GASTROINTESTINAL Flashcards
GI bleed discharge score
safely from the ED
Glasgow Blatchford
Gi Bleed
Pancreatitis cause and markers
GET SMASHED
Gall Stone, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpian Sting, ERCP, Drugs
- Amylase + lipase
Variceal bleeds treatment
Terlopressin and Broad Spec Abx
Vomiting Blood Causes
Mallory Weis Tear Duodenal Ulcer/ Peptic Eroded ulcer Epistaxsis swallowed Varices
**Upper GI bleeding
Oesophageal
- oesophagitis
- cancer
- mallory weiss tear
- varices
Gastric
- gastric cancer
- dielafoy lesion
- diffuse erosion gastritis
- gastric ulcer
Oesophageal
Oesophagitis= small volume, usually hx of GORD
Cancer = Small volume, associated dysphagia, weightloss, recurrent
Mallory Weis tear = brisk moderate volume bright red blood following repeated vomiting. Malaena rare. Ceases spontaneously.
Varices = Large vol freshblood haemodynamically unstable
Gastric
Gastric cancer = frank hameatemesis or altered blood mixed with vomit. Erosion of major vessel = big bleed
Dieulafoy lesion = No prodromal features prior. Arteriovenous malformaiton produces considerable haemorrhage.
Diffuse erosive = Haemetemesis and epigastric discomfort. usually underlying cause e.g recent NSAID usage. Large volume haemorrhage may occur with haemodynamic comproise
Gastric ulcer: small low volume bleeds more common = fe deficient anaemia.
**Constipation
Cause
CF
IVX
drugs:
Cause: Bowel obstruction, paralytic ileus, ano-rectal stricture/fissure/prolapose, poor diet, medicaitons, hypothyroid, neuromuscular
CF: abdo pain, hair irregular stool, distension, tinkling bowel/asbent, pr bleeding
IVX: over 40 + recent change in bowel habit, PR, FBC, U+E, ca
sigmoidoscipy
Drugs: Bulk forming: fybogel Stool softener Stimulant laxative: co-danthramer or senna X in bowel obstruction Osmotic laxative: movicol- lactulose
** Diarrhoea
cause
syx
ivx
management
- drug Tx
Cause: gastroenteritis, drugs, colorectal cancer, uc/crohns, coeliac, c.diff
RF: food poisioining, travel, recent abx use
Syx: stomach cramps, V+N, anorexia, anaemia, fresh Pr bleed mucus
IvX: bloods, U+E, ESR, coeliac serology, sigmoidoscpy, stool sample, colonoscopy
Management: treat cause
ORAL rehydration
codiene phosphate or LOPERAMIDE
refer urgent if over 40+ 6 week change in bowel habit
Malnutrition
- Nutritional deficiency state of protein, energy or micronutrients causing measurable harm to body composition, function or clinical outcome
- PEM = protein-energy malnutrition
o Kwashiorkor = fair to normal energy but inadequate protein
- Oedema and hepatomegaly
o Marasmus = inadequate energy and protein= Ass with severe wasting
Oesophagitis and reflux / GORD
Cause
RF
CF:
IVX:
TX drugs:
Cause: defective sphincter, hiatus heria, increased intra abdominao pressure, h.pylori.
RF: smoking, obesity, pregnancy
CF: heartburn, retrosternal discomfort, acid brash,
IVX: FBC to exclude anaemia
Upper GI endoscopy of symtoms >4 weeks +55 yrs
Oesophageal PH monitoring
Management: lifestyle, avoid fatty spicy food and alcohol
TX: Antacids
Alginates = gaviscon
PPI lansoprazole
Ranitidine = h2 receptor agonist
Refer if > cancer eg weight loss, dysphagia
Oesophageal carcinoma
Most common?
CF:
IVX:
Management
SCC most common then adeno
RF: diet, alcohol, smokingm barrets
CF: dysphagia, vomiting, anorxia, dyspepsia
IVX: Bloods, endoscopy urget, CXR
MAnagement: abx prophylaxis and chemo/ surgery
Hiatus hernia
Sliding
Para-oesopheal
CF:
Management:
• Herniation of a part of abdominal viscera through the oesophageal aperture of the diaphragm
- Sliding (stomach moves up into oesophagus through current hole) and Para-oesophageal (out side)
RF: obesity, pregnancy, ascites
CF: Many are asymptomatic, Heart burn esp on bending or lying, GOR, Diff in swallowing
Management: Rx not needed if aymptomatic except for para-oesophageal hernias = fundoplication
PPI higher dose long term
Peptic ulcer
IVX:
Management:
- Gastric and duodenal ulcers
Gastric = worsened by eating Duodenal = relieved by eating
Cause: H.pylori, smoking, Nsaids
IVX: Upper GI endoscopy, stop PPI 2 weeks before
FE def anemia
Test for H pylori- carbon 13 urea breath test
Management: stop smoking, Triple therapy for 4 weeks
PPI + Amoxicilin + Clarithromycin / metronidazole
Gastric Carcinoma
cF:
which node associated?
ivx:
Management:
• Poor prognosis and non specific presentation
Cause: often adenocarcinoma at gastro-oesophageal junction
RF: pernicious anaemia, H.pylori, smoking
CF: dyspepsia, vomiting, decrease weight, epigastric mass, virchows node
IVX: refer- urgent 2 week wait if chronic gi bleeding/ progressive dyspepsia
FBC +LFTs + rapid access flexible endoscopy
Management: nutritional support, total/subtotal gastrectomy
Palliative chemo, corticosteroids, stenting to relieve dysphagia
Prevention: high intake fruit and veg and weight loss
Carcinoma of pancreas
95% are?
CF:
IVX:
Late presentation, early mets and poor survival rates
95% adenocarcinomas
RF: smoking, alcohol, chronic pancreatitis
CF: tumours of head pancreas can cause painless obstructive jaundice, anaemia, weight loss, acute pancreatitis, splenomegaly, diabetes
IVX: bloods, CA-19, amylase, hyperglycamiea,
USS of live and pancreas
abdo CT
Management: radical surgery- and chemo, palliation
mean survivial 6 months
Coealic disease
which HLA?
CF:
IVX:
HLA-DQ2 (90%) or HLA-DQ8 (its bad 2. 8 gluten)
Gluten - gliadin
CF: steatorrhoea, diarrhoea, abdo pain, bloating, N+V, angular stomatitis, fatigue, weakness, Fe def anaemia, weight loss, FTT, buttock wasting
IVX: ILA and HLA DQ2 testing
–> Ensure that the person has eaten gluten-containing foods in 1+ meal a day, for 6 weeks, before testing
Check serum i(Ig)A tTGA and total IgA first-line.
Endoscopy
Management: Life long gluten free diet.
Acute pancreatitis
Key clinical features?
which sign?
IVX
Management
pain relief?
Biggest cause = Gallstones and Alcohol
GETSMASHED
Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, scorpian bite, hyperlipdeamia, ERCP, drugs.
CF: sudden epigrastric pain RADIATES TO BACK, vomiting, grey turner sign
IVX: Serum amylase- raised
Serum lipase = RAISED
Management: NBM, FLUIDS analgesia = pethidine
Peritonitis
- Inflammation in the peritoneum itself
- SBP = spontaneous bacterial peritonitis = occurs in pts with ascites secondary to chronic liver disease
CF: fever, pain anywhere in abdo, guarding, rigidity and lie with knees flexed
IVX: Fbc raised Acc, blood cultures, culture peritoneal fluid, urinalysis and XR
Management: Iv fluids, systemtic abx and surgery to treat cause
Inguinal hernia
• Protrusion of abdo contents through the fascia in the abdo wall, through the internal inguinal ring
RF: infants- male, obesity, constipation
CF: swelling in groin, indirect- pain in scrotum, soft and reducible
IVX: US and reduce heria and occlude deep ring
In children repair asap, adults can be left/ reduced using mesh
INDIRECT – thro’ internal inguinal ring, passes along inguinal cancal thro abdo wall – LAT to inf Epigastric vessels
DIRECT – hernia thro’ post wall inguinal canal. More common elderly. MEDIAL to inf Epigastric vessels
Femoral hernia
• Protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal position
RF: mainly females
CF: lump in groin, swells during coughing. pain if incarcerated
IVX: USS,CT, MRI
Management: high risk strangulation–> elective repairment
Incisional hernia
•Failure of wound to heal
CF: Bulge or protrusion at or near area of surgical incision
Management: Bulge or protrusion at or near area of surgical incision
Umbilical hernia
E.g Congenital hernia = omphalocele or Infantile
Adult- e.g. 90% acquired in women in pregnancy
If present over 4 yrs, then repair
Gallstones + biliary colic
Fair, Fat, Fertile, Female + Forty
Biliary colic: Stones made in GB → symptomatic with cystic duct obstruction, or if passed into CBD
⇒ Sudden RUQ pain – often following food
⇒ Radiating to R.Shoulder
⇒ Persists for 15 mins
⇒ Better with analgesia
⇒ A/w nausea + vomiting
x Fever (suggests cholecystitis or cholangitis) x Jaundice (suggests cholangitis)
Cholecystitis
CF:
what sign?
IVX
Treatment:
GB becomes inflamed following stone impaction at neck of GB
CF: Constant or colicky RUQ pain (biliary colic) –> Radiates to Back or R.Shoulder
Worse when eating Fatty Foods, GB mass at RUQ (gall stone), RUQ tender
⇒ Murphy’s sign (palpate RUQ, breathe in, ↑pain)
Fever, Nausea + Vomiting, bloating, NON peritonitic ± Obstructive Jaundice (if stone moves to CBD)
NB: pain is similar to biliary colic, but much more severe
IVX: Bloods, USS abdo to visualise stone
TX:
1. Analgesia, rehydrate, NBM
2. Abx – Co-Amoxiclav
3. Laparoscopic cholecystectomy – within 1 week!!
4. Open cholecystectomy – if GB perforation
Chronic: MRCP
Portal hypertension
Caused by?
Signs
Abnormally high pressure in hepatic portal vein (often caused by liver cirrhosis)
Portal HTN → oesophageal varices + HYPO-perfusion of kidneys + water/salt retention (→ascites, transudative pleural effusion, splenomegaly) + ↑CO
sings:
Ascites – can be detected clinically ≥ 1.5 litres
Caput medusae – veins radiating from umbilicus
Splenomegaly
Oesophageal varices → upper GI bleed
Viral hepatitis A B C D E
TREATMENTS?
HEP A: Faeco-oral: fever, malaise, Nauesea –> jaundice
TX: Metocopramide + Chorphenamine
HEP B: Blood products (IVDU + sex), incubation 1-6 months. Jaundice, malaise, urticaria
TX: Metocopramide + Chorphenamine
- Peg interferon + active immunisation to high risk
HEP C: Blood, IVDU. Often acute –> chronic. Early infection mild. Jaundice. High risk hepatocelluar carcinoma. TX: PEG interferon and ribbavarin
HEP D: Need HBV –> may need liver transplant
HEP E Feaeco-oral, always acute. High risk in pregnancy.
TX: metoclopramide, chlorphenamine.
Cirrhosis
CF decompensated
Signs:
Score for severity of Cirrhosis?
TREATMENT
for pruritis? for ascites?
Diffuse hepatic inflammation characterised by fibrosis
CF: Often asymptomatic (compensated) until obvious complications of liver disease (decompensated)
Initially vague systemic symptoms:
Fatigue + Malaise + Anorexia, Nausea + Weight loss + Jaundice + hair loss
Spider naevi, Leukonychia (↓Alb), Clubbing, Dupuytren’s contracture, Palmar erythema, Hepatomegaly
Hypogonadism: testicular atrophy or amenorrhoea, Gynaecomastia and Xanthelasma
Kayser-Fleischer ring – Wilson’s
Decompensated: Oedema + Ascites , Jaundice
Easy bruising due to coagulopathy
Oesophageal variceal rupture
Spontaneous bacterial peritonitis
Hepatic encephalopathy (Liver flap, Confusion, Drowsy, ↓GCS)
Bloods: LFTS, albumin, PT, INR
Liver USS, viral serology, genetic
Child-pugh score = severtiy of cirrhosis
Management: stop alcohol, treat cause
PRUTITIS –> COLESTERYRAMINE
SPIRONONELACTONE for ascites
Ascites
Cause
CF
IVX
Management:
Excessive accumulation of fluid in abdominal cavity
Cause: Cirrhosis or malignancy
CF: Abdo distension and discomfort, weight gain, nausea and dyspnoea
IVX: Exam patient. lying down
look for stigmata of cirrhosis: : jaundice, muscle wasting, spider naevi, gynaecomastia, caput medusae, leukonychia, palmar erythema
Virchow’s node – L side supraclavicular node, upper abdo malignancy
Shifting dullness – change in resonance, repeat both side
Fluid thrill – large ascites only
FBC: LFTS detramhed, increased INR as lower alb
Imaging: Abso USS 1st line
Diagnostic ascetic tap / paracentesis
FBC + clotting
U+E
Abdo USS: Microscopy + albumin/ protein level
Management: Fluid and salt restriction = SPIRONOLACTONE
Therapeutic paracentesis to relieve resp distress
Inflammatory bowel disease
UC
CF
IVX signs
test ?
Treatment
1. Initiate remission
2 Maintain
UC- Colonic and recla mucosa only, relapsing remitting
CF: diarrhoea, abdo pain Left Lower Quadrant, Aneamia, large joint arthritis
IVX:
AXR- thumb priting, lead pipe and mucosal islands
feaecal calcprotectin +ve for intestinal inflammation
Colonoscopy: continous red colon crypt abcesses
Biopsy: Plasma cells and mucosal base
- Induce remission Management: RECTAL Mesalazine + topical/po Prednisolone
- Mesalasie +-/ Infliximab to maintain
If failed = Proctocollectomy + ileostomy
Diverticular disease
Severity classification ?
↑Intraluminal pressure → mucosa herniates through muscle layers of gut wall –> infected becomes diverticulitis common Descending large colon (left)
CF: Altered bowel habit – constipation
Abdominal colic – LEFT sided
⇒Relieved by defecation (do not confuse with IBS), Bleeding, Nausea + Flatulence
Diverticulitis: all features above + systemic pyrexia, anoreoxia, tender colon, bleeding stool
IVX: Bloods, CT colonography
HINCHY score = severity classification
Management: high fibre diet, analgeisa + abx
Acute: Hospital admission + segmental resection
Appendicitis
Symtoms?
Key sign?
IVX
ABX
Treatment
Obstruction of appendix lumen - 10-20 yrs
CF: General central/peri-umbilical, colicky abdominal pain, Aggravated by movement, coughing etc, Nausea + Vomiting + Diarrhoea, Fever (mild) + Fatigue, Voluntary guarding Flushed face
LATE:
McBurney’s RIF pain (intense)
Involuntary guarding (absent in retrocaecal appendix)
Rovsing’s sign – palpate LIF and RIF pain
Psoas sign – pain on extending hip if retrocaecal
IVX: Urinalysis, Bloods, USS
Management: NBM, IV fluids, IV prophylactic Cefuroxime and metronidzaole
TX: Laparoscopic appendectomy
Intestinal Obstruction
CF:
IVX:
CXR:
Management:
Simple, Closed loop or strangulated
Causes: adhesions, hernias, voluvulus, malignancy divertiuclar disease, faecal impaction, intussusception
CF: N+V- feaculant, constipatio Dehydration, abdo distension, colicky abdo pain
IVX: DRE, examinae herinal orrifices, AXR
- small bowel: >3 cm, vulvulae conniventes cross lumen completely
- large bowel: >6 cm haustra do not completely cross lumen
CXR erect for pneumoperiteum
Bloods + contrast enema CT
MANAGEMENT: Drip and suck NGT, avoid prokinetic drugs
Emergency surgery if closed loop
Ileus
Non-mechanical obstruction (ileus), commonly paralytic i.e. absence of peristalsis → adynamic bowel
Causes: Post-abdo surgery, pancreatitis, hypokalaemia also ↓Mg+/↓Ca2+, uraemia, peritonitis, drugs (TCAs, Opioids)
- Painless distension!
- Bowel sounds absent entirely!!
- No bowel movement or flatus
Colorectal carcinoma
RF
CF:
Staging
Screening?
RF: IBD, HNPCC, pout-jegghers, obesity
CF: weight loss, anaemia, mass, colicky pain, tenesmus, change in bowel habit
IVX: Colonoscopy, FBC, LFT,
tumour markers
2 week refer over 40 with rectal bleeding/ change in bowel habit for 6 + weeks
DUKES STAGING!
Management: Surgery, radiotherapy and chemo
Bowel cancer screening 60-74 yrs every 2 yrs
Irritable bowel syndrome
IVX to do?
Treatment:
- Relapsing functional bowel disorder
- Pain and discomfort ass with defecation or change in bowel habit
CF: exacerbated by stress, menstruation and gastroenteritis
6 month history of change in bowel, bloating and abdo pain
IVX: ca-125 to rule out ovarian Ca, faecal calprotein, bloods FBC
Managment: CBT, Loperamide, antispasmodics,
Rectal prolapse
- Weak anal sphincter, prolonged straining
RF: elderly, multiparous
CF: mass protruding through anus after bowel movement -> can need manually replacing, pin, faecal incontinence, ulceration
IVX: DRE, barium enema, stool microspy and sweat test
MAnagement:
high fibre diet, mild laxative, surgery
haemorrhoids
Disrupted and dilated anal cushions → piles
CF: Painless rectal bleed, bright red, often coasts stools/on tissue
- Anaemia/ fatigue due to bleed
IV: Abdominal + PR exam, palpate 3 cushions, prolapsing piles are obvious but internal are not palpable
Proctoscopy to visualise internal haemorrhoids
Management: 1. Fluid, fibre and good anal hygeine, topical analgesia = sterods
- Surgery rubber band ligation
Perianal abcess
Abscess (collection of pus) located in anal or rectal region
- Caused by Infection (E.Coli or Staph), STI or blocked anal glands
- RF: DM, Immunoscomp, CD, Diverticulitis, Anal sex
CF: painful, hardened tissue, swollen, lumps, discharge from pus from rectum, fever
ivx: DRE< proctologist’s-sigmoidoscopy
Management: Surgical incision + drainage, Analgesia,
Anal fissure
Painful tear in squamous mucosa of lower anal canal
Causes: constipation, hard feaces, spasms, Crohns, Anal cancer
CF: Anal pain, exacerbation by pooping: feels like passing shards of glass, fresh bright red blood during pooping
Management: Analgesia- paracetemol + BULK forming laxative
Soak in shallow warm bath
Sigmoid volvulus
Chronic constipation → colon becomes distended with gas → twists on mesenteric pedicle → closed loop obstruction
CF: Acute abdo pain colicky, gross abdo distensison, constipation, vomiting, palpable mass
IVX: DRE, AXR, = coffee bean, erect CRR air under diaphragmm
Management: Decompression=- sogmoidscope into rectum and pass flatus tube into obstructed loop - leave in for 24 hrs
Surgical: Resection of redudent sigmoid colon if recurrent
2- Achalasia
Syx
Gold standard test?
Management>
Disorder of motility of the lower oesophageal or cardiac sphincter
SYX: Dysphagia of solid foods regurgitate, chest pain, heartburn
IVX: CXR: gastric air bubble small, signs of inhalation, dialted oesophagus behind heart
Barium swallow - contrast material passes slowly into stomach
- Manometry of oesophagus gold standard !!
- Mangement: CCB (nimfedipine) and nitrates to reduce pressure in lower sphincter
2- Gastritis
- Inflammatiion of stomach lining making it swollen and painful
Cause: infection eg h. pylori or alcohol or drugs such as NSAIDs
SYX: Dyspepsia, pain, loss of appetitie, bloating, N+V
IVX: bloods, gastroscopy,
Management: eat small meals, avoid irritating foods, reduce stress
–> Ranitadine + PPI
if H.pylori triple therapy
clarithromycin, amoxicillin and PPI
2- Chronic pancreatitis
CF
Management:
Syx: Epigastric pain – severe, Radiates to back, Relieved sitting forwards/hot water bottle on back, Bloating, Steatorrhoea
IVX: US, CT, glucose test
Management: analgesia, coeliac plexus block, lipase eg CREON, Fat soluble vitamins (ADEK), insulin
Low fat diet no alcohol
2- Chronic hepatitis
Symptoms
Inflammatory disease of the liver lasting >6 months
2 types: chronic persistent (no cell necrosis) and chronic active (cell necrosis)
Cause: viral help, metabolic, alcoholic fatty liver disease
Syx: fatigue, anorexai, muscle pain, arthralgia, weight loss, abdo distension, ankle swellling, haematemesis, pruritis, gynaecomastia
IVX: bilirubin, urobiillogen, LFTs,
ALP
Hepatobillary tree and bones
ALT
Hepatocellular damage
The complete Rockall Score
estimates mortality in patients with active upper GI bleed who have had endoscopy.
Murphys sign
Gall bladder hits hand on palpation –> cholecystitis
AST
muscle
** Upper GI Bleed
IVX
Treatment
Endoscopy immediately afterr resuscitations for unstabel patients FBC every 4-6 hours cross match 2-6 unuts Coag profile CXR Erect and supine AXR]
Admit; if shocked, aged >60
Major ulcer bleed = ompereazole
Terlepressin 2mg IV if vasrices suspected
2- Subphrenic abcess
Cause by?
CF:
Localised collections of pus underneath the right or left hemi-diaphragm
Often caused bu Generlaised Peritonitis following appendicitis, peptic ulcer or bowel surgery
CF: Swinging fever, N+V, malaise, abdo tenderness subcostal + dyspnoea if causes pleural effusion
IVX:WCC HIGH - US or CT abdo - CXR shws high diaphragm
IBS: CHRONS
CF
IVX
INDUCE REMISSION?
Transmural inflammation mouth to anus
CF: Weight loss, FTT, lethargy, diarrhoea, abdo pain, anal structures
Lage join arthtitis + erythema nodosum
IV:X: faecal calprotectin +ve, AXR strictures, small bowel enema, colonoscopy, COBBLESTONE muscosal appearance, skip lesions
Gobley cells
Management: 1. INDUCE REMISSION = PREDNISOLONE 2. KEEP REMISSION = Azathoprine Consider Infliximab / methotrexate Surgery if limited to distal ileum
Liver abcess
Cause: infection –> collection of pus
CF: R upper quadrant pain, tenderness, hepatomegaly, Swinging fever, Night seats, N and V
Management: Metronidazole, drainage USS
Perianal haematoma
Acutely painful condition with onest after straining at stool
Syx: Blue-black bulge in the skin near the margin of the anus, Pain
Fistula in ano
Abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin
- Previous anorectal abscess
- Ass with diverticular disease, IBD, malignancy, TB and actinomycosis
CF: perianal dischange, pain, swelling
UC + chrons treatment
- remission
- maintinaing remission
UC
- MESALASINE
- MESALASINE –> AZIATHROPINE if doesnt work
CHRONS
- STEROIDS
- AZIATHROPINE
Primary billiary cirrhosis
Primary sclerosing cholangitis
Autoimmune chronic liver disease 1. igM 2.anti Microbial antibodies 3. middle aged females = affectes the billiary tree
(Primary sclerosing cholangitis = UC = affects the duct (tube) like UC)
PPIs side effects
Low Na and low Mg
treat Hepatic encephalopathy
Lactulose!!!
Prevention = Rifaximin is a type of antibiotic
surgical sievere
Vascular Infective Trauama autoimmune Metabolic Iatrogenic Neoplastic degenerative
