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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
Symptoms of Barrett's oesophagus?
* Retrosternal pain * Haematemesis * Water-brash (sour taste) * Burning pain when swallowing, dysphagia * Bloating, belching
26
Investigation for Barrett's oesophagus and what do you see?
OGD and biopsy • Lower third of oesophagus • Metaplastic columnar epithelium • Goblet cells present
27
Management for Barrett's oesophagus?
Non-dysplastic • PPI + surveillance Low grade • Radiofrequency ablation • Nodular - endoscopic mucosal resection High grade (add to low grade) • PPI • Second-line: oesophagectomy
28
Presentation of cholangiocarcinoma?
``` (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 ```
29
Investigation for cholangiocarcinoma?
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
30
Relation of 3 'gallbladder' conditions with Charcot's triad?
* Biliary colic (gallstone) - RUQ pain * Cholecystitis - RUQ pain, fever * Cholangitis - RUQ pain, fever, jaundice
31
Signs of cholecystitis?
* Murphy's sign (only positive if the same test in the LUQ doesn't cause pain) * Localised peritonism - guarding/rebound tenderness * Tachycardia * Pyrexia
32
Investigation for cholecystitis?
1. Bloods - raised WCC, CRP and LFTs 2. USS - diagnostic if sepsis not suspected 2. CT/MRI - diagnostic if sepsis supected (can find perforation) 3. MRCP if others are negative with abnormal LFTs 4. Endoscopic ultrasound
33
When is cirrhosis "decompensated"?
``` Complicated by J BAE • Jaundice • Bleeding varices • Ascites • Encephalopathy ```
34
What's the most common cause of cirrhosis in the UK and worldwide?
* UK - chronic alcohol misuse | * Worldwide - hep B/C
35
Which condition associated with OBESITY, DIABETES, total parenteral nutrition and drugs can cause CIRRHOSIS?
Non-alcoholic steatohepatitis (NASH)
36
What are the investigations for cirrhosis?
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
37
Describe the grading used to estimate prognosis in cirrhosis/chronic liver disease?
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
38
Management for cirrhosis? 1 - ? treatment for: encephalopathy, ascites, SBP, portal hypertension 2 - ?
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 2. Liver transplant
39
What is the drug for paracetamol OD?
IV N-acetylcysteine
40
What causes coeliac disease?
Sensitivity to gliadin component of gluten
41
What happens to the intestinal cells in coeliac disease?
* Subtotal villous atrophy | * Crypt hyperplasia
42
Symptoms and signs of coeliac disease?
* 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)
43
Investigations for coeliac disease?
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) 3. Small-bowel histology (biopsy) - gold standard * Stool - exclude infection * D-xylose test - reduced urinary excretion => small bowel malabsorption
44
Management for coeliac disease?
1. Gluten-free diet • Calcium, vitamin D, iron supplements 2. Refractory => referral 3. Crisis => rehydration, correct electrolyte abnormalities, corticosteroids
45
Outline the distribution of colorectal cancer?
* 60% rectum and signmoid * 30% descending colon * 10% rest of colon
46
Outline Duke's staging of colorectal cancer?
``` A - contained in bowel B - grown through muscle layer of bowel C1 - regional lymph nodes C2 - apical node positive D - organ metastasis ```
47
Symptoms and signs of colorectal carcinoma?
* 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)
48
Investigations for colorectal carcinoma?
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
49
Crohn's characterisations
* 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
50
Symptoms and signs of Crohn's disease?
* 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
51
Investigations for Crohn's disease?
* 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)
52
Management of acute exacerbation of Crohn's?
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
53
Management for long-term Crohn's?
1. Corticosteroids for acute exacerbations 2. 5-ASA analogues 4. Immunosuppression e.g. Azathioprine, reduce relapse 5. 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
54
What is the difference between diverticulosis, diverticular disease and diverticulitis?
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
55
Outline the Hinchey Classification of Acute Diverticulitis?
Ia - phlegmon (diffuse inflammation with purulent exudate) Ib and II - localised abcess III - perforation and purulent peritonitis IV - faecal peritonitis
56
What causes diverticular disease?
* Low-fibre diet * High colonic intraluminal pressure * Herniation of mucosa and submucosa through muscle layers
57
Symptoms of diverticular disease?
* PR bleeding * Diverticulitis - LIF pain, fever * Diverticular fistulation - pneumaturia, faecaluria, recurrent UTI
58
Investigations for diverticular disease?
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
59
Management for diverticular disease?
• 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
60
What does IBS involve (symptoms/criteria)?
* 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 ```
61
Signs of IBS?
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
62
Investigation for IBS?
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
63
Management for IBS?
1. Lifestyle + dietary changes • Constipation predominant - laxatives • Diarrhoeal predominant - anti-diarrhoeals • Pain/bloating - add antispasmodics - dicycloverine 2. CBT/hypnotherapy, TCAs
64
What are gallstones made up of?
* 80% mixed - cholesterol, calcium bilirubinate, phosphate, protein * 10% cholesterol * 10% calcium bilirubinate - black "pigment" stones
65
Risk factors for gallstones?
``` 6Fs • Female • Fair • Fat • Forty • Family history • Fertile ``` (diabetes, contraceptive pill, octreotide)
66
Presentation of gallstones (cholelithiasis)?
* 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
67
Investigation for gallstones?
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
68
Management of gallstones?
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
69
Most common type of gastric cancer?
Adenocarcinoma
70
Signs of gastric cancer?
* 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
71
Investigations for gastric cancer?
1. Upper GI endoscopy with biopsy * Endoscopy ultrasound (EUS) - depth of gastric invasion and lymph node involvement * CT abdo/pelvis - metastases * CXR
72
Investigations for GORD?
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
73
Management of GORD?
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)
74
``` Cause of gastroenteritis/infectious colitis? • D+V outbreaks in institutions • Dysentery (bloody diarrhoea) • Uni student with watery diarrhoea • Elderly on antibiotics • Traveller's diarrhoea ```
* 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
75
Difference in time of onset for gastroenteritis caused by toxins, bacteria, virus, protozoa?
Toxins - early (1-24 hours) | Bacterial/viral/protozoal - 12+ hours
76
Investigation for gastroenteritis?
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)
77
Management for gastroenteritis?
• 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
``` Causes of GI perforation in: • Oesophagus • Stomach/duodenum • Small bowel (rare) • Large bowel (common) ```
* 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
Signs of GI perforation?
* Unwell * Shock * Pyrexia * Pallor * Dehydration * Peritonitis (guarding, rigidity, rebound tenderness, absent bowel sounds) * Loss of liver dullness (overlying gas)
80
Investigation for GI perforation?
``` 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
Management for GI perforation? (oesophageal, gastroduodenal, large bowel)
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
What is haemochromatosis?
* Increased absorption of iron => accumulation of iron in tissues * Organ damage * Autosomal recessive (HFE gene)
83
Presentation of haemochromatosis?
Early • Fatigue • Arthropathy • Erectile dysfunction ``` Late • Diabetes mellitus • Bronzed skin • Hepatomegaly • Amenorrhea • Arrhythmias, cardiomyopathy ```
84
Investigation for haemochromatosis?
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) 2. Liver biopsy - most senstive and specific test for liver iron content * Echo - check for cardiomyopathy, should be performed * HFE mutation analysis - rare
85
Describe the degrees of haemorrhoids
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
Symptoms of haemorrhoids?
* Bright red blood on toilet paper, not mixed with stool * Absence of alarm symptoms (weight loss etc.) * Itching * Painful external hmr. if thrombosed
87
Investigation for haemorrhoids?
1. DRE • Proctoscopy - to see internal haemorrhoids 2. Colonoscopy/flexible sigmoidoscopy 3. FBC - concern for signficant blood loss
88
Management for haemorrhoids?
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
What can cause hepatocellular carcinoma (3 groups of things)?
Chronic liver damage • Alcoholic liver disease • Hep B/C • Autoimmune disease Metabolic disease • Haemochromatosis Aflatoxins • Aspergillus flavus
90
Investigations for hepatocellular carcinoma?
``` 1. Bloods • α-fetoprotein (AFP) • B12 binding protein 2. Abdo USS 3. Contrast CT/MRI - gold standard (diagnostic) 4. Liver biopsy ```
91
Most common type of hernia?
Inguinal (indirect)
92
Where are inguinal and femoral hernias found?
Inguinal - Supero-Medial to pubic tubercle Femoral - Infero-Lateral to pubic tubercle
93
Difference between a direct and indirect inguinal hernia?
``` 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
How do you distinguish between direct and indirect hernias on examination?
* 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
Investigations for inguinal and femoral hernias?
1. Clinical diagnosis 2. USS 3. CXR/AXR - for perforation/obstruction • CT only in obese patients
96
Management for inguinal hernias?
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
What is Maydl's and Richter's hernia?
Maydl's - strangulated W-shaped loop Richter's - strangulation of only part of bowel circumference
98
Where do the contents of the abdomen herniate in a femoral hernia?
Femoral canal | tighter area than inguinal - more likely to incarcerate
99
Management of femoral hernias?
Surgical repair • Herniotomy - ligation and excision • Herniorrhaphy - repair of hernial defect
100
What are the different types/causes of hiatus hernias?
• 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
Symptoms and signs of hiatus hernia?
* Sliding - GORD symptoms * Rolling - chest/epigastric pain, fullness • No signs (Common in Western countries, obese women, > 70 years)
102
Investigations for hiatus hernia?
1. CXR - gastric bubble above diaphragm 2. Upper gastrointestinal series (barium swallow) - diagnostic 3. Endoscopy - check oesophagitis
103
Management for hiatus hernia? (acute vs ongoing)
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
What causes intestinal ischaemia?
* 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
What are the 3 types of intestinal ischaemia?
* Acute mesenteric ischaemia * Chronic mesenteric ischaemia (intestinal angina) * Chronic colonic ischaemia (ischaemic colitis)
106
What is the most common area affected in ischaemic colitis?
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
Symptoms and signs of intestinal ischaemia?
* 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
Investigations for intestinal ischaemia?
• 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
Main cause of intestinal obstruction in small bowel and large bowel (and general)?
Small bowel - adhesions from prior operations Large bowel - colorectal malignancies (general - paralytic ileus, postoperative ileus)
110
Signs and symptoms of intestinal obstruction?
* Colicky pain * Abdominal distension * Frequent vomiting * Absolute constipation * Anorexia * Visible peristalsis * Tinkling bowel sounds (unless peritonitis - which also has guarding and rebound tenderness)
111
Investigation for intestinal obstruction?
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
``` Management of intestinal obstruction? • General • Ileus and incomplete small bowel • Strangulation + Large bowel • Acute complete blockage + strangulation ```
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
Most common cause of liver abscess?
Biliary tract disease e.g. gallstones
114
Liver abscess symptoms and signs?
* Fever * Night sweats * Weight loss * RUQ pain => right shoulder * Jaundice * Tender hepatomegaly * Right lung base - dull, reduced breath sounds (reactive pleural effusion)
115
Liver abscess investigations?
1. Bloods | 2. USS/CT - diagnostic
116
Viral causes of liver failure?
Hep A, B, C, D and E
117
Investigation for liver failure
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
Investigation for Mallory-Weiss tear?
1. Bloods (including cross-match and PT) | 2. OGD after stabilisation - diagnostic
119
Management for Mallory-Weiss tear?
1. Evaluation + monitoring (phytomenadione? vitamin K) • or Hemoclip / adrenaline / thermocoagulation • or Endoscopic band ligation 2. Laparoscopic surgery • or angiotherapy
120
Investigation for Non-alcoholic Steatohepatitis?
1. Bloods - elevated AST and ALT 2. Liver USS - steatosis 3. Liver biopsy - diagnostic
121
Management for NASH?
1. Diet and exercise Diabetes • add insulin sensitiser e.g. metformin Dyslipidiaema • add statin
122
What are the 2 types of oesophageal cancer, where do they occur and where in the world are they most common?
Squamous cell carcinoma - upper and middle - most common worldwide Adenocarcinoma - lower - most common in UK
123
Investigations for oesophageal cancer?
1. OGD with biopsy 2. Bloods: metabolic profile - advanced cases if hypokalaemic 3. CT thorax/abdo - metastases 4. FDG-PET - before starting therapy
124
Symptoms and signs of pancreatic cancer?
* 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
Distrubution of pancreatic cancer in pancreas?
* Head/neck: 75% * Body: 15-20% * Tail: 5-10%
126
Investigations for pancreatic cancer?
1. Abdominal USS (• Bloods: LFTs - degree of jaundice; CA19-9 and CEA elevated) 2. Pancreas-specific CT - diagnostic
127
Causes of pancreatitis?
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
Symptoms and signs of pancreatitis?
* 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
``` What are: • Cullen's sign • Grey-Turner sign • Fox's sign • Chvostek's sign ```
* 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
Investigations for acute pancreatitis?
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
Investigations for chronic pancreatitis?
* Blood glucose elevated * AXR - calcification BEST • CT - calcification, atrophy and duct dilation • MCRP (beading pancreatic duct) • ECRP - therapeutic and diagnostic (beading pancreatic duct)
132
Management for acute pancreatitis?
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
What are the 2 main scoring systems for acute pancreatitis?
* Modified Glasgow Imrie Criteria combined with CRP > 210. 3 or more positive factors within 48 hours => severe, transfer to ITU * APACHE-II score
134
Management for chronic pancreatitis?
• 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
Pancreatic cyst vs pseudocyst?
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
Who are peptic ulcers most common in?
Males • Duodenal - 30s • Gastric - 50s
137
How are symptoms different in duodenal ulcers compared to gastric ulcers?
* Gastric - immediate post-prandial pain | * Duodenal - immediate post-prandial relief, pain several hours later
138
Investigations for peptic ulcer disease?
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
What does a test for H. pylori involve?
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
Management for peptic ulcer disease?
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
Symptoms and signs of perianal abscess and fistulae?
* 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
What is Goodsall's law?
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
Investigations for perianal abscess or fistulae?
1. DRE - diagnostic * Bloods * MRI - deep abscess/tract
144
Management of perianal abscess, low fistula and high fistula?
Antibiotics for all Abscess • Surgical - open dranage Fistula • Low fistula - fistolotomy • High fistula - seton (non-absorbable suture), fistulotomy would cause incontinence
145
What are the different types of peritonitis?
* 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
Signs of generalised peritonitis?
* Toxaemia or sepsis * Lie still * Shallow breathing * Rigid abdomen * Generalised abdominal tenderness * Reduced bowel sounds (absent due to paralytic ileus)
147
Investigation for peritonitis?
* Bloods * CXR, AXR * USS or CT * Laparoscopy * Ascitic tap - SBP > 250 * Gram stain and culture
148
Management of generalised peritonitis and SBP?
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
What causes a pilonidal sinus?
* Ingrowing hair - foreign body inflammatory reaction | * Can cause secondary tract to open laterally (abscess potential)
150
Presentation of pilonidal sinus?
* Painful natal cleft * Discharging swelling * Midline opening or pit between buttocks * Hairs may protrude
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Management for pilonidal sinus?
Asymptomatic • Hair removal + local hygiene Acute abscess • Incision and drainage under LA Chronic sinus • Excision under GA (or LA)
152
Most common cause of portal hypertension?
Cirrhosis
153
Divide the causes of portal hypertension into 3 categories, examples each
Pre-hepatic • Congenital stenosis • Splenic vein thrombosis Hepatic • Cirrhosis • Schistosomiasis Post-hepatic • Budd-Chiari syndrome • Constrictive pericarditis • RHF
154
Signs of portal hypertension?
* Caput medusae * Splenomegaly * Ascites
155
Investigations for portal hypertension?
* 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
Management for portal hypertension?
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
Define primary biliary cirrhosis
* Chronic inflammatory liver disease * Progressive destruction of intrahepatic bile ducts * Cholestasis => cirrhosis Cause unknown, likely autoimmune
158
Symptoms and signs of primary biliary cirrhosis?
* 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
Investigations for primary biliary cirrhosis?
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
Define primary sclerosing cholangitis
* Chronic cholestatic liver disease * Progressive inflammatory fibrosis * Obliteration of intrahepatic and extrahepatic bile ducts
161
What condition is primary sclerosing cholangitis associated with?
Ulcerative colitis (70%) | IBD
162
Investigation for primary sclerosing cholangitis?
``` 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
Investigations for rectal prolapse?
* Proctosigmoidoscopy * Defecating proctogram or barium enema * Manometry * Pudendal nerve studies • Sweat Chloride test in children for Cystic Fibrosis
164
Ulcerative colitis characterisations
* 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
Symptoms and signs of UC?
* Blood diarrhoea or mucous * Tenesmus and urgency * Weight loss * Fever * Abdominal pain before passing stool * Uveitis complication
166
Investigations for UC?
* 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
Management of UC?
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
Symptoms of acute and chronic viral hepatitis?
Acute • Nausea and vomiting • RUQ pain • Photophobia and headache Chronic • Asymptomatic until liver failure Absence of stigmata of chronic liver disease
169
Investigations for viral hepatitis?
* Bloods * Viral serology - Anti-HxV IgM (acute) + IgG (lifelong) * Urinalysis - bilirubin and urobilinogen * USS/CT - check cirrhosis
170
Management for viral hepatitis?
* 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
Cause and presentation of B12 deficiency?
* 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
Cause and presentation of folate deficiency?
* Low dietary intake * Alcoholism * Pregnancy • Similar to B12 deficiency
173
Investigation for B12 and folate deficiency?
B12 • High plasma total homocysteine • High methylmalonic acid • Schilling test - 10+% B12 in urine Folate • Serum folate • Normal methylmalonic acid
174
Management for B12 and folate deficiency?
B12 - IM B12 (cyanocobalamin) Folate - oral folic acid
175
What does vitamin A deficiency cause?
``` Xerophthalmia • Keratinisation of eyes • Dry conjunctiva and cornea • Bitots spots (oval/triangula) in conjunctivae • Cloudy and soft cornea ```
176
Investigations and management for vitamin A deficiency?
* Sight in darkness * Serum retinol binding protein * Zinc levels * Iron studies * Vitamin A supplements * Diet
177
What can vitamin B1 deficiency cause?
Beri beri • Dry - nervous system involvement, peripheral neuropathy, Wernicke's encephalopathy => Korsakoff's psychosis • Wet - cardiovascular involvement, vasodilation, salt and water retention, oedema
178
Investigation and management for vitamin B1 deficiency?
* Clinical * Red cell transketolase activity decreased * IV Thiamine (Pabrinex) FIRST * Oral supplements after IV * Glucose AFTER thiamine, if coexisting hypoglycaemia
179
What can cause vitamin D deficiency?
* 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
Signs of vitamin D deficiency?
• Osteomalacia - hypocalcaemia (Trousseau's sign - wrist spasm, Chvostek's sign - facial twitch) • Rickets
181
Investigation for vitamin D deficiency?
* Low or normal Ca2+ * Low phosphate * High PTH * X-ray - Looser's zones * Bone biopsy after double tetracycline labelling (deposited as a band)
182
Symptoms and signs of vitamin E deficiency?
* Weakness * Loss of vibration sense * Decline in visual field * Hyporeflexia * Decreased proprioception * Distal muscle weakness * Ataxia * Dysarthria
183
Cause of vitamin E deficiency?
Cystic Fibrosis - affects absorption Leads to haemolysis and neurological deficit
184
Presentation of vitamin K deficiency?
* Easy bruising * Dark stool * Nosebleeds
185
Investigation for vitamin K deficiency?
* History (anticoagulants, diet, antibiotics, conditions affecting absorption, infants - breast milk low in vit K) * PT
186
Distribution of volvulus?
* Sigmoid colon - 65% * Caecum - 30% (Volvulus Neonatorum in neonates around 3 months - midgut)
187
What is the presentation of volvulus similar to?
Bowel obstruction
188
Investigation for volvulus
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
Define Wilson's disease?
• Autosomal recessive • Reduced biliary excretion of copper • Accumulation of copper in liver and brain (basal ganglia) aka hepatolenticular degeneration
190
Presentation of Wilson's disease?
* 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
Investigation for Wilson's disease
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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