Gastrointestinal/ Liver Flashcards
1
Q
IBD
Epidemiology?
A
- Presents in 20’s
- 40 in UK per 100,000
2
Q
IBD
What mutation increases the risk of Crohn’s?
A
NOD 2
3
Q
IBD
Describe the macroscopic changes of Ulcerative Colitis
A
- only in the colon
- continuous
- has red mucosa that bleeds
4
Q
IBD
Describe the macroscopic changes of Crohn’s Disease
A
- any part of the gut
- skip lesions
- deep ulcers/ fissures in mucosa
5
Q
IBD
Describe the microscopic changes of Ulcerative Colitis
A
- no granulomas
- mucosal inflammation
- depleted goblet cells
6
Q
IBD
Describe the microscopic changes of Crohn’s Disease
A
- (50%) granulomas
- transmural inflammation (across whole width of the wall)
- more goblet cells
7
Q
IBD
Signs and Symptoms?
A
- Bloody diarrhoea with URGENCY
- abdo pain/ tenderness
- weight loss, fever, nausea, vomit, malaise (general)
- Perianal abscess/ tag/ fistula- Crohn’s
- Clubbing of nails
- Erythema nodosum
- Conjunctivitis
- Enteropathic arthritis
8
Q
IBD
Investigations?
A
- 2 stool tests (culture and faecal calprotectin)
- FBC
- Colonoscopy
- Video Capsule Endoscopy
9
Q
IBD
Treatment of Ulcerative Colitis
A
Sulfasalazine, add oral
prednisolone if no
response
Severe: Infliximab, PR steroids, surgery, IV hydrocortisone
10
Q
IBD
Treatment of Crohn’s Disease
A
Oral corticosteroids
IV hydrocortisone in severe flare ups
Add anti-TNF antibodies e.g. Infliximab if
no improvement
Consider adding Azathioprine or
Methotrexate to remain in remission if
frequent exacerbations/ SURGERY
11
Q
HERNIAS
Name the two types of common Hiatus Hernias
A
- Sliding Hiatus hernia (80%)
- Rolling Hiatus Hernia (20%)
12
Q
what is a Sliding Hiatus hernia
A
when the gastro- oesophageal junction slides into the chest
13
Q
what is a rolling hiatus hernia
A
when the bulge of stomach rolls into chest alongside oesophagus
14
Q
Epidemiology of Inguinal Hernias
A
M:F 8:1
15
Q
What is an Indirect Inguinal Hernia?
A
When the periotoneal sac goes through deep inguinal ring into the canal (also passing through the superficial ring of the inguinal cancal) - lateral to the inferior epigastric artery
16
Q
What is a Direct Inguinal Hernia?
A
when abdominal contents pushes into the inguinal canal through a weak spot (Hasselbach triangle) and passes through the superficial inguinal ring, medial to the inferior epigastric artery
17
Q
What is a Femoral Hernia?
A
when the bowel enters femoral canal. Can be felt as a mass in upper thigh
18
Q
What is Dyspepsia?
A
heartburn
19
Q
How long must symptoms last to be diagnosed with GORD
A
Over 2 weeks
20
Q
GORD
Causes?
A
- Sliding Hiatus Hernia (Reflux uncommon in rolling hiatus hernia)
- Slow gastric emptying
- alcohol
- smoking
- pregnancy
- obesity
- over-eating
- loss of peristalsis
21
Q
GORD
Presentation?
A
1) Heartburn/ retrosternal/ epigastric burning sensation
2) Aggravated by lying down
3) Cough
4 Belching
5) Acid taste
6) Increased saliva
22
Q
GORD
6 RED flags for a Gastroscopy?
A
1) Anaemia/ Age >55
2) Loss of weight
3) Anorexia
4) Recent onset
5) Melaena/ haematemesis
6) Swallowing is difficult (dysphagia)
ALARMS
23
Q
GORD
Complications?
A
1) Barratts Oesophagus
2) Oesophagitis
3) Ulcers
4) Increased risk of cancer
24
Q
GORD
1st line treatment
A
Lifestyle adaptations (food, alcohol, smoking, weight, spicy food)
Antacids
Gaviscon
25
GORD
| 2nd line treatment
PPI's (lansoprazole, omeprazole)
| H2 receptor agonists (Ranitidine)
26
GORD
3rd line treatment?
- Surgery (laparoscopic fundoplication)
27
How do you get a Mallory- Weiss Tear
persistent vomiting causes haematemesis via oesophageal mucosal tear
28
PEPTIC ULCERS
What is the most common peptic ulcer
Duodenal - 4x more common
29
PEPTIC ULCERS
Aetiology?
1)h.pylori- urease splits urea into NH3
NH3 then damages the epithelium
2) NSAIDs- inhibit COX-1 - reduced prostaglandin production = reduced mucosal protection as this is a prostaglandin fucntion
30
PEPTIC ULCERS
Risk Factors?
- Smoking
- Alcohol
- Obesity
- h.pylori
- NSAIDs
31
PEPTIC ULCERS
Symptoms?
- Burning epigastric pain (relieved by food&milk)
- Bloating/ tender
- ALARMS symptoms
- Normally acute and GORD is chronic
32
PEPTIC ULCERS
Diagnosis?
No red flags? = non invasive H.pylori breath tests ( 13C urea breath test)
Red flags? = gastroscopy + H.pylori tests
33
PEPTIC ULCERS
Treatment
- Triple therapy (omeprazole, metronidazole, clarithromycin)
6-8 weeks follow up to exclude gastric cancer
Eradication confirmed with stool/ breath tests
34
COELIAC DISEASE
What genes is coeliac disease associated with?
HLA class II molecules DQ2 and DQ8
35
COELIAC DISEASE
Pathology?
5 steps
1) Alpha- gliadin peptide (toxic bit of gluten) passes through epithelium
2) It is deaminated by tissue transglutamase
3) Interactions with APC's in lamina propria via HLA-DQ2 & HLA-DQ8
4) This activates gluten- sensitive T-cells and inflammatory cascade
5) Inflammatory cascade and mediator release leads to VILLOUS ATROPHY & CRYPT HYPERPLASIA
36
COELIAC DISEASE
| at what age is it normally the worst
it peaks at infancy and 50-60
37
COELIAC DISEASE
Symptoms
1) General - tired - malaise
2) GI symptoms
- Diarrhoea
- steatorrhea (foul smelling stools)
- Bloating
- Pain/discomfort
- Anorexia
- - vomiting
- aphthous ulcers (mouth ulcers)
38
COELIAC DISEASE
What diseases is it associated to
- type 1 DM
- hyper/hypothyroidism
- Addison's
- osteoporosis
39
COELIAC DISEASE
| tests?
- IgA tissue transglutamase antibodies test (endomysial antibodies)
-Duodenal biopsy
stage 1= increased in intraepithelial lymphocytes
stage 2= crypt hyperplasia
stage 3= flattening and atrophy of villi
40
COELIAC DISEASE
treatment
lifelong gluten free diet
41
IRRITABLE BOWEL SYNDROME
What are the three types
- diarrhoea
- constipation
- mixed
42
IRRITABLE BOWEL SYNDROME
Diagnostic criteria?
recent abdo pan for 1x week for 3 months, PLUS 2 of:
1) relief by defecation
2) Change In habit (urgency)
3) Change in stool appearance
AND bloating, food makes worse, lethargy, mucous in stool
43
IRRITABLE BOWEL SYNDROME
Tests?
- Enquire of red flags to ensure nothing threatening
| - Do faecal calprotectin- if +ve do colonoscopy or if theyre over 50
44
IRRITABLE BOWEL SYNDROME
Lifestyle changes?
Change diet avoid alcohol, fizzy drinks, caffeine
45
IRRITABLE BOWEL SYNDROME
Treatment of Diarrhoea?
Loperamide (bulking agent)
46
IRRITABLE BOWEL SYNDROME
Treatment of constipation?
senna
47
IRRITABLE BOWEL SYNDROME
| Treatment of pain?
1) Hyoscine butyl bromide
2) Amitriptyline
3) CBT
48
ACHALASIA
What is it?
How does it happen?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS)
due to degenerative loss of ganglia from Auerbach's plexus
49
ACHALSIA
Pathology?
Decrease in number of ganglionic nerve cells in oesophageal wall
50
ACHALASIA
Features?
- dysphagia for BOTH solids/liquids
| - regurgitation / heartburn leading to cough / aspiration pneumonia
51
ACHALASIA
Investigations?
oesophageal manometry -
excessive LOS tone which doesn't relax on swallowing
considered the most important diagnostic test
barium swallow
shows grossly expanded oesophagus, fluid level
'bird's beak' appearance
chest x-ray
wide mediastinum
fluid level
52
ACHALASIA
Treatment?
CCBs, Long acting nitrates, BBs (relax oesophageal muscle)
1st - pneumatic (balloon) dilation
2nd - Heller Myotomy
53
JAUNDICE
What is pre-hepatic jaundice
unconjugated hyperbilirubinemia
54
JAUNDICE
What is post- hepatic jaundice
conjugated hyperbilirubinemia
55
JAUNDICE
Causes of pre-hepatic?
- over haemolysis- e.g. Malaria
- impaired hepatic intake (drugs)
- decreased conjugation (gilberts syndrome)
56
JAUNDICE
| Causes of hepatic jaundice
- hepatitis
- drugs
- alcohol
- haemochromatosis
57
Name two causes of post hepatic jaundice?
- gallstones
| - PBC (primary biliary cirrhosis)
58
What is cholestasis?
Impaired hepatic excretion
59
APPENDICTIS
Causes?
Lumen of appendix blocked by faecolith (solid immovable faeces), lymphoid hyperplasia
60
APPENDICTIS
Symptoms?
- Periumbilical pain to RIF (McBurney's)
- anorexia
- vomiting
- flushes
- tachycardia
61
APPENDICTIS
Signs?
rebound tenderness in RIF, guarding
62
APPENDICTIS
Diagnosis?
- CT scan
- Rovsing's sign- pain in RIF increased when LIF pressed
- Psoas Sign - pain on extending hip
- Cope sign- pain on flexion and internal rotation of hip
63
APPENDICTIS
Treatment?
Surgery- appendicectomy
64
PERITONITIS
Cause of Primary?
- spontaneous bacterial peritonitis (SBP)
65
PERITONITIS
Cause of secondary?
- ectopic pregnancy
- appendicitis
- ischaemic colitis
66
PERITONITIS
| Symptoms?
gradual abdominal pain
67
PERITONITIS
Signs?
- guarding
- tenderness
- tachycardia
- silent abdomen
68
PERITONITIS
Investigations?
- CXR
- AXR (rule out obstruction)
- CT
bloods- amylase, increased WCC, B-HGC
69
PERITONITIS
Treat?
- resuscitate (ABCDE)
- treat underlying cause (Abx)
- surgery- repair perforated viscus (tear of Abdo organ)
70
Overdose treatment of Opioid?
- IV naloxone
71
Overdose treatment of Paracetamol
- Activated charcoal
| - N- acetylcysteine
72
What do you give to all people who have overdosed and why
Activated charcoal as it stops absorption in the bowel
73
Treatment of Anaphylaxis? (degranulation of mast cells)
antihistamines, adrenaline, steroids
74
GASTRO-OESOPHAGEAL VARICES?
what ARE THEY?
LOCAL DILATION OF VEINS
75
GASTRO-OESOPHAGEAL VARICES?
How do they occur?
1) Hepatic blood flow impaired (cirrhosis)
2) Pressure in portal vein increased and blood forced into smaller veins
3) Enlarged oesophageal veins elevate the mucosa and protrude into lumen
4) Here, easily traumatised by passing food= acute haemorrhage ( frequent and life- threatening)
76
GASTRO-OESOPHAGEAL VARICES?
Tests?
urgent gastroscopy to find location of bleeding
77
GASTRO-OESOPHAGEAL VARICES?
Treatment?
clotting- vit K and platelets
| Terlipressin (vasopressin analogue)
78
GASTRITIS
| What is it?
inflammation of gastric mucosa (red)
79
GASTRITIS
Cause? Acute/ chronic
H.pylori
Acute= neutrophil infiltration
Chronic= lymphocytes/ macrophages/ mononuclear/ plasma infiltration
80
GASTRITIS
Symptoms?
- Asymptomatic OR
| - epigastric pain/ vomit/ haematemesis
81
GASTRITIS
Treat?
PPIs
| H2 blocker
82
What is Haemochromatosis
excess iron deposits in parenchymal organs
83
Cause of Haemochromatosis
The HFE gene is located on chromosome 6. ...
When a mutant or nonfunctional variant of the HFE gene is present, increased uptake of transferrin occurs and leads to accumulation of iron in cells
84
Diagnosis of Haemochromatosis
1) Increased iron/ferritin
```
liver= hepatomegaly
pancreas= diabetes
skin= bronze discolouration
pituitary= reduced libido
myocardium= cardiomegaly and HF
```
85
How is Haemochromatosis treated
Venesection
86
What is WIlson's Disease
Decreased intake of copper = accumulation in organs
87
Diagnosis of Wilson's
- Increased Copper and increased 24hr urinary copper
88
Organ complications for someone with Wilson's?
liver- cirrhosis
basal ganglia- dementia + Parkinson's
cornea- Fleischer rings (dark rings of bronze colour- copper around iris)
renal tubules
89
Treatment of Wilson's?
Lifelong penicillamine (chelating agent)
90
What is Volvulus?
Twisting of digestive organs which causes constipation
91
How can you tell on an AXR if someone has volvulus?
inverted U bowel looks like 'coffee bean'
92
treatment of Volvulus?
Resuscitation/ laparotomy/ sigmoidoscopy
93
What is Cirrhosis?
a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue.
94
Cause of Cirrhosis?
alcohol
95
treatment of Cirrhosis?
need liver transplant
96
PRIMARY BILIARY CIRRHOSIS
What is it?
- Autoimmune destruction of intrahepatic bile ducts- Cholestasis
97
PRIMARY BILIARY CIRRHOSIS
What is the Epidemiology?
F:M 9:1 and onset average is around 50yrs
98
PRIMARY BILIARY CIRRHOSIS
What is it due to?
- Environmental trigger in genetically susceptible people
99
PRIMARY BILIARY CIRRHOSIS
Main distinguisher?
Antimitochondrial antibodies are PRESENT (AMA)
100
PRIMARY BILIARY CIRRHOSIS
Signs?
1) Pruritis +- jaundice
2) Xanthelasma (yellow lesions of cholesterol)
3) hepatosplenomegaly
4) Xanthomata ( fatty lesions on skin)
5) Fatigue
6) Steatorrhoea - decreased bile
101
PRIMARY BILIARY CIRRHOSIS
Tests?
- AMA test (positive result for PBC)
- IgM
- alkaline phosphate (high)
102
PRIMARY BILIARY CIRRHOSIS
Pathology?
T cells attack on bile duct epithelial cells
103
PRIMARY BILIARY CIRRHOSIS
Treatment?
- Pruritis (itching)- cholestyramine
- Specific
1) Ursodeoxycholic Acid (UDCA)
2) Vitamin Supplements (a, d, k)
3) Eventually liver transplant ( Prognosis is <2 years once jaundice develops without transplant)
104
PRIMARY BILIARY CIRRHOSIS
What is found on biopsy?
- Hepatic granuloma
105
PRIMARY BILIARY CIRRHOSIS
What does it increase the risk of?
- Increased risk of hepatocellular carcinoma
106
VIRAL HEPATITIS
What is it?
Inflammation of the liver
107
VIRAL HEPATITIS
Symptoms of Acute?
<6 months:
- Malaise
-Myalgia
- Upset GI
May have jaundice
- Tender hepatomegaly
- Raised AST, ALT, GGT, ALP
- May have raised bilirubin
- Nausea
108
VIRAL HEPATITIS
Symptoms of Chronic
Acute +- Palmar erythema and clubbing
109
VIRAL HEPATITIS
Investigations?
- Serology and viral PCR
110
VIRAL HEPATITIS
Which type of Viral Hepatitis is DNA?
-B
111
VIRAL HEPATITIS
Which types of Viral Hepatitis are RNA?
A, C, D, E
112
VIRAL HEPATITIS
How are Hepatitis A and E spread?
- Foecal-oral
113
VIRAL HEPATITIS
How are Hepatitis B, C and D spread?
bloodbourne
114
VIRAL HEPATITIS
Risk factors of Hepatitis B, C and D?
- IV drug users
- Healthcare workers
- Sex workers
115
VIRAL HEPATITIS
Risk factors of Hepatitis A?
- travel
- shellfish
- food-handlers
116
VIRAL HEPATITIS
Risk factors of Hepatitis e?
- Contaminated water
- poor sanitation
- farm animals
117
VIRAL HEPATITIS`
| What is the incubation time of Hep A and E?
2-6 weeks
118
VIRAL HEPATITIS
Incubation time of Hep B,C and D?
```
B&D= 1-6 month
C= shorter than HBV
```
119
VIRAL HEPATITIS
Are Hep A/B/C/D/E Acute or Chronic?
```
A= acute
B= acute but can be chronic
C= chronic
D= chronic
E acute but chronic in immunosuppressed
```
120
VIRAL HEPATITIS
Describe the vaccination process of the 5 types
```
A= 100% immunity after vaccination
B = inactivated HBsAg
C= N/A
D= Vaccination against HepB
E= Vaccine available in China
```
121
VIRAL HEPATITIS
Complications of B/C/D?
- Cirrhosis
- HCC
- B&C= cholangiocarcinoma
122
VIRAL HEPATITIS
Complications of hep A and E?
Fulminant hepatitis
123
VIRAL HEPATITIS
Test and treatment of A?
- Anti HAV, IgM and IgG tests
| - self- limiting supportive care and avoid alcohol
124
VIRAL HEPATITIS
tests and treatment of B?
Anti - HB core, IgM, IgG tests
- supportive care and antivirals
- (PEG-IFN, Tenoflavir, Entecavir)
125
VIRAL HEPATITIS
What Antiviral can be used for Hep B/C/D?
- PEG-IFN
126
VIRAL HEPATITIS
What antiviral can be used for chronic C and E?
Ribavirin
127
In all the types of hepatitis what is the main test?
- If there is Antibodies for that type (e.g. HDV antibody if someone has Hep D)
128
What is bile made up of?
- Cholesterol
- Phospholipids
- Bile acids
- Bile pigments
- Electrolytes
- water
129
GALLSTONES
Risk factors of of cholesterol gallstones?
1) Age (8% over 40)
2) Female
3) Obesity
4) Cirrhosis
130
GALLSTONES
Risk factors of pigment gallstones? (<10% of all cases)
haemolytic anaemia
131
what is biliary colic?
pain from cystic duct obstruction
132
GALLSTONES
Symptoms?
1) RUQ/ Epigastric pain (radiating to back/shoulder and subsides after hours)
2) maybe jaundice
133
GALLSTONES
Tests?
1) Ultrasound of abdo
| 2) Bloods have increased alkaline phosphate and bilirubin
134
GALLSTONES
Treatment?
- Analgesia
- Rehydration
- Elective Cholecystectomy
135
ACUTE CHOLECYSTITIS
What is it?
- Impaction of stone into wall of neck of gallbladder
136
ACUTE CHOLECYSTITIS
Difference to biliary colic?
1) Pain doesn't subside
2) Fever, guarding and tenderness
3) Inflammatory (increased WCC)
4) Murphy's Sign- pain on inspiration
137
ACUTE CHOLECYSTITIS
tests?
- FBC (increased WCC)
| - Ultrasound (distended gallbladder)
138
ACUTE CHOLECYSTITIS
Treatment?
- Analgesia
- IV Fluids
- Laparoscopic Cholecystectomy (48 hrs)
139
CHOLANGITIS
What is it?
- infection of the biliary tree, secondary to CBD stones & cholecystitis
140
CHOLANGITIS
Features?
- Charcots Triad
| 1) RUQ pain 2) Fever 3) Obstructive Jaundice (cholestatic)
141
CHOLANGITIS
tests?
1st line= ultrasound
| 2nd (gold standard)= ERCP (imaging and removal of stones)
142
Treatment of CHOLANGITIS?
- Abx ( Cefuroxime & Metronidazole)
143
For Biliary Colic, Acute Cholecystitis and Cholangitis:
do they have RUQ pain, increased WCC and jaundice?
```
BC= RUQ pain
AC= RUQ pain and Increased WCC
Cholangitis= All three (RUQ pain, WCC and jaundice)
```
144
What is Acute Hepatic Failure?
sudden Liver failure in a previously healthy liver
145
What is acute-on-chronic liver failure?
decompensated chronic liver disease
146
What is Fulminant Hepatic Failure?
Huge necrosis of liver cells and severe impairment of function
147
HEPATIC ENCEPHALOPATHY
Pathology?
1) Failing liver leaks out ammonia
2) Ammonia builds up in brain where astrocytes clear it (glutamate into glutamine)
3) Excess glutamine= fluid imbalance= fluid into cells = oedema
148
HEPATIC ENCEPHALOPATHY
What are the 3 grades?
Grade 1= altered moods/ sleep disturbance
Grade 2= Confusion, drowsy, slurred speech
Grade 3= Liver flap, restless = COMA
149
HEPATIC ENCEPHALOPATHY
Causes?
- Hepatitis
- Paracetamol OD
- Alcohol
- Primary Biliary Cirrhosis
- Hemochromatosis/ Wilson's
150
HEPATIC ENCEPHALOPATHY
Signs?
- jaundice
- encephalopathy
- Asterixis/ Flap (tremor hand/ wrist= bird flap)
151
HEPATIC ENCEPHALOPATHY
Tests?
- Bloods (FBC, Hepatitis antibodies, U&E, LFT, clotting, glucose)
- Ultrasound of Abdo
152
HEPATIC ENCEPHALOPATHY
Treatment?
- Monitor bloods and fluid output
| - treat cause and complications
153
COLO-RECTAL CANCER
what is a Polyps?
A polyp is an abnormal growth of tissue projecting from a mucous membrane
154
COLO-RECTAL CANCER
What is HNPCC?
Hereditary Non-polyposis Colorectal Cancer
155
COLO-RECTAL CANCER
How is HNPCC caused?
Mutations in DNA repair genes = increased formation of adenocarcinoma sequence
156
COLO-RECTAL CANCER
What is FAP?
Familial Adenomatous Polyposis
157
COLO-RECTAL CANCER
How is FAP caused?
Mutated APC gene
158
COLO-RECTAL CANCER
Sign of FAP?
hundreds of colorectal polyps in teenage years = 100% chance of colorectal cancer so colectomy is required
159
COLO-RECTAL CANCER
Risk factors?
- AGE
- Smoking
- red meat
- low fibre
- alcohol
- IBD
- HMPCC and APC gene
160
COLO-RECTAL CANCER
What is Dukes staging?
A- Not invaded through muscle wall (93%)
B- Invaded through muscle wall (77%)
C- Local lymph node involvement (48%)
D- Distant Metastases (6.6%)
percentages are the treated survival rates, 2nd biggest cancer killer in the U.K
161
COLO-RECTAL CANCER
Where is it most commonly found?
- rectal and Left colon
162
COLO-RECTAL CANCER
| Signs?
1) Blood and mucous in stool
2) Obstruction (colicky pain, vomit, abdo distension)
3) rectal Mass
4) Weight Loss
5) Thin stool and tenesmus (feeling of needing a bowel movement
163
COLO-RECTAL CANCER
What shows up on blood tests?
- iron deficiency anaemia
| - abnormal LFT's if Liver metastases
164
COLO-RECTAL CANCER
Gold standard investigation?
- Colonoscopy with biopsy
2nd- barium enema
- Check for metastases with CT, if yes, do PET scan
165
COLO-RECTAL CANCER
Treatment?
Dukes A+B= Surgery (part of bowel removed)
Dukes C= pre- op chemo adjunct
Rectal Cancer= pre- op radiotherapy offered
Liver Mets= liver resection
166
OESOPHAGEAL CANCER
Cause?
Barratt's Oesophagus
167
OESOPHAGEAL CANCER
Risks?
smoking, obesity, alcohol, hot drinks
168
OESOPHAGEAL CANCER
Pathology
Adenocarcinoma in distal 1/3
169
OESOPHAGEAL CANCER
Symptoms? (RED FLAG)
- Progressive Dysphagia
- Haematemesis (blood vomit)
- Weight loss
- Melaena (black stool)
170
OESOPHAGEAL CANCER
Diagnosis?
- gastroscopy and biopsy
171
OESOPHAGEAL CANCER
How is the cancer staged?
CT chest/ abdomen +- PET scan
172
OESOPHAGEAL CANCER
Treatment?
oesophagectomy with pre&post op chemo
173
OESOPHAGEAL CANCER
What do palliative patients receive?
stent to help swallowing
174
OESOPHAGEAL CANCER
List the different stages? (order of least to most)
```
T1- Invading Lamina propria
T2- " muscularis propria
T3- " adventitia
T4- " adjacent structures
N0- no nodal spreads
N1- regional node metastases
M0- no distant spreads
M1- distal metastases
```
175
GASTRIC CANCER
Epidemiology?
- 2nd in worldwide cancer deaths
- common in japan
- decreased incidence in U.K
176
GASTRIC CANCER
Pathology?
1) Insult to gastric mucosa= intestinal metaplasia
| 2) genetic changes lead to adenocarcinoma formation
177
GASTRIC CANCER
Symptoms?
- similar to peptic ulcer pain
- weight loss
- nausea
- anorexia
178
GASTRIC CANCER
Risk?
- salty food
- smoking
- pernicious anaemia
H.pylori
179
GASTRIC CANCER
Tests?
Diagnosis? = Gastroscopy and Biopsy
| Staging? CT- (epigastric mass&lymph node in jugular notch on exam)
180
GASTRIC CANCER
Treat?
- surgery with pre/post op chemo
| - laparoscopy before to see any spread not seen in scans
181
GASTRIC CANCER
What is a GIST?
Gastrointestinal stromal tumours (most common stromal tumour)
182
GASTRIC CANCER
How do you treat later staged tumours?
- Treated palliatively
| - removal to relieve symptoms
183
INFECTIVE DIARRHOEA
What is it?
- decreased stool consistency from water&fat (steatorrhoea), or inflammatory discharge
OSMOTIC, SECRETORY OR FUNCTIONAL
184
INFECTIVE DIARRHOEA
Risks?
- elderly
- infants
- travellers
- food workers
- immunocompromised
185
INFECTIVE DIARRHOEA
Cause
virus e.g. Norovirus
Bacteria:
Vomiting= S.aureus, B.cereus
Watery Diarrhoea= Enterotoxigenic E.coli, Rotavirus, V.choloerae
186
INFECTIVE DIARRHOEA
What is A common cause in the U.K
- Campylobacter jejuni (cattle & poultry meats)
187
What bacteria may cause meningitis?
Listeria monocytogenes causes meningitis in the immunocompromised
188
INFECTIVE DIARRHOEA
Treatment?
acute- fluids, electrolytes, loperamide if diarrhoea
189
What Antibiotics are commonly used for treating E.coli infections?
Cefuroxime
190
What Antibiotics are commonly used for treating gram negative infections?
Metronidazole
191
What Antibiotics are commonly used for treating Cholera infections?
tetracycline
192
What Antibiotics are commonly used for treating
Salmonella/shigella/campylobacter
infections?
Ciproflaxin
193
ALCOHOLIC LIVER DISEASE
What are the 3 types and describe each one?
- fatty Liver (triglycerides in Hepatocytes- reversible)
- Alcoholic Hepatitis (triglycerides and Mallory bodies in Hepatocytes)
- Alcoholic Cirrhosis (destruction of Liver/ fibrosis)
194
ALCOHOLIC LIVER DISEASE
Sign?
- rapid jaundice
- increased AST/ALT, bilirubin and prothrombin time
- decreased Albumin
195
ALCOHOLIC LIVER DISEASE
Treatment?
- stop drinking alcohol
| - treat complications
196
Parenchymal causes of Hepatomegaly?
alcoholic, viral Hepatitis, PBC
197
Malignant causes of Hepatomegaly?
tumour and metastases
198
Haematological causes of Hepatosplenomegaly?
lymphoma and leukaemia
199
rare causes of Hepatosplenomegaly?
Amyloidosis
200
infective causes of Splenomegaly?
Glandular fever and Endocarditis
201
ASCITES
What is it?
fluid in peritoneal cavity
202
ASCITES
causes?
Transudate- 1) Portal HTN- cirrhosis 2) HF
Exudate- 1) Malignancy 2) Pancreatitis 3) Peritonitis
203
ASCITES
How does Cirrhosis lead to Ascites?
1) Increased pressure in vessels leads to peripheral vasodilation
2) causes release of AG-II = vasoconstriction and salt/water retention
3) Along with hypalbuminaemia from liver disease = transudate in peritoneal cavity
204
ASCITES
signs?
- distended abdomen
- fluid thrill
- shifting dullness
- fullness in flanks
205
ASCITES
Investigations?
- Aspiration
- Albumin (find if exudate or transudate)
- Neutrophil count (bacterial peritonitis?)
- Gram stain and culture for bacteria
- Cytology for malignant cells
- amylase (check no pancreatitis/ exclude pancreatic exudate)
206
ASCITES
Treatment?
1st line- restrict salt- furosemide- aim to lose 1kg/day
| 2nd line- paracentesis (hollow needle to remove fluid or gas)
207
ASCITES
complications?
bacterial peritonitis - suspect in ascites patient with fever
- check with WCC on ascetic tap
if so treat with IV Cefotaxime
208
HEPATOCELLULAR CARCINOMA
how many cancers of the liver are secondary tumours and what are the causes?
90%
hepB and hepC virus
209
HEPATOCELLULAR CARCINOMA
Features?
Most have Cirrhosis
| + weight loss, fever, anorexia, ascites, RUQ pain
210
Investigation of HEPATOCELLULAR CARCINOMA
- Alpha- fetoprotein increase
| - Ultrasound
211
HEPATOCELLULAR CARCINOMA
treatment?
- percutaneous ablation
| - surgical resection
212
PANCREATIC CARCINOMA
Risk factors and common onset?
Smoking, DM, Chronic Pancreatitis, Alcohol, Obesity
>60 years
213
PANCREATIC CARCINOMA
Features of Cancer Of the head?
Painless Jaundice,
weight loss,
Scratch marks,
Distended bladder
214
PANCREATIC CARCINOMA
Features of cancer of the body/tail?
Epigastric pain radiating and back- relieved by sitting forwards
anorexia and weight loss
215
PANCREATIC CARCINOMA
Investigations?
Ultrasound and CT
216
PANCREATIC CARCINOMA
Treatment?
poor prognosis, most care is palliative
- chemo and radiotherapy
- 5yr survival= 3%
217
PANCREATIC CARCINOMA
Treatment of palliative patient?
ERCP
(Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems.)
218
ACUTE PANCREATITIS
Aetiology?
```
Gallstones
Ethanol (alcohol)
Trauma
Steroids
M
Autoimmune
Scorpion venom
Hyperlipidaemia
ERCP
Drugs
```
219
ACUTE PANCREATITIS
Pathology?
1) Increased calcium
2) Increased proteases and pancreatic enzymes
3) Migration of inflammatory cells, mediators ands cytokines
220
ACUTE PANCREATITIS
Symptoms
- vomiting
| - severe epigastric pain radiating to back
221
ACUTE PANCREATITIS
Signs?
SEVERE= grey- turners Sign (flank bruising) and Cullen's Sign (umbilical bleeding)
- tenderness and guarding
- Tachycardia
- Fever
- increased amylase
222
ACUTE PANCREATITIS
Investigations?
- FBC, LFT U&E, CRP
- CXR- exclude peptic ulcer
- Abdo US/CT/MRI to confirm
223
ACUTE PANCREATITIS
Treatment?
Analgesia, O2, IV fluids, NG nutrition
224
CHRONIC PANCREATITIS
What is it?
Irreversible, inappropriate activation of enzymes
225
CHRONIC PANCREATITIS
Cause?
-Alcohol ,CF, Autoimmune
226
CHRONIC PANCREATITIS
Signs?
- epigastric pain radiating to back
- weight loss
- diabetes
- steatorrhoea
- jaundice!
pancreatic calcification
227
Tests of CHRONIC PANCREATITIS?
ABDO US/CT
228
CHRONIC PANCREATITIS
Treatment?
- analgesia
- no alcohol
- surgery
229
GASTRIC CANCER
What is Bowman’s staging?
Type 1= tumour polyp
Type 2= ulcerated tumour
Type 3= ulcerating and infiltrating
Type 4= diffusely infiltrative carcinoma
230
DIVERTICULAR DISEASE
What is Diverticulum?
An outpouching of gut wall, sites of entry of perforating arteries
231
DIVERTICULAR DISEASE
What is Diverticulosis?
presence of diverticula
232
DIVERTICULAR DISEASE
What is Diverticulitis?
Inflammation of diverticula (when faeces obstructs the diverticula)
233
DIVERTICULAR DISEASE
Aetiology?
1) low fibre = intracolic pressure increase
| 2) = herniation of mucosa @ BV's
234
DIVERTICULAR DISEASE
It is commonly asymptomatic but found on barium enema/ colonoscopy, what are other possible signs?
- LIF pain
- fever
- nausea
- perforation causes an abscess (bad)
OR
- intestinal obstruction (bad)
235
DIVERTICULAR DISEASE
Diagnosis?
CT
236
DIVERTICULAR DISEASE
Treatment of:
Diverticulosis?
Diverticulitis?
Diverticulosis- high fibre diet and paracetamol
Diverticulitis- Abx & surgery if complications
237
OBSTRUCTION
Causes? (small and large bowel)
Small bowel- hernias and adhesions
large- colon cancer, constipation,, diverticula, volvulus
238
OBSTRUCTION
Features?
1) Colicky pain
2) Vomiting
3) Constipation
4) Distension
239
OBSTRUCTION
Features of small bowel obstruction?
- early vomit
- late constipation
- less distension
- pain higher on abdomen
240
OBSTRUCTION
Features of large bowel obstruction?
- more constant pain
- vomiting late
- early constipation
241
OBSTRUCTION
Describe the AXR?
small bowel obstruction X-ray:
- central gas shadow
- plicae circularis across whole bowel
Large bowel obstruction X-ray:
- peripheral gas shadows
- haustra not completely across width
242
Describe simple Obstruction?
1 obstruction , no vascular compromise
243
Describe closed-loop obstruction?
2 obstructions, distended bowel/ high risk of perforation
244
Describe strangulated obstruction?
blood supply compromised, very ill and painful
245
What is Ileus Obstruction?
functional obstruction from reduced motility - no pain and no bowel sounds
246
Treatment of Ileus and Small bowel Obstruction?
TREATED conservatively
247
Treatment of strangulated and large bowel Obstruction?
surgery
+
1) Nasogastric tube for nutritional support
2) Pain relief
248
Tests for obstruction?
- AXR/CXR
| - Bloods
249
MESENTERIC ISCHAEMIA
Signs? (classic traid)
- possible AF
1) abdo pain
2) not really any signs
3) Hypovolaemic shock
- increased WCC
250
MESENTERIC ISCHAEMIA
Test and sign of Ischaemic Colitis?
- bloody diarrhoea
confirmed by colonoscopy and biopsy
251
MESENTERIC ISCHAEMIA
Treatment?
- surgery
- fluids
- Abx
252
What are haemorrhoids?
DISRUPTED AND DILATED ANAL CUSHIONS
253
Describe how piles form and what turns these into haemorrhoids?
1) Straining while passing stool and stress can cause anal cushions to become loose and bulky, causing them to protrude (piles)
2) They are then vulnerable to trauma and bleed = haemorrhoids
254
How are haemorrhoids classified?
1st degree- remain in rectum
2nd degree- prolapse on defecation but reduce
3rd degree- prolapse and placing back manually
4th degree- remain prolapsed
255
How do haemorrhoids present and how would you investigate?
- Bright red, painless rectal bleeding, coats stool and on tissue/ drips after
- abdo and PR exam
256
What is the 1st and 2nd line treatments of haemorrhoids?
1st - stool softener, increased fluid/fibre
2nd- non- operative but invasive- rubber band ligation
257
What can cause an anorectal abscess? what would you do to investigate and treat?
- Crohn's
- diverticular disease
- give MRI
- treat with fistulotomy
258
What can an anorectal abscess lead to?
anal fistula
259
GIve 3 causes and the treatment of Pruritis ani
- threadworm, poor hygiene, tight underwear
| - treated with better hygiene and anaesthetic cream
260
Name the ALARMS symptoms?
- Bleeding
- Vomiting
- Fever
- Weight Loss
- Dysphagia
Chest Pain
BCDFVW
261
What is the AST/ALT ratio
The AST/ALT ratio is the ratio between the concentrations of the enzymes aspartate transaminase (AST) and alanine transaminase, aka alanine aminotransferase (ALT).
It can show possible liver damage e.g.
AST:ALT ratio of more than 2:0 is suggestive of alcoholic liver disease
262
What is ERCP
Endoscopic retrograde cholangiopancreatography
263
What is Cholestasis
decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile ducts
