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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

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2
Q

What causes Large bowel perforations?

A 
Diverticulitis
Colorectal cancer
Appendicitis
Volvulus
UC (Toxic megacolon)
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3
Q

What causes Gastroduodenal perforations?

A

Perforated duodenal or Gastric ulcer

Gastric cancer

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4
Q

What causes Small bowel perforations?

A

Just to note they are rare!
Trauma
Infections (Ileo-coecal TB)
Crohn’s disease

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5
Q

What is Oesophageal perforation called?

A

Boerhaave’s perforation

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6
Q

What is Boerhaave’s perforation?

A

Rupture of the oesophagus following forceful vomiting

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7
Q

What are risk factors for GI perforation?

A 
Risk factors for cause!
E.g. Low Residue diet
Steroids
NSAIDs
Bisphosphonates
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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

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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)

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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!

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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
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12
Q

How do you manage perforations generally?

A

Correct fluid and electrolyte balance

IV ABX - efuroxime and metronidazole

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13
Q

How do you manage large bowel perforations?

A

Identify site
Peritoneal lavage
Resect perforated section

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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
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15
Q

How do you manage oesopageal perforations?

A

Pleural lavage

Repair of rupture oesophagus

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16
Q

What are the comlications of bowel perforations?

A

Large and Small bowel - Peritonitis
Oesophagus - Mediastinitis
Overall: Shock, sepsis, death

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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

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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

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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

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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

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21
Q

What is a Mucosal rosette?

A

Redundant mucosal folds causing a weakened anti-reflux valve

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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
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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
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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

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25
Q

What are the signs of GORD?

A

Usually normal
Occasionally - epigastric tenderness, wheeze on auscultation, dysphonia
Bloating

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26
Q

What are investigations for GORD?

A

Clinical diagnosis!
If suspected, PPI trial
If GORD persists - OGD and biopsy
Other tests: 24hr pH monitoring, manometry, Barium swallow

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27
Q

How do you manage GORD?

A 
Advice
Medicines
Endoscopy
Surgery 
Nissen fundoplication
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28
Q

What Advice do you give to someone with GORD?

A 
Weight loss
Elevating head of bed
Avoid provoking factors
Stop smoking 
Lower fat meals
Avoid large meals late in the evening
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29
Q

What medicines do you give to someone with GORD?

A

Antacids
Alginates
H2 antagonists (e.g. Ranitidine)
PPI (e.g. Omeprazole ,Lansoprazole)

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30
Q

What is Nissen fundoplication?

A

Fundus of the stomach is wrapped around the lower oesophagus - reduces risk of hiatus hernia and reduce reflex

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31
Q

What are the complications for GORD?

A

Oesophageal ulcer, haemorrhage or perforation
Oesophageal stricture
Barret’s oesophagus
Adenocarcinoma of the oesophagus

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32
Q

What are Haemorrhoids?

A

Disrupted and dilated anal cushions. Lined by discontinuous masses of spongy vascular tissue

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33
Q

What are the classifications of Haemorrhoids?

A

Internal
(Arise from the superior haemorrhoidal plexus - above the dentate line)
External (Below the dentate line)

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34
Q

What are the degrees of Haemorrhoids?

A

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

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35
Q

What causes Haemorrhoids?

A

Increased intra-abdominal pressure

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36
Q

What are the Risk Factors for haemorrhoids?

A 
Age 45-65
Constipation
Pregnancy or SOL
Hepatic insufficiency
Ascites
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37
Q

What are symptoms of Haemorrhoids?

A 
May be asymptomatic
Bright red rectal bleeding
Anal itching
Intense pain if strangulated
Lack of FLAWS!
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38
Q

What is FLAWS?

A 
F - Fever
L - Lethargy
A - Appetite change
W - Weight loss
S - Night Sweats
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39
Q

What are signs of Haemorrhoids?

A

1st/2nd degree not visible
Internal haemorrhoids not palpable unless thrombosed
Visible on proctoscopy

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40
Q

What are differentials for Haemorrhoids?

A 
Anal tags
Anal fissures
Rectal prolapse
Polyps
Tumours
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41
Q

What are the complications of Haemorrhoids?

A 
Anaemia from continuous/excessive bleeding
Thrombosis
Incarceration
Faecal incontinence
Pelvic sepsis
Anal stenosis
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42
Q

What is Haemochromatosis?

A

An autosomal recessive disease in which increased intestinal absorption of iron causes accumulation of iron in tissues, which may lead to iron damage

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43
Q

What causes Haemochromatosis?

A

AR condition
Caused by defect in HFE gene
Not everyone who is homozygous develop the disease

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44
Q

What are the risk factors for Haemochromatosis?

A 
Middle aged
Male
White ethnicity
Family history 
Iron supplements
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45
Q

What are symptoms of Haemochromatosis?

A 
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
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46
Q

What investigations can be done for Haemochromatosis?

A

Haematinics - Serum ferritin (High), Transferrin (Low), Transferrin saturation (high), TIBC (Low)
CRP - Low
LFT - raised

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47
Q

What is Hepatocellular carcinoma?

A

Primary malignancy of the liver Parenchyma

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48
Q

What is associated with Hepatocellular carcinoma?

A

Chronic liver damage (Hep B/C, AI disease)
Metabolic disease (Haematochromatosis)
Aflatoxins (Aspergillus flavus)

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49
Q

What are the symptoms of hepatocellular carcinoma?

A

Symptoms of malignancy (Malaise, weight loss, loss of appetitie)
Symptoms of chronic liver diseae (Ascites, Jaundice)

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50
Q

What are the signs of Hepatocellular carcinome?

A

Signs of malignancy - Cachexia, Lymphadenopathy
Hepatomegaly
Jaundice
Ascites

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51
Q

What are the investigations for Hepatocellular carcinoma?

A 
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
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52
Q

What is a Hernia?

A

Protrusion of a viscus or part of a viscus through a defect of the wall of its containing cavity into abnormal position

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53
Q

What are the 2 main types of Hernia?

A

Femoral and Inguinal

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54
Q

What is the most common type of Hernia?

A

Inguinal

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55
Q

Where are hernias found?

A

Inguinal -Superomedial to the tubercle

Femoral - Inferolateral to teh tubercle

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56
Q

If a Hernia is irreducible what does that mean?

A

Cannot be pushed back into the right place

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57
Q

What does it mean if a Hernia is incarcerated?

A

Contents of the hernia are stuck inside by adhesions

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58
Q

When is a Hernia strangulated?

A

When they become ischaemia

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59
Q

What is an Inguinal Hernia?

A

Abnormal protrusion of the peritoneal sac through a weakness of the abdominal wall

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60
Q

What are the 2 types of inguinal hernia?

A

Direct and Indirect

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61
Q

What is a Direct inguinal hernia?

A

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

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62
Q

What is Hesselbach’s triangle?

A

Border of Rectus Abdominis, INferior epigastric vessels and the inguinal ligament

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63
Q

What is an indirect inguinal hernia?

A

Protrusion of the hernia through the deep inguinal ring, following the inguinal canal

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64
Q

Who are inguinal hernias more common in?

A

Men

55-85

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65
Q

Who are femoral hernias more common in?

A

Women
Increasing age
Pregnancy (more pregnancies)
Increased intra-abdominal pressure

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66
Q

What is a Femoral Hernia?

A

Abdominal contents pass through a naturally occurring weakness call the femoral canal and present as a mass in the upper medial thigh

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67
Q

What are the Risk Factors for inguinal hernias?

A 
Male sex
Old age
Smoking
Family history
Prematurity
AAA
Marfans
Lathyrism
Chronic bronchitis/emphysema
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68
Q

What are the risk factors for femoral hernias?

A

Female
Increasing age
Pregnancy
Increased intra-abdominal pressure

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69
Q

What symptoms are there of inguinal hernias?

A 
Often asymptomatic
Notices lump in groin
May be painful
May be irreducible
May present due to growth
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70
Q

What signs are there of Inguinal hernias?

A

Groin lump that extends to scrotum/labia
Check cough impulse
Tender if strangulated

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71
Q

How can you tell between direct and indirect on examination?

A

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

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72
Q

What are the symptoms of femoral hernias?

A

Lump in groin
Usually asymptomatic
30% present as an emergency due to obstruction or strangulation

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73
Q

What are the signs of femoral hernia on examination?

A

Look for B/L lumps
Ask to reduce and ask to cough
If no lump visible assess cough reflex
Repeat exam with patient standing

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74
Q

What investigations are done for all Hernias?

A

Only done if acute with painful irreducible hernia!
FBC
CRP
ABG - show lactic acidosis from bowel ischaemia
Erect CXR - check for perforation

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75
Q

What is the management of Inguinal hernias?

A

Surgical - only if symptomatic
Laparoscpic mesh repair
Emergency - if obstructed or strangulated - need laparotomy with bowel resection if gangrenous

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76
Q

What is the management for Femoral Hernias?

A

Surgical repair

  • Herniotomy (Ligation and excision of the sac)
  • Herniorrhaphy (Repair of hernial defect)
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77
Q

What are complications of Inguinal hernias?

A 
Incarceration 
Strangulation
Maydl's hernia
Richter's hernia
Surgery complications
Haematoma
Penile/scrotal oedema
Mesh infection
Testicular ischaemia
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78
Q

What are complications of Femoral hernias?

A

High risk of strangulation !
Risk of becoming irreducible or obstructed
Wound infection

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79
Q

What is a Maydl’s hernia?

A

Strangulated w-shaped loop of S.Bowel

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80
Q

What is a Richter’s hernia?

A

Strangulation of part of the bowel circumference

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81
Q

What is a Hiatus Hernia?

A

Herniation of part of the abdominal viscera through the Oesophageal aperture of the diaphragm

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82
Q

What causes a Hiatus Hernia?

A

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

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83
Q

Risk Factors for hiatus hernia?

A 
Obesity
Elevated intra-abdominal pressure
Male sex
Structural abnormalities 
Incisional, umbilical or inguinal hernia
Ascites
advaced age
84
Q

What are symptoms of a Hiatus Hernia?

A 
Many asymptomatic
Retrosternal burning sensation, especiallly on bending or laying down
Flatulence 
GORD
Rarely, diffuclty swallowing
85
Q

What are signs of a Hiatus Hernia?

A

Usually no signs

Uncommonly bowel sounds in the chest

86
Q

What investigation are done for a Hiatus Hernia?

A

FBC (Iron deficiency anaemia)
CXR (First line)- air bubble above diaphragm
Barium swallow
Endoscopy

87
Q

How do you manage an acute Hiatus hernia?

A

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
Q

How do you manage an ongoing hiatus hernia?

A

Type I refractory or types II, III and IV: surgical repair with or without anti-reflux procedure

89
Q

What are the complications of Hiatus Hernia?

A 
Bloating 
Volvulus
Obstruction 
Diarrhoea following surgery
Fundal necrosis
90
Q

What is intestinal obstruction?

A

Obstruction of normal bowel contents - Mechanical blockage of the bowel due to structural pathology

91
Q

What are the classifications of intestinal obstruction?

A

Small or Large Bowel
Partial or complete obstruction
Simple or strangulated

92
Q

What are the causes of Large Bowel obstruction?

A

90% by underlying
5% by colonic volvulus
3% benign strictures
2% rarer conditions

93
Q

What are the causes of small bowel obstruction?

A

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
Q

What are Risk factors for Large Bowel obstruction?

A 
Older age 
Female gender 
Institutionalisation
Mental illness
Megacolon
Low or High dietary fibre
Previous colorectal resection
Previous abdominal surgery
IBD
Laxative abuse
Diabetes
95
Q

What are the Risk Factors for Small Bowel obstruction?

A 
Previous abdominal surgery
Malrotation
Crohn's disease
Hernia
Appendicitis
Intestinal malignancy
Intussussception
Volvulus
Intestinal atresia
Foreign body ingestion
96
Q

What are the symptoms for Bowel obstruction?

A

Severe, colicky pain with periods of ease
Abdominal distention
Frequent vomiting (Bile-stained or Faeculent)
Absolute constipaiton
Anorexia

97
Q

What is Absolute constipation?

A

No Flatulence or defecation

98
Q

What are signs of bowel obstruction?

A 
Abdominal distention
May see visible peristalsis
Tinkling bowel sounds
Peritonitis
Inspect for hernias
Look for abdominal scars
Inspect for abdominal mass
99
Q

What investigations are done for obstruction?

A 
AXR
- LBO: Peripheral, Haustra
- SBO: Central, Valvulae coniventae
Erect CXR - Look for perforation
CT-scan - more sensitive
Amylase - elevated 
FBC - Leucocytosis
U&amp;Es - hyponatraemia, hypokalaemia, alkalosis
Group&amp; Save for surgery
100
Q

How do you manage Bowel obstruction?

A 
Fluid resuscitation
Electrolyte replacement
Intestinal decompression
NBM
Bowel rest
Surgery if complicated: Laparotomy with a clear diagnosis
101
Q

In a patient with bowel obstruction what indicates an early surgery?

A

Local or generalised peritonitis
Palpable mass
Failure to improve
Risk of perforation of ischaemic bowel

102
Q

What are non-surgical treatments for bowel obstruction?

A

Endoscopic stenting further advance in managing bowel obstructions
If thought to be due to adhesions, conservative measures may be sufficient

103
Q

What are the complications of Bowel obstruction?

A 
Intestinal necrosis
Sepsis
Multi-organ failure
Intra-abdominal abscess
Short bowel syndrome
Intestinal perforation
104
Q

What is intestinal Ischaemia?

A

Obstruction of mesenteric vessel leading to Bowel ischaemia and necrosis
Note: AF with abdominal pain should point towards mesenteric ischaemia

105
Q

What are the 3 main types of intestinal ischaemia?

A

Acute mesenteric ischaemia (AMI)
Chronic mesenteric ischaemia aka intestinal angina (CMI)
Chronic colonic ischaemia aka ischaemic colitis (CCI)

106
Q

What are the causes of Acute mesenteric ischaemia?

A

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
Q

What are the causes of Chronic mesenteric ischaemia?

A

Usually due to a flow state with atheroma, likely to have a history of vascular disease

108
Q

What are the causes of Chronic colonic ischaemia?

A

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
Q

What is a watershed area?

A

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
Q

What are Risk Factors for Intestinal ischaemia?

A

Atrial fibrillation
Endocarditis
Arterial thrombosis: Hypercholesterolaemia, hypertension, DM, smoking
Venous thrombosis: Portal HTN, Splenectomy, Septic thrombophlebitis, OCP, thrombophilia

111
Q

What are the symptoms of Intestinal Ischaemia?

A

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
Q

What are the signs of Intestinal ischaemia?

A 
Fever and Tachycrdia
Diffuse abdominal tenderness
Tender palpable mass 
Bowel sounds may be absent
Disproportionate degree of CVS collapse
Upper abdominal bruit
113
Q

What investigations can be done for Intestinal ischaemia?

A

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
Q

What is Irritable bowel syndrome?

A

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
Q

What are Risk Factors for Irritable bowel syndrome?

A 
Physical and sexual abuse
Age <50 years
Female sex
Previous enteric infection
Family and Job stress
116
Q

What are the symptoms of IBS?

A

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
Q

What is Tenesmus?

A

Continuous or persistent feeling of needing to evacuate the bowels

118
Q

What are signs of IBS?

119
Q

What investigations are done for IBS?

A 
FBC (Normal)
CRP (=0.5)
Anti-TTG antibodies (negative)
Anti-endomysial antibodies (negative)
All studies are normal
120
Q

How do you manage IBS?

A

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
Q

What are the complications of IBS?

A

Damage to family and work relationships

Diverticulosis

122
Q

What is a Liver abscess?

A

Liver infection resulting in a walled off collection of pus

123
Q

What organisms cause a Liver abscess?

A 
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
Q

What are the Risk factors for Liver abscesses/cysts?

A 
Biliary tract diseae/intervention
Age > 50 years
Malignancy
Diabetes Mellitus
Endemic amoebiasis areas
125
Q

What are the symptoms of Liver abscesses/cysts?

A 
Fever
Malaise
Nausea
Anorexia
Night sweats
Weight loss
RUQ/Epigastric pain 
Jaundice
Diarrhoea
Pyrexia 
May see Reactive pleural effusion in R lower lobe
126
Q

What are the signs for Liver abscesses/cysts?

A 
Fever 
Jaundice
Tender hepatomegaly
Right lung base
- Dull to percussion
- Reduced  breath sounds
- Due to reactive pleural effusion
127
Q

What investigations are done for liver abscesses/cysts?

A

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
Q

What are Liver Cysts?

A

Liver infection resulting in a walled off collection of cystic fluid

129
Q

What Causes liver cysts that dont cause liver abscesses?

A

Hydatid cysts caused by Echinococcus granulosis

130
Q

Who are Hydatic cysts common in?

A

Sheep-rearing countries

131
Q

What is liver Failure?

A

Severe liver dysfunction leading to Jaundice, encephalopathy and coagulopathy
Can occur suddenly (Acute) but usually a result of decompensation of chronic liver disease

132
Q

What causes liver failure?

A 
Toxins
Infections
Neoplasms (hepatocellular carcinoma)
Metabolic causes (Wilson's, alpha-1 antitrypsin)
Pregnancy-related
Vascular
Other
133
Q

What is Reye’s syndrome?

A

Rare syndrome causing swelling in the liver and brain

134
Q

How do you classify liver failure?

A

Time between onset of Jaundice and Hepatic encephalopathy

  • Hyperacute <7 days
  • Acute 1-4 weeks
  • Subacute 4-12 weeks
135
Q

What toxins cause liver failure?

A 
Alcohol
Paracetamol
Drugs
Poisoning
Herbal preparations
Illicit drugs
Reye's syndrome
136
Q

Which drugs are hepatotoxic?

A 
Paracetamol
Co-amoxiclav
Methotrexate
Statins
Nitrofurantoin
Halothane
Erythromycin
Ciprofloxacin
Doxycycline
137
Q

What are the Risk factors of liver failure?

A 
Chronic alcohol abuse
Poor nutritional status
Age >40 years
Chronic paracetamol use
Pregnancy
HIV and Hepatitis C co-infection
Medicines that are hepatotoxic
138
Q

What are the symptoms of Liver failure?

A 
May be asymptomatic
Fever
Nausea
Jaundice (not always)
Abdominal pain
Malaise
139
Q

What are the signs of Liver failure?

A 
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
Q

What is Fetor Hepaticus?

A

Breath smells of pear drops

141
Q

What investigations are done for Liver failure?

A 
Viral serology
Paracetamol levels
Autoantibodies
Ferritin
Ceruloplasmin and Urinary Copper
U&amp;Es (Hepatorenal syndrome)
LFT (Raised)
Glucose (Raised)
Ascitic tap
142
Q

What can be seen on ascitic tap?

A

Colour
Biochemistry
Microscopy
SAAG (Serum ascitic albumin gradient)

143
Q

What are the different colours seen on ascitic tap?

A

Clear/straw - Cirrhosis
Cloudy - SBP, Perforated bowel, Pancreatitis
Bloody - Malignancy, Haeomrrhagic pancreatitis
Chylous (Milky) - Lymphoma, TB, Malignancy

144
Q

What different biochemistries are seen on ascitic tap?

A

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
Q

What can be seen on ascitic fluid microscopy?

A

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
Q

What causes a high SAAG?

A

> 11 and suggests the fluid is a transudate

Suggesting portal HTN - Cirrhosis, hepatic failure, Venous occlusion, alcoholic hepatitis, Kwashiorkor malnutrition

147
Q

What causes a low SAAG?

A

<11 and suggests it is an exudate

Causes: Malignancy, Infection, Pancreatitis, Nephrotic syndrome

148
Q

Whats another way of telling whether Ascites is exucdate or transudate?

A

Measuring LDH

LDH <225 is transudate
LDH >225 is exudate

149
Q

How do you manage Liver Failure?

A

Resuscitation
Treat cause if possible
Treat complications
Antibiotic and antifungal prophylaxisi

150
Q

How do you treat a paracetamol overdose?

A

N-acetylcysteine

151
Q

What are complications of Liver failure?

A 
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
Q

How do you treat Cerebral Oedema?

A

Decreased the ICP with Mannitol

153
Q

What is a Mallory-Weiss tear?

A

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
Q

What causes a Mallory-Weiss tear?

A 
Coughing
Retching
Vomiting
Straining
Hiccups
Acute abdominal blunt trauma
Alcohol
Medications
Oesophageal instrumentation
155
Q

What are the Risk Factors for a Mallory-weiss tear?

A 
Condition predisposing to retching, vomiting and/or straining
Chronic cough
Hiatal hernia
Retching during endoscopy
Significant alcohol use
Previous instrumentation
156
Q

What are the symptoms of Mallory-Weiss tear?

A 
Abdominal pain
Severe vomiting
Haematemesis
Involuntary retching
Black/tarry stools
Symptoms of hypovolaemia
157
Q

What are the signs of Mallory-Weiss tear?

A

Melaenia
Orthostatic hypotension
Anaemia (Pallor)

158
Q

What investigations are done for Mallory-Weiss tear?

A 
FBC (anaemia)
Urea (High)
PT/INR/aPTT (normal)
OGD (tear or laceration)
ECG (Normal)
159
Q

What is Non-alcoholic steatohepatitis (NASH)?

A

Conditions caused by a build-up of fat in the liver due to causes other than excessive alcohol

160
Q

What causes NASH?

A

Imbalance of fatty acid metabolism, leads to hepatic triglyceride accumulation, dysregulated cytokine production

161
Q

What are the Risk Factors for NASH?

A 
Obesity
Insulin resistance or diabetes
Dyslipidaemia
Hypertension
Metabolic syndrome
Rapid weight loss
Hepatotoxic medications
TPN
Diseases associated with fatty liver deposition
162
Q

What are the symptoms of NASH?

A 
Dull or aching RUQ pain
Fatigue
Unexplained weight loss
Weakness
Testicular atrophy
Melaena
163
Q

What are the signs of NASH?

A 
RUQ pain/tenderness
Signs of cirrhosis
Hepatosplenomegaly
Truncal obesity
Nail changes
Palmar erythema
Alopecia
Caput medusae
Petechiae
164
Q

What investigations are done for NASH?

A 
LFTs (Raised GGT)
Fasting lipids (Raised)
Serum albumin (Decreased)
FBC
Viral studies
AI studies (ANA, ASMA may be raised)
Liver US - steatosis
165
Q

What is the management for NASH?

A

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
Q

What are the complications of NASH?

A 
Ascites
Variceal Haemorrhage
Portosystemic encephalopathy
Hepatocellular carcinoma
Hepatorenal syndrome
Hypatopulmonary syndrome
Death
167
Q

What is Oesophageal cancer?

A

Most are mucosal lesions that originate in the epithelial cells lining the oesophagus

168
Q

What are the 2 main types of Oesophageal cancer?

A

Adenocarcinoma

Squamous cell carcinoma

169
Q

What are the causes of adenocarcinoma?

A

Barret’s oesophagus/GORD
High BMI
Male sex
Dietary factors (High fat diets)

170
Q

What are the causes of Squamous cell carcinoma?

A

Tobacco smoking
Alcohol consumption
HPV

171
Q

What are the Risk Factors for Squamous cell carcinoma?

A 
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
Q

What are Risk Factors for Adenocarcinoma?

A 
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
Q

What are the symptoms of Oesophageal cancer?

A 
Progressive dysphagia (initially worse for solids)
Regurgitation
Cough
Choking after food
Voice hoarseness
Odynophagia
Weight loss
Fatigue
Hiccups
174
Q

What are the signs of oesophageal cancer?

A

No signs other than mets

  • Supraclavicular lymphadenopathy
  • Hepatomegaly
  • Hoarseness
  • Signs of bronchopulmonary involvement
175
Q

What are the investigations of Oesophageal cancer?

A 
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
Q

What is Pancreatic cancer?

A

Malignancy arising from the exocrine or endocrine tissues of the pancreas

177
Q

What are the Risk Factors for Pancreatic cancer?

A 
Smoking
Family history
Other hereditary cancer syndromes
Chronic sporadic pancreatitis
Diabetes mellitus
Obesity
Dietary factors
178
Q

What are the symptoms of Pancreatic cancer?

A 
Epigastric discomfort or dull backache
Jaundice (obstructive - in tumour of head)
Weight loss
Anorexia
Haematemesis
Melaena
Malaise
Nausea
Diabetes Mellitus
179
Q

What are the signs of Pancreatic cancer?

A

Acute pancreatitis
Epigastric mass
Palpable gallbladder + Jaundice
Hepatomegaly/Splenomegaly/Lymphadenopathy
Trousseau’s sign of malignancy (superficial thrombophlebitis)

180
Q

What are the investigations for Pancreatic cancer?

A 
Abdominal ultrasound
Pancreatic protocol CT
LFTs
PT time (elevated)
CA 19-9 tumour marker
Biopsy
181
Q

What is Acute Pancreatitis?

A

A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory response

182
Q

What causes acute pancreatitis?

A 
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
Q

What drugs cause pancreatitis?

A 
TASS!
Thiazides
Azathioprine (Only in those being treated with IBD)
Steroids
Sodium valproate
184
Q

What are the Risk Factors for acute pancreatitis?

A 
Middle aged women
Young-to-middle aged men
Gallstones
Alcohol
Hypertriglyceridaemias
Use of causative drugs
ERCP
Trauma
SLE
Sjorgen's 
Hypercalcaemia
Mumps
Coxsackie
185
Q

What are the symptoms of acute pancreatitis?

A 
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
Q

What are the signs of Pancreatitis?

A 
Epigastric tenderness
Fever
Shock
Decreased bowel sounds
Jaundice
if haemorrhage - Cullen's sign, Grey-Turner's sign, Fox's sign, Chvostek's sign
187
Q

What is Cullen’s and Grey-Turner’s sign?

A

Cullen’s : Belly button bruising

Grey-Turner’s: Flank bruising

188
Q

What is Fox’s sign?

A

Ecchymosis over inguinal ligament area

189
Q

What is Chvostek’s sign?

A

Low calcium via saponificaiton

190
Q

What is saponification?

A

Process by which triglycerides are reacted with sodium or potassium hydroxides

191
Q

What are investigations for acute pancreatitis?

A

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
Q

How do you classify Pancreatitis?

A

Glasgow prognostic score

Can also use Ranson’s criteria but dont normally

193
Q

What is Glasgow’s prognostic score?

A 
Age >55
WBC >15
Urea >16
Glucose >10
pO2 <8
Albumin <32
Calcium <2
LDH >600
AST/ALT >200
194
Q

What is Ranson’s criteria? (Not often used)

A 
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
Q

What indicates a severe pancreatitis?

A

A score of 3 or more in either Ranson’s or Glasgow prognostic score indicates severe pancreatitis

196
Q

How do you manage mild pancreatitis?

A 
Analgesia
IV fluids
NBM
NG tube for severe vomiting
ABx for specific infections
197
Q

How do you manage severe pancreatitis?

A 
Treat in ITU or HDU
Evidence of significant necrosis
NBM
NG tube
Surgery if infectious or necrotic
198
Q

What are the complications of pancreatitis?

A 
Acute Renal failure
Pancreatic abscess
Abdominal compartment syndrome
Chronic pancreatitis
Enteric fistulas
Sepsis
Acute lung injury/ARDS
Pseudocyst
Pancreatic ascites/pleural effusion
199
Q

What is Chronic pancreatitis?

A

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
Q

What Causes chronic pancreatitis?

A

Alcohol (70%)
Idiopathic (20%)
Ductal obstruction
Hereditary pancreatitis

201
Q

What are Risk Factors for chronic pancreatitis?

A 
Alcohol
Smoking
Family history
Coeliac disease
Psoriasis
High-fat, High-protein diet
Tropical geography
202
Q

What are the symptoms of chronic pancreatitis?

A

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
Q

What are the signs of Chronic pancreatitis?

A

Epigastric tenderness
Weight loss, malnutrition
Jaundice

204
Q

What are the investigations of chronic pancreatitis?

A 
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
Q

How do you manage chronic pancreatitis?

A 
Lifestyle support
Analgesia
Replace pancreatic enzymes
Octreotide
Surgical management - drainage
Pancreatoduodenectomy in chronic and cancer
206
Q

What are the complications of chronic pancreatitis?

A 
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

Conditions (18 decks)

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