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Gastrointestinal Examination Flashcards

1
Q

What is xerostomia?

A

Dry mouth

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2
Q

What is halitosis?

A

Bad breath due to gingivitis, dental or pharyngeal infection

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3
Q

What is dysgeusia?

A

Altered taste sensation

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4
Q

What is cacageusia?

A

Foul taste sensation eg. rotting food

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5
Q

What is haematochezia?

A

Rectal bleeding

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6
Q

Causes of a painful mouth

A

Idiopathic- recurrent aphthous ulcers
Infections- candidiasis, dental sepsis, herpes simplex virus
Trauma
Systemic disorder
Skin disorder- pemphigoid, lichen planus, pemphigus vulgaris, erythema multiforme

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7
Q

Dyspepsia that is worse on an empty stomach and relieved by eating is likely to be

A

Peptic/ duodenal ulceration

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8
Q

Likely causes of odynophagia

A

Oesophagitis or candidiasis

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9
Q

Severe abdominal pain sudden onset that rapidly becomes progressively generalised and constant is likely…

A

Hollow viscus perforation, ruptured AAA or mesenteric infarction

Clues may be in the previous history- constipation from colorectal cancer or diverticular disease, dyspepsia

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10
Q

Severe abdominal pain sudden onset radiating to the back

A

Ruptured or dissecting abdominal aortic aneurysm

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11
Q

Angor animi

A

The feeling of impending death

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12
Q

Achalasia

A

Lower oesophageal sphincter fails to relax normally- dysphagia with both solids and liquids

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13
Q

Neuromuscular causes of dysphagia

A

Achalasia, pharyngeal pouch, myasthenia gravis, oesophageal dysmotility

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14
Q

Oral causes of dysphagia

A

Tonsillitis, glandular fever, peritonsillar abscess, painful mouth ulcers, pharyngitis

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15
Q

Symptom checklist in dysphagia

A 
Painful or painless?
Intermittent or progressive?
Length of history and onset?
Solid or liquid or both?
Previous Hx of dysphagia or heartburn?
Where does food stick?
Complete obstruction with regurgitation?
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16
Q

Gastric outlet obstruction causes what type of vomiting?

A

Projectile non-bilious vomiting

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17
Q

Neurological causes of vomiting

A 
Raised ICP- SOL, meningitis
Labyrinthitis 
Meniere's disease 
Migraine
Vasovagal syncope, shock, fear and severe pain
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18
Q

Causes of ascites

A

Common- hepatic cirrhosis with portal hypertension, intra-abdominal malignancy with peritoneal spread
Uncommon- hepatic vein occlusion (Budd-Chiari syndrome), constrictive pericarditis and other right sided heart failure, hypoproteinaemia (nephrotic syndrome), tuberculosis peritonitis, pancreatitis

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19
Q

Causes of bloody diarrhoea

A

IBD, colonic ischaemia or infective gastroenteritis

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20
Q

What is Mallory- Weiss syndrome?

A

Forceful retching and vomiting ruptures oesophageal mucosa causing the vomiting of fresh blood

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21
Q

Coffee ground vomit

A

Blood that has been degraded by gastric pepsin is vomited

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22
Q

Causes of melaena

A

Upper GI bleeding that is then passed through the system- excessive alcohol ingestion causing erosive gastritis, Mallory-Weiss tear, bleeding oesophageal varices, peptic ulceration

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23
Q

Causes of rectal bleeding

A 
Haemorrhoids
Anal fissure
Colorectal polyps/ cancer
IBD
Ischaemic colitis
Complicated diverticulitis disease
Vascular malformation
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24
Q

Causes of angular stomatitis

A

Denture problems, candidiasis, iron deficiency or B12 deficiency

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25
ALARMS symptoms
``` Anaemia Loss of weight Anorexia Recent progression or onset of symptoms Melaena/ haematemesis Swallowing difficulty ```
26
Differentials for dyspepsia
``` Non-ulcer dyspepsia Duodenal/ gastric ulcer Duodenitis Oesophagitis/ GORD Gastric malignancy Gastritis ```
27
When should upper GI endoscopy be done in dyspepsia cases?
Dysphagia >55 ALARMS symptoms
28
Treatment for H. pylori
PPI | 2 antibiotics eg. Clarithromycin and amoxicillin
29
Treatment of GORD
Conservative- lifestyle, smoking cessation, weight loss, small regular meals, avoidance of causative food and drink, raise the bed head, avoid eating 3 hours before bed Medical- antacids, PPI, H2 receptor antagonist, avoid drugs that can affect oesophageal motility or that damage mucosa Surgical- laparoscopic Nissen fundoplication to increase resting LOS pressure
30
Symptoms of GORD
Retrosternal burning Discomfort after eating, straining, lying Belching Acid regurgitation Odynophagia from oesophagitis or ulceration Extra-oesophageal such as nocturnal cough
31
Acute management of an upper GI bleed
A-E assessment Senior involvement High flow oxygen and protection of the airway Insert 2 large bore cannulae Bloods- FBC, U&Es, LFT, clotting and crossmatch IV fluids whilst waiting for crossmatched blood Catheter insertion and monitor hourly fluids CXR, ECG, ABG Transfuse if significant Hb drop (<70) Correct clotting abnormality If suspicion of varices then give terlipressin Broad spectrum abx cover Monitor obs hourly until stable URGENT ENDOSCOPY (clips, cautery, adrenaline) If endoscopic control fails then surgery or emergency mesenteric embolisation may be needed If uncontrollable oesophageal variceal bleeding then Sengstaken-Blakemore tube may compress varicies
32
Risk score used for upper GI bleeds
Rockall score | Predicts risk of rebleeding and death
33
Causes of portal hypertension (leading to gastro-oesophageal varices)
Pre-hepatic- thrombosis Intra-hepatic- cirrhosis (80% in UK), schistosomiasis (commonest worldwide), sarcoid, myeloproliferative diseases Post-hepatic- budd-chiari syndrome, right heart failure, constrictive pericarditis
34
Management of gastro-oesophageal varices
Endoscopic banding or sclerotherapy Non-selective beta blockade TIPS for resistant varices
35
Causes of bloody diarrhoea
Campylobacter, Shigella, Salmonella, E. coli, amoebiasis UC, Crohn's, colorectal cancer, colonic polyps Colitis (ischaemic)
36
Treatment of C. difficile in mild and severe cases
Mild- metronidazole | Severe- vancomycin
37
Proctalgia fugax
Temporary pain around the anal area of unknown origin | Usually intense muscle spasm- similar to levator ani syndrome
38
Endocrine causes of constipation
Hypercalcaemia | Hypothyroidism
39
Description of UC pathology
Continuous inflammation limited to the mucosa and distal to the ileocaecal valve Haemorrhagic colonic mucosa +/- pseudopolyps formed by inflammation
40
What kind of UC flare? 5 motions/per day, some rectal bleeding 70-90BPM
Moderate
41
Complications of UC
Acute- toxic megacolon with risk of perforation VTE, hypokalaemia Chronic- colonic cancer, risk related to disease activity and extent- surveillance colonoscopy important
42
Treatment of UC Mild Moderate Severe
Mild- 5-ASA PR eg mesalazine for distal disease or PO if more extensive. Steroids may be used in addition Moderate- 4-6 motions per day but otherwise well(ish) oral prednisolone to induce remission, maintain on 5-ASA Severe- admission, IV hydration, eletrolyte replacement, IV steroids- hydrocortisone 100mg, VTE prophylaxis, stool MC&S to exclude infection
43
Description of Crohn's disease pathology
Chronic inflammatory condition characterised by transmural granulomatous inflammation affecting any part of the gut. Skip lesions Rose thorn ulceration
44
Clinical features of Crohn's disease
``` 20-40 years old classically Diarrhoea Generally unwell- fever, malaise, fatigue, anorexia Failure to thrive Weight loss Abdominal pain ``` Signs: adbo tenderness/ mass, perianal abscess, fistulae, skin tags, anal strictures, clubbing, skin and joint involvement, anterior uveitis/ iritis/
45
Crohn's disease treatment
SMOKING CESSATION mild-moderate- Prednisolone 40mg and then taper off, dietary advice Severe- Admission for IV hydration/ electrolyte replacement, IV steroids- hydrocortisone or methylpred, VTE prophylaxis, MC&S to exclude infection Daily FBC, ESR, CRP, U&E and AXR, blood transfusions and nutritional support if necessary If improving switch to oral pred, consider biologic use Peri-anal disease: TNF-alpha, other immunosuppressants, oral antibiotics, local surgery and seton insertion
46
Biologic therapies that can be used in Crohn's disease
Azathioprine Methotrexate TNF-alpha- infliximab, adalimumab Other monoclonal antibodies
47
Genetic associations with coeliac disease
HLA DQ2 is 95% HLA DQ8 are the rest Autoimmune disease Dermatitis herpetiformis
48
Presentation of coeliac disease
Any age but peaks in childhood and 50-60 Steatorrhoea, diarrhoea, abdo pain, bloating, nausea and vomiting, aphthous ulcers, angular stomatitis, weight loss, fatigue, osteomalacia, failure to thrive
49
Antibody in coeliac disease and further test to confirm
``` Anti-tissue transglutaminase and total IgA check to exclude subclass deficiency Duodenal biopsy to confirm (whilst on a gluten containing diet) ```
50
Mucosal changes in coeliac disease
Villus atrophy Crypt hyperplasia Intra-epithelial WBC's
51
Complications of coeliac disease
``` Anaemia Dermatitis herpetiformis Osteopenia/osteoporosis Hyposplenism- flu and pneumococcal vaccine Increased risk of malignancy ```
52
Things to rule out when diagnosing IBS
``` Chronic >6 months Query if age >60 No weight loss, anorexia, waking at night with pain/ diarrhoea, mouth ulcers Abnormal CRP, ESR FH of ovarian or bowel cancer (CA-125) Endometriosis- cyclical pain Stool culture FBC, LFTs, U&Es, coeliac serology ```
53
Clinical features of scurvy
Poor, pregnant or odd diet Anorexia, cachexia, gingivitis, loose teeth, halitosis, bleeding from gums or into joints, bladder, gut, muscle pain, weakness, oedema
54
Beriberi
Thiamine deficiency Wet beriberi- heart failure with general oedema Dry beriberi- neuropathy
55
Classical triad of pellagra
Lack of nicotinic acid- B3- niacin | Diarrhoea, dementia and dermatitis
56
Causes of acute pancreatitis
``` Gallstones Ethanol Trauma Steroids Mumps and other infections Autoimmune Scorpion bites Hypercalcaemia, hypertriglyceridaemia, hypothermia ERCP Drugs ```
57
Tests for pancreatic cancer query
CA19-9 Bloods show cholestatic jaundice Imaging- US or CT- pancreatic mass, biliary tree dilatation or hepatic mets
58
What is a Whipple's resection?
Pancreatoduodenectomy
59
Gilbert's syndrome
Decreased UGT-1 activity resulting in unconjugated hyperbilirubinaemia Often presents with intermittent jaundice in young adulthood during infections
60
Crigler-Najjar syndrome
Inherited unconjugated hyperbilirubinaemia presenting in the first days of life Mutation in the UGT enzyme causing absent (1) or impaired (2) bilirubin excretion
61
Causes of unconjugated hyperbilirubinaemia
Haemolysis, ineffective erythropoiesis Impaired hepatic uptake- drugs- paracetamol, rifampicin, ischaemic hepatitis Impaired conjugation Physiological neonatal
62
Causes of conjugated hyperbilirubinaemia
Hepatocellular dysfunction- viruses- hepatitis, CMV, EBV, drugs, alcohol, cirrhosis etc Impaired hepatic excretion- PBC, PSC, gallstones, pancreatic CA, compression, cholangiocarcinoma,
63
Questions to ask the patient in jaundice
``` Blood transfusions IV drug use Piercings Tattoos Sexual activity Travel Jaundiced contacts FH Alcohol Medications ```
64
Investigations for jaundice
Haematology- FBC, clotting, blood film, Coomb's test, haptoglobins Biochemistry- U&Es, LFTs, GGT, total protein, albumin, paracetamol levels Microbiology- blood cultures, hepatitis serology USS- bile duct dilatation, masses, gallstones
65
'Coagulopathy' in terms of INR
>1.5
66
Causes of liver failure
``` Infections- viral hepatitis- B,C, CMV, yellow fever, leptospirosis Drugs- paracetamol, isoniazid Toxins- deathcap Vascular- Budd Chiari syndrome- occlusion of the hepatic veins Alcoholic Liver Disease Non Alcoholic Fatty Liver Disease PBC PSC Haemochromatosis Autoimmune hepatitis Alpha-1 antitrypsin deficiency Wilson's disease Malignancy Fatty liver of pregnancy ```
67
Hepatic encephalopathy pathogenesis
Nitrogenous waste builds up from liver failure | Astrocytes mop up by conversion of glutamate to glutamine and this excess causes osmotic imbalance and cerebral oedema
68
Signs of liver failure
Jaundice Hepatic encephalopathy- incoherent, restless, confusion, asterixis, stupor Asterixis Signs of acute or chronic liver failure
69
What is hepatorenal syndrome?
Cirrhosis+ ascites + renal failure | Abnormal haemodynamics result in renal vasoconstriction and hypoperfusion
70
Treating ascites
Restrict fluid, low salt diet, weight daily, diuretics
71
Signs of liver cirrhosis
``` Leukonychia Telangiectasia Clubbing Palmar erythema Dupuytren's contracture Spider naevi Xanthelasma Gynaecomastia Loss of body hair Parotid enlargement- alcohol Hepatomegaly (small in late disease) Ascites Splenomegaly ```
72
Complications of liver cirrhosis
Hepatic failure: coagulopathy, hypoalbuminaemia, encephalopathy, sepsis, spontaneous bacterial peritonitis, hypoglycaemia Portal hypertension- ascites, caput medusae, splenomegaly, oesophageal varices
73
When should spontaneous bacterial peritonitis be considered?
Any patient with ascites that deteriorates very quickly
74
Only definitive treatment for cirrhosis
Liver transplant
75
Investigations once recovery from a HepB virus infection
Normal LFTs Anti-HBs Anti-HBc IgG
76
Vaccinated against HepB virus
Anti-HBs | Normal LFTs
77
What does HBeAg mean
Implies high infectivity, present 6-12 weeks after acute illness
78
Hep C percentage of chronic silent infections
85%
79
Managing alcoholic hepatitis
``` Hospital admission Stop alcohol consumption + alcohol withdrawal- long acting benzodiazepine- CIWA-Ar IV vit K and pabrinex- B1 Optimise nutrition Daily weight, INR, LFT and U&Es Steroids ```
80
Antibody in primary biliary cholangitis
Anti-mitochondrial antibodies
81
Signs of primary biliary cholangitis
``` Jaundice Skin pigmentation Xanthelasma Xanthomata Hepatosplenomegaly ```
82
Tests for primary biliary cholangitis
Raised ALP Raised GGT AMA USS- exclude extrahepatic cholestasis
83
Treatment for primary biliary cholangitis
Symptomatic- pruritus, diarrhoea, osteoporosis prevention, fat soluble vitamin ADEK prophylaxis Ursodeoxycholic acid/ cholestyramine Monitoring Liver transplant for end-stage disease
84
Primary sclerosing cholangitis who gets it, increased risk of...
Over 80% have IBD- usually UC Men 30-40 Increased risk of cancers- yearly colonoscopy and ultrasound
85
Antibodies in primary sclerosing cholangitis
ANA SMA pANCA
86
Who does autoimmune hepatitis tend to affect?
Young or middle aged women in a bimodal distribution
87
Antibodies likely to be positive in autoimmune hepatitis
ASMA
88
Type 1 autoimmune hepatitis
80% of cases Typically women <40 ASMA positive, IgG in 97% 25% have cirrhosis at presentation
89
Type 2 autoimmune hepatitis
Children Less treatable and more commonly progresses to cirrhosis LKM1 antibodies ASMA negative
90
Management of autoimmune hepatitis
Immunosuppressant therapy- prednisolone Azathioprine as steroid sparing agent to maintain remission Liver transplant indicated for decompensated cirrhosis
91
Associations of autoimmune hepatitis
``` Pernicious anaemia UC Glomerulonephritis Autoimmune thyroiditis Autoimmune haemolysis DM PSC ```
92
Pathology of non-alcoholic fatty liver disease
Increased fat in the hepatocytes- steatosis
93
Wilson's disease pathology
Rare inherited disorder of copper excretion with excess deposition in the liver and CNS Autosomal recessive
94
Signs of Wilson's disease
Children- liver disease- hepatitis, cirrhosis, fulminant liver failure Young adults- CNS signs- tremor, dysarthria, dysphagia, dyskinesias, dystonias, dementia, parkinsonism, ataxia Mood- depression, mania, labile emotions, personlity change Cognitive deprivation Kayser-Fleischer rings- copper deposition in iris
95
Management of Wilson's disease
Diet- avoidance of copper rich food Lifelong penicillamine Liver transplantation
96
How can you tell if ALP is from bone or liver?
Other deranged LFTs, particularly GGT
97
Alcoholic liver disease LFT classic
AST/ALT ratio is 2:1
98
Suspected liver tumour investigations
Bloods- FBC, LFT, clotting, hepatitis serology, alpha-fetoprotein US or CT to identify lesions and guide biopsy ERCP and biopsy if cholangiocarcinoma suspected
99
Two most common mutations for hereditary haemochromatosis
C282Y and H63D
100
Signs of haemochromatosis
``` Tiredness early on Arthralgia Decreased libido Slate grey skin Signs of liver disease, cirrhosis Bronze diabetes from iron deposition in the pancreas ```
101
Management of haemochromatosis
Venesection Well balanced diet Avoid alcohol and uncooked seafood Monitor LFTs and glucose
102
Tests if suspecting A1AT deficiency
Serum A1AT levels low (but can be disguised by inflammation as it is an acute phase protein) Lung function tests- obstructive picture (emphysema) Liver biopsy
103
Best imaging modality for acute diverticulitis
CT abdomen
104
Symptoms of diverticulitis
``` Altered bowel habit Left-sided colic relieved by defecating Pyrexia Increased CRP/ESR and WCC Tender colon +/- localised or general peritonism ```
105
Complications of diverticulitis
``` Perforation Haemorrhage Fistulae Abscesses Post-infective strictures ```
106
Fissure-in-ano often if chronic found with a...
'Sentinel pile' or mucosal tag at the external aspect
107
Treatment for fissure-in-ano
conservative- dietary fibre, fluids, stool softener and hygiene advice 5% lidocaine ointment and GTN ointment or topical diltiazem
108
Treatment for fistula-in-ano
Fistulotomy and excision High require a seton suture Low need to be laid open to allow healing by secondary intention
109
Symptoms of haemorrhoids
Bright red rectal bleeding (on wiping or coating stools) Mucous discharge and pruritus ani Anaemia may be severe

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