation
- ) Fistulae
- ) Perforation
- ) Colon cancer
- ) PSC
- ) Malnutrition
109
What tests do we do in Crohn's?
- ) Blood
- ) Stool
- ) Colonscopy and biopsy
- ) Barium enema
- ) Small bowel MRI
110
What does a barium enema show in Crohn's? (3)
- ) Cobblestoning
- ) Deep fissuring ulcers
- ) Strictures
111
What lifestyle changes do we advise in Crohn's?
Smoking cessation and optimisation of nutrition
112
What do we give to treat mild attacks of Crohn's?
Prednisolone
113
What do we give to treat severe attacks of Crohn's?
- ) IV hydration/electrolytes
- ) IV steroids (hydrocortisone)
- ) Thromboembolism prophylaxis
114
What do we give if the patient is improving on severe Crohn's treatment?
Prednisolone
115
What do we give if the patient is not improving on severe Crohn's treatment?
Biologics - anti-TNFalpha, infliximab
116
What treatment is given in perianal disease of Crohn's?
- ) Oral antibiotics
- ) Immunosuppressant therapy
- ) +/- anti-TNFalpha
- ) Local surgery
- ) Metronidazole
117
What is bowel obstruction?
Blockage to the lumen of the gut
118
What are the 3 types of obstruction?
1) Intraluminal
2) Intramural
3) Extraluminal
119
What is Hirschsprung's disease?
Developmental abnormality of an aganglionic segment - no rhythm cells, so impaired motility
120
Give 2 causes for a SBO
- ) Adhesions
| - ) Hernias
121
Give 4 causes for a LBO
- ) Colon cancer
- ) Constipation
- ) Diverticular stricture
- ) Volvulus
122
What are adhesions?
Parts of the bowel connected by thin white fibrous bands
123
What are adhesions usually secondary to?
Previous surgery
124
What are 4 rarer causes of a bowel obstruction?
- ) Crohn's
- ) Gallstone ileus
- ) Appendicitis
- ) Intussusception
- ) Foreign bodies
125
What are the 4 ways in which we classify bowel obstructions?
- ) Site
- ) Extent of luminal obstruction
- ) Mechanism (true/paralytic)
- ) Pathology
126
What are the 4 cardinal features of bowel obstruction?
1) Vomiting
2) Colicky pain
3) Constipation
4) Abdominal distension
127
What does fermentation of the intestinal contents in established obstruction cause?
Faeculent vomiting
128
What are the bowel sounds like in an obstruction?
Active, tinkling
129
What are the differences in presentation between a SBO and a LBO? (5)
- ) Vomiting occurs earlier in SBO
- ) Less distension in SBO
- ) Pain higher in abdomen in SBO
- ) Earlier constipation in LBO
- ) More constant pain in LBO
130
What is absolute constipation?
Obstipation
131
What are the bowel sounds like in a paralytic ileus obstruction?
Absent
132
What is a paralytic ileus?
Functional obstruction from decreased bowel motility, less pain
133
What is a simple bowel obstruction?
One obstruction point and no vascular compromise
134
What is a closed loop bowel obstruction?
Obstruction at 2 points forming a loop of grossly distended bowel at risk of perforation
135
What is a strangulated bowel obstruction?
Blood supply is compromised, sharper and more localised pain, peritonitis, possible fever
136
Give an example of a closed loop obstruction
Colonic volvulus
137
What is a closed loop obstruction due to?
Axial rotation at mesenteric attachments
138
What is the rule when looking at AXRs of bowel obstruction?
3-6-9 rule
139
What does a SBO look like on an AXR? (3)
- ) Central gas shadows with valvular conniventes that completely cross lumen
- ) No gas in large bowel
- ) Normal diameter of SB <3cm
140
What does a LBO look like on an AXR? (4)
- ) Peripheral gas shadows proximal to blockage
- ) Large bowel haustria do not cross lumen width
- ) Normal diameter of LB <6cm
- ) Normal diameter of caecum and sigmoid <9cm
141
What does an intersusseption look like on a CT?
Doughnut
142
What does a volvulus look like on a CT?
Coffee bean
143
What is the treatment for an obstruction?
Surgery - strangulations, LBOs, volvulus, hernias, tumours
| Medical - Ileus, incomplete SBOs
144
What is the medical treatment for an obstruction?
- ) NGT
- ) IV fluids
- ) Analgesia
- ) Catheter
145
What is a pseudo-obstruction?
Like a mechanical GI obstruction but with no cause found
146
How do we treat a pseudo-obstruction? (2)
Neostigmine or colonscopic decompression
147
What is a sigmoid volvulus?
Bowel twists on mesentery and proceeds severe strangulated obstruction
148
How do we manage a sigmoid vovulus? (2)
Sigmoidoscopy and insertion of flatus tube
149
What is intussusception?
Where the small bowel telescopes, and there is invagination of one part into the other
150
What are intussusceptum and intussuscipien?
Intussusceptum - invaginating portion
| Intussuscipien - receiving portion
151
How do we treat an intussusception?
Air enema
152
How do we diagnose an intussusception?
US
153
Where does acute mesenteric ischaemia almost always involve?
Small bowel
154
What are the 3 things acute mesenteric ischaemia may follow?
1) Superior mesenteric artery thrombosis/embolism
2) Mesenteric vein thrombosis
3) Non-occlusive disease
155
What is the classic clinical triad of presentation for acute mesenteric ischaemia?
1) Acute severe abdominal pain
2) No/minimal abdominal signs
3) Rapid hypovolaemia leading to shock
156
What is the pain like in acute mesenteric ischaemia?
Contant and central/around right iliac fossa
157
How are most diagnoses of acute mesenteric ischaemia found?
Necrotic bowel at laparotomy
158
What does an AXR show in acute mesenteric ischaemia?
Gasless abdomen
159
What are 4 findings on tests with acute mesenteric ischaemia?
1) Increased Hb
2) Increased WCC
3) Raised plasma amylase
4) Persistent metabolic acidosis (high lactate)
160
What are the 2 main complications of acute mesenteric ischaemia?
1) Septic peritonitis
| 2) Progression of a systemic inflammatory response syndrome (SIRS) to muti-organ failure
161
How do we treat acute mesenteric ischaemia?
Resus with fluid, antibiotics (piperacillin), LMWH/heparin, dead bowel surgically removed
162
What is the presenting triad of chronic mesenteric ischaemia?
1) Severe, colicky post-prandial pain
2) Weight loss (eating hurts)
3) Upper abdominal bruit
163
What are some other symptoms of chronic mesenteric ischaemia?
- ) PR bleeding
- ) Malabsorption
- ) Nausea and vomiting
164
What is chronic mesenteric ischaemia typically brought on by?
Combination of a low flow state with atheroma
165
What tests do we use to diagnose chronic mesenteric ischaemia? (2)
CT angiography and contrast enhanced MR angiography
166
How do we treat chronic mesenteric ischaemia?
Surgery is percutaneous transluminal angioplasty and stent insertion
167
What is ischaemic colitis also known as?
Chronic colonic ischaemia
168
What does chronic colonic ischaemic usually follow?
Low flow in the inferior mesenteric artery territory
169
What is the presentation of chronic colonic ischaemia?
Lower left sided abdominal pain +/- bloody diarrhoea
170
What is the gold standard for diagnosis of chronic colonic ischaemia?
Lower GI endoscopy
171
What is the treatment for chronic colonic ischaemia?
Fluids and antibiotics
172
What does gangrenous ischaemic colitis present with? (2)
Peritonitis and hypovolaemic shock
173
What is the treatment for gangrenous ischaemic colitis?
Resus and resection of affected bowel and stoma formation
174
What is a GI diverticulum?
An out pouching of the gut wall
175
Where does a GI diverticulum usually occur?
At the sites of entry of perforating arteries
176
What is diverticulosis?
Inflammation of a diverticulum
177
What is diverticular disease?
Symptomatic diverticula, when the pouch fills with material that becomes secondarily infected
178
Which are the most important type of diverticulum?
Acquired colonic diverticula
179
Where are most colonic diverticula?
Sigmoid colon
180
What is the pathology of a diverticula?
High intraluminal pressure possible to due lack of dietary fibre force the mucosa to herniate through the muscle layers of the gut at weak points adjacent to penetrating vessels
181
How is peritonitis caused in diverticular disease?
Pouches rupture
182
How are diverticula usually found?
Incidental finding at colonoscopy
183
What test confirms a diagnosis of acute diverticulitis?
Abdominal CT
184
What does diverticular disease present with? (2)
- ) Altered bowel habit +/- left sided colic relieved be defecation
- ) Nausea and flatulence
185
What is a treatment of diverticular disease?
Antispasmodics (mebeverine)
186
What does diverticulitis present with?
Diverticular disease features and:
- ) Pyrexia
- ) High WCC
- ) High CRP/ESR
- ) Tender colon
- ) +/- localised/generalised peritonism
187
How do we treat mild attacks of diverticulitis?
Bowel rest (fluids only) +/- antibiotics
188
How do we treat less mild attacks of diverticulitis?
Admit for analgesia, NBM, IV fluids, IV antibiotics
189
Give 3 complications of diverticulitis
1) Abscess formation
2) Perforation
3) Haemorrhage
4) Fistulae
5) Post infective strictures
190
How does appendicitis occur?
Gut organisms invade the appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith, or filarial worms
191
What does gut organisms invading the appendix wall lead to? (3)
- ) Oedema
- ) Ischaemic necrosis
- ) Perforation
192
What is the classic presentation of appendicitis?
Periumbilical pain that moves to the right iliac fossa
193
Give 3 associated signs of appendicitis
- ) Tachycardia
- ) Fever
- ) Peritonism with guarding and reboud/percussion tenderness in RIF
- ) Anorexia
- ) Constipation
- ) Possibly vomiting, diarrhoea
194
What do we use to diagnose appendicitis?
CT
195
What does CRP stand for?
C-reactive protein
196
What does ESR stand for?
Erythrocyte sedimentation rate
197
What is the treatment for appendicitis? (2)
- ) Appendicetomy
| - ) Antibiotics (piperacillin, metronidazole, cefuroxime)
198
What is peritonitis?
Inflammation of the peritoneum
199
Give 4 causes of peritonitis
Perforation of:
- ) Peptic/duodenal ulcer
- ) Diverticulum
- ) Appendix
- ) Bowel
- ) Gallbladder
200
What is the classification of peritonitis? (4)
- ) Onset
- ) Origin
- ) Cause
- ) Location
201
Give 3 symptoms of peritonitis
- ) Pain
- ) Tenderness
- ) Systemic symptoms
202
Give 4 signs of peritonitis
- ) Prostration
- ) Lying still
- ) Positive cough test
- ) Tenderness (+/- rebound)
- ) Abdominal righty
- ) Guarding
- ) No bowel sounds
- ) Shock
203
How do we differentiate peritonitis from pancreatitis?
Serum amylase levels (raised in pancreatitis)
204
What may an erect CXR show in peritonitis?
Gas under the diaphragm
205
What colour is the fluid on peridyalisis?
Yellow (infection)
206
What ascites lactate level is 100% sensitive of an infection?
>25mg/dL
207
What is the management of peritonitis?
- ) Resus
- ) Antibiotics
- ) Treat cause
208
What is a hernia?
An abnormal protrusion of a viscus/part of a viscus through a defect of the wall of its containing cavity into an abnormal position
209
What is a irreducible hernia?
Contents cannot be pushed back into place
210
What is an obstructed hernia?
Bowel contents cannot pass
211
What is a strangulated hernia?
Ischaemia occurs
212
What is an incarceration hernia?
Contents of hernial sac are stuck inside by adhesions
213
Which is the most common hernia, and which gender is it more common in?
Inguinal, male
214
What are the 2 types of inguinal hernia?
1) Indirect
| 2) Direct
215
Where does an indirect inguinal hernia pass?
Through the internal inguinal ring, through the external ring if large
216
Where does a direct inguinal hernia go?
Pushes directly forward through the posterior wall of the inguinal cancel into a defect in the abdominal wall (Hesselbach's triangle)
217
Is a direct or indirect inguinal hernia more common?
Indirect
218
Give 3 predisposing conditions for an inguinal hernia
- ) Male
- ) Chronic cough
- ) Constipation
- ) Urinary obstruction
- ) Heavy lifting
- ) Ascites
- ) Past abdominal surgery
219
How do we distinguish a direct inguinal hernia from an indirect one?
Reduce the hernia and occludes deep (internal) ring with 2 fingers. Ask patient to cough/stand. If the hernia is restrained, it is indirect.
220
Which side of the inferior epigastric vessels does each inguinal hernia arise?
Direct - medial
| Indirect - lateral
221
What surgery do we do to repair an inguinal hernia?
Polypropylene mesh reinforces posterior wall
222
What are the 2 types of hiatus hernia?
1) Sliding (80%)
| 2) Rolling (20%)
223
What occurs in a sliding hiatus hernia?
Gastro-oesophageal junction slides up into the chest, acid reflux often happens
224
What occurs in a rolling hiatus hernia?
Gastro-oesophageal junction remains in abdomen but bulge of stomach herniates into chest alongside oesophagus
225
How do we treat a hiatus hernia?
- ) Weight loss
- ) GORD treatment
- ) Possibly surgery
226
What is a femoral hernia?
Where bowel enters the femoral canal
227
How does a femoral hernia present?
Mass in upper medial thigh or above inguinal ligament (points down leg)
228
What is the treatment of a femoral hernia?
Surgical repair (herniotomy/herniorrhaphy)
229
Which gender is a femoral hernia more common in?
Female
230
What is an incisional hernia?
Follows breakdown of muscle closure after surgery
231
What is gastroenteritis?
Diarrhoea (+/- vomiting) due to enteric infection with viruses, bacteria, parasites
232
What are 5 things diarrhoea can be defined as?
- ) Acute diarrhoea
- ) Dysentery
- ) Persistent
- ) Traveller's
- ) Food poisoning
233
What is diarrhoea?
A decreased stool consistency from water, fat, or inflammatory discharge
234
What is the rule of C with C. diff infections?
C. diff is linked to clindamycin, ciprofloxacin, co-amoxiclav, cephalosporins - we should give additional antibiotics
235
How can we prevent C. diff infections?
Thorough handwashing with soap and water
236
Give 2 viral causes of infective diarrhoea
Norovirus, rotavisus
237
Give 4 bacterial causes of infective diarrhoea
Salmonella, campylobacter, E. coli, shigella
238
Give 1 parasitic cause of infective diarrhoea
Giardia
239
What does C. diff stand for?
Clostridium difficile
240
Give 4 signs of infective diarrhoea
- ) Dehydration
- ) Dry mucous membranes
- ) Decreased skin tugor
- ) Slow capillary refill
- ) Weight loss
- ) Anaemia
- ) Oral ulcers
- ) Fever
241
What tests can we do for infective diarrhoea? (5)
- ) Rectal exam
- ) Bloods
- ) Stool MC&S, faecal fat
- ) Sigmoidoscopy with biopsy
- ) Colonoscopy/barium enema
242
How do we treat infective diarrhoea? (2)
- ) Treat cause
| - ) Oral rehydration unless severe (IV)
243
Which 2 drugs will decrease the frequency of the diarrhoea?
1) Codeine phosphate
| 2) Loperamide
244
What is acute pancreatitis characterised by?
Self perpetuating pancreatic enzyme mediated auto digestion
245
What are the causes of acute pancreatitis? (10)
```
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (PAN)
Scorpion venom
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP and emboli
Drugs
```
246
Give the 2 main symptoms of acute pancreatitis
- ) Gradual/sudden severe epigastric or central abdominal pain
- ) Vomiting prominent
247
How is the pain relieved in acute pancreatitis?
Sitting forward
248
Give 4 signs of acute pancreatitis
- ) Increased HR
- ) Fever
- ) Jaundice
- ) Shock
- ) Ileus
- ) Rigid abdomen
- ) +/- local/general tenderness
- ) Periumbilical bruising (Cullen's sign)
- ) Flanks bruising (Grey Turner's sign)
249
What do we test for in pancreatitis? (2)
- ) Raised serum amylase
| - ) Serum lipase
250
What does an AXR show in pancreatitis?
- ) No psoas shadow
| - ) Sentinel loop of proximal jejunum from ileus
251
What is the modified Glasgow criteria for predicting severity of pancreatitis? (8)
```
PANCREAS
PaO2, <8kPa
Age, >55
Neutrophilia, high WCC
Calcium, low
Renal function, urea high
Enzymes, LDH and AST high
Albumin, low
Suger, high
```
252
What are the causes of pancreatitis when using the modified Glasgow criteria? (2)
- ) Gallstones
| - ) Alcohol
253
What is the treatment of acute pancreatitis?
- ) NBM
- ) Catheter
- ) IV fluids
- ) Analgesia
- ) Monitor
- ) If worsening, oxygen, antibiotics, debridement
- ) ERCP and gallstone removal if progressive jaundice
254
Give 3 complications of acute pancreatitis
- ) Shock
- ) ARDs
- ) Renal failure
- ) Increased glucose and decreased calcium
- ) Sepsis
- ) Necrosis
- ) Fluid in lesser sac
- ) Abscesses
- ) Bleeding
- ) Thrombosis
- ) Fistulae
255
What does chronic pancreatitis present with?
Epigastric pain that 'bores' through to the back
256
Give 3 signs of chronic pancreatitis
- ) Erythema ab igneous mottled dusky geyness
- ) Bloating
- ) Steatorrhoea
- ) Weight loss
- ) Brille diabetes (up and down)
257
What do symptoms do in chronic pancreatitis?
Relapse and worsen
258
Give 3 causes of chronic pancreatitis
- ) Alcohol
- ) Smoking
- ) Autoimmune
- ) Familial, CF, haemochromatosis, pancreatic duct obstruction, congenital
259
How do we diagnose chronic pancreatitis?
Pancreatic calcifications on US
260
What is the treatment for chronic pancreatitis?
- ) Analgesia
- ) Lipase
- ) Insulin
- ) No alcohol and low fat
- ) Surgery for unremitting pain, weight loss, narcotic abuse
261
What is the surgery in chronic pancreatitis?
Pancreatectomy
262
Give 3 complications of chronic pancreatitis
- ) Pseudocyst
- ) Diabetes
- ) Biliary obstruction
- ) Local arterial aneurysm
- ) Splenic vein thrombosis
- ) Gastric varices
- ) Pancreatic carcinoma
263
What occurs in primary biliary cholangitis? (PBC)
Interlobular bile ducts damaged by chronic autoimmune granulomatous inflammation causing cholestasis
264
What may cholestasis in PBC lead to? (3)
- ) Fibrosis
- ) Cirrhosis
- ) Portal hypertension
265
What is PBC caused by?
Unknown environmental triggers and genetic predisposition leading to loss of immune tolerance to self-mitochondrial proteins
266
What gender is PBC more common in?
Women
267
Give 2 risk factors for PBC
- ) Family history
- ) Many UTIs
- ) Smoking
- ) Past pregnancy
- ) Other autoimmune diseases
- ) Nail polish/hair dye use
268
What (found in blood) are the hallmark of PBC?
Antimitochondrial antibodies (AMA)
269
How is a patient with PBC usually diagnosed?
Asymptomatic, incidental finding of increased ALP
270
What does ALP stand for?
Alkaline phosphate
271
Give 3 symptoms of PBC
- ) Lethargy
- ) Sleepiness
- ) Pruritus preceding jaundice
272
Give 3 signs of PBC
- ) Jaundice
- ) Skin pigmentation
- ) Xanthelasma (lipid laden yellow plaques around eyes)
- ) Hepatosplenomegaly
273
Give a complication of PBC
Osteomalacia/osteoporosis
274
What type of AMA subtype are 98% of PBC patients?
M2 subtype positive
275
What is the treatment for symptomatic PBC? (3)
- ) Colestyramine for pruritus
- ) Codeine phosphate for diarrhoea
- ) Bisphosphonates for osteoporosis prevention
276
What is a specific treatment for PBC? (2)
- ) Fat soluble vitamin prophylaxis - A, D, K
| - ) High dose ursodeoxycholic acid
277
What is primary sclerosis cholangitis? (PSC)
Progressive cholestasis with bile duct inflammation and strictures
278
Give 2 symptoms of PSC
- ) Pruritus
| - ) Fatigue
279
Give 3 genetic associations with PSC
- ) HLA-A1
- ) HLA B8
- ) HLA DR3
280
What does advanced PSC present with?
- ) Ascending cholangitis
- ) Cirrhosis
- ) Hepatic failure (jaundice)
281
Is IBD associated with PSC, and what does it raise the risk of?
IBD, colorectal malignancy
282
What are the positive antibodies in PSC? (and the one negative one?)
Positive
-) ANA, SMA, ANCA
Negative
-) AMA
283
What does ANA stand for?
Antinuclear antibody
284
What does SMA stand for?
Smooth muscle antibody
285
What does ANCA stand for?
Antineutrophil cytoplasmic antibody
286
What is the mainstay treatment for PSC?
Liver transplant
287
What is hereditary haemochromatosis? (HH)
An inherited disorder of iron metabolism in which increased intestinal iron absorption leads to iron deposition
288
Where does iron deposition occur in hereditary haemochromatosis?
- ) Joints
- ) Liver
- ) Heart
- ) Pancreas
- ) Pituitary
- ) Adrenals
- ) Skin
289
Why are women affected less severely & present later in hereditary haemochromatosis?
Menstrual blood loss is protective
290
What is the gene responsible for most HH?
HFE, recessive
291
What are the 2 most common mutations in HH?
C282Y
| H63D
292
Give 2 early symptoms of HH
- ) Tiredness
- ) Arthralgia
- ) Decreased libido
293
Give 2 later symptoms/signs of HH
- ) Slate grey skin pigmentation
- ) Signs of chronic liver disease
- ) Hepatomegaly
- ) Cirrhosis
- )Dilated cardiomyopathy
294
What 3 things can deposition cause in organs in HH?
- ) Pancreas - DM
- ) Pituitary - hypogonadism
- ) Adrenals - hypoaldosteronism
295
What stain on a liver biopsy quantifies iron loading? (HH)
Perl's
296
What do liver and cardiac MRIs show in HH?
Iron overload
297
What is the treatment for HH?
Venesect until ferritin decreased, then maintenance for life
298
What is the treatment if the patient is intolerant of HH?
Desferrioxamine
299
What other management is there for HH?
- ) No iron in other drugs
- ) Screening
- ) Diet - alcohol, seafood
300
What does bile contain?
Cholesterol, bile pigments (from broken down Hb), phospholipids
301
What are pigment gallstones and what are they caused by?
- ) Small, friable, irregular
| - ) Haemolysis
302
What are cholesterol gallstones and what are they caused by?
- ) Large, often solitary
| - ) Age, obesity, female
303
What are mixed gallstones?
-) Faceted (calcium salts, pigment, cholesterol)
304
What are 2 risk factors for gallstones becoming symptomatic?
Smoking, parity
305
How do we treat gallbladder stones? (2)
- ) Laparoscopic cholecystectomy
| - ) Bile acid dissolution therapy
306
How do we treat bile duct stones? (3)
- ) ERCP with sphincterotomy and removal
- ) Crushing (mechanical/laser)
- ) Stent placement
307
What is ascending cholangitis?
Infection of the bile duct
308
What is ascending cholangitis caused by?
Bacteria ascending from duodenum, occurs more often with stones
309
What are the 3 main symptoms of ascending cholangitis?
Charcot's triad
- ) Jaundice
- ) Fever
- ) Abdominal pain
310
What is Reynold's triad of symptoms?
Charcot's triad plus low BP and confusion
311
What are the most common causative organisms of ascending cholangitis? (2)
- ) E. coli
| - ) Klebsiella
312
How do we treat ascending cholangitis? (3)
- ) Fluid
- ) Antibiotics
- ) Treat obstruction
313
What is acute cholecystitis?
Inflammation of the gallbladder
314
What can recurrent episodes of acute cholecystitis cause?
Pancreatitis
315
What is the pain in acute cholecystitis like?
Continuous epigastric or right upper quadrant pain referred to right shoulder
316
What symptoms of acute cholecystitis are there?
- ) Pain
- ) Vomiting
- ) Fever
- ) Local peritonism
- ) GB mass
317
What is Murphy's sign? (acute cholecystitis)
Lay 2 fingers over the RUQ, when the patient breaths in there is pain and arrest of inspiration
318
What does an US show in acute cholecystitis?
Thick walled shrunken GB, pericholecystitc fluid, stones, dilated common bile duct
319
What is the treatment of acute cholecystitis? (4)
- ) NBM
- ) Pain relief
- ) Antibiotics (cefuroxime)
- ) Surgery
320
What is jaundice?
Yellowing of skin, sclerae, mucosa from increase plasma bilirubin
321
What on an AXR of a GB shows an increased risk of cancer?
Porcelain GB
322
What is jaundice classified by? (2)
- ) Site of problem
| - ) Type of circulating bilirubin
323
What are the sites of jaundice? (3)
- ) Pre-hepatic
- ) Hepatocellular
- ) Post-hepatic (cholestatic/obstructive)
324
What are the types of circulating bilirubin in jaundice? (2)
- ) Conjugated
| - ) Unconjugated
325
What is unconjugated hyperbilirubinaemia caused by? (4)
- ) Overproduction (haemolysis)
- ) Impaired hepatic uptake (drugs)
- ) Impaired conjugation (Gilbert's)
- ) Physiological neonatal jaundice
326
Why does unconjugated bilirubin not go into the urine?
Insoluble
327
What is conjugated hyperbilirubinaemia caused by? (2)
- ) Hepatocellular dysfunction
| - ) Impaired hepatic excretion (cholestasis)
328
What do the urine and faeces look like in conjugated hyperbilirubinaemia?
Urine - dark
| Faeces - pale
329
Give 3 causes of hepatocelluar dysfunction in jaundice
- ) Viruses (hepatitis)
- ) Drugs
- ) Alcohol
- ) Cirrhosis
- ) Liver mets/abscess
- ) Budd-Chiari
- ) Wilson's
330
Give 3 causes of impaired hepatic excretion in jaundice
- ) Primary biliary cholangitits
- ) Primary sclerosis cholangitis
- ) Drugs
- ) Common bile duct gallstones
- ) Pancreatic cancer
- ) Compression of bile duct
331
How is bilirubin formed in the breakdown of haemoglobin? (7)
1) Hepatic uptake
2) In liver, bilirubin conjugated with glucuronic acid by hepatocytes to conjugated bilirubin
3) Secreted in bile and passes into gut
4) Some reuptaken in liver
5) Rest converted to urobilinogen by gut bacteria
6) Urobilinogen reabsorbed and excreted by kidney
7) Or urobilinogen converted to stercobilin for faeces
332
What is absent in the urine in each stage of jaundice?
- ) Pre-hepatic - no bilirubin
- ) Obstructed - no urobilinogen
- ) Post-hepatic - N/A
333
What are the 3 mainstays of tests in jaundice?
- ) Liver enzymes (high AST/ALT)
- ) Biliary obstruction on US
- ) Urine
334
How do we treat jaundice?
- ) Treat cause
- ) Antibiotics if obstruction
- ) Hydration
335
What is cirrhosis?
Irreversible liver damage
336
What does cirrhosis look like histologically?
Loss of normal hepatic architecture with bridging fibrosis and nodular regeneration
337
What are the 3 most common causes of cirrhosis?
- ) Chronic alcohol abuse
- ) HBV
- ) HCV
338
Give 4 signs of cirrhosis/chronic liver disease
- ) Leuconychia (white nails)
- ) Terry's nails (proximally white, distal red)
- ) Clubbing
- ) Palmar erythema
- ) Hyperdynamic circulation
- ) Spider nave
- ) Xanthelasma (yellow deposit of cholesterol under skin)
- ) Gynaecomastia (swelling o breast tissue in males)
- ) Loss of body hair
- ) Parotid enlargement
- ) Hepatomegaly
- ) Ascites
- ) Splenomegaly
339
Give 3 complications of cirrhosis
- ) Hepatic failure
- ) Portal hypertension
- ) HCC
340
What is the most common serious infection in cirrhosis?
Spontaneous bacterial peritonitis
341
What are increased (bloods) in cirrhosis? (6)
- ) Bilirubin
- ) AST
- ) ALT
- ) Gamma GT
- ) ALP
- ) PT/INR later
342
What are decreased (bloods) in cirrhosis? (3)
-) Albumin
-) WCC
-) Platelets
Last 2 indicate hypersplenism
343
How do we diagnose a spontaneous bacterial peritonitis?
Ascitic tap - neutrophils high presence
344
What is the treatment for cirrhosis?
- ) Good nutrition
- ) Avoid alcohol, NSAIDs, sedatives, opiates
- ) Colestyramine for pruritis
- ) US screen for cancer
- ) High dose ursodeoxycholic acid in PBC
- ) Penicillamine in Wilson's disease
345
What is the treatment for ascites?
- ) Fluid restriction
- ) Low salt diet
- ) Spironolactone
346
How do we treat spontaneous bacterial peritonitis?
Piperacillin with tazobactam until sensitivities known
347
What is the only definite treatment/cure for cirrhosis?
Liver transplant
348
What is portal hypertension?
High blood pressure in the hepatic portal vein
349
What can portal hypertension lead to? (2)
Varices and haemorrhages
350
What are the 3 types of causes of portal hypertension?
- ) Pre-hepatic
- ) Intra-hepatic
- ) Post-hepatic
351
Give 4 causes of portal hypertension
- ) Thrombosis
- ) Cirrhosis
- ) Schistosomiasis
- ) Budd-Chiari syndrome
- ) Right HF
352
What are gastro-oesophageal varices?
Submucosal venous dilatation secondary to increased portal pressures
353
What is the management of gastro-oesophageal varices?
Endoscopic banding or sclerotherapy
354
What is the prophylaxis for gastro-oesophageal varices?
Non-selective beta-blocker, propranolol or repeat endscopic banding
355
What is the management for resistant gastro-oesophageal varices?
Transjugular intrahepatic porto-systemic shunt
356
What is a liver abscess?
Pus filled mass inside liver
357
What is a liver abscess commonly caused by? (2)
Appendicities or diverticulititis due to haematogenous spread
358
Give 3 symptoms of a liver abscess
- ) Fever
- ) Lethargy
- ) RUQ discomfort
- ) Anorexia
- ) Enlarged liver if chronic
359
What are common causative bacteria of liver abscesses?
- ) Strep. milleri
- ) E. coli
- ) Klebsiella
- ) Opportunistic staphs
360
How do we treat a liver abscess?
Antibiotics, percutaneous drainage, possible laparotomy
361
What is an amoebic liver abscess?
Pus is like 'anchovy sauce'
362
What is an amoebic liver abscess due to?
Entamoeba histolytica
363
What are 3 symptoms of amoebic liver abscesses?
- ) High swinging fever
- ) Sweats
- ) RUQ pain and tenderness
- ) Pallor
- ) Weight loss
364
How do we treat an amoebic liver abscess? (2)
Aspiration and metronidazole
365
What does alcoholic liver disease include? (3)
- ) Fatty liver
- ) Alcoholic hepatitis
- ) Cirrhosis
366
What drug do we give for alcohol withdrawal symptoms?
Chlordiazepoxide
367
What drug do we give for cravings or anxiety?
Acamprosate
368
What drug can we give for chronic alcohol dependence?
Disulfiram
369
What is ascites?
Accumulation of fluid in the peritoneal cavity
370
What is exudate?
High protein fluid
371
What is transudate?
Low protein fluid
372
What does ascites present with? (2)
Swelling of abdomen and SOB
373
Give 3 signs of ascites
- ) Medusa veins
- ) Possible umbilical hernia
- ) Visible bulging of flanks
- ) Shifting dullness on examination
374
What is transudate due to in ascites? (3)
- ) Decreased oncotic pressure
- ) High serum to ascites albumin gradient
- ) Outflow problem
375
What is exudate due to in ascites? (2)
- ) Low serum to ascites albumin gradient
| - ) Membrane more porous
376
Is exudate or transudate worse?
Exudate
377
Give 2 causes of transudate ascites
Cirrhosis, cardiac failure, Budd-Chiari syndrome
378
Give 2 causes of exudate ascites
Cancer (ovarian), sepsis, TB, nephrotic syndrome
379
What can the stasis of fluid in an ascites cause?
Infection - spontaneous bacterial peritonitis
380
How do we diagnose an ascites?
Paracentesis
381
Do transudates or exudates have increased pressure on the hepatic portal vein?
Transudates
382
Are transudates or exudates actively excreted?
Exudates
383
What occurs in non-alcoholic fatty liver disease? (NAFLD)
Increased fat in hepatocytes with inflammation
384
Give 4 risk factors for NAFLD
- ) Obesity
- ) Female
- ) DM
- ) Dyslipiaemia
- ) Parenteral feeding
- ) Hyperlipidaemia
- ) Wilson's disease
385
How do we distinguish NAFLD from NASH?
Biopsy
386
What is NASH?
Non-alcoholic steatohepatitis
387
How do we treat NAFLD?
Control risk factors
388
What is alpha 1 antitrypsin deficiency?
Inherited conformational disease that commonly affects lungs and liver
389
What is A1AT?
Glycoprotein (serine protease inhibitor) made in the liver that controls inflammatory cascades
390
What is Wilson's disease?
Inherited disorder copper excretion with excess deposition in liver and CNS
391
What is the genetic component of Wilson's disease?
Autosomal recessive disorder of a copper transporting ATPase, ATP78
392
What is impaired in the liver in Wilson's disease?
Copper incorporation into caeruloplasmin
393
What do children present with in Wilson's disease?
Liver disease (hepatitis, cirrhosis)
394
What do adults present with in Wilson's disease?
CNS signs (tremor, dysarthria, dysphagia, dementia, ataxia etc)
395
What is the mood like in Wilson's disease? (3)
- ) Depression/mania
- ) Changed libido
- ) Personality change
396
What is cognition like in Wilson's disease?
Decreased memory, slow to solve problems, decreased IQ, delusions
397
What are Kayser-Fleischer rings, and in which disease are they found?
Rings of copper in iris, Wilson's
398
What 3 other symptoms does Wilson's present with?
Haemolysis, blue lunulae, arthritis, hyper mobile joints, grey skin
399
Give 3 tests for Wilson's
- ) Copper high in urine
- ) Serum caeruloplasmin low
- ) Hepatic copper increased
- ) Genetic testing
400
What is the management for Wilson's? (3)
- ) Avoid foods with high copper content
- ) Lifelong penicillamine
- ) Possible liver transplantation
401
What is acute liver failure?
Suddenly occuring, 8-21 days
402
What is chronic liver failure?
Occurs with a background of cirrhosis
403
What is fulminant hepatic failure?
Clinical syndrome resulting from massive necrosis of liver cells, leading to a severe impairment of function
404
Give 4 causes of liver failure
- ) Viral hepatitis (B, C)
- ) Yellow fever
- ) Paracetamol overdose
- ) Toxins
- ) Budd-Chiari syndrome
- ) Alcohol
- ) Fatty liver disease
- ) PBC
- ) PSC
- ) Autoimmune hepatitis
- ) A1AT deficiency
- ) Wilson's
- ) Malignancy
405
Give 3 signs of liver failure
- ) Jaundice
- ) Hepatic encephalopathy
- ) Fector hepaticas (pear drop smell)
- ) Asterixis/flap
- ) Apraxia
406
Give 4 tests for liver failure
- ) Blood
- ) Microbiology
- ) Radiology, Doppler flow
- ) Neurophysiology
407
What is the treatment for liver failure?
- ) Intubate, NGT, catheter
- ) Monitor
- ) Glucose 10% to avoid hypoglycaemia
- ) Treat cause
- ) Treat complications
408
What drug is given for seizures?
Phenytoin/lorazepam
409
What do we do if there is renal failure?
Haemofiltration/haemodialysis
410
Give 3 complications of liver failure
- ) Cerebral oedema
- ) Ascites
- ) Bleeding
- ) Infection
- ) Hypoglycaemia
- ) Encephalopathy
411
What is the drug treatment for paracetamol poisoning?
N acetyl cysteine
412
What is the drug given for cerebral oedema?
Mannitol
413
What type of virus is hepatitis A?
RNA virus
414
How is hepatitis A spread?
Faecal-oral or shellfish
415
Give 3 symptoms of hepatitis A
- ) Fever
- ) Malasie
- ) Anorexia
- ) Nausea
- ) Arthralgia
- ) Then jaundice, hepatosplenomegaly, adenopathy
416
What Ig shows that it is a recent infection?
IgM
417
What 2 things are raised in hepatitis A?
ALT and AST
418
What is ALT?
Alanine aminotransferase
419
What is AST?
Aspartate aminotransferase
420
What is the treatment for hepatitis A?
Supportive, avoid alcohol
421
Which hepatitis types are chronic? (or can be)
B, C, D
422
What do we give for fulminant hepatitis?
Interferon alfa
423
What type of virus is hepatitis B?
DNA virus
424
How is hepatitis B spread?
Blood/sexual
425
Give 3 risk groups for hepatitis B
- ) IVDU
- ) Sexual partners/carers
- ) Health workers
- ) Haemophiliacs
- ) MSM
- ) Haemodialysis
- ) etc
426
How does hepatitis B present?
Resembles hepatitis A but arthralgia and urticaria are more common
427
Give 2 antigens present in stages of hepatitis B
HBsAg - 1-6 months after exposure, >6 months means carrier, alone means vaccination
HBeAg - 1.5-3 months after illness, high infectivity
HBcAg - past infection
428
Is hepatitis B highly infective?
Yes
429
Give 3 complications of hepatitis B
- ) Fulminant hepatic failure
- ) Cirrhosis
- ) HCC
430
What is the treatment for hepatitis B?
- ) Avoid alcohol
- ) Immunise sexual contacts
- ) Antivirals for chronic liver inflammation (tenofovir, entecavr)
431
What type of virus is hepatitis C?
RNA flavivirus
432
How is hepatitis C spread?
Blood/sexual
433
Give 2 risk factors for progression of hepatitis C?
- ) Male
- ) Older
- ) Higher viral load
- ) Alcohol
- ) HIV, HBV
434
Is hepatitis C more acute or chronic?
Chronic (C for chronic!)
435
The presence of what confirms exposure to hepatitis C
Anti-HCV antibodies
436
What is the treatment for hepatitis C?
Avoid alcohol, pegylated interferon with ribavirin and protease inhibitor
437
Give 2 complications of hepatitis C
- ) Glomerulonephritis
- ) Autoimmune hepatitis
- ) Thyroiditis
- ) Cryoglobulinaemia
- ) PAN
438
What is higher in a LFT in hepatitis C?
ALT
439
What type of virus is hepatitis D?
Incomplete RNA virus
440
What does hepatitis D need for its assembly?
HBV
441
What can hepatitis D cause?
Acute liver failure/cirrhosis
442
What can prevent hepatitis D?
HBV vaccination
443
What type of virus is hepatitis E?
RNA virus
444
Is HAV or HEV more common in the UK?
HEV
445
How does hepatitis D spread?
Blood/seuxal
446
How does hepatitis E spread?
Faeco-oral
447
What is non alcoholic steatohepatitis?
NAFLD with inflammation
448
What is autoimmune hepatitis?
An inflammatory liver disease of unknown cause characterised by abnormal T cell function and autoantibodies directed against hepatocyte surface antigens
449
What does (some) autoimmune hepatitis present with?
- ) Acute hepatitis
- ) Signs of autoimmune disease (fever, malaise, rash, poly arthritis, glomerulonephritis)
- ) Jaundice
- ) Asypmtomatic
450
What antibodies are usually positive in autoimmune hepatitis? (2)
ANA and ASMA
451
What does a liver biopsy show in autoimmune hepatitis?
Mononuclear infiltrate of portal and periportal areas and piecemeal necrosis +/- fibrosis
452
How do we diagnose autoimmune hepatitis?
Exclude other diseases, look at IgG, autoantibodies, histology
453
What is the management of autoimmune hepatitis?
Immunosuppression with prednisolone +/- azathioprine
454
Give 3 risk factors for oesophageal cancer
- ) Diet
- ) Alcohol excess
- ) Smoking
- ) Achalasia
- ) Reflux oesophagitis +/- Barrett's oesophagus
- ) Obesity
- ) Hot drinks
- ) etc
455
What is Barrett's oesophagus also known as?
CELLO - columnar lined lower oesophagus
456
Where does oesophageal cancer occur most?
In the middle (50%)
457
Give 3 symptoms/signs of oesophageal cancer
- ) Dysphagia
- ) Weight loss
- ) Retrosternal chest pain
- ) Upper 1/3rd of oesophagus - hoarseness, cough
458
What is the main investigation for oesophageal cancer?
Oesophagoscopy with biopsy
459
What are the 5 T stages of oesophageal cancer?
```
Tis - carcinoma in situ
T1 - invading lamina propria/submucosa
T2 - muscularis propria
T3 - adventitia
T4 - adjacent structures
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460
What are the survival rates of oesophageal cancer like?
Poor with/without treatment :(
461
What are some options for treatment of oesophageal cancer?
- ) Radical curative oesophagectomy
- ) Pre-op chemo
- ) Chemoradiotherapy
- ) Palliation with chemo/radio, stenting to restore swallowing
462
What type of cancer can oesophageal be? (2)
- ) Squamous cell (proximal)
| - ) Adenocarcinomas (distal)
463
Give 3 risk factors for gastric cancer
- ) Pernicious anaemia
- ) Blood group A
- ) H. pylori
- ) Atrophic gastritis
- ) Smoking, diet (pickled food), lower social class)
464
What are the symptoms of gastric cancer?
- ) Often non-specific
- ) Dyspepsia
- ) Weight loss
- ) Vomiting
- ) Dysphagia
- ) Anaemia
465
Give 2 signs of gastric cancer
- ) Epigastric mass
- ) Hepatomegaly
- ) Jaundice
- ) Ascites
466
What is the spread of gastric cancer?
Local, lymphatic, blood bourne, transcoelomic (eg to ovaries)
467
What are the tests for gastric cancer?
Gastroscopy and multiple ulcer edge biopsies
468
What are the treatments for gastric cancer?
- ) Gastrectomy - total/partial
- ) Combination chemotherapy
- ) Surgical palliation
469
What may be given as a target therapy for HER-2 positive tumours?
Trastuzumab
470
What is the commonest predisposing factor for bile duct and gallbladder cancers?
Primary sclerosis cholangitis
471
Give 3 presenting features of bile duct and gallbladder cancer
- ) Obstructive jaundice
- ) Pruritus
- ) Abdominal pain
- ) Weight loss
- ) Anorexia
472
How do we treat bile duct and gallbladder cancer?
Surgical resection if operable
473
Give 3 predisposing factors to colorectal cancer
- ) Neoplastic polyps
- ) IBD
- ) Genetic predisposition
- ) Diet (low fibre, high red meat)
- ) Alcohol
- ) Smoking
- ) Previous cancer
474
What drug reduces the incidence and mortality of colorectal cancer?
Daily aspirin
475
What is familial adenomatous polyposis (FAP) due to?
Germline mutations in the APC tumour suppressor gene
476
What are the 2 genetic predispositions to colorectal cancer?
FAP and HNPCC
477
What prevents cancer in those with FAP?
Total colectomy
478
What is HNPCC?
Hereditary non-polyposis colorectal cancer entails familial aggregation of colorectal cancer
479
Where are the mutations in HNPCC 1?
1/5 DNA mismatch repair genes
480
Is HNPCC autosomal dominant or recessive?
Dominant
481
What do virtually all colorectal cancers develop from?
Adenomatous polyps
482
Give 3 symptoms of left sided colorectal cancer
- ) Bleeding/mucus PR
- ) Altered bowel habit/obstruction
- ) Tenesmus
- ) Mass PR
483
Give 2 symptoms of right sided colorectal cancer
- ) Weight loss
- ) Low haemoglobin
- ) Abdominal pain
484
Give 3 symptoms of either sided colorectal cancer
- ) Abdominal mass
- ) Perforation
- ) Haemorrhage
- ) Fistula
485
Give 3 tests for colorectal cancer
- ) PR
- ) Sigmoidoscopy/colonscopy
- ) Faecal occult blood
- ) FBC
486
What is the NHS screening programme for colorectal (bowel) cancer?
Faecal occult blood (FOB) every 2 years if 60-75yrs
487
What is the spread of colorectal cancer?
Local, lymphatic, by blood (liver, lung, bone), transcoelomic
488
What is the Duke's classification of colorectal cancer?
A - limited to muscular mucosae
B - extension through muscular mucosae
C - involvement of regional lymph nodes
D - distant mets
489
What is the TNM staging in colorectal cancer? (T)
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Tx - primary tumour cannot be assessed
Tis - carcinoma in situ
T1 - invading submucosa
T2 - muscular propria
T3 - subserosa and beyond (not other organs)
T4 - adjacent structures
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490
What is the TNM staging in colorectal cancer? (N)
Nx - nodes cannot be assessed
N0 - no node spread
N1 - mets in 1-3 regional nodes
N2 - mets in >3 regional nodes
491
What is the TNM staging in colorectal cancer? (M)
M0 - no distant spread
| M1 - distant mets
492
What does a positive CRM (circumferential resection margin) have a large risk of?
Local recurrence and lower survival
493
What is the treatment for colorectal cancer? (5)
- ) Right hemicolectomy - caecal, ascending, proximal transverse
- ) Left hemicolectomy - distal transverse, descending
- ) Sigmoid colectomy - sigmoid
- ) Anterior resection - low sigmoid, high rectal
- ) Abdomino-perianal - low in rectum
494
What procedure do we do in emergency bowel obstruction, perforation or palliation?
Hartmann's
495
When is radiotherapy used in colorectal cancer? (3)
- ) Palliation
- ) Pre-op rectal cancer
- ) Post-op rectal cancer with high risk of local recurrance
496
When is chemotherapy used in colorectal cancer? (2)
- ) Palliative
| - ) Adjuvant for stage 3 disease (FOLFOX)
497
What improves survival when added to combination therapy in advanced colorectal cancer?
Bevacizumab, anti VEGF antibody
498
What improves response and survival in KRAS wild type metastatic colorectal cancer?
Cetuximab and panotumumab
499
Where are adenocarcinomas of the SB usually found? (2)
Duodenum and jejunum
500
Where are lymphomas (non-Hodgkin's) usually found?
Ileum
501
Give 2 predisposing factors to small bowel cancer
Coeliac disease, Crohn's
502
Give 3 risk factors for pancreatic cancer
- ) Smoking
- ) Alcohol
- ) Carcinogen
- ) DM
- ) Chronic pancreatitis
- ) Obesity
503
What are most types of pancreatic cancer?
Ductal adenocarcinomas
504
Where do pancreatic cancers present?
- ) 60% head
- ) 25% body
- ) 15% tail
505
Mutations in which gene is present in 95% of pancreatic cancer cases?
KRAS2
506
What do tumours of the pancreatic head present with?
Painless obstructive jaundice
507
What do tumours of the body and tail present with?
Epigastric pain radiating to back, relieved by sitting forwards
508
What can any pancreatic cancer present with?
- ) Anorexia
- ) Weight loss
- ) DM
- ) Acute pancreatitis
509
Give 3 signs of pancreatic cancer
- ) Jaundice
- ) Palpable gallbladder
- ) Epigastric mass
- ) Hepatomegaly
- ) Splenomegaly
- ) Lymphadenopathy
- ) Ascites
510
What tests do we do to diagnose pancreatic cancer?
US/CT
511
What is the treatment for pancreatic cancer?
- ) Resection surgery - pancreaticoduodenectomy (Whipple's) only when curative
- ) Tail lesions easiest
- ) <20% suitable for surgery
- ) Stent insertion for palliation
- ) Opiates
512
The commonest (90%) of liver tumours are from where? (3)
Breast, bronchus, GI tract
513
What is primary HCC caused by? (3)
- ) HBV
- ) HCV
- ) Cirrhosis
514
Give 4 symptoms of liver tumours
- ) Fever
- ) Malaise
- ) Anorexia
- ) Weight loss
- ) RUQ pain
- ) Late jaundice (except with HCC)
515
What are the signs of a liver tumour?
Hepatomegaly, chronic liver disease signs, decompensation, abdominal mass, bruit over liver
516
What (bloods) is found in 50-80% of HCC?
Alpha-fetoprotein
517
What tests can we do to diagnose liver cancer?
- ) Bloods
- ) US/CT
- ) MRI
- ) Biopsy
518
What does HCC stand for?
Hepatocellular carcinoma
519
How do we treat liver tumour mets?
- ) Chemo maybe
- ) Resection maybe
- ) Palliation
520
How do we treat primary HCC?
- ) Resect small solitary tumours
- ) Liver transplant
- ) Percutaneous ablation
- ) Sorafenib
521
How do we treat cholangiocarcinoma?
Surgery, usually not suitable and recur, stenting possible
522
What is a cholangiocarcinoma?
Biliary tree cancer
523
Give 4 causes of infection
- ) Norovirus
- ) E. coli
- ) Giardia
- ) Salmonella
- ) C. diff
524
What is a Mallory Weiss tear?
Persistent vomiting/retching causes haematemesis via and oesophageal mucosal tear
525
Where does the tear occur most often? (MW tear)
Lower oesophagus close to junction with stomach
526
Give 2 causes of a Mallory Weiss tear
- ) Alcohol
- ) Bulimia
- ) Pregnancy
527
What is achalasia?
Coordinated peristalsis is lost and the lower oesophageal sphincter fails to relax (due to degeneration of the myenteric plexus)
528
Give 3 things achalasia causes
- ) Dysphagia
- ) Regurgitation
- ) Weight loss
529
What does a barium swallow/manometry in achalasia show?
Dilated tapering oesophagus
530
What is the treatment for achalasia?
- ) Endoscopic balloon dilatation
- ) Heller's cardiomyotomy
- ) PPIs
531
What occurs in tropical sprue? (3)
- ) Villous atrophy
- ) Inflammation of small interstine
- ) Malabsorption
532
Give 3 symptoms of tropical sprue
- ) Diarrhoea
- ) Fever
- ) Malaise
- ) Later weight loss, anorexia, nutritional deficiencies
533
What is the only cure of tropical sprue?
To leave the infected area
534
What are haemorrhoids?
Disrupted and dilated anal cushions
535
What are anal cushions?
The anus is lined mainly by discontinuous masses of spongy vascular tissue (anal cushions), which contribute to anal closure
536
Give 2 causes of haemorrhoids
- ) Increased anal tone (stress)
- ) Straining due to constipation
- ) Other congestion (tumour, pregnancy)
537
Give 2 symptoms of haemorrhoids
- ) Bright red rectal bleeding
- ) Mucus discharge
- ) Pruritus
- ) Severe anaemia
538
How do we diagnose haemorrhoids?
PR exam, abdominal exam, colonoscopy/flexible sigmoidoscopy
539
What is the pathogenic circle of haemorrhoids?
1) Vascular cushions protrude through a high anus
2) Become more congested
3) Hypertrophy to protrude again more readily
4) Protrusions may strangulate
540
What is the medical treatment for haemorrhoids?
Medical - fluid and fibre, stool softener, topical analgesics
541
What is the non medical treatment for haemorrhoids?
- ) Rubber band ligation
- ) Sclerosant injections
- ) Infra red coagulation
- ) Bipolar diathermy and direct current electroptherapy
542
What is the surgical treatment for haemorrhoids?
Excisional haemorrhoidectomy
543
What is a fistula-in-ano?
A track communicated between the skin and the anal canal/rectum
544
What is the pathogenesis of a fistula-in-ano?
Blockage of deep intramuscular gland ducks thought to predispose to formation of abscesses. which discharge to form the fistula
545
Give 3 causes of a fistula-in-ano
- ) Perianal sepsis
- ) Abscesses
- ) Crohn's
- ) TB
- ) Diverticular disease
- ) Rectal carcinoma
- ) Immunocompromise
546
What are the tests for a fistula-in-ano?
MRI and endoanal US
547
What is the treatment for a fistula-in-ano?
Fistulotomy and excision
548
What is a fissure-in-ano?
A painful tear in the squamous lining of the lower anal canal
549
Are fissures-in-ano most anterior or posterior?
Posterior (90%)
550
What is the main cause of fissures-in-ano?
Hard faeces
551
What is the treatment for fissures-in-ano?
- ) 5% lidocaine ointment and GTN ointment
- ) Increase fibre and fluids
- ) Stool softener
- ) Topical botulinum and diltiazem
552
What is a perianal abscess?
Anorectal abscesses
553
What are perianal abscesses usually caused by?
Gut organisms
554
What are perianal abscesses associated with?
DM, Crohn's, malignancies, fistulaes
555
What is the treatment for a perianal abscess?
Incision and drainage
556
What is a pilonidal sinus?
Obstruction of the natal cleft hair follicles around 6cm above the anus
557
What does the ingrowing of hair in a pilonidal sinus do?
Excites a foreign body reaction and may cause secondary tracts to open laterally +/- abscesses with foul smelling discharge
558
Give 2 risk factors for a pilonidal sinus
Male, obese
559
What is the treatment of a pilonidal sinus?
Excision of the sinus tract +/- primary closure
560
What is biliary colic?
Pain from symptomatic gallstones if there is cystic duct obstruction or if the gallstones have passed into the common bile duct
561
What does biliary colic present with?
RUQ pain which radiates to back, possible jaundice
562
What is the treatment for biliary colic?
Analgesia, rehydration, NBM
563
What symptom would indicate IBD not IBS?
Nocturnal diarrhoea
564
What is the cystic artery a branch of?
Right hepatic artery
565
What is the treatment for peptic ulcers?
PAC MAN
PPI
Amoxicillin
Clarithromycin
566
Give the urine, stools, itching and liver tests in pre-hepatic jaundice
Urine - normal
Stools - dark/normal
Itching - none
Liver tests - normal
567
Give the urine, stools, itching and liver tests in hepatic jaundice
Urine - dark
Stools - pale
Itching - maybe
Liver tests - abnormal
568
Give the urine, stools, itching and liver tests in post-hepatic jaundice
Urine - dark
Stools - clay
Itching - yes
Liver tests - abnormal
