Gastrointestinal - Level 3 Flashcards
1
Q
Definition of achalasia?
A
- Oesophageal motor disorder characterised by loss of oesophageal peristalsis and failure of lower oesophageal sphincter relaxation in response to swallowing
- Results from denervation of oesophageal myenteric plexus
- Causes functional stenosis or stricture
2
Q
Definition of pseudoachalasia?
A
o Achalasia-pattern dilatation of oesophagus due to narrowing of distal oesophagus from cause other than primary denervation
o E.g. Malignancy
3
Q
Epidemiology of achalasia?
A
- Incidence peaks at 60
4
Q
Triggers of achalasia?
A
o Infection – Chagas, herpes, measles
o Autoimmunity – HLA Class 2
Genetic
5
Q
Symptoms of achalasia?
A
- Dysphagia o Solids more than soft foods and liquids o Posturing to aid swallowing - Food bolus impaction - Regurgitation - Chest pain o After eating, retrosternal - Heartburn - Loss of weight – think malignancy
6
Q
Investigations in suspected achalasia?
A
- Endoscopy
- Barium Swallow
- Manometry of Oesophagus
- CXR
- Lower oesophageal pH monitoring
7
Q
Endoscopy findings of achalasia?
A
o Essential first-line investigation to exclude malignancy
o Biopsies from cardia performed to exclude pseudoachalasia
8
Q
Barium swallow findings of achalasia?
A
o Oesophagus dilated, contrast material passes slowly into stomach as sphincter opens intermittently
o Birds beak appearance of distal oesophagus
9
Q
Manometry findings of achalasia?
A
o Gold standard – high resting pressure in cardiac sphincter, incomplete relaxation on swallowing and absent peristalsis
10
Q
CXR findings of achalasia?
A
o Classical - vastly dilated oesophagus behind heart
11
Q
Management of achalasia - medical - when and what?
A
Medical (waiting for definitive treatment OR if unable to tolerate other forms of treatment)
o Calcium channel blockers (Nifedipine OR Verapamil)
o Nitrates
12
Q
Management of achalasia - surgical?
A
Laparoscopic Heller myotomy (cardio-myotomy)
Muscle fibres of lower oesophagus divided in a longitudinal direction above stomach
Pneumatic Dilatation
If unfit for myotomy, balloon inserted and inflated to rupture muscle of oesophagus
Risk of perforation which requires emergency surgery
Can have multiple times with increasing dilatation
Endoscopic injection of botulinum toxin
If cannot tolerate any surgery
13
Q
Complications of achalasia?
A
- Nocturnal inhalation of material
- Aspiration pneumonia
- Perforation
- GORD
- Oesophageal cancer
14
Q
Definition of gastritis?
A
- Gastric mucosal inflammation
15
Q
Causes of gastritis?
A
o Alcohol, NSAIDs o H.pylori o GORD, Hiatus Hernia, Atrophic Gastritis o Crohn’s, sarcoidosis o CMV o Zollinger-Ellison
16
Q
Symptoms and signs of gastritis?
A
- Epigastric pain
- Nausea & Vomiting
- Loss of Appetite
- Haematemesis
- Bloating
17
Q
Investigations of gastritis - when to offer upper GI endoscopy?
A
- Offer urgent access upper GI endoscopy if:
o Dysphagia OR
o >55 with weight loss and:
Upper abdominal pain, reflux or dyspepsia
18
Q
Investigations of gastritis if no alarm symptoms?
A
o H.pylori urea breath test o FBC (anaemia)
19
Q
Management of gastritis - prevention?
A
o Eat smaller and frequent meals o Avoid spicy, acidic, fried or fatty foods o No alcohol o Stop smoking o Give PPI gastroprotection with NSAIDs
20
Q
Management of gastritis - general measures?
A
Reduce alcohol and NSAIDs if possible
Lifestyle measures
OTC antacids
21
Q
Management of gastritis - if no improvement?
A
H.pylori Urea breath test or stool antigen test
If negative:
o PPIs/H2 blockers for 4 weeks
o Consider non-urgent endoscopy if no improvement
If positive:
o Eradicate H.pylori as needed
PPI + Amoxicillin + Clarithromycin OR Metronidazole
o H.pylori breath test to test cure
o Consider non-urgent endoscopy if not improving
22
Q
Complications of gastritis?
A
- Peptic ulcer disease
- Gastric Carcinoma
- Gastric Lymphoma
23
Q
Definition of chronic pancreatitis?
A
- Chronic, irreversible, inflammation and fibrosis of pancreas
- Inappropriate activation of enzymes leads to protein plugs in lumen and calcification
- Ductal hypertension and damage leads to impaired function
24
Q
Risk factors of chronic pancreatitis?
A
o Smoking, Sjogren’s, IBD
o Drugs – thiazide diuretics, azathioprine
o Gallstones
25
Causes of chronic pancreatitis?
```
o Alcohol (70-80%)
o Familial
o CF
o Haemochromatosis
o Pancreatic duct obstruction (stones/tumour)
o Hyperparathyroidism
o Pancreas divisum
```
26
Symptoms of chronic pancreatitis?
```
o Epigastric pain
Deep, severe, dull pain into back
Worsened with eating
Relieved by sitting up or hot water bottles
o Nausea and vomiting
o Bloating
o Steatorrhoea
o Anorexia/Weight loss
o Diabetes
```
27
Signs of chronic pancreatitis?
o Chronic liver disease
o Epigastric tenderness
o Jaundice
Distention
28
When to refer in primary care of chronic pancreatitis?
- In primary care, if suspected – refer to gastroenterology or regional pancreatic specialist centre
o Urgent if acute pancreatitis
o Routine if chronic
Perform LFTs, Abdominal USS
29
Tests performed in chronic pancreatitis in secondary care
```
o Bloods – LFTs, glucose (raised)
o Abdminal USS
o CT
Pancreatic calcifications confirm diagnosis
o MRCP + ERCP
o AXR
Speckled calcification
```
30
Referral of suspected chronic pancreatitis from primary care?
Urgent if acute pancreatitis or complications of chronic (malabsorption, DM, chronic pain, opioid dependency, low-trauma fracture)
Routine – all other suspected people
Investigations if no urgent admission/referral need
Bloods
• LFTs
Abdominal USS
31
Management of chronic pancreatitis - general advice?
Abstain from alcohol and smoking
Analgesia – NSAIDs, paracetamol, weak opioids
If uncontrolled – ERCP to remove stones, adjuvant drugs or coeliac plexus block
Dietician referral
Low fat diet, avoid legumes and high-fibre foods
Pancreatin enzymes – contain lipase, amylase and protease (Creon)
Fat soluble vitamins
32
Management of chronic pancreatitis -Surgery?
o Pancreatic duct obstructed – surgery open or minimally invasive
o Pseudocysts drained using EUS-guided drainage
o Pancreatojejunostomy
33
Management of chronic pancreatitis -follow up?
o Annual – HbA1c, DEXA scan, test for malnutrition or vitamin deficiencies
34
Complications of chronic pancreatitis?
- Malabsorption
- Pseudocyst
- Diabetes
- Biliary obstruction
- Local arterial aneurysm
- Pancreatic carcinoma
35
Definition of chronic hepatitis?
o Inflammation of liver for >6 months
36
Causes of chronic hepatitis?
o Viral – HepB, HepC, CMV, EBV
o Metabolic – NAFLD, haemochromatosis, Wilson’s disease, alpha-1-antitrypsin disease
o Toxins – alcoholic liver disease, amiodarone, isoniazid, methyldopa, methotrexate, nitrofurantoin
o Autoimmune – hepatitis, PBC, PSC
o Sarcoidosis
37
Symptoms of chronic hepatitis?
o Fatigue, anorexia, arthralgia, myalgia, weight loss
o RUQ pain
o Abdominal pain
o Ankle swelling
o Pruritus
o Gynaecomastia, testicular atrophy, loss of libido, amenorrhoea
o Confusion and drowsiness
38
Signs of chronic hepatitis?
```
o Spider Naevi
o Palmar erythema
o Jaundice
o Clubbing
o Dupuytren’s contracture
o Xanthomas
o Splenomegaly
o Hirsutism
```
39
Bloods to performed in chronic hepatitis?
```
o FBC (anaemia)
o Clotting
o U&E
o LFTs
o Albumin
o Immunoglobulins
o Autoantibodies
o Hepatitis B and C serology
o Iron
o AFP
```
40
Imaging to performed in chronic hepatitis?
o US
| o CT/MRI
41
Diagnostic tests to performed in chronic hepatitis?
- Transient elastography
| - Liver biopsy
42
Definition of subphrenic abscess?
- Localised collection of pus, underneath left/right hemidiaphragm
43
Causes of subphrenic abscess?
o Upper GI – malignancy, trauma, peptic ulcer perforation, endoscopy
o Lower GI – ischaemic bowel, diverticulitis, obstruction, hernia, IBD, appendicitis, trauma
o Biliary Tract/Pancreas – cholecystitis, malignancy, pancreatitis, endocarditis
o GU – PID, malignancy
o Bowel surgery
44
Epidemiology of subphrenic abscess?
- Commonest cause of intra-abdominal abscess
45
Symptoms of subphrenic abscess?
o Chest/shoulder tip pain
o Abdominal pain
o Swinging fever
o Diarrhoea, nausea, malaise
46
Signs of subphrenic abscess?
o Swinging/Spikey temperature
o Systemically unwell patient
o Often few physical signs – subcostal abdominal tenderness
o Leucocytosis
47
Investigations of subphrenic abscess?
```
- Bloods
o FBC (High WCC)
o Cultures
- Urgent US – localises collection of pus
- Ct detects abscess and estimate volume
```
48
Management of subphrenic abscess?
- IV Antibiotics – broad spectrum
- US/CT-guided drainage
- May need percutaneous drainage, laparoscopy or open surgery
49
Definition of liver abscess?
- Caused by organisms invading liver parenchyma
50
Epidemiology of liver abscess?
- UK – pyogenic most common
| - Worldwide – amoebic most common
51
Aetiology of pyogenic liver abscess?
o Right lobe predominantly, can be single or multiple
o Secondary to abdominal infections (cholecystitis, cholangitis, stones, malignancy, diverticulitis, IBD, appendicitis, perforate peptic ulcer, iatrogenic, bacterial endocarditis)
o Organisms – Klebsiella pneumoniae, E.coli, Bacteroides, enterococci, staph/strep (endocarditis), Candida (immunocompromised)
52
Aetiology of amoebic liver abscess?
o Entamoeba histolytica – occurs in tropical/subtropical areas due to poor sanitation and overcrowding
o Faecal-oral transmission
o Invade intestinal mucosa and access portal venous system
o Symptoms – colitis, dysentery and liver abscess
o Right lobe 80%
o Endemic in South America, Indian subcontinent and Africa
53
Symptoms of liver abscess?
```
o RUQ pain
Referred shoulder tip pain
o Fever (swinging)
o Night sweats
o Nausea and vomiting
o Anorexia and weight loss
o Cough
```
54
Signs of liver abscess?
o Swinging fever
o Tender RUQ
o Hepatomegaly, palpable mass
o Jaundice
55
Investigations of liver abscess?
```
Bloods
o FBC (High WCC, normo, normo anaemia)
o Raised ESR
o LFTs (raised ALP, AST/ALT, bilirubin, low albumin)
o Blood Cultures
```
Stool sample – cysts of E.histiolytica
USS
o Aspiration fluid sent for culture and sensitivity
CT definitive
56
Management of pyogenic liver abscess?
Fluids/PRN analgesics
Antibiotics
Cephalosporin + metronidazole 1st line
US/CT-guided aspiration
57
Management of amoebic liver abscess?
Antibiotics
Metronidazole 800mg TDS for 5 days (or tinidazole)
Then, Diloxanide Furoate 500mg TDS for 10 days
US/CT-guided aspiration if large or no response to antibiotics after 72 hours
58
Description of hepatocellular carcinoma?
o Primary hepatocyte neoplasia
| o Spread – lung, portal vein, periportal nodes, bone and brain
59
Description of benign liver tumours?
o Haemangiomas – commonest benign liver tumours, often incidental finding on US or CT and don’t require treatment
o Adenomas – common, caused: anabolic steroids, OCP, pregnancy. Treat if symptomatic or >5cm
60
Epidemiology of hepatocellular carcinoma?
- 90% of all primary liver tumours
- Common in China and Africa
- Men more common
- 90% of liver tumours are secondary metastatic tumours
61
Types of malignant primary liver tumours?
```
HCC
Cholangiocarcinoma
Angiosarcoma
Hepatoblastoma
Hepatic GIST
```
62
Types of benign primary liver tumours?
```
Cysts
Haemangioma
Adenoma
Focal nodular hyperplasia
Fibroma
```
63
Origins of secondary liver tumours in liver?
o Men – Stomach, lung, colon
o Women – breast, stomach, colon, uterus
o Either Sex – Pancreas, leukaemia, lymphoma, carcinoid tumours
64
Causes of hepatocellular carcinoma?
```
o Hepatitis B
o Hepatitis C
o Autoimmune hepatitis
o Cirrhosis (alcohol, haemachromatosis, PBC)
o NAFLD
o Anabolic stenosis
o Aflatoxins
o DM and smoking
```
65
Symptoms of hepatocellular carcinoma?
```
o Fatigue
o Anorexia
o RUQ pain
o Weight loss
o Pruritus
o Abdominal distention
```
66
Signs of hepatocellular carcinoma?
```
o Hepatomegaly
o Jaundice (late)
o Ascites
o Bruit over liver
o Spider Naevi
o Anaemia
```
67
Investigations of hepatocellular carcinoma - referral?
o Urgent direct access US (within 2 weeks) if upper abdominal mass consistent with enlarged liver
68
Investigations of hepatocellular carcinoma - secondary care?
o USS
o AFP
o CT
o Fine-needle aspiration or biopsy
69
Investigations of hepatocellular carcinoma - other tests?
Blood
FBC, clotting, LFT, hepatitis serology, AFP
Imaging
US
CT
ERCP if cholangiocarcinoma
If suspected secondary:
CXR, mammogram, endoscopy, colonoscopy, CT, marrow biopsy
70
Investigations of hepatocellular carcinoma - Staging?
o Child-Pugh Stage
| o Cancer of Liver Italian Program (CLIP) – prognostic marker
71
Management of hepatocellular carcinoma - surgical?
o If platelets <50000 and planned invasive procedure, give Lusutrombopag
o Liver Resection (Child-Pugh A-B and ECOG 0-2)
Radiofrequency Assisted Resection
Laparoscopic Liver Resection
o Liver Transplant
72
Management of hepatocellular carcinoma - non-resectable disease - Stage A/B?
o Stage A/B ineligible for surgery:
Radiofrequency/Microwave ablation
Chemo-embolisation into hepatic artery
73
Management of hepatocellular carcinoma - non-resectable disease - Stage C/D?
o Chemotherapy (Stage C, D)
Lenvatinib if:
• Child-Pugh grade A liver impairment and ECOG of 0/1
Sorafenib & Regorafenib alternative
o Internal radiation therapy
74
Surveillance in people at high risk of HCC?
o 6-monthly AFP and US
| If high risk for HCC – cirrhotic HBV carriers, non-cirrhotic HBV with high DNA, HCV-related or alcoholic cirrhosis
75
Prognosis of HCC?
- Median survival from diagnosis is 6 months
76
Description, symptoms, Ix and management of hepatoblastoma?
- Affects children <3
- Associated with Beckwith-Wiedemann syndrome and FAP syndrome, fetal alcohol syndrome
- Usually unifocal and affect right lobe
- Symptoms – abdominal mass and distention, vomiting, anaemia and failure to thrive
- Ix – AFP raised, normocytic normochromic anaemia, AXR, US and CT
- Management – Surgical resection and chemotherapy
77
Definition of cholangiocarcinoma?
- Carcinoma arising from any part of biliary tree – from small intrahepatic bile ducts to ampulla of Vater
78
Epidemiology of cholangiocarcinoma?
- Most commonly, perihilar region near bifurcation of hepatic ducts (Klatskin’s tumour)
- 90% are ductal adenocarcinomas
- 10% SCC
- Common in South Asia
79
Causes of cholangiocarcinoma?
```
o Flukes (Clonorchis)
o PSC
o Biliary cysts
o Caroli’s disease (congenital disorder of intrahepatic bile duct and polycystic kidney disease)
o HBV
o HCV
o DM
o N-nitroso toxins (chemicals in aircraft, rubber, wood-finishing)
```
80
Symptoms of cholangiocarcinoma?
```
o Jaundice early - painless
o RUQ pain
o Fatigue
o Anorexia
o Weight loss
o Pruritus
o Abdominal distention
```
81
Signs of cholangiocarcinoma?
```
o Hepatomegaly
o Jaundice (early)
o Ascites
o Bruit over liver
o Spider Naevi
o Anaemia
```
82
Investigations of cholangiocarcinoma - primary care referral?
o Urgent direct access US if upper abdominal mass consistent with enlarged gall bladder
83
Investigations of cholangiocarcinoma - secondary care?
o CT
o Biopsy - Fine-needle aspiration or biliary brush cytology
o ERCP
84
Investigations of cholangiocarcinoma - other tests?
```
o LFTs (elevated conjugated bilirubin, raised alkaline phosphatase, raised GGT, raised aminotransferase)
o Clotting
o Tumour markers – Ca19-9, CEA, AFP (not raised)
```
85
Investigations of cholangiocarcinoma - staging?
o Bismuth-Corlette classification
86
Management of cholangiocarcinoma - surgical?
o Liver Resection (30%)
Major hepatectomy + extrahepatic bile duct excision + caudate lobe resection
o Stenting of bile duct
o Liver Transplant (rare)
87
Management of cholangiocarcinoma - non-resectable?
```
o Chemotherapy and radiotherapy
Photodynamic therapy
Internal radiation
Endoscopic bipolar radiofrequency
Hepatic artery chemosaturation
```
88
Types of hepatic failure?
Acute – suddenly in previous healthy liver
Acute-on-chronic – Decompensation of chronic liver disease
Fulminant – massive necrosis of liver cells
Hyperacute = encephalopathy within 7 days of jaundice
Acute = 8-28 days
Subacute = within 5-26 weeks
89
Causes of hepatic failure - infection?
Viral hepatitis (B, C, CMV, EBV)
Yellow Fever
Leptospirosis
90
Causes of hepatic failure - drugs, toxins & vascular?
Drugs
Paracetamol
Halothane
Isoniazid
Toxins
Amanita phalloides
Vascular
Budd-Chiari syndrome
91
Causes of hepatic failure - others?
```
Alcohol
PBC
Haemochromatosis
Autoimmune hepatitis
Alpha-1 antitrypsin deficiency
Wilson’s disease
HELLP syndrome
Malignancy
```
92
Signs of hepatic failure?
```
o Nausea, vomiting
o Abdominal pain
o Malaise
o Jaundice
o Hepatic Encephalopathy
o Fetor Hepaticus (smells like pear drops)
o Asterixis/Flap
o Bleeding
o Chronic liver disease suggest acute-on-chronic
```
93
Stages of hepatic encephalopathy of hepatic failure?
1 = altered mood/behaviour, sleep disturbance, dyspraxia
2= drowsiness, confusion, slurred speech +/- flap
3= incoherent, restless, liver flap
4 = coma
94
Bloods to perform of hepatic failure?
```
o FBC (infection, GI bleed, thrombocytopenia)
o U&E
o LFT (raised AST/ALT, bilirubin)
o Clotting (raised PT/INR)
o Glucose (low)
o Paracetamol levels
o Hepatitis, CMV and EBV serology
o Ferritin
o Alpha-1 antitrypsin
o Caeruloplasmin autoantibodies
```
95
Microbiology Ix of hepatic failure?
o Blood culture
o Urine culture
o Ascitic tap (M, C & S)
96
Imaging of hepatic failure?
o CXR
| o Abdominal US and Doppler flow
97
Initial management of hepatic failure?
o Nurse with bed 20o head-up tilt in ITU
o NG tube
o Insert urine and central venous catheter
o IV glucose
o If malnourished – thiamine and folate
o Seizures – lorazepam
o Renal failure – haemodialysis or haemofiltration
98
Monitoring in initial management of hepatic failure?
o Monitor
Temp, RR, HR, BP, pupils, urine output hourly
Blood glucose 4-hourly
Daily weight
o Daily
FBC, U&E, LFT, INR
99
Drugs to avoid in hepatic failure?
Opiates, hypoglycaemics, paracetamol, methotrexate, azathioprine, isoniazid, salicylates, tetracycline, mitomycin
100
When to liase with transplant team of hepatic failure?
• Paracetamol-Induced
o Arterial pH <7.3 24h after ingestion OR
o PT>100s, Creatinine >300umol/L, Grade ¾ encephalopathy
```
• Non paracetamol liver failure
o PT >100s OR
o 3 of the following:
Drug-induced
Age <10 or >40
>1 week from jaundice to encephalopathy
PT>50s
Bilirubin >300umol/L
```
101
Managing complication of hepatic failure?
o Cerebral oedema – ITU, mannitol IV, hyperventilate
o Ascites – restrict fluid, diuretics, low salt diet, daily weight
o Bleeding – Vitamin K IV
o Prophylactic Abx – Ceftriaxone IV
o Encephalopathy – Lactulose and regular enemas
102
Definition of epigastric hernia?
- Pass through linea alba above umbilicus
103
Epidemiology of epigastric hernia?
- Prevalence up to 10%, mostly middle-aged men
104
Aetiology of epigastric hernia?
o Typically secondary to raised chronic intra-abdominal pressure (obesity, pregnancy, ascites, straining, coughing)
105
Symptoms of epigastric hernia?
- Typical asymptomatic
- Midline mass – disappears when lying on the back
- Epigastric pain
- N &V, often after meals
106
Investigations of epigastric hernia?
Clinical Examination
```
US and CT to confirm diagnosis if needed
o Must be differentiated from diastasis recti (widening of linea alba without a defect in fascia)
Usually resolves by age of 10
US can help confirm not a hernia
Treatments – strengthen core training
```
107
Management of epigastric hernia?
- Surgical repair essential – risk of strangulation or incarceration
o Mesh and suture repair possible
108
Description of familial adenomatous polyposis?
o Autosomal dominant condition with >100 tubular adenomas which carpet colon
o Germline mutation of APC gene (5q)
o Offspring 50% risk of being carrier and gene penetrance ~100% for colorectal cancer by 50 years old
o Associated with papillary thyroid cancer, carcinoid tumours of ileum, medullloblastomas and glioblastomas
109
Description of Peutz-Jeghers syndrome?
o Autosomal dominant disorder characterised by mucosal pigmentation of lips and gums with multiple intestinal hamartomatous polyps
o Due to germline mutation in STK11
o Increased risk of GI, pancreatic, breast, thyroid, lung, uterine, testicular and ovarian tumours
110
Description of Hereditary Non-Polyposis Colorectal cancer (Lynch syndrome)?
o Autosomal dominant aggregation of colorectal cancer (60%) +/- endometrium (40%)/ovarian/stomach/renal pelvis/small bowel/pancreas
o Mutation in DNA mismatch repair genes (1 of 5)
111
Description of juvenile polyposis?
o Multiple juvenile polyps in GI tract – benign hamartoma
112
Symptoms of Familial adenomatous polyposis?
```
Adenomas develop during 20s
Colorectal cancer by 50
Rectal bleeding
Diarrhoea
Abdominal pain
Mucous discharge
Obstruction – constipation, vomiting
```
113
Signs of Familial adenomatous polyposis?
```
Rectal polyps or masses
Congenital hypertrophy of retinal pigment epithelium
Supernumery teeth
Epidermoid cysts
Thyroid masses
```
114
Symptoms of Peutz-Jeghers syndrome?
```
o FHx
o Deeply pigmented lesions on lips and buccal mucosa
o Bouts of abdominal pain
o GI bleeding
o Iron-deficiency anaemia
```
115
Investigations in colonic polyposis?
- Bloods – FBCs, LFTs, TFTs
- Faecal occult blood
- Colonoscopy with biopsies diagnostic
- Upper GI endoscopy
- Genetic testing – APC gene
- CT scan
116
Management of FAP - genetic analysis?
If 2 1st-degree relative aged <70, one 1st degree relative aged <45, 3 close relatives <60 on average, FAP, HNPCC Endoscopic surveillance
117
Management of FAP - surgical?
Proctocolectomy and ileostomy – abolishes risk of large bowel cancer but stoma required
Colectomy and ileorectal anastomosis – does not abolish risk of large bowel cancer and need lifelong 6-monthly surveillance
118
Management of FAP - surveillance?
Upper GI endoscopy three-yearly
119
Management of Peutz-Jeghers syndrome - genetic analysis?
If 2 1st-degree relative aged <70, one 1st degree relative aged <45, 3 close relatives <60 on average, FAP, HNPCC
120
Management of Peutz-Jeghers syndrome - Surgery?
Endoscopic polypectomy
| Polypectomy
121
Management of Peutz-Jeghers syndrome - surveillance?
2-yearly from 25 years old – colonoscopy & upper GI endoscopy
122
Management of HNPCC - genetic analysis?
If 2 1st-degree relative aged <70, one 1st degree relative aged <45, 3 close relatives <60 on average, FAP, HNPCC
123
Management of HNPCC -surveillance?
Annual or biannual colonoscopies from 25 years old
| Upper GI endoscopy every 2 years from 50
124
Management of Juvenile Polyposis - surgery?
Colectomy
125
Management of Juvenile polyposis - surveillance?
Colonoscopy every 18-24 months from 18
| Upper GI endoscopy every 1-2 years from 25
126
Anatomy of anal canal?
o Anal canal extends from anorectal junction to anal margin
o Dentate line marks junction between squamous and mucosal epithelium in anal canal
o Anal margin is pigmented skin surrounding anal orifice
127
Behaviour of anal cancer?
o Anal margin – well differentiated, more common in men and good prognosis
o Anal canal – poorly differentiated, more common in women and poor prognosis
128
Spread of anal cancer?
o Above dentate line – spread to pelvic lymph nodes
| o Below dentate line – spread to inguinal lymph nodes
129
Risk factors of anal cancer?
```
o Syphilis
o Anal warts in HPV (SCC)
o Anal intercourse
o High number of sexual partners
o MSM
o HIV
o Smoking
```
130
Types of anal cancer?
o Squamous Cell Carcinoma (80%)
o Adenocarcinoma
o Melanoma
o Lymphoma
131
Symptoms of anal cancer?
- Bleeding
- Pain
- Change in bowel habit
- Pruritus ani
- Mass in or around anus
- Anal ulceration
132
Referral for 2-week appointment of anal cancer?
- Refer for 2-week wait appointment if:
| o Unexplained anal mass or anal ulceration
133
Assessment of anal cancer?
o DRE
o Palpation of inguinal lymph nodes
o Examination under anaesthetic (EUS) with biopsy
o CT/MRI/US/PET
134
Management of AIN?
o Topical imiquimod, 5-FU
| o Ablative electrocautery, laser
135
Management of anal carcinoma?
o Small well-differentiated carcinoma – local excision
o All other – chemo-radiotherapy (5-FU and mitomycin)
Surgery if fail to respond, causing GI obstruction
• Anorectal excision & colostomy
136
Definition of perianal haematoma?
- Blue or dark coloured swelling at anal verge
| - Caused by rupture of small vein near anal margin then blood clots
137
Risk factors of perianal haematoma?
- Caused by straining, constipation, anal sex, heavy lifting, coughing
138
Symptoms of perianal haematoma?
- Acutely painful – usually after straining
| - 2-4mm dark blueberry under skin at anal margin
139
Referral of perianal haematoma?
- Refer for non-urgent assessment and management if <24 hours old
140
Management of perianal haematoma?
o Spontaneous resolve over a few days to week
o PRN analgesia
o If pain intolerable:
Evacuated and drained under LA
141
Definition of fistula-in-ano?
- Abnormal connection between skin and anal canal/rectum
142
Classification of fistula-in-ano?
o Intersphincteric
o Trans-sphincteric
o Suprasphincteric
o Extrasphincteric
143
Pathology of fistula-in-ano? What is Goodsall's rule?
o Blockage of deep intramuscular gland ducts predisposes to abscesses, which discharge to form fistulas
o Goodsall’s rule
If anterior – track is straight line (radial)
If posterior – internal opening is always at 6 o’clock position
144
Causes of fistula-in-ano?
```
o Perianal sepsis
o Abscesses (90%)
o Crohn’s
o TB
o Diverticular disease
o Rectal carcinoma
```
145
Symptoms of fistula-in-ano?
- Pain
| - Leak blood or pus
146
Investigations of fistula-in-ano?
- Proctoscopy to visualise anal canal and opening of tract
- MRI
- Endoanal US scan
147
Park's classification of fistula-in-ano?
```
Extrasphincteric
Suprasphincteric
Transsphincteric
Intersphincteric
Submucosal
```
148
Management of fistula-in-ano - if no symptoms?
- If no symptoms – conservative management (PRN analgesia)
149
Management of fistula-in-ano - if symptoms?
- Fistulotomy & Excision
o High fistula (involving continence muscles of anus) – need seton suture tightening over time to maintain continence
o Low fistulas laid open
150
Definition of re-feeding syndrome?
- Life-threatening complication of refeeding via any route after prolonged period of starvation
151
Pathology of re-feeding syndrome?
o As body turns to fat and protein metabolism in starved state, there is drop in circulating insulin, depletes intracellular phosphate
o When refeeding begins, insulin rises and causes increased cellular uptake of phosphate, potassium, magnesium, glucose, thiamine
o Hypophosphataemic state (<0.50) develops within 4d and is responsible for features of refeeding syndrome
152
Symptoms of re-feeding syndrome?
- Rhabdomyolysis
- Red and white cell dysfunction
- Respiratory insufficiency
- Arrhythmias
- Cardiogenic shock
- Seizures
- Death
153
Bloods to perform in re-feeding syndrome?
```
o Glucose
o FBC
o Albumin
o U&Es
o Urine and stool culture
o Iron, B12, folate, TFTs, coeliac, Ca, PO4, Zn, Vitamin, selenium
```
154
Prevention of re-feeding syndrome?
Identify at risk patients and monitor daily for 1 week and then 3x a week (glucose, lipids, sodium, potassium, phosphate, calcium, magnesium, zinc)
Group includes – anorexia, chronic alcoholic, cancer, elderly, uncontrolled diabetes, marasmus, prolonged fasting
Start refeeding at 50% energy requirement and increase to meet full needs over a week
5-10cal/kg depending on level of risk in patient
155
Screening for malnutrition in people at risk of refeeding syndrome?
When
All hospital inpatients and done weekly
How
BMI, % unintentional weight loss, Mid upper arm diameter
Malnutrition Universal Screening Test (MUST)
156
Indications for nutritional support of re-feeding syndrome?
o BMI <18.5
o Unintentional weight loss >10% within last 3-6 months
o BMI <20 and unintentional weight loss >5% within last 3-6 months
o Consider in people who have eaten nothing >5 days
157
Oral nutritional support - indications?
People with safe swallow and malnorished or at risk of malnutrition
158
Oral nutritional support - amount?
25-35kcal/kg/day total energy
0.8-1.5g protein/kg/day
30-35ml fluid/kg
If not eaten for last 5 days – 50% requirements for 2 days to reduce risk of refeeding syndrome
159
Oral nutritional support - people at risk of refeeding syndrome?
1 or more of:
• BMI<16, WL >15%, little/no intake in 10 days, low K, PO4, Mg
2 or more:
• BMI<18.5, WL>10%, little/no intake 5 days, Hx of alcohol, drug, insulin, diuretic abuse
Starting nutrition at 10kcal/kg/day and increase slowly for needs to be met within 7 days (5kcal/kg/day in extreme cases)
Oral thiamine 200-300mg daily, Vitamin B co strong and multivitamin daily
May need IV/oral K, PO4, Mg
160
Oral nutritional support -monitoring?
Measurements
• Daily nutrient intake and fluid balance charts
• Weight and BMI daily if concerned but up to weekly
Bloods
• FBC, U&E, LFT, glucose, Mg, PO4, Ca, CRP, Iron, Folate, B12, Zn, Cu, zelenium
161
Enteral feeding tube - indications?
Malnourished or risk of and inadequate or unsafe oral intake & functional GI tract
People with unsafe swallow diagnosed by SALT team
162
Enteral feeding tube - amount?
25-35kcal/kg/day total energy
0.8-1.5g protein/kg/day
30-35ml fluid/kg
If not eaten for last 5 days – 50% requirements for 2 days to reduce risk of refeeding syndrome
163
Enteral feeding tube - people at risk of re-feeding syndrome?
1 or more of:
• BMI<16, WL >15%, little/no intake in 10 days, low K, PO4, Mg
2 or more:
• BMI<18.5, WL>10%, little/no intake 5 days, Hx of alcohol, drug, insulin, diuretic abuse
Starting nutrition at 10kcal/kg/day and increase slowly for needs to be met within 7 days (5kcal/kg/day in extreme cases)
Oral thiamine 200-300mg daily, Vitamin B co strong and multivitamin daily
May need IV/oral K, PO4, Mg
164
Enteral feeding tube - route and method of delivery?
NG tube unless upper GI dysfunction
If upper GI dysfunction – duodenal or jejunal feeding
Gastrostomy (PEG) – likely need long-term (>4 weeks) enteral feeding
• PEG tubes – used for enteral feeding 4 hours after insertion
165
Enteral feeding tube - monitoring?
Measurements
• Daily nutrient intake and fluid balance charts
• Weight and BMI daily if concerned but up to weekly
• N&V, Diarrhoea, constipation
Bloods
• FBC, U&E, LFT, glucose, Mg, PO4, Ca, CRP, Iron, Folate, B12, Zn, Cu, zelenium
166
Parenteral nutrition - indications?
Inadequate or unsafe oral and/or enteral nutritional intake and non-functional, inaccessible or perforated GI tract
167
Parenteral nutrition -Amount?
25-35kcal/kg/day total energy
0.8-1.5g protein/kg/day
30-35ml fluid/kg
If not eaten for last 5 days – 50% requirements for 2 days to reduce risk of refeeding syndrome
168
Parenteral nutrition - people at risk of refeeding syndrome?
1 or more of: BMI<16, WL >15%, little/no intake in 10 days, low K, PO4, Mg
2 or more: BMI<18.5, WL>10%, little/no intake 5 days, Hx of alcohol, drug, insulin, diuretic abuse
Starting nutrition at 10kcal/kg/day and increase slowly for needs to be met within 7 days
Oral thiamine 200-300mg daily, Vitamin B co strong and multivitamin daily
May need IV/oral K, PO4, Mg
169
Parenteral nutrition - route and method of delivery?
Peripherally inserted central catheter (PICC line) – if <14 days
Tunnelling subclavian line if >30 days
Continuous administration is preferred method
170
Parenteral nutrition - monitoring?
Measurements
• Daily nutrient intake and fluid balance charts
• Weight and BMI daily if concerned but up to weekly
• N&V, Diarrhoea, constipation
Bloods
• FBC, U&E, LFT, glucose, Mg, PO4, Ca, CRP, Iron, Folate, B12, Zn, Cu, zelenium
