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Priority 1 > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

Presentation of cholangiocarcinoma

A 
Obstructive jaundice (pale stools, dark urine, generalised itching)
Unexplained weight loss
RUQ pain
Palpable gallbladder 
Hepatomegaly
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2
Q

Causes of jaundice in previously stable cirrhosis patient

A

Sepsis
Malignancy
Alcohol/drugs
GI bleeding

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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

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4
Q

Define hiatus hernia

A

Herniation of stomach up through diaphragm

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5
Q

Signs & symptoms of obstructive jaundice

A

Pale stools

Dark urine

Generalised itching

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6
Q

Define obturator hernia

A

Through obturator canal

Pain in medial thigh

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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
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8
Q

Define diverticulum

A

Outpouching of bowel wall

Usually at sites of entry of perforating arteries (acquired or congenital)

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9
Q

Management of hiatus hernias

A

Antacids
Weight loss
Sleep propped up
Not usually treated surgically

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10
Q

Pathophysiology of biliary colic and acute cholecystitis

A

Acute obstruction - stone in cystic duct

Inflammatory response

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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

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12
Q

Predisposing factors to hernias

A 
Male
Chronic cough
Constipation
Urinary obstruction
Heavy lifting 
Ascites
Past abdominal surgery
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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
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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

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15
Q

Define sliding hernia

A

Type 1 hiatus hernia

Stomach slides up through diaphragm, with gastro-oesophageal junction passing up into thorax

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16
Q

Management for chronic cholecystitis

A

ERCP

Laparoscopic cholecystectomy

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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

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18
Q

Presentation of gallstone ileus

A 
SBO
Colicky pain
Vomiting
Absolute constipation
Abdominal distension
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19
Q

Define ascending cholangitis

A

Bacterial infection of the biliary tree

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20
Q

Define spigelan hernia

A

Between lateral border of recuts abdominis and linea semilunaris

Increased risk of incarceration, obstruction and strangulation

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21
Q

Investigations for acute cholecystitis

A

Raised WCC
Abdominal USS
AXR

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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

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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
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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)

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25
Q

Location of stone in jaundice +/- ascending cholecystitis

A

Stone in common bile duct

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26
Q

Risk factors for gallstones

cholesterol and bilirubinate

A 
Cholesterol: 5Fs
Fat
Female
Forty
Fertile
Fair (caucasians)
Crohn's
Family history

Bilirubinate:
Haemolytic anaemia

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27
Q

Investigations for chronic cholecystitis

A

Abdominal USS

MRCP

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28
Q

Pathogenesis of gallstones

A

Imbalance between proportions of cholesterol and bile salts

Precipitation of excess component as gallstones

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29
Q

Signs and symptoms of diverticular disease

A 
Altered bowel habit
Nausea
Flatulance
L-sided colic relieved by defacation
LBO
Blood and mucus per rectum
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30
Q

Define epigastric hernia

A

Hernia in epigastric area (upper abdomen)

Through linea alba

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31
Q

Meckel’s diverticulum: Rules of 2s

A

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

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32
Q

Treatment of paraumbilical hernia

A

Surgery to repair rectus sheath (Mayo repair)

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33
Q

Define Littres hernia

A

Hernia containing strangulated Meckel’s diverticulum

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34
Q

What is Charcot’s triad?

What does it indicate?

A

Fever
Raised bilirubin
RUQ pain

Acute cholangitis

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35
Q

Complications of acute cholecystitis

A

Sepsis
Gallbladder empyema
Gangrenous gallbladder
Perforation

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36
Q

What is obstructive/post-hepatic jaundice?

Causes

A

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
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37
Q

Hasselbach’s triangle boundaries

A

RIP

Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior/lateral border
Poupart’s ligament (inguinal ligament) - inferior border

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38
Q

What is haemolytic/pre-hepatic jaundice?

Causes

A

Excess bilirubin presented to liver
Unconjugated hyperbilirubinaemia

Causes:
Sickle cell crisis
Blood transfusion
Haemolytic drugs/anaemia
Drugs
Impaired conjugation
Physiological neonatal jaundice
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39
Q

Epidemiology of gallstones

A

10-15% lifetime prevalence in Western world

8% of those >40yrs

90% remain asymptomatic

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40
Q

Define Richter’s hernia

A

Only part of bowel wall and lumen herniates through defect

Other side of that section of bowel remains within peritoneal cavity

41
Q

What is Mirizzi’s syndrome

A

Stone in gallbladder presses on bile duct causing jaundice

42
Q

Define lumbar hernia

A

Through inferior or superior lumbar triangles in posterior abdominal wall

43
Q

Define Maydl’s hernia

A

Herniating double loop of bowel

Strangulated portion may reside as a single loop inside umbilical cavity

44
Q

Define direct inguinal hernia

A

Due to weakness in abdominal wall at Hasselbach’s triangle

Hernia protrudes directly through abdominal wall

45
Q

Pathogenesis of jaundice +/- ascending cholecystitis

A

Obstruction and inflammation of CBD
Stasis increases risk
Superimposed infection

46
Q

How to distinguish indirect and direct inguinal hernia?

A

Reduce hernia and apply pressure to deep inguinal ring (mid-way point from ASIS to pubic tubercle)

Indirect = hernia will remain reduced

47
Q

Define paraumbilical hernia

A

Omentum/bowel herniating through

Above or below umbilicus

48
Q

Risk factors for paraumbilical hernia

A

Common in neonates (can resolve spontaneously)

Obesity

Ascites

49
Q

Define diverticulitis

A

Inflammation and infection of diverticula

50
Q

Define internal hernia

A

Through adhesions - closed loop obstruction

Into paraduodenal or paracaecal fossae

51
Q

Investigations for cirrhosis/jaundice

A

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
Q

Examination findings in cirrhosis/jaundice

A 
Signs of chronic liver disease
Hepatic encephalopathy
Lymphadenopathy
Hepatomegaly
Splenomegaly
Ascites
Palpable gallbladder
53
Q

Presentation of acute diverticulitis

A

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
Q

Management of gallstones

A

Asymptomatic:
Conservative treatment
Possibly no intervention required

Symptomatic:
Analgesia
Rehydrate
NBM
Cholecystectomy
55
Q

Location of stone in gallstone pancreatitis

A

Stone in ampulla of vater

56
Q

Pathophysiology of gallstone ileus

A

Fistula between gallbladder and loop of small bowel

57
Q

Risk factors for diverticular disease

A

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
Q

Jaundice history

A

Foreign travel
Sex
Tattoos and piercings
IVDU

59
Q

4 classifications of body wall hernias

A

Reducible/irreducible

Incarcerated (contents of hernia stuck inside - adhesions)

Obstructed (bowel contents cannot pass through)

Strangulated (ischaemia)

60
Q

Differentials for inguinal hernia

A 
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
Q

Complications of acute diverticulitis

A

Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g. between the colon and the bladder or vagina)
Ileus/obstruction

62
Q

Location of stone in gallstone ileus

A

Stone in small bowel

63
Q

Presentation in jaundice +/- ascending cholecystitis

A

Charcot’s triad:
Jaundice
Fever (with rigors)
RUQ abdominal pain)

Liver infection (abscesses +/- sepsis)
High mortality if untreated
64
Q

Investigations of cholangiocarcinoma

A

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
Q

Define jaundice

A

Yellowing of skin, sclerae, mucosae from increased plasma bilirubin

66
Q

Management of acute diverticulitis

A 
NBM/clear fluids only
IV antibiotics
IV fluids
Analgesia
Urgent investigations (e.g. CT scan)
Urgent surgery may be required for complications
67
Q

Investigations for gallstones

A

Bloods:
LFTs
High conjugated bilirubin

USS gallbladder

MRCP/ERCP

68
Q

Types of hernias

A 
Paraumbilical 
Epigastric 
Spigelian
Lumbar
Richter's
Maydl's
Littre's
Obturator
Sciatic
Sliding
Hiatus (sliding, rolling)
69
Q

Define sciatic hernia

A

Through lesser sciatic foramen

GI obstruction, gluteal mass

70
Q

Types of gallstones

A 
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
Q

What are the 3 types of jaundice?

A

Haemolytic/pre-hepatic

Hepatocellular/hepatic

Obstructive/post-hepatic

72
Q

Define incisional hernia

A

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
Q

Complications of stones in common bile duct

A 
Ascending cholangitis (Charcot's triad)
Obstructive jaundice
Pancreatitis
74
Q

Define diverticulosis

A

Presence of diverticula, without inflammation or infection

May be referred to as diverticular disease when patients experience symptoms

75
Q

Define rolling hernia

A

Type 2 hiatus hernia

Separate portion of stomach (i.e. fundus) folds around and enters through diaphragm opening alongside the oesophagus

76
Q

Define chronic cholecystitis

A

Chronic inflammation of gallbladder +/- colic

flatulant dyspepsia

77
Q

Management of acute cholecystitis

A 
Emergency admission 
NBM
IV fluids
Analgesia
NG (if vomiting)
ERCP to remove stones from CBD
Cholecystectomy
78
Q

When is jaundice visible?

A

Bilirubin >60umol/L

79
Q

Pathophysiology of diverticulitis complications

A

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
Q

Presentation of gallstones

A 
RUQ pain (radiates to back +/- jaundice)
Symptomatic with cystic duct obstruction or if passed into CBD
81
Q

Risk factors for cholangiocarcinoma

A

Primary sclerosing cholangitis

Liver flukes (parasitic infection)

82
Q

Management of cholangiocarcinoma

A

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
Q

Complications of stones in bowel

A

Gallstone ileus (fistula)

84
Q

Complications of stones in gallbladder

A 
Biliary colic 
Cholecystitis
Empyema
Mucocele
Perforation
Carcinoma
Mirizzi's syndrome
85
Q

Pathogenesis of chronic cholecystitis

A

Healing by fibrosis
Gallbladder wall thickened
Gallbladder shrinks
Chronic stone

86
Q

Presentation of inguinal hernia

A

Soft lump in inguinal region (groin)

87
Q

Risk factors for jaundice

A

Excessive alcohol use
Use of illicit drugs
Exposure to hepatitis A, B, or C
Exposure to certain industrial chemicals

88
Q

Pathophysiology of diverticular disease

A

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
Q

Types of inguinal hernia

A

Indirect inguinal hernia

Direct inguinal hernia

90
Q

Imaging in acute cholecystitis

A

Abdominal USS

Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder

91
Q

Prevention of diverticular disease complications

A 
High fibre diet
Low animal fat/processed food diet
Smoking cessation
Exercise
Avoid NSAIDs
92
Q

Investigations for acute diverticulitis

A 
FBC
CRP
Erect CXR
AXR
USS
CT
Barium enema
Colon/sigmoidoscopy
93
Q

Clinical presentation of gallstone pancreatitis

A 
Severe epigastric pain
Radiating through to the back
Associated vomiting
Abdominal tenderness
Systemically unwell (e.g. low-grade fever and tachycardia)
94
Q

Location of stone in biliary colic and acute cholecystitis

A

Stone in cystic duct

95
Q

Signs and symptoms of sliding hernia

A 
Asymptomatic
GORD
Oesophagitis
Iron deficiency anaemia/bleeding
Pain
Post-prandial fullness
Nausea
Retching
96
Q

Define indirect inguinal hernia

A

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
Q

Treatment of diverticular disease

A

Conservative (high fibre diet)

Medical (mebeverin, anti-cholinergic)

Surgical (elective resection)

98
Q

Pathogenesis of gallstone pancreatitis

A

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
Q

Define Meckel’s diverticulum

A

A remnant of vitellointestinal duct of embryo

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