Gastrointestinal Flashcards
Presentation of cholangiocarcinoma
Obstructive jaundice (pale stools, dark urine, generalised itching) Unexplained weight loss RUQ pain Palpable gallbladder Hepatomegaly
Causes of jaundice in previously stable cirrhosis patient
Sepsis
Malignancy
Alcohol/drugs
GI bleeding
Courvoisier’s Law
In a jaundiced patient, presence of palpable gallbladder means jaundice is unlikely to be due to gallstones impacted in the biliary system
Define hiatus hernia
Herniation of stomach up through diaphragm
Signs & symptoms of obstructive jaundice
Pale stools
Dark urine
Generalised itching
Define obturator hernia
Through obturator canal
Pain in medial thigh
Functions of liver
Carbohydrate metabolism Fat metabolism Protein metabolism Hormone metabolism Drugs and foreign compounds - cytochrome P450 etc. Storage - vitamin D + iron Metbaolism and excretion of bilirubin
Define diverticulum
Outpouching of bowel wall
Usually at sites of entry of perforating arteries (acquired or congenital)
Management of hiatus hernias
Antacids
Weight loss
Sleep propped up
Not usually treated surgically
Pathophysiology of biliary colic and acute cholecystitis
Acute obstruction - stone in cystic duct
Inflammatory response
Major pathologies of the liver
Hepatitis:
Damage to hepatocytes
Cirrhosis:
Increased fibrosis, liver shrinkage, decreased hepatocellular function, obstruction of bile flow
Tumours:
Frequently secondary to colon, stomach, bronchus
Predisposing factors to hernias
Male Chronic cough Constipation Urinary obstruction Heavy lifting Ascites Past abdominal surgery
What is hepatocellular/hepatic jaundice?
Causes
Cannot conjugate bilirubin
Leaks (initially) conjugated bilirubin
Both conjugated and unconjugated bilirubin may be elevated in serum
Causes: Hepatitis Cirrhosis Hepatic carcinoma/METs Drugs Sepsis Liver abscesses Fungi Systemic disorders
4 types of hiatus hernia
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering thorax
Define sliding hernia
Type 1 hiatus hernia
Stomach slides up through diaphragm, with gastro-oesophageal junction passing up into thorax
Management for chronic cholecystitis
ERCP
Laparoscopic cholecystectomy
Define cholangiocarcinoma
Type of cancer originating in bile duct
Majority are adenocarcinomas
May affect intrahepatic or extrahepatic bile ducts
Most common site is perihilar region
Presentation of gallstone ileus
SBO Colicky pain Vomiting Absolute constipation Abdominal distension
Define ascending cholangitis
Bacterial infection of the biliary tree
Define spigelan hernia
Between lateral border of recuts abdominis and linea semilunaris
Increased risk of incarceration, obstruction and strangulation
Investigations for acute cholecystitis
Raised WCC
Abdominal USS
AXR
Define hernia
Protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position
Presentation of acute cholecystitis
RUQ pain (may radiate to right shoulder) Nausea & vomiting Fever Biliary colic Tachycardia and tachypnoea Murphy’s sign Raised inflammatory markers and white blood cells
What is acalculous cholecystitis?
What type of patients does this occur in?
Gallbladder not being stimulated by food to regularly empty, resulting in a build up of pressure
Patients on TPN or having long periods of fasting (e.g. in ICU)
Location of stone in jaundice +/- ascending cholecystitis
Stone in common bile duct
Risk factors for gallstones
cholesterol and bilirubinate
Cholesterol: 5Fs Fat Female Forty Fertile Fair (caucasians) Crohn's Family history
Bilirubinate:
Haemolytic anaemia
Investigations for chronic cholecystitis
Abdominal USS
MRCP
Pathogenesis of gallstones
Imbalance between proportions of cholesterol and bile salts
Precipitation of excess component as gallstones
Signs and symptoms of diverticular disease
Altered bowel habit Nausea Flatulance L-sided colic relieved by defacation LBO Blood and mucus per rectum
Define epigastric hernia
Hernia in epigastric area (upper abdomen)
Through linea alba
Meckel’s diverticulum: Rules of 2s
2% of the population have a Meckel’s diverticulum
2% of those are symptomatic
They occur within ~2 feet of the ileocecal valve
2 inches long
Treatment of paraumbilical hernia
Surgery to repair rectus sheath (Mayo repair)
Define Littres hernia
Hernia containing strangulated Meckel’s diverticulum
What is Charcot’s triad?
What does it indicate?
Fever
Raised bilirubin
RUQ pain
Acute cholangitis
Complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation
What is obstructive/post-hepatic jaundice?
Causes
Conjugated hyperbilirubinaemia
Intra-hepatic or extrahepatic causes (impaired hepatic excretion - cholestasis)
Causes: Gallstones in CBD Malignancy (head of pancreas) Inflammation (biliary cirrhosis, sclerosis, cholangitis) Drugs Biliary atresia
Hasselbach’s triangle boundaries
RIP
Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior/lateral border
Poupart’s ligament (inguinal ligament) - inferior border
What is haemolytic/pre-hepatic jaundice?
Causes
Excess bilirubin presented to liver
Unconjugated hyperbilirubinaemia
Causes: Sickle cell crisis Blood transfusion Haemolytic drugs/anaemia Drugs Impaired conjugation Physiological neonatal jaundice
Epidemiology of gallstones
10-15% lifetime prevalence in Western world
8% of those >40yrs
90% remain asymptomatic
Define Richter’s hernia
Only part of bowel wall and lumen herniates through defect
Other side of that section of bowel remains within peritoneal cavity
What is Mirizzi’s syndrome
Stone in gallbladder presses on bile duct causing jaundice
Define lumbar hernia
Through inferior or superior lumbar triangles in posterior abdominal wall
Define Maydl’s hernia
Herniating double loop of bowel
Strangulated portion may reside as a single loop inside umbilical cavity
Define direct inguinal hernia
Due to weakness in abdominal wall at Hasselbach’s triangle
Hernia protrudes directly through abdominal wall
Pathogenesis of jaundice +/- ascending cholecystitis
Obstruction and inflammation of CBD
Stasis increases risk
Superimposed infection
How to distinguish indirect and direct inguinal hernia?
Reduce hernia and apply pressure to deep inguinal ring (mid-way point from ASIS to pubic tubercle)
Indirect = hernia will remain reduced
Define paraumbilical hernia
Omentum/bowel herniating through
Above or below umbilicus
Risk factors for paraumbilical hernia
Common in neonates (can resolve spontaneously)
Obesity
Ascites
Define diverticulitis
Inflammation and infection of diverticula
Define internal hernia
Through adhesions - closed loop obstruction
Into paraduodenal or paracaecal fossae
Investigations for cirrhosis/jaundice
Screening tests for suspected liver disease
Urine:
Bilirubin absent in pre-hepatic
Haematology:
FBC, clotting, film, reticulocyte count, Coomb’s test, haptoglobulins (for haemolysis), malaria parasites, Paul Bunnell (EBV)
Chemistry:
U&E, LFTs, Gamma-GT, total protein, albumin, paracetamol (AST>1000 probably viral hepatitis)
Microbiology: blood and other cultures, serology
Imaging:
USS, ERCP, MRCP, liver biopsy, CT/MRI for abdominal malignancy
Examination findings in cirrhosis/jaundice
Signs of chronic liver disease Hepatic encephalopathy Lymphadenopathy Hepatomegaly Splenomegaly Ascites Palpable gallbladder
Presentation of acute diverticulitis
Pain and tenderness in the left iliac fossa / lower left abdomen
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass (if an abscess has formed)
Raised inflammatory markers (e.g. CRP) and white blood cells
Management of gallstones
Asymptomatic:
Conservative treatment
Possibly no intervention required
Symptomatic: Analgesia Rehydrate NBM Cholecystectomy
Location of stone in gallstone pancreatitis
Stone in ampulla of vater
Pathophysiology of gallstone ileus
Fistula between gallbladder and loop of small bowel
Risk factors for diverticular disease
Areas of weakness in colonic wall - sites of entry of perforating arteries
Raised intraluminal pressure due to insufficient dietary fibre
Increased age
Obesity
Use of NSAIDs
Jaundice history
Foreign travel
Sex
Tattoos and piercings
IVDU
4 classifications of body wall hernias
Reducible/irreducible
Incarcerated (contents of hernia stuck inside - adhesions)
Obstructed (bowel contents cannot pass through)
Strangulated (ischaemia)
Differentials for inguinal hernia
Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended/ectopic testes Kidney transplant
Complications of acute diverticulitis
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g. between the colon and the bladder or vagina)
Ileus/obstruction
Location of stone in gallstone ileus
Stone in small bowel
Presentation in jaundice +/- ascending cholecystitis
Charcot’s triad:
Jaundice
Fever (with rigors)
RUQ abdominal pain)
Liver infection (abscesses +/- sepsis) High mortality if untreated
Investigations of cholangiocarcinoma
Imaging:
CT TAP/MRI
CA19-9 may be raised
MRCP to assess biliary system + obstruction
ERCP to stent + relieve obstruction, and obtain biopsy from tumour
Define jaundice
Yellowing of skin, sclerae, mucosae from increased plasma bilirubin
Management of acute diverticulitis
NBM/clear fluids only IV antibiotics IV fluids Analgesia Urgent investigations (e.g. CT scan) Urgent surgery may be required for complications
Investigations for gallstones
Bloods:
LFTs
High conjugated bilirubin
USS gallbladder
MRCP/ERCP
Types of hernias
Paraumbilical Epigastric Spigelian Lumbar Richter's Maydl's Littre's Obturator Sciatic Sliding Hiatus (sliding, rolling)
Define sciatic hernia
Through lesser sciatic foramen
GI obstruction, gluteal mass
Types of gallstones
Cholesterol stones (20%) Large sized, yellow, coloured stones caused by high cholesterol, low lecithin
Bilirubinate stones (5%) Small sized, pigmented stones caused by haemolysis
Mixed stones (75%) Ca salts, bile pigment and cholesterol
What are the 3 types of jaundice?
Haemolytic/pre-hepatic
Hepatocellular/hepatic
Obstructive/post-hepatic
Define incisional hernia
Occur at site of incision from previous surgery
Due to weakness where muscles and tissues were closed
Bigger the incision, bigger the risk of hernia
Complications of stones in common bile duct
Ascending cholangitis (Charcot's triad) Obstructive jaundice Pancreatitis
Define diverticulosis
Presence of diverticula, without inflammation or infection
May be referred to as diverticular disease when patients experience symptoms
Define rolling hernia
Type 2 hiatus hernia
Separate portion of stomach (i.e. fundus) folds around and enters through diaphragm opening alongside the oesophagus
Define chronic cholecystitis
Chronic inflammation of gallbladder +/- colic
flatulant dyspepsia
Management of acute cholecystitis
Emergency admission NBM IV fluids Analgesia NG (if vomiting) ERCP to remove stones from CBD Cholecystectomy
When is jaundice visible?
Bilirubin >60umol/L
Pathophysiology of diverticulitis complications
Faecal impaction and obstruction of neck of diverticulum
Trapping of bacteria infection, mucosal injury and inflammatory response
Local trauma to mucosa by faecolith, mucosal injury, inflammatory response
Presentation of gallstones
RUQ pain (radiates to back +/- jaundice) Symptomatic with cystic duct obstruction or if passed into CBD
Risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
Liver flukes (parasitic infection)
Management of cholangiocarcinoma
Curative surgery may be possible in early cases
Palliative treatment may involve: Stents inserted to relieve the biliary obstruction Surgery to improve symptoms Palliative chemotherapy Palliative radiotherapy End of life care with symptom control
Complications of stones in bowel
Gallstone ileus (fistula)
Complications of stones in gallbladder
Biliary colic Cholecystitis Empyema Mucocele Perforation Carcinoma Mirizzi's syndrome
Pathogenesis of chronic cholecystitis
Healing by fibrosis
Gallbladder wall thickened
Gallbladder shrinks
Chronic stone
Presentation of inguinal hernia
Soft lump in inguinal region (groin)
Risk factors for jaundice
Excessive alcohol use
Use of illicit drugs
Exposure to hepatitis A, B, or C
Exposure to certain industrial chemicals
Pathophysiology of diverticular disease
Wall of large intestine contains layer of circular muscle
Points where this muscle is penetrated by blood vessels are areas of weakness
Increased pressure inside lumen over time can cause gap to form in these areas
Mucosa can herniate through to form diverticula
Types of inguinal hernia
Indirect inguinal hernia
Direct inguinal hernia
Imaging in acute cholecystitis
Abdominal USS
Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder
Prevention of diverticular disease complications
High fibre diet Low animal fat/processed food diet Smoking cessation Exercise Avoid NSAIDs
Investigations for acute diverticulitis
FBC CRP Erect CXR AXR USS CT Barium enema Colon/sigmoidoscopy
Clinical presentation of gallstone pancreatitis
Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g. low-grade fever and tachycardia)
Location of stone in biliary colic and acute cholecystitis
Stone in cystic duct
Signs and symptoms of sliding hernia
Asymptomatic GORD Oesophagitis Iron deficiency anaemia/bleeding Pain Post-prandial fullness Nausea Retching
Define indirect inguinal hernia
Bowel herniates through inguinal canal
In some patients, inguinal ring remains patent
Leaving tract/tunnel from abdominal contents through inguinal canal and into scrotum
Bowel can herniate along this tract, creating indirect inguinal hernia
Treatment of diverticular disease
Conservative (high fibre diet)
Medical (mebeverin, anti-cholinergic)
Surgical (elective resection)
Pathogenesis of gallstone pancreatitis
Gallstones get trapped at end of biliary system (ampulla of Vater)
Blocking flow of bile and pancreatic juice into duodenum
Reflux of bile and prevention of juice being secreted results in inflammation in pancreas
Define Meckel’s diverticulum
A remnant of vitellointestinal duct of embryo
