Gastrointestinal Flashcards
1
Q
Presentation of cholangiocarcinoma
A
Obstructive jaundice (pale stools, dark urine, generalised itching) Unexplained weight loss RUQ pain Palpable gallbladder Hepatomegaly
2
Q
Causes of jaundice in previously stable cirrhosis patient
A
Sepsis
Malignancy
Alcohol/drugs
GI bleeding
3
Q
Courvoisier’s Law
A
In a jaundiced patient, presence of palpable gallbladder means jaundice is unlikely to be due to gallstones impacted in the biliary system
4
Q
Define hiatus hernia
A
Herniation of stomach up through diaphragm
5
Q
Signs & symptoms of obstructive jaundice
A
Pale stools
Dark urine
Generalised itching
6
Q
Define obturator hernia
A
Through obturator canal
Pain in medial thigh
7
Q
Functions of liver
A
Carbohydrate metabolism Fat metabolism Protein metabolism Hormone metabolism Drugs and foreign compounds - cytochrome P450 etc. Storage - vitamin D + iron Metbaolism and excretion of bilirubin
8
Q
Define diverticulum
A
Outpouching of bowel wall
Usually at sites of entry of perforating arteries (acquired or congenital)
9
Q
Management of hiatus hernias
A
Antacids
Weight loss
Sleep propped up
Not usually treated surgically
10
Q
Pathophysiology of biliary colic and acute cholecystitis
A
Acute obstruction - stone in cystic duct
Inflammatory response
11
Q
Major pathologies of the liver
A
Hepatitis:
Damage to hepatocytes
Cirrhosis:
Increased fibrosis, liver shrinkage, decreased hepatocellular function, obstruction of bile flow
Tumours:
Frequently secondary to colon, stomach, bronchus
12
Q
Predisposing factors to hernias
A
Male Chronic cough Constipation Urinary obstruction Heavy lifting Ascites Past abdominal surgery
13
Q
What is hepatocellular/hepatic jaundice?
Causes
A
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
14
Q
4 types of hiatus hernia
A
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering thorax
15
Q
Define sliding hernia
A
Type 1 hiatus hernia
Stomach slides up through diaphragm, with gastro-oesophageal junction passing up into thorax
16
Q
Management for chronic cholecystitis
A
ERCP
Laparoscopic cholecystectomy
17
Q
Define cholangiocarcinoma
A
Type of cancer originating in bile duct
Majority are adenocarcinomas
May affect intrahepatic or extrahepatic bile ducts
Most common site is perihilar region
18
Q
Presentation of gallstone ileus
A
SBO Colicky pain Vomiting Absolute constipation Abdominal distension
19
Q
Define ascending cholangitis
A
Bacterial infection of the biliary tree
20
Q
Define spigelan hernia
A
Between lateral border of recuts abdominis and linea semilunaris
Increased risk of incarceration, obstruction and strangulation
21
Q
Investigations for acute cholecystitis
A
Raised WCC
Abdominal USS
AXR
22
Q
Define hernia
A
Protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position
23
Q
Presentation of acute cholecystitis
A
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
24
Q
What is acalculous cholecystitis?
What type of patients does this occur in?
A
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)
25
Location of stone in jaundice +/- ascending cholecystitis
Stone in common bile duct
26
Risk factors for gallstones
| cholesterol and bilirubinate
```
Cholesterol: 5Fs
Fat
Female
Forty
Fertile
Fair (caucasians)
Crohn's
Family history
```
Bilirubinate:
Haemolytic anaemia
27
Investigations for chronic cholecystitis
Abdominal USS
| MRCP
28
Pathogenesis of gallstones
Imbalance between proportions of cholesterol and bile salts
Precipitation of excess component as gallstones
29
Signs and symptoms of diverticular disease
```
Altered bowel habit
Nausea
Flatulance
L-sided colic relieved by defacation
LBO
Blood and mucus per rectum
```
30
Define epigastric hernia
Hernia in epigastric area (upper abdomen)
Through linea alba
31
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
32
Treatment of paraumbilical hernia
Surgery to repair rectus sheath (Mayo repair)
33
Define Littres hernia
Hernia containing strangulated Meckel's diverticulum
34
What is Charcot's triad?
What does it indicate?
Fever
Raised bilirubin
RUQ pain
Acute cholangitis
35
Complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation
36
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
```
37
Hasselbach's triangle boundaries
RIP
Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior/lateral border
Poupart's ligament (inguinal ligament) - inferior border
38
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
```
39
Epidemiology of gallstones
10-15% lifetime prevalence in Western world
8% of those >40yrs
90% remain asymptomatic
40
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
41
What is Mirizzi's syndrome
Stone in gallbladder presses on bile duct causing jaundice
42
Define lumbar hernia
Through inferior or superior lumbar triangles in posterior abdominal wall
43
Define Maydl's hernia
Herniating double loop of bowel
Strangulated portion may reside as a single loop inside umbilical cavity
44
Define direct inguinal hernia
Due to weakness in abdominal wall at Hasselbach's triangle
Hernia protrudes directly through abdominal wall
45
Pathogenesis of jaundice +/- ascending cholecystitis
Obstruction and inflammation of CBD
Stasis increases risk
Superimposed infection
46
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
47
Define paraumbilical hernia
Omentum/bowel herniating through
Above or below umbilicus
48
Risk factors for paraumbilical hernia
Common in neonates (can resolve spontaneously)
Obesity
Ascites
49
Define diverticulitis
Inflammation and infection of diverticula
50
Define internal hernia
Through adhesions - closed loop obstruction
Into paraduodenal or paracaecal fossae
51
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
52
Examination findings in cirrhosis/jaundice
```
Signs of chronic liver disease
Hepatic encephalopathy
Lymphadenopathy
Hepatomegaly
Splenomegaly
Ascites
Palpable gallbladder
```
53
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
54
Management of gallstones
Asymptomatic:
Conservative treatment
Possibly no intervention required
```
Symptomatic:
Analgesia
Rehydrate
NBM
Cholecystectomy
```
55
Location of stone in gallstone pancreatitis
Stone in ampulla of vater
56
Pathophysiology of gallstone ileus
Fistula between gallbladder and loop of small bowel
57
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
58
Jaundice history
Foreign travel
Sex
Tattoos and piercings
IVDU
59
4 classifications of body wall hernias
Reducible/irreducible
Incarcerated (contents of hernia stuck inside - adhesions)
Obstructed (bowel contents cannot pass through)
Strangulated (ischaemia)
60
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
```
61
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
62
Location of stone in gallstone ileus
Stone in small bowel
63
Presentation in jaundice +/- ascending cholecystitis
Charcot's triad:
Jaundice
Fever (with rigors)
RUQ abdominal pain)
```
Liver infection (abscesses +/- sepsis)
High mortality if untreated
```
64
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
65
Define jaundice
Yellowing of skin, sclerae, mucosae from increased plasma bilirubin
66
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
```
67
Investigations for gallstones
Bloods:
LFTs
High conjugated bilirubin
USS gallbladder
MRCP/ERCP
68
Types of hernias
```
Paraumbilical
Epigastric
Spigelian
Lumbar
Richter's
Maydl's
Littre's
Obturator
Sciatic
Sliding
Hiatus (sliding, rolling)
```
69
Define sciatic hernia
Through lesser sciatic foramen
| GI obstruction, gluteal mass
70
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
```
71
What are the 3 types of jaundice?
Haemolytic/pre-hepatic
Hepatocellular/hepatic
Obstructive/post-hepatic
72
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
73
Complications of stones in common bile duct
```
Ascending cholangitis (Charcot's triad)
Obstructive jaundice
Pancreatitis
```
74
Define diverticulosis
Presence of diverticula, without inflammation or infection
May be referred to as diverticular disease when patients experience symptoms
75
Define rolling hernia
Type 2 hiatus hernia
Separate portion of stomach (i.e. fundus) folds around and enters through diaphragm opening alongside the oesophagus
76
Define chronic cholecystitis
Chronic inflammation of gallbladder +/- colic
| flatulant dyspepsia
77
Management of acute cholecystitis
```
Emergency admission
NBM
IV fluids
Analgesia
NG (if vomiting)
ERCP to remove stones from CBD
Cholecystectomy
```
78
When is jaundice visible?
Bilirubin >60umol/L
79
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
80
Presentation of gallstones
```
RUQ pain (radiates to back +/- jaundice)
Symptomatic with cystic duct obstruction or if passed into CBD
```
81
Risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
Liver flukes (parasitic infection)
82
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
```
83
Complications of stones in bowel
Gallstone ileus (fistula)
84
Complications of stones in gallbladder
```
Biliary colic
Cholecystitis
Empyema
Mucocele
Perforation
Carcinoma
Mirizzi's syndrome
```
85
Pathogenesis of chronic cholecystitis
Healing by fibrosis
Gallbladder wall thickened
Gallbladder shrinks
Chronic stone
86
Presentation of inguinal hernia
Soft lump in inguinal region (groin)
87
Risk factors for jaundice
Excessive alcohol use
Use of illicit drugs
Exposure to hepatitis A, B, or C
Exposure to certain industrial chemicals
88
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
89
Types of inguinal hernia
Indirect inguinal hernia
| Direct inguinal hernia
90
Imaging in acute cholecystitis
Abdominal USS
Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder
91
Prevention of diverticular disease complications
```
High fibre diet
Low animal fat/processed food diet
Smoking cessation
Exercise
Avoid NSAIDs
```
92
Investigations for acute diverticulitis
```
FBC
CRP
Erect CXR
AXR
USS
CT
Barium enema
Colon/sigmoidoscopy
```
93
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)
```
94
Location of stone in biliary colic and acute cholecystitis
Stone in cystic duct
95
Signs and symptoms of sliding hernia
```
Asymptomatic
GORD
Oesophagitis
Iron deficiency anaemia/bleeding
Pain
Post-prandial fullness
Nausea
Retching
```
96
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
97
Treatment of diverticular disease
Conservative (high fibre diet)
Medical (mebeverin, anti-cholinergic)
Surgical (elective resection)
98
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
99
Define Meckel's diverticulum
A remnant of vitellointestinal duct of embryo
