Gastrointestinal Conditions 2 Flashcards
2nd/3rd of GI conditions Will be Lower GI in summer!
1
Q
What is a GI perforation?
A
Perforation of the wall of the GI tract with spillage of bowel contents
2
Q
What causes Large bowel perforations?
A
Diverticulitis Colorectal cancer Appendicitis Volvulus UC (Toxic megacolon)
3
Q
What causes Gastroduodenal perforations?
A
Perforated duodenal or Gastric ulcer
Gastric cancer
4
Q
What causes Small bowel perforations?
A
Just to note they are rare!
Trauma
Infections (Ileo-coecal TB)
Crohn’s disease
5
Q
What is Oesophageal perforation called?
A
Boerhaave’s perforation
6
Q
What is Boerhaave’s perforation?
A
Rupture of the oesophagus following forceful vomiting
7
Q
What are risk factors for GI perforation?
A
Risk factors for cause! E.g. Low Residue diet Steroids NSAIDs Bisphosphonates
8
Q
What are symptoms of GI perforation?
A
Depends on cause
Large bowel: Peritonitic abdomen pain
Gastroduodenal: Sudden onset severe pain, becomes generalise, malignancy symptoms
Oesophageal: Severe pain, Neck/chest pain and dysphagia
9
Q
What are signs of GI perforation?
A
Very unwell
Signs of shock
Pyrexia
Pallor
Dehydration
Signs of peritonitis (Guarding, Rigidity, rebound tenderness, absent bowel sounds)
Loss of liver dullness (due to overlying gas)
10
Q
What is Blumberg’s sign?
A
Rebound tenderness!
This is shown by someone pressing on the abdomen and as they release, there is tenderness!
11
Q
What investigations are done for GI perforation?
A
FBC U&Es LFTs Amylase - raised but <1000 Erect CXR - air under diaphragm Gastrograffin swallow - for suspected oesophageal perforation
12
Q
How do you manage perforations generally?
A
Correct fluid and electrolyte balance
IV ABX - efuroxime and metronidazole
13
Q
How do you manage large bowel perforations?
A
Identify site
Peritoneal lavage
Resect perforated section
14
Q
How do you manage Gastroduodenal perforations?
A
Laparotomy Peritoneal lavage Close it with an omental patch Biopsy ulcers Eradicate H.Pyloir if thats the cause
15
Q
How do you manage oesopageal perforations?
A
Pleural lavage
Repair of rupture oesophagus
16
Q
What are the comlications of bowel perforations?
A
Large and Small bowel - Peritonitis
Oesophagus - Mediastinitis
Overall: Shock, sepsis, death
17
Q
What is the prognosis of those with a Gastroduodenal perforation?
A
Worse with Gastric than Duodenal ulcers
Poor prognosis for perforated gastric carcinomas
18
Q
What is the prognosis for those with a large bowel perforation?
A
High risk of faecal peritonitis if left untreated
Lead to DEATH from septicaemia and multiorgan failure
19
Q
What is Gastrooesophageal reflux disease?
A
Symptoms of complications resulting from the reflux of gastric contents into the oesophagus or beyond, into the oral cavity or lung
20
Q
What causes GORD?
A
Caused by disruption of mechanisms that prevent reflux:
Lower oesophageal sphincter
Acute angle of junction
Mucosal rosette
Intra-abdominal portion of oesophagus (obesity, pregnancy)
Prolonged oesophageal acid clearance
Increased dietary fat
21
Q
What is a Mucosal rosette?
A
Redundant mucosal folds causing a weakened anti-reflux valve
22
Q
What are the risk factors for GORD?
A
Family history Older age Hiatus Hernia Obesity Lower oesophageal sphincter tone-reducing drugs (e.g. anticholingergics, nitrates, CCBs) Stress Asthma NSAIDs Smoking Alcohol consumption Per-oral endoscopic myotomy Dietary factors
23
Q
What are the symptoms of GORD?
A
Substernal/epiastric burning discomfort or heartburn Halitosis Bloating Aggravated by: Lying supine, bending down, large meals, dirnking alcohol Pain relieved by antacids Waterbrash Aspiration Dysphagia
24
Q
What is waterbrash?
A
Regurgitation of an excessive accumulation of saliva from the lower part of the oesophagus often with some acid material from the stomach
25
What are the signs of GORD?
Usually normal
Occasionally - epigastric tenderness, wheeze on auscultation, dysphonia
Bloating
26
What are investigations for GORD?
Clinical diagnosis!
If suspected, PPI trial
If GORD persists - OGD and biopsy
Other tests: 24hr pH monitoring, manometry, Barium swallow
27
How do you manage GORD?
```
Advice
Medicines
Endoscopy
Surgery
Nissen fundoplication
```
28
What Advice do you give to someone with GORD?
```
Weight loss
Elevating head of bed
Avoid provoking factors
Stop smoking
Lower fat meals
Avoid large meals late in the evening
```
29
What medicines do you give to someone with GORD?
Antacids
Alginates
H2 antagonists (e.g. Ranitidine)
PPI (e.g. Omeprazole ,Lansoprazole)
30
What is Nissen fundoplication?
Fundus of the stomach is wrapped around the lower oesophagus - reduces risk of hiatus hernia and reduce reflex
31
What are the complications for GORD?
Oesophageal ulcer, haemorrhage or perforation
Oesophageal stricture
Barret's oesophagus
Adenocarcinoma of the oesophagus
32
What are Haemorrhoids?
Disrupted and dilated anal cushions. Lined by discontinuous masses of spongy vascular tissue
33
What are the classifications of Haemorrhoids?
Internal
(Arise from the superior haemorrhoidal plexus - above the dentate line)
External (Below the dentate line)
34
What are the degrees of Haemorrhoids?
1st - Haemorrhoids that do not prolapse
2nd - Prolapse with defecation but reduce spontaneously
3rd - Prolapse and require manual reduction
4th - Prolapse than cannot be reduced
35
What causes Haemorrhoids?
Increased intra-abdominal pressure
36
What are the Risk Factors for haemorrhoids?
```
Age 45-65
Constipation
Pregnancy or SOL
Hepatic insufficiency
Ascites
```
37
What are symptoms of Haemorrhoids?
```
May be asymptomatic
Bright red rectal bleeding
Anal itching
Intense pain if strangulated
Lack of FLAWS!
```
38
What is FLAWS?
```
F - Fever
L - Lethargy
A - Appetite change
W - Weight loss
S - Night Sweats
```
39
What are signs of Haemorrhoids?
1st/2nd degree not visible
Internal haemorrhoids not palpable unless thrombosed
Visible on proctoscopy
40
What are differentials for Haemorrhoids?
```
Anal tags
Anal fissures
Rectal prolapse
Polyps
Tumours
```
41
What are the complications of Haemorrhoids?
```
Anaemia from continuous/excessive bleeding
Thrombosis
Incarceration
Faecal incontinence
Pelvic sepsis
Anal stenosis
```
42
What is Haemochromatosis?
An autosomal recessive disease in which increased intestinal absorption of iron causes accumulation of iron in tissues, which may lead to iron damage
43
What causes Haemochromatosis?
AR condition
Caused by defect in HFE gene
Not everyone who is homozygous develop the disease
44
What are the risk factors for Haemochromatosis?
```
Middle aged
Male
White ethnicity
Family history
Iron supplements
```
45
What are symptoms of Haemochromatosis?
```
Often asymptomatic
Fatigue
Weakness
Arthropathy
Erectile dysfunction
Heart problems
Late symptoms:
Diabetes mellitus
Bronzed skin
Hepatomegaly
Impotence
Amenorrhoea
Hypogonadism
Cirrhosis
Arrhythmias and cardiomyopathy
Neuro and psych problems
```
46
What investigations can be done for Haemochromatosis?
Haematinics - Serum ferritin (High), Transferrin (Low), Transferrin saturation (high), TIBC (Low)
CRP - Low
LFT - raised
47
What is Hepatocellular carcinoma?
Primary malignancy of the liver Parenchyma
48
What is associated with Hepatocellular carcinoma?
Chronic liver damage (Hep B/C, AI disease)
Metabolic disease (Haematochromatosis)
Aflatoxins (Aspergillus flavus)
49
What are the symptoms of hepatocellular carcinoma?
Symptoms of malignancy (Malaise, weight loss, loss of appetitie)
Symptoms of chronic liver diseae (Ascites, Jaundice)
50
What are the signs of Hepatocellular carcinome?
Signs of malignancy - Cachexia, Lymphadenopathy
Hepatomegaly
Jaundice
Ascites
51
What are the investigations for Hepatocellular carcinoma?
```
FBC
ESR
LFTs
Clotting
AFP - tumour marker
B12 binding protein is a marker for fibrolamellar HCC
Serology
Imaging - US (Not good for small); CT/MRI (Gold standard)
Ascitic tap
Liver biopsy
```
52
What is a Hernia?
Protrusion of a viscus or part of a viscus through a defect of the wall of its containing cavity into abnormal position
53
What are the 2 main types of Hernia?
Femoral and Inguinal
54
What is the most common type of Hernia?
Inguinal
55
Where are hernias found?
Inguinal -Superomedial to the tubercle
| Femoral - Inferolateral to teh tubercle
56
If a Hernia is irreducible what does that mean?
Cannot be pushed back into the right place
57
What does it mean if a Hernia is incarcerated?
Contents of the hernia are stuck inside by adhesions
58
When is a Hernia strangulated?
When they become ischaemia
59
What is an Inguinal Hernia?
Abnormal protrusion of the peritoneal sac through a weakness of the abdominal wall
60
What are the 2 types of inguinal hernia?
Direct and Indirect
61
What is a Direct inguinal hernia?
Protrusion of the hernial sac through a weakness in the posterior wall of the inguinal cancal - through Hesselbach's triangle, medially to the inferior epigastric vessels
62
What is Hesselbach's triangle?
Border of Rectus Abdominis, INferior epigastric vessels and the inguinal ligament
63
What is an indirect inguinal hernia?
Protrusion of the hernia through the deep inguinal ring, following the inguinal canal
64
Who are inguinal hernias more common in?
Men
| 55-85
65
Who are femoral hernias more common in?
Women
Increasing age
Pregnancy (more pregnancies)
Increased intra-abdominal pressure
66
What is a Femoral Hernia?
Abdominal contents pass through a naturally occurring weakness call the femoral canal and present as a mass in the upper medial thigh
67
What are the Risk Factors for inguinal hernias?
```
Male sex
Old age
Smoking
Family history
Prematurity
AAA
Marfans
Lathyrism
Chronic bronchitis/emphysema
```
68
What are the risk factors for femoral hernias?
Female
Increasing age
Pregnancy
Increased intra-abdominal pressure
69
What symptoms are there of inguinal hernias?
```
Often asymptomatic
Notices lump in groin
May be painful
May be irreducible
May present due to growth
```
70
What signs are there of Inguinal hernias?
Groin lump that extends to scrotum/labia
Check cough impulse
Tender if strangulated
71
How can you tell between direct and indirect on examination?
Reduce hernia and occlude deep internal ring with 2 fingers
Ask to cough / stand, if restrained it is Indirect
Gold standard: Direct are medial to inferior epigastric vessels, Indirect are lateral
72
What are the symptoms of femoral hernias?
Lump in groin
Usually asymptomatic
30% present as an emergency due to obstruction or strangulation
73
What are the signs of femoral hernia on examination?
Look for B/L lumps
Ask to reduce and ask to cough
If no lump visible assess cough reflex
Repeat exam with patient standing
74
What investigations are done for all Hernias?
Only done if acute with painful irreducible hernia!
FBC
CRP
ABG - show lactic acidosis from bowel ischaemia
Erect CXR - check for perforation
75
What is the management of Inguinal hernias?
Surgical - only if symptomatic
Laparoscpic mesh repair
Emergency - if obstructed or strangulated - need laparotomy with bowel resection if gangrenous
76
What is the management for Femoral Hernias?
Surgical repair
- Herniotomy (Ligation and excision of the sac)
- Herniorrhaphy (Repair of hernial defect)
77
What are complications of Inguinal hernias?
```
Incarceration
Strangulation
Maydl's hernia
Richter's hernia
Surgery complications
Haematoma
Penile/scrotal oedema
Mesh infection
Testicular ischaemia
```
78
What are complications of Femoral hernias?
High risk of strangulation !
Risk of becoming irreducible or obstructed
Wound infection
79
What is a Maydl's hernia?
Strangulated w-shaped loop of S.Bowel
80
What is a Richter's hernia?
Strangulation of part of the bowel circumference
81
What is a Hiatus Hernia?
Herniation of part of the abdominal viscera through the Oesophageal aperture of the diaphragm
82
What causes a Hiatus Hernia?
Unknown aetiology
Raised intraabdomianl pressure causes phsyiological movement of the distal oesophagus and possible the gastro-oesophageal junction through the oesophageal hiatus and into the posterior mediastinum
83
Risk Factors for hiatus hernia?
```
Obesity
Elevated intra-abdominal pressure
Male sex
Structural abnormalities
Incisional, umbilical or inguinal hernia
Ascites
advaced age
```
84
What are symptoms of a Hiatus Hernia?
```
Many asymptomatic
Retrosternal burning sensation, especiallly on bending or laying down
Flatulence
GORD
Rarely, diffuclty swallowing
```
85
What are signs of a Hiatus Hernia?
Usually no signs
| Uncommonly bowel sounds in the chest
86
What investigation are done for a Hiatus Hernia?
FBC (Iron deficiency anaemia)
CXR (First line)- air bubble above diaphragm
Barium swallow
Endoscopy
87
How do you manage an acute Hiatus hernia?
Upper GI haemorrhage and/or obstruction and/or volvulus
- 1st: Resuscitation and urgent surgical repair
Irreversible organ ischaemia and/or necrosis
- 1st: Surgical resection and supportive care
88
How do you manage an ongoing hiatus hernia?
Type I refractory or types II, III and IV: surgical repair with or without anti-reflux procedure
89
What are the complications of Hiatus Hernia?
```
Bloating
Volvulus
Obstruction
Diarrhoea following surgery
Fundal necrosis
```
90
What is intestinal obstruction?
Obstruction of normal bowel contents - Mechanical blockage of the bowel due to structural pathology
91
What are the classifications of intestinal obstruction?
Small or Large Bowel
Partial or complete obstruction
Simple or strangulated
92
What are the causes of Large Bowel obstruction?
90% by underlying
5% by colonic volvulus
3% benign strictures
2% rarer conditions
93
What are the causes of small bowel obstruction?
Previous surgery with formation of adhesions
Inguinal hernia with incarceration
Crohn's disease
Intestinal malignancy
Appendicitis
In children: Appendicitis, Intestinal artresia, intussussception, volvulus
Rare causes: Radiation enteritis, intra-abdominal abscess, gallstone ileus, foreign body and intestinal bezoar
94
What are Risk factors for Large Bowel obstruction?
```
Older age
Female gender
Institutionalisation
Mental illness
Megacolon
Low or High dietary fibre
Previous colorectal resection
Previous abdominal surgery
IBD
Laxative abuse
Diabetes
```
95
What are the Risk Factors for Small Bowel obstruction?
```
Previous abdominal surgery
Malrotation
Crohn's disease
Hernia
Appendicitis
Intestinal malignancy
Intussussception
Volvulus
Intestinal atresia
Foreign body ingestion
```
96
What are the symptoms for Bowel obstruction?
Severe, colicky pain with periods of ease
Abdominal distention
Frequent vomiting (Bile-stained or Faeculent)
Absolute constipaiton
Anorexia
97
What is Absolute constipation?
No Flatulence or defecation
98
What are signs of bowel obstruction?
```
Abdominal distention
May see visible peristalsis
Tinkling bowel sounds
Peritonitis
Inspect for hernias
Look for abdominal scars
Inspect for abdominal mass
```
99
What investigations are done for obstruction?
```
AXR
- LBO: Peripheral, Haustra
- SBO: Central, Valvulae coniventae
Erect CXR - Look for perforation
CT-scan - more sensitive
Amylase - elevated
FBC - Leucocytosis
U&Es - hyponatraemia, hypokalaemia, alkalosis
Group& Save for surgery
```
100
How do you manage Bowel obstruction?
```
Fluid resuscitation
Electrolyte replacement
Intestinal decompression
NBM
Bowel rest
Surgery if complicated: Laparotomy with a clear diagnosis
```
101
In a patient with bowel obstruction what indicates an early surgery?
Local or generalised peritonitis
Palpable mass
Failure to improve
Risk of perforation of ischaemic bowel
102
What are non-surgical treatments for bowel obstruction?
Endoscopic stenting further advance in managing bowel obstructions
If thought to be due to adhesions, conservative measures may be sufficient
103
What are the complications of Bowel obstruction?
```
Intestinal necrosis
Sepsis
Multi-organ failure
Intra-abdominal abscess
Short bowel syndrome
Intestinal perforation
```
104
What is intestinal Ischaemia?
Obstruction of mesenteric vessel leading to Bowel ischaemia and necrosis
Note: AF with abdominal pain should point towards mesenteric ischaemia
105
What are the 3 main types of intestinal ischaemia?
Acute mesenteric ischaemia (AMI)
Chronic mesenteric ischaemia aka intestinal angina (CMI)
Chronic colonic ischaemia aka ischaemic colitis (CCI)
106
What are the causes of Acute mesenteric ischaemia?
AMI - Small bowel, 35% arterial thrombosis, 35% embolism
Affect Superior mesenteric artery, non-occlusive ischaemia
Occurs in flow states, likely to have low CO (Venous thrombosis - 5%)
Affecting mesenteric vein: More common in younger patients with hypercoagulable states
107
What are the causes of Chronic mesenteric ischaemia?
Usually due to a flow state with atheroma, likely to have a history of vascular disease
108
What are the causes of Chronic colonic ischaemia?
Inflammation of the colon caused by decreased blood supply
Follows low flow state in inferior mesenteric artery. Ischaemia leads to mucosal inflammation, oedema, necrosis and ulceratio
109
What is a watershed area?
A region that receives a dual blood supply from the most distal branches of 2 large arteries. If there is a blockage of one artery, they are normally fine but if general hypoperfusion these regions are most susceptible
110
What are Risk Factors for Intestinal ischaemia?
Atrial fibrillation
Endocarditis
Arterial thrombosis: Hypercholesterolaemia, hypertension, DM, smoking
Venous thrombosis: Portal HTN, Splenectomy, Septic thrombophlebitis, OCP, thrombophilia
111
What are the symptoms of Intestinal Ischaemia?
Acute mesenteric ischaemia - Acute severe abdominal pain + no abdominal signs _ rapid hypovolaemia + Shock
Constant pain
Generally: Fever, Severe acute colicky abdo pain, Vomiting, Nausea, Bloody diarrhoea, History of heart or liver disease, History of chronic mesenteric artery insufficiency
(Gross weight loss, post-prandial abdominal pain)
112
What are the signs of Intestinal ischaemia?
```
Fever and Tachycrdia
Diffuse abdominal tenderness
Tender palpable mass
Bowel sounds may be absent
Disproportionate degree of CVS collapse
Upper abdominal bruit
```
113
What investigations can be done for Intestinal ischaemia?
AXR (Thickening of small bowel folds and signs of obstruction, shows gas less abdomen)
FBC (Anaemia, leucocytosis)
U&Es
LFTs
Clotting
Cross-Match
Barium Enema shows thumb printing of submucossal swelling
114
What is Irritable bowel syndrome?
A functional bowel disorder defined as recurrent episodes of abdominal pain / discomfort for >6 months with 2 of:
- Altered stool passage
- Abdominal bloating
- Symptoms made worse by eating
- Passage of mucous
115
What are Risk Factors for Irritable bowel syndrome?
```
Physical and sexual abuse
Age <50 years
Female sex
Previous enteric infection
Family and Job stress
```
116
What are the symptoms of IBS?
6+ month history of abdominal pain (colicky, in lower abdomen, relieved by defecation or flatus)
Altered bowel frequency (>3/day or <3 /week)
Mucous in stool
Worsening of symptoms after food
Tenesmus
Nausea, bladder symptoms, Back ache
Chronic and exacerbated by stress
117
What is Tenesmus?
Continuous or persistent feeling of needing to evacuate the bowels
118
What are signs of IBS?
None
119
What investigations are done for IBS?
```
FBC (Normal)
CRP (=0.5)
Anti-TTG antibodies (negative)
Anti-endomysial antibodies (negative)
All studies are normal
```
120
How do you manage IBS?
Dietary medification - fibre, lactose, fructose, wheat, starch, caffeine, alcohol, fizzy drinks may worsen symptoms
For constipation: Increase fibre, bisacodyl and sodium picosulfate
Medicines: Antispasmodics, Prokinetic agents, Anti-diarrhoeal, Laxatives
121
What are the complications of IBS?
Damage to family and work relationships
| Diverticulosis
122
What is a Liver abscess?
Liver infection resulting in a walled off collection of pus
123
What organisms cause a Liver abscess?
```
Pyogenic (producing pus)
E. Coli
Klebsiella
Enterococcus
Bacteroides
Streptococci
Staphylococci
60% caused by biliary tract disease (e.g. gall sontes, strictures, congenital cysts)
Amoebic abscess
- Caused by entamoeba histolytica
```
124
What are the Risk factors for Liver abscesses/cysts?
```
Biliary tract diseae/intervention
Age > 50 years
Malignancy
Diabetes Mellitus
Endemic amoebiasis areas
```
125
What are the symptoms of Liver abscesses/cysts?
```
Fever
Malaise
Nausea
Anorexia
Night sweats
Weight loss
RUQ/Epigastric pain
Jaundice
Diarrhoea
Pyrexia
May see Reactive pleural effusion in R lower lobe
```
126
What are the signs for Liver abscesses/cysts?
```
Fever
Jaundice
Tender hepatomegaly
Right lung base
- Dull to percussion
- Reduced breath sounds
- Due to reactive pleural effusion
```
127
What investigations are done for liver abscesses/cysts?
FBC (Mild anaemia, leucocytosis, eosinophilia)
LFTs (High ALP, High bilirubin)
ESR/CRP (High)
Amoebic and Hydatid serology
Blood cultures if spetic
Stool MC&S - E. Histolytica
CXR - check for pleural effusion or atelectasis
128
What are Liver Cysts?
Liver infection resulting in a walled off collection of cystic fluid
129
What Causes liver cysts that dont cause liver abscesses?
Hydatid cysts caused by Echinococcus granulosis
130
Who are Hydatic cysts common in?
Sheep-rearing countries
131
What is liver Failure?
Severe liver dysfunction leading to Jaundice, encephalopathy and coagulopathy
Can occur suddenly (Acute) but usually a result of decompensation of chronic liver disease
132
What causes liver failure?
```
Toxins
Infections
Neoplasms (hepatocellular carcinoma)
Metabolic causes (Wilson's, alpha-1 antitrypsin)
Pregnancy-related
Vascular
Other
```
133
What is Reye's syndrome?
Rare syndrome causing swelling in the liver and brain
134
How do you classify liver failure?
Time between onset of Jaundice and Hepatic encephalopathy
- Hyperacute <7 days
- Acute 1-4 weeks
- Subacute 4-12 weeks
135
What toxins cause liver failure?
```
Alcohol
Paracetamol
Drugs
Poisoning
Herbal preparations
Illicit drugs
Reye's syndrome
```
136
Which drugs are hepatotoxic?
```
Paracetamol
Co-amoxiclav
Methotrexate
Statins
Nitrofurantoin
Halothane
Erythromycin
Ciprofloxacin
Doxycycline
```
137
What are the Risk factors of liver failure?
```
Chronic alcohol abuse
Poor nutritional status
Age >40 years
Chronic paracetamol use
Pregnancy
HIV and Hepatitis C co-infection
Medicines that are hepatotoxic
```
138
What are the symptoms of Liver failure?
```
May be asymptomatic
Fever
Nausea
Jaundice (not always)
Abdominal pain
Malaise
```
139
What are the signs of Liver failure?
```
Jaundice
Encephalopathy
Hepatomegaly
Asterixis
Fetor hepaticus
Ascites and splenomegaly
Bruising or bleeding
Signs of secondary causes (Bronze skin, kayser-Fleischer rings)
Pyrexia
Palmar erythema
Spider naevi
```
140
What is Fetor Hepaticus?
Breath smells of pear drops
141
What investigations are done for Liver failure?
```
Viral serology
Paracetamol levels
Autoantibodies
Ferritin
Ceruloplasmin and Urinary Copper
U&Es (Hepatorenal syndrome)
LFT (Raised)
Glucose (Raised)
Ascitic tap
```
142
What can be seen on ascitic tap?
Colour
Biochemistry
Microscopy
SAAG (Serum ascitic albumin gradient)
143
What are the different colours seen on ascitic tap?
Clear/straw - Cirrhosis
Cloudy - SBP, Perforated bowel, Pancreatitis
Bloody - Malignancy, Haeomrrhagic pancreatitis
Chylous (Milky) - Lymphoma, TB, Malignancy
144
What different biochemistries are seen on ascitic tap?
Protein:
0.3-4 g/dL = normal
>4g/dL = SBP/TB
Glucose:
Similar to serum = normal
Less than serum = TB/malignancy
Amylase:
Similar to serum = normal
More than serum = pancreatitis
145
What can be seen on ascitic fluid microscopy?
Red cell count:
None = normal
>100 = Malignancy/TB
>10,000 = Haemorrhage/trauma
White cell count:
<250 = Normal/Cirrhosis
>250: If mostly neutrophils, SBP; If mostly lymphocytes, TB
146
What causes a high SAAG?
>11 and suggests the fluid is a transudate
| Suggesting portal HTN - Cirrhosis, hepatic failure, Venous occlusion, alcoholic hepatitis, Kwashiorkor malnutrition
147
What causes a low SAAG?
<11 and suggests it is an exudate
| Causes: Malignancy, Infection, Pancreatitis, Nephrotic syndrome
148
Whats another way of telling whether Ascites is exucdate or transudate?
Measuring LDH
LDH <225 is transudate
LDH >225 is exudate
149
How do you manage Liver Failure?
Resuscitation
Treat cause if possible
Treat complications
Antibiotic and antifungal prophylaxisi
150
How do you treat a paracetamol overdose?
N-acetylcysteine
151
What are complications of Liver failure?
```
Encephalopathy
Infection
Coagulopathy
Hypoglycaemia
Disturbance of electrolyte balance and acid-base balance
Disturbance of CVS system
Hepatorenal syndrome
Cerebral oedema (Raised ICP)
Respiratory failure
```
152
How do you treat Cerebral Oedema?
Decreased the ICP with Mannitol
153
What is a Mallory-Weiss tear?
Tear or laceration along the right border of, or near the gastro-oesophageal junction. Usually as a result of violent vomiting or straining to vomit
Spontaneously stops in 80-90% of patients
154
What causes a Mallory-Weiss tear?
```
Coughing
Retching
Vomiting
Straining
Hiccups
Acute abdominal blunt trauma
Alcohol
Medications
Oesophageal instrumentation
```
155
What are the Risk Factors for a Mallory-weiss tear?
```
Condition predisposing to retching, vomiting and/or straining
Chronic cough
Hiatal hernia
Retching during endoscopy
Significant alcohol use
Previous instrumentation
```
156
What are the symptoms of Mallory-Weiss tear?
```
Abdominal pain
Severe vomiting
Haematemesis
Involuntary retching
Black/tarry stools
Symptoms of hypovolaemia
```
157
What are the signs of Mallory-Weiss tear?
Melaenia
Orthostatic hypotension
Anaemia (Pallor)
158
What investigations are done for Mallory-Weiss tear?
```
FBC (anaemia)
Urea (High)
PT/INR/aPTT (normal)
OGD (tear or laceration)
ECG (Normal)
```
159
What is Non-alcoholic steatohepatitis (NASH)?
Conditions caused by a build-up of fat in the liver due to causes other than excessive alcohol
160
What causes NASH?
Imbalance of fatty acid metabolism, leads to hepatic triglyceride accumulation, dysregulated cytokine production
161
What are the Risk Factors for NASH?
```
Obesity
Insulin resistance or diabetes
Dyslipidaemia
Hypertension
Metabolic syndrome
Rapid weight loss
Hepatotoxic medications
TPN
Diseases associated with fatty liver deposition
```
162
What are the symptoms of NASH?
```
Dull or aching RUQ pain
Fatigue
Unexplained weight loss
Weakness
Testicular atrophy
Melaena
```
163
What are the signs of NASH?
```
RUQ pain/tenderness
Signs of cirrhosis
Hepatosplenomegaly
Truncal obesity
Nail changes
Palmar erythema
Alopecia
Caput medusae
Petechiae
```
164
What investigations are done for NASH?
```
LFTs (Raised GGT)
Fasting lipids (Raised)
Serum albumin (Decreased)
FBC
Viral studies
AI studies (ANA, ASMA may be raised)
Liver US - steatosis
```
165
What is the management for NASH?
Without end-stage liver disease
- Diet and exercise w/ vitamin E (alpha tocopherol) with weight loss
- With diabetes - insulin sensititser
- With dyslipidaemia - add statin
With end-stage liver disease
- Liver transplantation
- Transjugular intrahepatic portosystemic shunt
166
What are the complications of NASH?
```
Ascites
Variceal Haemorrhage
Portosystemic encephalopathy
Hepatocellular carcinoma
Hepatorenal syndrome
Hypatopulmonary syndrome
Death
```
167
What is Oesophageal cancer?
Most are mucosal lesions that originate in the epithelial cells lining the oesophagus
168
What are the 2 main types of Oesophageal cancer?
Adenocarcinoma
| Squamous cell carcinoma
169
What are the causes of adenocarcinoma?
Barret's oesophagus/GORD
High BMI
Male sex
Dietary factors (High fat diets)
170
What are the causes of Squamous cell carcinoma?
Tobacco smoking
Alcohol consumption
HPV
171
What are the Risk Factors for Squamous cell carcinoma?
```
Tobacco use
Alcohol use
FHx
Non-Caucasian
High temperature beverahes and goods
Drinking maté (Special S. American drink)
HPV
Achalasia
Vitamin and Mineral deficiencies
Male sex
Low socioeconomic status
Low intake of fruit and veg
Poor oral hygeine
```
172
What are Risk Factors for Adenocarcinoma?
```
GORD and Barret's oesophagus
Hiatus hernias
Obesity
GTN
Anticholinergics
Beta adrenergisc
Aminophylline
Benzodiazepines
Male sex
Low socioeconomic status
Low intake of fruit and veg
Poor oral hygeine
```
173
What are the symptoms of Oesophageal cancer?
```
Progressive dysphagia (initially worse for solids)
Regurgitation
Cough
Choking after food
Voice hoarseness
Odynophagia
Weight loss
Fatigue
Hiccups
```
174
What are the signs of oesophageal cancer?
No signs other than mets
- Supraclavicular lymphadenopathy
- Hepatomegaly
- Hoarseness
- Signs of bronchopulmonary involvement
175
What are the investigations of Oesophageal cancer?
```
Oesophagogastroduodenoscopy with biopsy
Comprehensive metabolic profile (adv: Hypokalaemia, raised creatinine, serum urea/nitrogen)
CT thorax/abdomen (Size and see it)
Bronchoscopy + FNA
Cardiac stress test
```
176
What is Pancreatic cancer?
Malignancy arising from the exocrine or endocrine tissues of the pancreas
177
What are the Risk Factors for Pancreatic cancer?
```
Smoking
Family history
Other hereditary cancer syndromes
Chronic sporadic pancreatitis
Diabetes mellitus
Obesity
Dietary factors
```
178
What are the symptoms of Pancreatic cancer?
```
Epigastric discomfort or dull backache
Jaundice (obstructive - in tumour of head)
Weight loss
Anorexia
Haematemesis
Melaena
Malaise
Nausea
Diabetes Mellitus
```
179
What are the signs of Pancreatic cancer?
Acute pancreatitis
Epigastric mass
Palpable gallbladder + Jaundice
Hepatomegaly/Splenomegaly/Lymphadenopathy
Trousseau's sign of malignancy (superficial thrombophlebitis)
180
What are the investigations for Pancreatic cancer?
```
Abdominal ultrasound
Pancreatic protocol CT
LFTs
PT time (elevated)
CA 19-9 tumour marker
Biopsy
```
181
What is Acute Pancreatitis?
A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory response
182
What causes acute pancreatitis?
```
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps/HIV/Coxsackie and malignancy
Autoimmune
Scorpion venom
Hypercalcaemia/hyperPTH/Hyperlipidaemia/hypothermia
ERCP and emboli
Drugs
```
Also pregnancy!
183
What drugs cause pancreatitis?
```
TASS!
Thiazides
Azathioprine (Only in those being treated with IBD)
Steroids
Sodium valproate
```
184
What are the Risk Factors for acute pancreatitis?
```
Middle aged women
Young-to-middle aged men
Gallstones
Alcohol
Hypertriglyceridaemias
Use of causative drugs
ERCP
Trauma
SLE
Sjorgen's
Hypercalcaemia
Mumps
Coxsackie
```
185
What are the symptoms of acute pancreatitis?
```
Severe epigastric or central abdomen pain
Radiating to the back
Relieved by sitting forward
Aggravated by movement
Anorexia, nausea and vomiting
Pain decreases over 72 hours
```
186
What are the signs of Pancreatitis?
```
Epigastric tenderness
Fever
Shock
Decreased bowel sounds
Jaundice
if haemorrhage - Cullen's sign, Grey-Turner's sign, Fox's sign, Chvostek's sign
```
187
What is Cullen's and Grey-Turner's sign?
Cullen's : Belly button bruising
| Grey-Turner's: Flank bruising
188
What is Fox's sign?
Ecchymosis over inguinal ligament area
189
What is Chvostek's sign?
Low calcium via saponificaiton
190
What is saponification?
Process by which triglycerides are reacted with sodium or potassium hydroxides
191
What are investigations for acute pancreatitis?
Amylase (>1000)
FBC (Raised Hct, leucocytosis)
Serum calcium (Raised)
ABG (Hypoxaemia and acid base disturbances)
Urea and Creatinine (Elevated in severe cases, U>7.14,C>/=2)
Erect CXR (Pleural effusion or atelectasis)
192
How do you classify Pancreatitis?
Glasgow prognostic score
Can also use Ranson's criteria but dont normally
193
What is Glasgow's prognostic score?
```
Age >55
WBC >15
Urea >16
Glucose >10
pO2 <8
Albumin <32
Calcium <2
LDH >600
AST/ALT >200
```
194
What is Ranson's criteria? (Not often used)
```
Age >55 years
WBC >15
Glucose >10
Serum AST >250
Serum LDH >350
In the first 48 hours:
Haematocrit fall >10%
Urea increase >5
Serum Ca <2
Hypoxaemia O2 <8
Base deficit >4
Estimated fluid sequestration >6
```
195
What indicates a severe pancreatitis?
A score of 3 or more in either Ranson's or Glasgow prognostic score indicates severe pancreatitis
196
How do you manage mild pancreatitis?
```
Analgesia
IV fluids
NBM
NG tube for severe vomiting
ABx for specific infections
```
197
How do you manage severe pancreatitis?
```
Treat in ITU or HDU
Evidence of significant necrosis
NBM
NG tube
Surgery if infectious or necrotic
```
198
What are the complications of pancreatitis?
```
Acute Renal failure
Pancreatic abscess
Abdominal compartment syndrome
Chronic pancreatitis
Enteric fistulas
Sepsis
Acute lung injury/ARDS
Pseudocyst
Pancreatic ascites/pleural effusion
```
199
What is Chronic pancreatitis?
Clinical diagnosis defined by pancreatic inflammation. Characterised by recurrent or persistent abdominal pain and progressive injury to the pancreas and surrounding structures, resulting in scarring and loss of function
200
What Causes chronic pancreatitis?
Alcohol (70%)
Idiopathic (20%)
Ductal obstruction
Hereditary pancreatitis
201
What are Risk Factors for chronic pancreatitis?
```
Alcohol
Smoking
Family history
Coeliac disease
Psoriasis
High-fat, High-protein diet
Tropical geography
```
202
What are the symptoms of chronic pancreatitis?
Recurrent, severe epigastric pain, radiating to the back, relieved by sitting forward
Aggravated by eating or alcohol
Over many years - weight loss, bloating, steatorrhoea
203
What are the signs of Chronic pancreatitis?
Epigastric tenderness
Weight loss, malnutrition
Jaundice
204
What are the investigations of chronic pancreatitis?
```
Blood glucose (High)
Pancreatic function test (Decreased)
IgG4 levels (Raised)
Amylase and lipase normally
Faecal elastase (Reflects exocrine function)
CT scan (Pancreatic calcification and cysts)
```
205
How do you manage chronic pancreatitis?
```
Lifestyle support
Analgesia
Replace pancreatic enzymes
Octreotide
Surgical management - drainage
Pancreatoduodenectomy in chronic and cancer
```
206
What are the complications of chronic pancreatitis?
```
Pancreatic exocrine insufficiency
Diabetes mellitus
Pancreatic calcification
Pancreatic duct obstruction
Low-trauma fracture
Biliary obstruction
Gastroduodenal obstruction
Pancreatic cancer
Opioid addiction
Pancreatic pseudocyst
Ascites
fistula
Gastrointestinal bleeding
```
