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Year 3 diagnosis and management > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

Symptoms and signs of achalasia?

A
  • Insidious onset
  • Intermittent dysphagia
  • Weight loss
  • Heartburn
  • Chest pain
  • Aspiration pneumonia
  • Malnutrition
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2
Q

Investigation for achalasia?

A
  1. CXR - widened mediastinum, double heart border, absence of gastric bubble
  2. Barium swallow
  3. Endoscopy - exclude malignancy
  4. Manometry - gold standard
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3
Q

Symptoms of acute cholangitis?

A

(aka ascending cholangitis)

Charcot’s Triad
• RUQ pain
• Jaundice
• Fever with rigors

(Reynolds’ pentad, add)
• Confusion
• Septic shock (hypotension)

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4
Q

What is the cause of acute cholangitis?

A

Bile duct obstruction
• Gall stones
• Tumour
• Iatrogenic

Increased pressure in duct brings bacteria in contact with blood - infection

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5
Q

Investigation for acute cholangitis?

A
  • Bloods - raised WCC, CRP and LFTs
  • USS - cholangitis vs cholecystitis
  • => (if -ve) CT => (if -ve) MRCP
  • ERCP - gold standard by finding stones (and therapeutic)
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6
Q

Management for acute cholangitis?

A
  1. Broad spectrum ABx + biliary decompression non-surgical: ERCP => Lithotripsy if too big
  2. Broad spectrum ABx + biliary decompression - surgical: Cholecystectomy

(consider analgesia)

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7
Q

Symptoms of alcohol withdrawal?

A
  • Insomnia and fatigue
  • Palpitations
  • Nausea, vomiting, headache
  • Anorexia
  • Depression
  • Delerium tremens (anxiety, tremor, sweating, hallucinations)
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8
Q

Management for alcohol withdrawal?

A
  1. Benzodiazepines (chlordiazepoxide)
    • Barbiturates if severe
    • Pabrinex to prevent W-K syndrome
    • Antipsychotic (haloperidol) if psychotic e.g. delerium tremens
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9
Q

What 3 forms of liver disease is caused by excessive alcohol intake?

A
  • Alcoholic fatty liver (steatosis)
  • Alcoholic hepatitis
  • Chronic cirrhosis
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10
Q

Symptoms and signs of alcoholic hepatitis?

A
  • Nausea, malaise, right hyp. pain, low-grade fever
  • Jaundice
  • Swollen ankles
  • GI bleed
  • Palmar erythema
  • Gynaecomastia
  • Dupuytren’s contracture
  • Malnutrition
  • Hepatomegaly
  • Facial telangiectasia
  • Spider naevi
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11
Q

Investigation for alcoholic hepatitis?

A
  1. Bloods - AST, ALT, FBC, U+Es, prolonged PT
  2. USS - check for malignancy
  3. Endoscopy - varices
  4. Liver biopsy - gold standard
  5. EEG - encephalopathy
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12
Q

Management for alcoholic hepatitis?

A
  1. Alcohol abstinency + withdrawal management
    • Nutrition + vitamin supplementation (zinc, thiamine, Vit C) - be careful with re-feeding syndrome
    • Immunisation
  2. Corticosteroids
  3. Diuretics (furosemide and spirinolactone) - ascites
  4. Pentoxifylline - hepatorenal syndrome

Nutrition
• Oral/NG feeding
• Protein restriction (unless encephalopathic)

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13
Q

What is amyloidosis of the cerebral cortex and cerebral blood vessels called?

A
  • Cerebral cortex - Alzheimer’s

* Cerebral blood vessels - amyloid angiopathy

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14
Q

Outline the 3 types of amyloidosis?

A

Type AL
• Primary amyloidosis
• Monoclonal immunoglobulin light chains
• Affects kidneys, heart, nerves, gut, vascular

Type AA
• Secondary amyloidosis
• Serum amyloid A protein
• Affects kidneys, liver and spleen

Type ATTR
• Familial amyloidosis
• Genetic-variant transthyretin
• Sensory or autonomic neuropathy
• Renal or cardiac
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15
Q 
Presentation of amyloidosis?
• Renal
• Cardiac 
• GI 
• Neurological 
• Skin
• Joints 
• Haematological
A
  • Renal - nephrotic syndrome
  • Cardiac - restrictive cardiomyopathy
  • GI - macroglossia
  • Neurological - neuropathy
  • Skin - waxy skin, purpura around eyes
  • Joints - painful, asymmetrical enlargement
  • Haematological - bleeding tendency
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16
Q

Investigation for amyloidosis?

A
  • Serum immunofixation - AL
  • Urine immunofixation - AL
  • Bone marrow biopsy - AL
  • SAP scan
  • Tissue biopsy - gold standard (Congo red stain => pink (green in polarised light)
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17
Q

Management for anal fissure?

A

Acute
1. Conservative - increase fibre + fluid, laxatives
2. Lidocaine ointment, GTN
• Diltiazem if GTN headaches

Resistant
1. Botox injection
• or sphincterectomy
2. Anal advancement flap

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18
Q

Symptoms and signs of appendicitis?

A
  • Periumbilical pain => right iliac fossa
  • Anorexia
  • Vomiting
  • Diarrhoea
  • Furred tongue
  • Tachycardia, fever, shallow breath
  • Foetor (bad breath)
  • Guarding, rebound tenderness
  • Rovsing’s, Psoas and Cope sign
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19
Q

What are Rovsing’s, Psoas and Cope signs?

A
  • Rovsing’s - palpation of left iliac fossa causes more pain than right
  • Psoas - extending hip causes pain (retrocaecal appendix)
  • Cope - flexion and internal rotation of hip causes pain (appendix close to obturator internus)
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20
Q

Investigations for appendicitis?

A
  • FBC - leukocytosis
  • USS - not always visualised
  • Abdominal/pelvic CT - gold standard, but fatal delay possible
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21
Q

Management for appendicitis?

A
  1. Appendectomy (laparoscopy)

2. ABx for 24 hours post-surgery (cefuroxime/metronidazole)

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22
Q

What are the 2 types of autoimmune hepatitis?

A

Type 1 - classic
• ANA, ASMA, AAA, anti-SLA
• all age groups (mainly young women)

Type 2
• ALKM-1, ALC-1
• Girls and young women

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23
Q

Extra signs of autoimmune hepatitis?

A

Cushingoid features

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24
Q

Investigation for autoimmune hepatitis?

A
  1. Bloods (High LFTs but low albumin, antibodies, high PT, low Hb, platelets and WCC)
  2. Liver biopsy - diagnostic
  • USS to visualise lesions
  • ERCP - rule out primary sclerosing cholangitis
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25
Q

Symptoms of Barrett’s oesophagus?

A
  • Retrosternal pain
  • Haematemesis
  • Water-brash (sour taste)
  • Burning pain when swallowing, dysphagia
  • Bloating, belching
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26
Q

Investigation for Barrett’s oesophagus and what do you see?

A

OGD and biopsy
• Lower third of oesophagus
• Metaplastic columnar epithelium
• Goblet cells present

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27
Q

Management for Barrett’s oesophagus?

A

Non-dysplastic
• PPI + surveillance

Low grade
• Radiofrequency ablation
• Nodular - endoscopic mucosal resection

High grade (add to low grade)
• PPI
• Second-line: oesophagectomy

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28
Q

Presentation of cholangiocarcinoma?

A 
(bile duct cancer)
• Jaundice
• Pale stool
• Dark urine
• Pruritus
• Systemic malignancy signs
• Palpable gallbladder (Courvoisier's Law - unlikely due to gallstones where pancreatic or biliary tree cancer is more likely)
• Hepatomegaly
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29
Q

Investigation for cholangiocarcinoma?

A
  1. Bloods - high ALP + GGT, CA19-9 (also for pancreatic cancer) high
  2. Abdo USS (benign vs malignant)
  3. ERCP - bile cytology and tumour biopsy
  4. CT/MRI/bone scan - staging
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30
Q

Relation of 3 ‘gallbladder’ conditions with Charcot’s triad?

A
  • Biliary colic (gallstone) - RUQ pain
  • Cholecystitis - RUQ pain, fever
  • Cholangitis - RUQ pain, fever, jaundice
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31
Q

Signs of cholecystitis?

A
  • Murphy’s sign (only positive if the same test in the LUQ doesn’t cause pain)
  • Localised peritonism - guarding/rebound tenderness
  • Tachycardia
  • Pyrexia
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32
Q

Investigation for cholecystitis?

A
  1. Bloods - raised WCC, CRP and LFTs
  2. USS - diagnostic if sepsis not suspected
  3. CT/MRI - diagnostic if sepsis supected (can find perforation)
  4. MRCP if others are negative with abnormal LFTs
  5. Endoscopic ultrasound
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33
Q

When is cirrhosis “decompensated”?

A 
Complicated by J BAE
• Jaundice
• Bleeding varices
• Ascites
• Encephalopathy
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34
Q

What’s the most common cause of cirrhosis in the UK and worldwide?

A
  • UK - chronic alcohol misuse

* Worldwide - hep B/C

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35
Q

Which condition associated with OBESITY, DIABETES, total parenteral nutrition and drugs can cause CIRRHOSIS?

A

Non-alcoholic steatohepatitis (NASH)

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36
Q

What are the investigations for cirrhosis?

A
  1. Bloods - low platelets and Hb (hypersplenism from portal hypertension), high LFTs but low albumin, prolonged PT, high AFP

Check for cause
• Caeruloplasmin low in Wilson’s disease
• Iron studies
• ANA, ASMA (autoimmune)

  • Ascitic tap (> 250 = spontaneous bacterial peritonitis)
  • Liver Biopsy - diagnostic (fibrosis, nodular)
  • Imaging to detect complications
  • Endoscopy for varices
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37
Q

Describe the grading used to estimate prognosis in cirrhosis/chronic liver disease?

A

Child-Pugh grading
• 1, 2 or 3 given to the following

  1. Albumin
  2. Bilirubin
  3. PT
  4. Ascites
  5. Encephalopathy

Class A: 5-6
Class B: 7-9
Class C: 10-15

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38
Q

Management for cirrhosis?
1 - ? treatment for: encephalopathy, ascites, SBP, portal hypertension
2 - ?

A
  1. Treat underlying cause
  • Encephalopathy - lactulose and phosphate enema, prevents ammonia absorption
  • Ascites - sodium restriction and diuretic therapy for ascites
  • SBP - ABx (cefuroxime and metroniazole), prophylaxis
  • TIPS shunt reduces portal hypertension
  1. Liver transplant
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39
Q

What is the drug for paracetamol OD?

A

IV N-acetylcysteine

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40
Q

What causes coeliac disease?

A

Sensitivity to gliadin component of gluten

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41
Q

What happens to the intestinal cells in coeliac disease?

A
  • Subtotal villous atrophy

* Crypt hyperplasia

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42
Q

Symptoms and signs of coeliac disease?

A
  • Abdominal distention
  • Steatorrhoea
  • Tireness, malaise, weight loss
  • Failure to ‘thrive’ in children
  • Signs of anaemia
  • Signs of maltnutrition (short, wasted buttocks in children)
  • Itchy blisters on elbows, knees, buttocks (dermatitis herpetiformis)
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43
Q

Investigations for coeliac disease?

A
  1. FBC - iron deficiency anaemia
  2. IgA-tTG (tissue transglutaminase) - diagnostic

(IgG anti-gliadin, IgG anti-endomysial - diagnostic if IgA doesn’t work - check Ig levels to avoid false negatives)

  1. Small-bowel histology (biopsy) - gold standard
  • Stool - exclude infection
  • D-xylose test - reduced urinary excretion => small bowel malabsorption
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44
Q

Management for coeliac disease?

A
  1. Gluten-free diet
    • Calcium, vitamin D, iron supplements
  2. Refractory => referral
  3. Crisis => rehydration, correct electrolyte abnormalities, corticosteroids
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45
Q

Outline the distribution of colorectal cancer?

A
  • 60% rectum and signmoid
  • 30% descending colon
  • 10% rest of colon
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46
Q

Outline Duke’s staging of colorectal cancer?

A 
A - contained in bowel
B - grown through muscle layer of bowel
C1 - regional lymph nodes
C2 - apical node positive
D - organ metastasis
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47
Q

Symptoms and signs of colorectal carcinoma?

A
  • Change in bowel habit
  • Rectal bleeding
  • Tenesmus - sensation of incomplete emptying
  • (Right sided presents later, anaemia symptoms)
  • 20% present as emergency due to large bowel obstruction or perforation
  • Abdominal mass
  • Low-lying rectal - palpable on DRE
  • Metastatic - hepatomegaly, shifting dullness (ascites)
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48
Q

Investigations for colorectal carcinoma?

A
  1. FBC - anaemia, LFTs, CEA
    • FIT screening
  2. Colonoscopy - ulcerating lesions (biopsy for confirmation)
  3. Double-contrast barium enema
  4. Contrast CT thorax, abdomen, pelvis - for metastases
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49
Q

Crohn’s characterisations

A
  • Th1 mediated - TNF-alpha
  • Inflammation anywhere from mouth to anus (40% in terminal ileum)
  • Can affect all layers - transmural
  • Patchy
  • Cobblestone appearance
  • Abscesses, fissures and fistulae
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50
Q

Symptoms and signs of Crohn’s disease?

A
  • Crampy abdominal pain
  • Diarrhoea
  • Fever, malaise, weight loss
  • RIF pain - inflammation of terminal ileum
  • Clubbing
  • Mouth ulcers
  • Perianal skin tags, fistulae, abscesses
  • Uveitis, seronegative arthritis, erythema nodosum, anaemia
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51
Q

Investigations for Crohn’s disease?

A
  • Bloods - anaemia, normal/low iron, low albumin, high ESR, normal/high CRP
  • Stool microscopy - exclude infective colitis
  • Abdo XR - check toxic megacolon
  • CXR - perforation
  • Small-bowel barium follow-through - strictures, rose-thorn appearance
  • Endoscopy and biopsy - differentiate UC and CD (biopsy: transmural, granulomatous inflammation, fissuring ulcers, lymphoid aggregates, neutrophil infilitrates)
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52
Q

Management of acute exacerbation of Crohn’s?

A
  1. Fluid resus
  2. IV/oral corticosteroids
  3. 5-ASA analogues e.g. mesalazine
  4. Immunosuppresion e.g. Azathioprine, reduce relapse
  5. Anti-TNF agents e.g. Infliximab, maintain remission
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53
Q

Management for long-term Crohn’s?

A
  1. Corticosteroids for acute exacerbations
  2. 5-ASA analogues
  3. Immunosuppression e.g. Azathioprine, reduce relapse
  4. Anti-TNF agents e.g. Infliximab, maintain remission
  • Stop smoking, dietician referral, education
  • Surgery indiciated by failure of medical treatment - resection of bowel and stoma formation
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54
Q

What is the difference between diverticulosis, diverticular disease and diverticulitis?

A

Diverticulosis - presence of diverticulae outpouchings of the colonic mucosa and submucosa through the muscular wall of the large bowel

Diverticular disease - diverticulosis + complications e.g. haemorrhage, infection

Diverticulitis - acute inflammation and infection of diverticulae

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55
Q

Outline the Hinchey Classification of Acute Diverticulitis?

A

Ia - phlegmon (diffuse inflammation with purulent exudate)
Ib and II - localised abcess
III - perforation and purulent peritonitis
IV - faecal peritonitis

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56
Q

What causes diverticular disease?

A
  • Low-fibre diet
  • High colonic intraluminal pressure
  • Herniation of mucosa and submucosa through muscle layers
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57
Q

Symptoms of diverticular disease?

A
  • PR bleeding
  • Diverticulitis - LIF pain, fever
  • Diverticular fistulation - pneumaturia, faecaluria, recurrent UTI
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58
Q

Investigations for diverticular disease?

A
  1. FBC - polymorphonuclear leukocytosis (increased WCC)
  2. CT - DIAGNOSTIC in acute setting
  • Colonoscopy - establish source in acute bleeding
  • Barium enema - ONLY when symptoms have resolved
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59
Q

Management for diverticular disease?

A

• Analgesia
• ABx
• Low-residue diet
(• IV fluids, IV Abx, blood transfusion if GI bleed)

Abscess >3cm, unresponsive to IV ABx
• Radiological drainage/surgery

Recurrent or uncontrolled haemorrhage
• Hartmann’s procedure - proctosigmoidectomy leaving stoma
• One-stage resection + anastomosis - with/without defunctioning stoma

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60
Q

What does IBS involve (symptoms/criteria)?

A
  • Recurrent abdominal pain/discomfort
  • > 6 months of previous year
• Relieved by defection and associated with altered bowel frequences AND
Associated with 2 of:
• Altered stool passage
• Abdominal bloating
• Worse on eating
• Passage of mucous
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61
Q

Signs of IBS?

A

May have similar red flags to colon cancer (> 6 month history, weight loss, anaemia, PR bleeding, late onset - must be excluded)

  • Abdomen may appear distended
  • Mildly tender on palpation in one/both iliac fossae
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62
Q

Investigation for IBS?

A

Mainly history and exclusion
• FBC - normal
• Stool - normal
• Anti-endomysial, anti-tTG - negative (abnormal suggets coeliac)
• AXR - normal (abnormal suggests obstruction)
• Flexible sigmoidoscopy - normal (abnormal suggests IBD)
• Urease breath test - normal (excluse H. pylori)
• Colonscopy - normal
• Faecal calprotectin - < 40 more likely IBS than IBD

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63
Q

Management for IBS?

A
  1. Lifestyle + dietary changes
    • Constipation predominant - laxatives
    • Diarrhoeal predominant - anti-diarrhoeals
    • Pain/bloating - add antispasmodics - dicycloverine
  2. CBT/hypnotherapy, TCAs
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64
Q

What are gallstones made up of?

A
  • 80% mixed - cholesterol, calcium bilirubinate, phosphate, protein
  • 10% cholesterol
  • 10% calcium bilirubinate - black “pigment” stones
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65
Q

Risk factors for gallstones?

A 
6Fs
• Female
• Fair
• Fat
• Forty
• Family history
• Fertile

(diabetes, contraceptive pill, octreotide)

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66
Q

Presentation of gallstones (cholelithiasis)?

A
  • Severe RUQ or epigastric pain
  • Radiation to right scapula
  • Precipitated by fatty meal
  • Symptoms of acute cholecystitis if it leads to it - RUQ pain, fever
  • Symptoms of acute cholangitis if it leads to it - RUQ pain, fever, jaundice
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67
Q

Investigation for gallstones?

A
  1. Bloods
    • FBC - normal (raised in acute cholecystitis => cholangitis)
    • LFT - elevated ALP - blocked duct
    • Lipase/amylase - exclude pancreatitis
  2. Abdominal USS - diagnostic (gold standard)
    note: AXR - only 10% of gallstones are radio-opaque
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68
Q

Management of gallstones?

A

Asymptomatic - low-fat diet, observation

Just symptomatic cholelithiasis (in gallbladder) - cholecystectomy

Choledocholithiasis (in bile duct)

  1. ERCP
  2. Laparoscopic common bile duct exploration
  3. Cholecystectomy (laparoscopic) if all symptomatic gallstones removed
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69
Q

Most common type of gastric cancer?

A

Adenocarcinoma

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70
Q

Signs of gastric cancer?

A
  • Epigastric mass
  • Ascites
  • Virchow’s Node (Troisier’s sign) - left supraclavicular fossa
  • Sister Mary Joseph’s Nodule - metastatic node on umbilicus
  • Krukenberg’s Tumour - ovarian metastases
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71
Q

Investigations for gastric cancer?

A
  1. Upper GI endoscopy with biopsy
  • Endoscopy ultrasound (EUS) - depth of gastric invasion and lymph node involvement
  • CT abdo/pelvis - metastases
  • CXR
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72
Q

Investigations for GORD?

A
  1. PPI trial
  2. OGD (routine biopsy not recommended if no suggestion of oesophagitis / Barrett’s)
  • Barium swallow - detect hiatus hernia, endoscopy contraindicated
  • 24hr pH monitor
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73
Q

Management of GORD?

A

Acute
• Standard dose PPI + lifestyle changes
• Elevated head when sleeping

Ongoing
1. Continued dose PPI
2. High dose PPI -
+ OGD referral (consider H2 antagonists e.g. ranitidine if nocturnal)
3. Surgery - Anti-reflux, Nissen fundoplication

(annual endoscopic surveillance for Barrett’s)

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74
Q 
Cause of gastroenteritis/infectious colitis?
• D+V outbreaks in institutions
• Dysentery (bloody diarrhoea)
• Uni student with watery diarrhoea
• Elderly on antibiotics
• Traveller's diarrhoea
A
  • D+V outbreaks in institutions - norovirus
  • Dysentery (bloody diarrhoea) - Shigella/E. coli
  • Uni student with watery diarrhoea - C. jejuni
  • Elderly on antibiotics - C. difficile
  • Traveller’s diarrhoea - E. coli
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75
Q

Difference in time of onset for gastroenteritis caused by toxins, bacteria, virus, protozoa?

A

Toxins - early (1-24 hours)

Bacterial/viral/protozoal - 12+ hours

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76
Q

Investigation for gastroenteritis?

A
  1. Bloods
    • FBC - required if starting IV fluids. Anaemia => chronic diarrhoea. High Hb => dehydration. High WCC.
    • U&Es - electrolytes, dehydration
    • Creatinine - required if starting IV fluids
  2. Stool for culture/toxins (particularly C. difficile toxin causing pseudomembranous colitis)

• AXR/USS/sigmoidoscopy - exclusion (sig. for IBD)

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77
Q

Management for gastroenteritis?

A

• Bed rest - home until D+V cleared for 48 hours

  1. Oral rehydration (IV if severe)
  2. anti-emetic
  3. anti-diarrhoeal (bismuth)
  • ABx if severe or infective agent identified
  • Botulism detected - IM botulism antitoxin => ITU
  • C diff - isolate, oral metronidazole 10-14 days, vancomycin if refractory
78
Q 
Causes of GI perforation in:
• Oesophagus
• Stomach/duodenum
• Small bowel (rare)
• Large bowel (common)
A
  • Oesophagus - Boerhaave’s perforation (forceful vomiting)
  • Stomach/duodenum - perforated ulcer
  • Small bowel - trauma, infection (e.g. TB), Crohn’s
  • Large Bowel - appendicitis, cancer, diverticulitis
79
Q

Signs of GI perforation?

A
  • Unwell
  • Shock
  • Pyrexia
  • Pallor
  • Dehydration
  • Peritonitis (guarding, rigidity, rebound tenderness, absent bowel sounds)
  • Loss of liver dullness (overlying gas)
80
Q

Investigation for GI perforation?

A 
1. Bloods
• Raised urea (upper GI)
• Amylase raised
2. AXR/CXR - air under diaphragm, abnormal gas shadowing
3. CT - visualise location

• Gastrograffin swallow - suspected oesophageal perforation

81
Q

Management for GI perforation? (oesophageal, gastroduodenal, large bowel)

A

Resus
• Correct fluid and electrolytes
• IV antibiotics (with anaerobic cover) - cefuroxime and metronidazole

Surgical
Oesophageal: 1) pleural lavage 2) repair of ruptured oesophagus
Gastroduodenal: 1) peritoneal lavage 2) omental patch
Large bowel: 1) peritoneal lavage 2) resection

82
Q

What is haemochromatosis?

A
  • Increased absorption of iron => accumulation of iron in tissues
  • Organ damage
  • Autosomal recessive (HFE gene)
83
Q

Presentation of haemochromatosis?

A

Early
• Fatigue
• Arthropathy
• Erectile dysfunction

Late
• Diabetes mellitus
• Bronzed skin
• Hepatomegaly
• Amenorrhea
• Arrhythmias, cardiomyopathy
84
Q

Investigation for haemochromatosis?

A
  1. Haematinics
    • HIGH ferritin
    • LOW transferrin
    • HIGH transferrin saturation

(check CRP, ALT to rule out other causes of high ferritin as it is an inflammatory marker)

  1. Liver biopsy - most senstive and specific test for liver iron content
  • Echo - check for cardiomyopathy, should be performed
  • HFE mutation analysis - rare
85
Q

Describe the degrees of haemorrhoids

A

1st degree - do not prolapse
2nd degree - prolapse with defecation but reduce spontaneously
3rd degree - prolapse and require manual reduction
4th degree - prolapse and cannot be reduced

86
Q

Symptoms of haemorrhoids?

A
  • Bright red blood on toilet paper, not mixed with stool
  • Absence of alarm symptoms (weight loss etc.)
  • Itching
  • Painful external hmr. if thrombosed
87
Q

Investigation for haemorrhoids?

A
  1. DRE
    • Proctoscopy - to see internal haemorrhoids
  2. Colonoscopy/flexible sigmoidoscopy
  3. FBC - concern for signficant blood loss
88
Q

Management for haemorrhoids?

A

All - diet + lifestyle changes (fluids and fibre)

1st degree - topical corticosteroids
2nd degree - rubber band ligation/sclerotherapy or IR photocoagulation
3rd degree - rubber band ligation
4th degree (or persistent 3rd) - surgical haemorrhoidectomy under GA (Milligan-Morgan, stapled)

• Thrombosed - conservative with analgesia

89
Q

What can cause hepatocellular carcinoma (3 groups of things)?

A

Chronic liver damage
• Alcoholic liver disease
• Hep B/C
• Autoimmune disease

Metabolic disease
• Haemochromatosis

Aflatoxins
• Aspergillus flavus

90
Q

Investigations for hepatocellular carcinoma?

A 
1. Bloods
• α-fetoprotein (AFP)
• B12 binding protein
2. Abdo USS
3. Contrast CT/MRI - gold standard (diagnostic)
4. Liver biopsy
91
Q

Most common type of hernia?

A

Inguinal (indirect)

92
Q

Where are inguinal and femoral hernias found?

A

Inguinal - Supero-Medial to pubic tubercle

Femoral - Infero-Lateral to pubic tubercle

93
Q

Difference between a direct and indirect inguinal hernia?

A 
Direct
• Protrusion through weakness in posterior wall of inguinal canal - emerge medial to deep ring
• Medial to inferior epigastric vessels
• Hesselbach's triangle
• More easily reducible 
Indirect (80%)
• Protrusion through the deep inguinal ring
• Follows path of inguinal canal
• Lateral to inferior epigastric vessels
• More likely to be irreducible

(both together = pantaloon hernia)

94
Q

How do you distinguish between direct and indirect hernias on examination?

A
  • Reduce the hernia
  • Occlude the deep internal ring with two fingers (above mid inguinal point, lateral to epigastric vessels)
  • Ask patient to cough/stand
  • If hernia is restrained - it is indirect
95
Q

Investigations for inguinal and femoral hernias?

A
  1. Clinical diagnosis
  2. USS
  3. CXR/AXR - for perforation/obstruction
    • CT only in obese patients
96
Q

Management for inguinal hernias?

A

Ongoing
• Small/asymptomatic - monitor and reassure
• Large/asymptomatic - laparoscopic mesh repair + prophylactic ABx

Acute - incarcerated/strangulated
• Bowel viable - laparoscopic mesh repair
• Bowel gangrenous - bowel resection
• Prophylactic ABx

97
Q

What is Maydl’s and Richter’s hernia?

A

Maydl’s - strangulated W-shaped loop

Richter’s - strangulation of only part of bowel circumference

98
Q

Where do the contents of the abdomen herniate in a femoral hernia?

A

Femoral canal

tighter area than inguinal - more likely to incarcerate

99
Q

Management of femoral hernias?

A

Surgical repair
• Herniotomy - ligation and excision
• Herniorrhaphy - repair of hernial defect

100
Q

What are the different types/causes of hiatus hernias?

A

• Congenital (asymptomatic)
• Traumatic
• Non-traumatic
- sliding (80%): moves in and out of chest, acid reflux due to less competent sphincter
- paroesophageal/rolling (20%): goes through hole next to oesophagus, acid reflux less common

101
Q

Symptoms and signs of hiatus hernia?

A
  • Sliding - GORD symptoms
  • Rolling - chest/epigastric pain, fullness

• No signs

(Common in Western countries, obese women, > 70 years)

102
Q

Investigations for hiatus hernia?

A
  1. CXR - gastric bubble above diaphragm
  2. Upper gastrointestinal series (barium swallow) - diagnostic
  3. Endoscopy - check oesophagitis
103
Q

Management for hiatus hernia? (acute vs ongoing)

A

Acute, symptomatic GORD
1. PPI + lifestyle changes

Ongoing
1. Maintain PPI
2. Surgery if severe/unresponsive/rolling hernia
• Nissen fundoplication (360) or Belsey Mark IV (270)

104
Q

What causes intestinal ischaemia?

A
  • Obstruction of superior mesenteric artery
  • Low flow states - venous thrombosis
  • Mesenteric vein - younger patients with hypercoagulable states

Almost always involves small bowel (thrombosis or embolism)

105
Q

What are the 3 types of intestinal ischaemia?

A
  • Acute mesenteric ischaemia
  • Chronic mesenteric ischaemia (intestinal angina)
  • Chronic colonic ischaemia (ischaemic colitis)
106
Q

What is the most common area affected in ischaemic colitis?

A

Splenic flexure

  • Watershed between superior and inferior mesenteric artery territories
  • Spared if one artery is blocked as it receives a dual supply, but susceptible with systemic hypoperfusion
107
Q

Symptoms and signs of intestinal ischaemia?

A
  • Colicky post-prandial pain
  • Constant
  • Poorly localised
  • Eating hurts
  • PR bleeding/bloody diarrhoea
  • Upper abdominal bruit
  • Tender palpable mass
  • Absent bowel sounds
  • Fever and tachycardia
108
Q

Investigations for intestinal ischaemia?

A

• Bloods

  • FBC - high WCC
  • Coagulation panel
  • ABG - acidosis

• AXR/CXR - gassless, thumb printing (mucosal oedema) - worse prognosis, perforation - air under diaphragm

  1. CT - first line when acute ischaemia is suspected
  2. Sigmoidoscopy/colonoscopy - gold standard (diagnostic)
109
Q

Main cause of intestinal obstruction in small bowel and large bowel (and general)?

A

Small bowel - adhesions from prior operations

Large bowel - colorectal malignancies

(general - paralytic ileus, postoperative ileus)

110
Q

Signs and symptoms of intestinal obstruction?

A
  • Colicky pain
  • Abdominal distension
  • Frequent vomiting
  • Absolute constipation
  • Anorexia
  • Visible peristalsis
  • Tinkling bowel sounds (unless peritonitis - which also has guarding and rebound tenderness)
111
Q

Investigation for intestinal obstruction?

A
  1. AXR - diagnostic with large bowel
  2. CT - diagnostic with small bowel
  3. Contrast enema

For AXR:
Small bowel - > 3cm, valvulae conniventes completely cross, no gas in large bowel
Large bowel - > 6cm, or > 9 cm at caecum, peripheral gas proximal to blockage, haustra do not cross whole lumen

112
Q 
Management of intestinal obstruction?
• General
• Ileus and incomplete small bowel
• Strangulation + Large bowel
• Acute complete blockage + strangulation
A

General
• Drip + suck (NBM + NG tube with gastric aspiration)
• IV fluids
• Analgesia
• Urinary catheter - monitor fluid balance

Ileus + incomplete small bowel
• Conservative

Strangulation + Large bowel
• Surgery

Acute complete blockage + strangulation
• Surgery - emergency laparotomy

113
Q

Most common cause of liver abscess?

A

Biliary tract disease e.g. gallstones

114
Q

Liver abscess symptoms and signs?

A
  • Fever
  • Night sweats
  • Weight loss
  • RUQ pain => right shoulder
  • Jaundice
  • Tender hepatomegaly
  • Right lung base - dull, reduced breath sounds (reactive pleural effusion)
115
Q

Liver abscess investigations?

A
  1. Bloods

2. USS/CT - diagnostic

116
Q

Viral causes of liver failure?

A

Hep A, B, C, D and E

117
Q

Investigation for liver failure

A
  1. Identify cause (viral serology, paracetamol levels, autoantibodies, ferritin, caeruloplasmin + urinary cooper)
  2. Bloods
  3. Liver USS/CT
  4. Ascitic tap - neutrophils >250 = SBP
  5. Doppler scan of hepatic/portal veins - Budd-Chiari syndrome (occlusion)
118
Q

Investigation for Mallory-Weiss tear?

A
  1. Bloods (including cross-match and PT)

2. OGD after stabilisation - diagnostic

119
Q

Management for Mallory-Weiss tear?

A
  1. Evaluation + monitoring (phytomenadione? vitamin K)
    • or Hemoclip / adrenaline / thermocoagulation
    • or Endoscopic band ligation
  2. Laparoscopic surgery
    • or angiotherapy
120
Q

Investigation for Non-alcoholic Steatohepatitis?

A
  1. Bloods - elevated AST and ALT
  2. Liver USS - steatosis
  3. Liver biopsy - diagnostic
121
Q

Management for NASH?

A
  1. Diet and exercise

Diabetes
• add insulin sensitiser e.g. metformin

Dyslipidiaema
• add statin

122
Q

What are the 2 types of oesophageal cancer, where do they occur and where in the world are they most common?

A

Squamous cell carcinoma

  • upper and middle
  • most common worldwide

Adenocarcinoma

  • lower
  • most common in UK
123
Q

Investigations for oesophageal cancer?

A
  1. OGD with biopsy
  2. Bloods: metabolic profile - advanced cases if hypokalaemic
  3. CT thorax/abdo - metastases
  4. FDG-PET - before starting therapy
124
Q

Symptoms and signs of pancreatic cancer?

A
  • General cancer symptoms
  • Painless/epigastric pain - radiates to back and relieved by sitting forward
  • Diabetes mellitus
  • Jaundice (head of pancreas)
  • Palpable gallbladder
  • Trosseau’s sign of malignancy - superficial thrombophlebitis
125
Q

Distrubution of pancreatic cancer in pancreas?

A
  • Head/neck: 75%
  • Body: 15-20%
  • Tail: 5-10%
126
Q

Investigations for pancreatic cancer?

A
  1. Abdominal USS
    (• Bloods: LFTs - degree of jaundice; CA19-9 and CEA elevated)
  2. Pancreas-specific CT - diagnostic
127
Q

Causes of pancreatitis?

A

I GET SMASHED - First 4 most common

  • Idiopathic
  • Gallstones - females
  • Ethanol - males
  • Trauma
  • Steroids
  • Mumps/HIV/Coxsackie/malignancy
  • Autoimmune
  • Scorpion venom
  • Hypercalcaemia/hyperPTH
  • ERCP and emboli
  • Drugs e.g. sodium valproate

• Also pregnancy

128
Q

Symptoms and signs of pancreatitis?

A
  • Epigastric pain => back
  • Relieved by sitting forward
  • Aggravated by movement
  • Anorexia, nausea, vomiting
  • Fever, shock
  • Decreased bowel sounds (ileus)
  • Jaundice
  • Cullen’s sign, Grey-Turner sign, Fox’s sign, Chvostek’s sign
129
Q 
What are: 
• Cullen's sign
• Grey-Turner sign
• Fox's sign
• Chvostek's sign
A
  • Cullen’s sign - periumbilical bruising
  • Grey-Turner sign - flank bruising
  • Fox’s sign - bruising over inguinal ligament
  • Chvostek’s sign - elicited twitching facial muscle due to low calcium (saponification)
130
Q

Investigations for acute pancreatitis?

A
  1. Bloods
    • > 3x upper limit of normal lipase (and amylase) - diagnostic if with upper abdominal pain
    • Elevated ALT - gallstones cause
    • Hypercalcaemia - cause?
  2. CT - especially if CRP > 200 suggesting necrosis

(USS can be done to check for biliary aetiology)

131
Q

Investigations for chronic pancreatitis?

A
  • Blood glucose elevated
  • AXR - calcification

BEST
• CT - calcification, atrophy and duct dilation
• MCRP (beading pancreatic duct)

• ECRP - therapeutic and diagnostic (beading pancreatic duct)

132
Q

Management for acute pancreatitis?

A
  1. Fluid resus + analgesia
    • Anti-emetic, O2, Ca2+, Mg2+
    • NG tube
  2. ERCP and sphincterotomy if gallstone obstruction or cholangitis, < 72 hours
  3. Cholecystectomy if gallstone without cholangitis (with prophylactic ABx)
  4. No change > 5 days - Contrast CT then FNA for necrosis/infection
  5. Necresectomy if pancreatic necrosis
133
Q

What are the 2 main scoring systems for acute pancreatitis?

A
  • Modified Glasgow Imrie Criteria combined with CRP > 210. 3 or more positive factors within 48 hours => severe, transfer to ITU
  • APACHE-II score
134
Q

Management for chronic pancreatitis?

A

• Treat acute episodic pain (pain specialist in chronic)

  1. Alcohol/smoking cessation - lifestyle changes
    • Analgesia, pancreatin, PPI
  2. If complications
    • Pseudocyst - ERCP
    • Biliary compression - stenting and dilation
    • Calcification - extracorporeal shock wave lithotripsy (ESWL)
  3. Consider resection or pancreatectomy if indicated
135
Q

Pancreatic cyst vs pseudocyst?

A

Cyst
• Enclosed sac lined with epithelium
• Non-inflammatory

Pseudocyst
• Within cavity or space inside pancreas
• Surrounded by fibrous tissue
• Contain inflammatory pancreatic fluid (amylase)

136
Q

Who are peptic ulcers most common in?

A

Males
• Duodenal - 30s
• Gastric - 50s

137
Q

How are symptoms different in duodenal ulcers compared to gastric ulcers?

A
  • Gastric - immediate post-prandial pain

* Duodenal - immediate post-prandial relief, pain several hours later

138
Q

Investigations for peptic ulcer disease?

A

Under 55, no alarm symptoms

  1. H. pylori breath test/stool antigen test
  2. Endoscopy and biopsy - diagnostic
  3. FBC - microcytic anaemia
  4. Serum gastrin - high
  • H. pylori test not needed if over 55 or alarm symptoms are present
  • Repeat endoscopy 6-8 weeks after treatment if ulcer was present
  • Duodenal ulcers do not need to be biopsied
139
Q

What does a test for H. pylori involve?

A

Urea breath test
• Radio-labelled urea ingested, C13 expelled

Blood antibody test
• IgG against H. pylori confirms exposure

Stool antigen test

Campylobacter-like organism (CLO) test
• Biopsy + urea substrate + pH indicator
• H. pylori present - ammonia produced from urea
• Yellow => red

140
Q

Management for peptic ulcer disease?

A
  1. Conservative e.g. stop NSAIDs, aspirin and bisphosophonates
Active bleeding ulcer
1. Endoscopy
• IV omeprazole
• Blood transfusion if severe
2. Surgery or embolisation via laser coagulation

H. pylori, not bleeding
1. Omeprazole, clarithromycin + amoxicillin

Not H. pylori, not bleeding
1. Omeprazole > ranitidine (H2 antagonist)

141
Q

Symptoms and signs of perianal abscess and fistulae?

A
  • Constant throbbing pain
  • Intermittent discharge (mucus or faecal staining)
  • Localised tender perineal mass
  • Small skin lesion near anus
  • DRE - thickened area over abscess/fistula
  • Goodsall’s Law
142
Q

What is Goodsall’s law?

A

Relates external opening of anal fistula to internal opening

Anterior external opening - fistula runs directly into anal canal (radial - like radius of a circle)

3cm or posterior - fistula follows a curved path to the posterior midline of the anal canal

143
Q

Investigations for perianal abscess or fistulae?

A
  1. DRE - diagnostic
  • Bloods
  • MRI - deep abscess/tract
144
Q

Management of perianal abscess, low fistula and high fistula?

A

Antibiotics for all

Abscess
• Surgical - open dranage

Fistula
• Low fistula - fistolotomy
• High fistula - seton (non-absorbable suture), fistulotomy would cause incontinence

145
Q

What are the different types of peritonitis?

A
  • Localised e.g. diverticulitis (common)
  • Primary generalised - bacterial infection of peritoneal cavity without obvious source (rare)
  • Secondary generalised - bacterial translocation from localised focus e.g. spillage of bowel contents (common)
146
Q

Signs of generalised peritonitis?

A
  • Toxaemia or sepsis
  • Lie still
  • Shallow breathing
  • Rigid abdomen
  • Generalised abdominal tenderness
  • Reduced bowel sounds (absent due to paralytic ileus)
147
Q

Investigation for peritonitis?

A
  • Bloods
  • CXR, AXR
  • USS or CT
  • Laparoscopy
  • Ascitic tap - SBP > 250
  • Gram stain and culture
148
Q

Management of generalised peritonitis and SBP?

A
  1. Resus - IV fluids + Abx
  2. Catheter, NG tube, central line
  3. Laparotomy may be indicated

SBP

  1. Ciprafloxacin + vancomycin
  2. or cefuroxime + metronidazole
149
Q

What causes a pilonidal sinus?

A
  • Ingrowing hair - foreign body inflammatory reaction

* Can cause secondary tract to open laterally (abscess potential)

150
Q

Presentation of pilonidal sinus?

A
  • Painful natal cleft
  • Discharging swelling
  • Midline opening or pit between buttocks
  • Hairs may protrude
151
Q

Management for pilonidal sinus?

A

Asymptomatic
• Hair removal + local hygiene

Acute abscess
• Incision and drainage under LA

Chronic sinus
• Excision under GA (or LA)

152
Q

Most common cause of portal hypertension?

A

Cirrhosis

153
Q

Divide the causes of portal hypertension into 3 categories, examples each

A

Pre-hepatic
• Congenital stenosis
• Splenic vein thrombosis

Hepatic
• Cirrhosis
• Schistosomiasis

Post-hepatic
• Budd-Chiari syndrome
• Constrictive pericarditis
• RHF

154
Q

Signs of portal hypertension?

A
  • Caput medusae
  • Splenomegaly
  • Ascites
155
Q

Investigations for portal hypertension?

A
  • Bloods
  • Specific tests for aetiology
  • USS - liver and spleen size
  • Dopler USS - direction of flow
  • CT/MRI if others are inconclusive
  • Endoscopy - varices (> 10mmHg)
  • Hepative venous pressure gradient (HVPG)
156
Q

Management for portal hypertension?

A
  1. Terlipressin (assists with bleeding) and prophylactic ABx
  2. Endoscopy within 12h - band ligation
  3. Sclerotherapy
  4. Transjugular Intrahepatic Portosystemic Shunt (TIPS) - between hepatic vein and portal vein

Long term: beta blockers and nitrates reduce portal pressure

157
Q

Define primary biliary cirrhosis

A
  • Chronic inflammatory liver disease
  • Progressive destruction of intrahepatic bile ducts
  • Cholestasis => cirrhosis

Cause unknown, likely autoimmune

158
Q

Symptoms and signs of primary biliary cirrhosis?

A
  • Insidious onset (slow, no obvious symptoms at first)
  • Fatigue, weight loss
  • Pruritus
  • May have RUQ, liver decompensation symptoms

• Unlikely early symptoms. Late - jaundice, scratch marks, xanthomas, hepatosplenomegaly, ascites

159
Q

Investigations for primary biliary cirrhosis?

A
  1. Bloods
    • Antimitochondrial antibodies (AMAs) positive - hallmark
    • High IgM
    • High cholesterol
  2. Abdo USS - exclude obstructive duct lesions
    (MRCP - alternative to USS)
  3. Liver biopsy - uncertain diagnosis. Diagnostic but not used as much anymore.
160
Q

Define primary sclerosing cholangitis

A
  • Chronic cholestatic liver disease
  • Progressive inflammatory fibrosis
  • Obliteration of intrahepatic and extrahepatic bile ducts
161
Q

What condition is primary sclerosing cholangitis associated with?

A

Ulcerative colitis (70%)

IBD

162
Q

Investigation for primary sclerosing cholangitis?

A 
1. Bloods
• IgG high in children
• IgM high in adults
• ASMA and ANA in 30%
• pANCA positive in 70%
• AMA NEGATIVE unlike in PBC
2. MRCP - best test: biliary strictures
 (ERCP - if MRCP isn't diagnostic)
3. Liver biopsy - diagnostic
163
Q

Investigations for rectal prolapse?

A
  • Proctosigmoidoscopy
  • Defecating proctogram or barium enema
  • Manometry
  • Pudendal nerve studies

• Sweat Chloride test in children for Cystic Fibrosis

164
Q

Ulcerative colitis characterisations

A
  • Th2 mediated - IL-13
  • Inflammation only in colon and rectum (proctitis if rectum only, pan-colitis if all colon)
  • Starts in rectum and spreads proximally
  • Only affects mucosa/submucosa
  • Mucosal ulcers, goblet cell depletion, crypt abscesses
  • Inflamed areas are continuous rather than patchy
  • No fistulae
165
Q

Symptoms and signs of UC?

A
  • Blood diarrhoea or mucous
  • Tenesmus and urgency
  • Weight loss
  • Fever
  • Abdominal pain before passing stool
  • Uveitis complication
166
Q

Investigations for UC?

A
  • Bloods - anaemia, leukocytosis, thrombocytosis
  • Stool microscopy - exclude infective colitis
  • Abdo XR - dilated loops with air-fluid level (free air - perforation)
  • Endoscopy and biopsy - differentiate UC and CD (biopsy DIAGNOSTIC: goblet cell depletion, crypt abscesses, inflammatory infiltrates)
  • Barium enema - mucosal ulceration with granular appearance, lead pipe, loss of haustra
167
Q

Management of UC?

A

Acute

• IV rehydration + prophylactic ABx, bowel rest

  1. Topical 5-ASA (mesalazine)
  2. Oral 5-ASA + corticosteroids
  3. Infliximab (anti-TNF-a)
    • Toxic megacolon - emergency colectomy

Maintaining remission
1. Moderate - oral/rectal 5-ASA
2. Moderate or severe - oral azathioprine (immunosuppression)
• Infliximab if unresponsive
• Colectomy with ileostomy/ileo-anal pouch if unresponsive

168
Q

Symptoms of acute and chronic viral hepatitis?

A

Acute
• Nausea and vomiting
• RUQ pain
• Photophobia and headache

Chronic
• Asymptomatic until liver failure

Absence of stigmata of chronic liver disease

169
Q

Investigations for viral hepatitis?

A
  • Bloods
  • Viral serology - Anti-HxV IgM (acute) + IgG (lifelong)
  • Urinalysis - bilirubin and urobilinogen
  • USS/CT - check cirrhosis
170
Q

Management for viral hepatitis?

A
  • Bed rest and symptomatic treatment
  • Liver transplant if fulminant

Following recent exposure:
• Immunisation with IM human immunglobulin (over 40) or active attenuated (under 40) for HAV

171
Q

Cause and presentation of B12 deficiency?

A
  • Pernicious anaemia
  • Gastritis
  • Vegan
  • Anaemia symptoms
  • PARASTHESIA, numbness, cognitive changes, visual disturbance
  • Glossitis
  • Angular stomatitis
  • Irritability, dementia, depression
  • Subacute combined degeneration of spinal cord
  • Peripheral neuropathy
172
Q

Cause and presentation of folate deficiency?

A
  • Low dietary intake
  • Alcoholism
  • Pregnancy

• Similar to B12 deficiency

173
Q

Investigation for B12 and folate deficiency?

A

B12
• High plasma total homocysteine
• High methylmalonic acid
• Schilling test - 10+% B12 in urine

Folate
• Serum folate
• Normal methylmalonic acid

174
Q

Management for B12 and folate deficiency?

A

B12 - IM B12 (cyanocobalamin)

Folate - oral folic acid

175
Q

What does vitamin A deficiency cause?

A 
Xerophthalmia
• Keratinisation of eyes
• Dry conjunctiva and cornea
• Bitots spots (oval/triangula) in conjunctivae
• Cloudy and soft cornea
176
Q

Investigations and management for vitamin A deficiency?

A
  • Sight in darkness
  • Serum retinol binding protein
  • Zinc levels
  • Iron studies
  • Vitamin A supplements
  • Diet
177
Q

What can vitamin B1 deficiency cause?

A

Beri beri
• Dry - nervous system involvement, peripheral neuropathy, Wernicke’s encephalopathy => Korsakoff’s psychosis
• Wet - cardiovascular involvement, vasodilation, salt and water retention, oedema

178
Q

Investigation and management for vitamin B1 deficiency?

A
  • Clinical
  • Red cell transketolase activity decreased
  • IV Thiamine (Pabrinex) FIRST
  • Oral supplements after IV
  • Glucose AFTER thiamine, if coexisting hypoglycaemia
179
Q

What can cause vitamin D deficiency?

A
  • Lack of sunlight
  • Dietary deficiency
  • Malabsorption
  • Decreased 25-hydroxylation (liver disease)
  • Decreased 1a-hydroxylation (kidney disease, hypoparathyroidism)
  • Renal phosphate wasting - loss of phosphate in urine e.g. Fanconi’s syndrome (phophaturia, glycosuria, amino aciduria)
180
Q

Signs of vitamin D deficiency?

A

• Osteomalacia
- hypocalcaemia (Trousseau’s sign - wrist spasm, Chvostek’s sign - facial twitch)
• Rickets

181
Q

Investigation for vitamin D deficiency?

A
  • Low or normal Ca2+
  • Low phosphate
  • High PTH
  • X-ray - Looser’s zones
  • Bone biopsy after double tetracycline labelling (deposited as a band)
182
Q

Symptoms and signs of vitamin E deficiency?

A
  • Weakness
  • Loss of vibration sense
  • Decline in visual field
  • Hyporeflexia
  • Decreased proprioception
  • Distal muscle weakness
  • Ataxia
  • Dysarthria
183
Q

Cause of vitamin E deficiency?

A

Cystic Fibrosis - affects absorption

Leads to haemolysis and neurological deficit

184
Q

Presentation of vitamin K deficiency?

A
  • Easy bruising
  • Dark stool
  • Nosebleeds
185
Q

Investigation for vitamin K deficiency?

A
  • History (anticoagulants, diet, antibiotics, conditions affecting absorption, infants - breast milk low in vit K)
  • PT
186
Q

Distribution of volvulus?

A
  • Sigmoid colon - 65%
  • Caecum - 30%

(Volvulus Neonatorum in neonates around 3 months - midgut)

187
Q

What is the presentation of volvulus similar to?

A

Bowel obstruction

188
Q

Investigation for volvulus

A
  1. Upper GI contrast series (barium) - diagnostic
  2. CT with contrast
  3. FBC - elevated WCC

Plain AXR in emergency but need other tests anyway
• Caecal: embryo sign
• Sigmoid: coffee-bean sign

189
Q

Define Wilson’s disease?

A

• Autosomal recessive
• Reduced biliary excretion of copper
• Accumulation of copper in liver and brain (basal ganglia)
aka hepatolenticular degeneration

190
Q

Presentation of Wilson’s disease?

A
  • General liver disease signs
  • Neurological signs e.g. tremor, dementia, ataxia
  • Psychiatric signs e.g. conduct disorder
  • Kayser-Fleischer rings in eyes
  • Sunflower cataract
191
Q

Investigation for Wilson’s disease

A
  1. LFTs
  2. Low ceruloplasmin - diagnostic (but may give false-negative in inflammatory process)
  3. Copper - high
  4. Liver biopsy - high copper - “gold standard”
  • MRI brain - degeneration of basal ganglia
  • Genetic - no simple genetic test due to variety of mutations

Year 3 diagnosis and management (9 decks)

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