Gastrointestinal Week 3 Flashcards
What’s is charcots triad and its significance?
Jaundice, fever, rigors. Suggests cholangitis
what kind of organ typically cause colicky pain
hollow, tube muscular type organs like bowel, or gall bladder
how what a peritonitis pain present
patient would say that pain is worse on movement
what kind of pain will start at the front at go to the back and to the right shoulder?
gallbladder
where does pancreas pain often radiate to
to the back
an abdominal pain that comes and stays at around the same intensity in the epigastric region - what is the first ddx?
peptic ulcer
what kind of pain is acute cholescytistis
constant pain
what foods often aggravate cholescystitis
fatty foods
what kind of foods will aggravate a peptic ulcer
citrus, spicy food
where in the GI would melena suggest its origin from?
upper GI
what pathology is tenesmus associated with
cancer
colitis
IBS
what is GET SMASHED
risk factors for pancreatitis
gall stones
ethanol
trauma
steroids mumps autoimmune scorpion venom hyperlipidaemia/hypercalcaemia/hyperparathyroidism ERCP Drugs
why do you get swollen ankles with hepatitis
reduced albumin synthesis
what GI diseases are related to clubbing
IBD (crohns, UC), primary biliary cirrhosis, malabsorption (celiac), cirrhosis
difference between telangiectasia and spider naevi
telangiectasia fill from outside in. spider naevi from inside out. can differentiate by pressing on it
what are kayser fleischer rings indicative of
wilsons disease, copper retention
what does angle stomatitis indicate
iron deficiency anaemia
what does glossitis indicate
iron/b12/folate deficiency
what is rovsing’s sign
push left side, if right side pain then positive rovsing sign, may be appendicitis
complications with GORD
esfgitis
peptic ulcer
benign strictures
barrett’s esfgs
difference between duodenal ulcer and peptic ulcer in regards to pain relief
duodenal ulcers are usually relieved by eating, vs peptic ulcers which are often relieved by lying down or vomiting
complications in peptic ulcer
erosion, perforation, peritonitis
difference between crohn’s and UC
UC assoc w cancer
crohns have skip lesions, UC is continuous
Uc affects large colon, crohn’s anywhere in GI
crohn’s affect transmurally, while UC is just surface
bloody stool is common in UC or CD?
UC
how does CF affect the pancreas
thickened secretions block ducts
what are the SSS CCC TTT F to describe a lump
size
shape
site
color
consistency
contour
transilluminance
tethering
tenderness
fluctuance
contents of the spermatic cord
piles dont contribute to a good sex life
pimpiniform plexus ductus deference cremasteric artery testicular artery artery of ductus deferens genital branch of the genito femoral nerve sympathetic nerves lymphatics
what forms the inguinal canal? (ant/post/floor/roof)
anterior wall - external oblique
posterior - fascoa transversalis
roof - conjoint tendon
floor - inguinal ligament
difference between a direct and indirect hernia
direct hernia goes through the abdominal wall away from the inguinal canal
indirect hernia goes through the deep ring of the inguinal canal and out through the superficial ring
where does a femoral hernia happen
below inguinal canal, lateral to pubic tubercle, through femoral ring and into femoral canal
how to conduct a hernia exam
patient standing, expose testicles if male
inspect patient, cough
palpate lump
lie down, fingers on lump and cough, if hernia reappears is direct hernia
3 things that can happen to a hernia
reducible - can be pushed back in
incarcerated - stuck between structures
strangulated - stuck with blood flow cut off
what does a bag of worms in the testicles mean
varicocele (enlargement of pampiniform plexus)
who gets femoral hernias more often
women
what position should a patient be in when doing a DRE
lying on side with knees tucked in
what is hematochezia
fresh red blood from rectum with stool
what is the most common cause of UGI bleeding
Peptic ulcer disease
what kind of bleed arises from a PUD bleed
fresh red blood
what is a mallory weiss tear
tear in esfgs at junction between stomach and esfgs
what bloods are important in massive GI bleed cases
HB, ABG, cross match, LFTs, coagulation
what is “fluid challenge”?
give 500ml crystalloid then assess condition again after
noteworthy history to take in GI bleed case
previous episode previous endoscopy drug history chronic liver dz state family history
what drugs can exacerbate GI bleeds
antiplatelets
anticoagulatives
options for treating GI bleed after initial stabilisation
endoscopic therapy including adrenaline injection in situ, heat energy therapy, clips
what drugs should be prescribed after PUD bleed?
IV PPI for 3 days
antibiotics if H pylori +ve
how large dilatations in small and big bowel to be considered obstruction
> 6cm for colon, >9cm for caecum
>3cm in small bowel in at least 3 places
what level is the transpyloric plane (rib and spinal level)
L1 // 9th rib
which vein supply the portal vein
sup and inferior mesenteric veins
why do you get dark urine and pale stools in biliary obstruction?
bilirubin is usually excreted through the faeces through a process done by the liver, however in biliary obstruction, the bilirubin is unable to reach the intestine and hence high amounts of soluble conjugated bilirubin enter the circulation which are then excreted by the kidneys.
pale stools because the bilirubin is unable to reach the stools
genetic mutation that causes decreased activity of protein which helps conjugate bilirubin in the liver, leading to impaired excretion and build up
what is gilbert’s syndrome
route of transmissions of hepatitis viruses A B C E
A and E, oral faecal, shellfish and pork
B blood born/sex IVDU
C IVDU, blood, sex
how does sphincter of oddi dysfunction cause issues
failure to relax causes build up of bile in the CBD
what is courvoisier’s law
painless jaundice + palpable GB = malignancy of pancreas or biliary tree, until proven otherwise
which cells in the pancreas are responsible for its exocrine and endocrine functions
islets of langerhans - endocrine
acinar cells - exocrine
loss of pancreatic function leads to what kind of stool?
steatorrhea
what imaging can be used for pancreatic investigations
CT/MRCP
EUS
what levels are tested for in LFTs (5)
GGT ALT Alk phos albumin bilirubin
what is the most reliable marker of liver function
PT/INR
what is the healthy range for INR in a normal person and someone on warfarin
<1.1 for normal
2-3.0 for warfarin therapy
albumin goes down in malnutrition - T or false
False, except in kwashiokor which is protein malnutrition
what is ALT a marker of?
marker of liver cell death.
if ALT is raised, what else can cause it other than liver cell death
muscle/heart
what is alk phos a marker of in relation to liver function
goes up if damage is in bile duct, gives an obstructive picture of liver function
what else can a raised alk phos mean if not liver related?
raised in high bone resorption also
what is GGT typically used in conjunction with and what do they suggest?
a raised ALT or alk phos should be seen with raised GGT to suggest any liver issues.
if ALT/alk phos is raised without GGT rise, then likely to be non-liver related
whats the right investigation for suspected obstruction?
Ultrasound
CT/MCRP
what is the LFT picture for fulminant liver failure?
ALT very raised
alk phos may or may not be raised
PT raised
if PT is raised, other than liver failure, what can be the cause?
vitamin K deficiency
case 1 on LFTs
39M, prev well
3 days lethargy, achy
pale stool and dark urine
LFTs GGT 546 ALT 2554 Alk phos 228 bili 78 albumin 46
PT normal
what investigations to do? and why?
serology test - viral hepatitis?
case 2 on LFTs
77M, hx of renal cell cancer surgery
PC with sudden onset abdo pain
GGT 215 ALT 25 alk phos 173 bili 30 albumin 45
what picture is this? what investigations should you do?
obstructive - do ultrasound
ERCPs are a diagnostic procedure - T or F
false, risky, only do for treatment
Case 3 LFTs
65M hx of colon cancy and colectomy
GGT 233 alt 25 alp 154 bili 11 albumin 46
what picture is this? what investigation?
slight obstructive picture w normal bilirubin
US
case 4
unwell, abdo pain, swelling, leg edema
GGT 249 ALT 99 alk phos 270 bili 42 albumin 18
what picture is this? what further investigations?
mixed picture, PT, platelets
=> cirrhosis?
what LFT picture does alcoholic cirrhosis give?
obstructive picture
case 5 LFT
77M recently treated for UTI w co-amoxiclav
jaundice and itch
GGT 52 ALT 690 alk phos 148 bili 291 albumin 31
what picture is this? what causes are we thinking about? what further investigations?
hepatitic picture, could be drug induced? do acute liver screen for other causes, autoimmune?
why do acutely very raised LFTs sometimes go down very quickly after a few days?
liver cells have died to the point where there is nothing left to give a bad reading
what are the steps for a MUST assessment?
M - BMI
U - unexplained weight loss
S - acute disease
T - add up the scores to obtain overall risk
what MUST score warrants referral to dietitian?
2 or more
how much unplanned weight loss in the last 3-6 months gives a score of 2? on the MUST assessment tool
more than 10% of weight
what investigations are done for suspected GI cancer?
CT, PET, EUS, Laproscopy
who should always have gastroscopy for dyspepsia?
> 55 with indigestion
older >50M with severe abdomen and back pain, what are we thinking of?
AAA or renal colic
in abdo pain what systems are we thinking about
Gi, gynae, urinary
what kind of pain can testicular torsion present with
abdo pain
how is suspected appendicitis investigated
USS or CT
what kind of pain is characteristic of biliary conditions
colicky, comes in waves, pain.
worse after eating fatty foods
where is PUD pain usually located
epigastric
in small bowel obstruction why is surgical hx important?
surgical adhesions
how to differentiate pneumoperitnoeum from gastric bubble?
gastric bubble is dark but hazy and blends into stomach opacity
what can a large pneumoperitoneum indicate?
bowel perforation
what kind a small amount of gas under the diaphragm be caused by?
recent laproscopic surgery, Co2
if suspected bowel perf, what kind of xray to get?
erect CXR
what is the systematic way to interpret an AXR
projection + patient deets + adequacy
obvious abnormalities
systematic observation from rectum and up noting any dilatations, wall thickening.
others like foreign bodies and bones
what is the normal limits of bowel dilatations SB, LB
LB - 6cm, or 9 for caecum
SB - 3cm
how to tell if dilatation is small bowel or large bowel
look at valvulae conniventes if present, then SBO
look for haustra, if present then LBO
presentation of SBO
abdo pain, abdo distension, vomitting, absolute constipation, lack of bowel sounds or tinkling sounds
why is a patent ileocaecal valve good in bowel obstruction
then backlog of gas can fill up the small bowel as well to reduce pressure and perforation risk
how to tell if sigmoid or caecal volvulus?
left side is sigmoid, coffee been shape
right side is caecal, kidney bean shape
how to see inflamed bowel wall?
“thumb printing” sign, bowel wall thickening
how to differentiate between IBS and IBD
IBS has no bloody stool
IBS has bloating, IBD doesn’t
IBS abdominal pain is relieved by passing stool
IBD has more systemic symptoms like fever, fatigue, weight loss, change in appetite
Is IBS usually associated with change in appetite?
no
what environmental factor is commonly associated with IBS
stress
How to tell if someone has UC gastroenteritis
Stool cultures
If someone has symptoms suggesting UC flare, what should be done to rule out what ?
Rule out gastroneteritis by doing a stool culture
Why can gastroenteritis look like uc?
pain, diarrhea; sometimes fever
what skin conditions can you get with IBD
pyoderma gangrenosum
what is koilonychia and what does it present
curved nails - irond deficiency anaemia
what is leukonychia and what does it typically present
white nails - chronic liver disease
what is koilonychia and what does it present
curved nails - irond deficiency anaemia
what is leukonychia and what does it typically present
white nails - chronic liver disease
what is painless jaundice suggestive of?
malignancy
5 F’s that can cause distended abdomen
Fluid fat fetus fletus faeces
What signs will u get on abdomen palpation if someone has peritonitis
Rebound tenderness, guarding, percussion tenderness
what is the criteria used to diagnose IBS?
ROME IV criteria
abdo pain at least once a week for 3 months, related to change in stool frequency, change in stool form and pain related to defecation
what is important to rule out before diagnosing IBS?
IBD gastric cancer gastric ulcers diverticulitis appendicitis GB problems medications gastroenteritis coeliac disease gynaecological conditions
what 2 specific blood tests are important in diagnosing IBS
CRP and fecal calprotectin - rule out IBD
red flag symptoms in GI presentations
onset after 50 y/o rectal bleeding/bloody stool nocturnal diarrhea progressive abdo pain weight loss family hx of colorectal cancer or IBD blood markers - anaemia, raised CRP, raised fecal calprotectin
3 types of laxatives
bulk forming e.g. husk
stimulating e.g. senna
osmotic e.g. macrogol
red flags in someone with constipation
tenesmus
rectal bleeding
anaemia
weight loss
what is important in managing someone with constipation?
find out what out the cause is
difference in microscopic pathology between crohn’s and UC
crohns commonly have granulomas
UC has crypt cell abscess, goblet cell depletion and no granulomata
difference between macroscopic pathology between crohn’s and UC
crohns - skip lesions, mouth to anus, transmural involvement
UC - continuous, only in colon, red mucosa, easily bleeding,
what will bloods look like in IBD?
commonly anaemic - of chronic disease or iron def, or b12/folate def.
raised inflammatory markers,
what is the diagnostic procedure for IBD
colonscopy + biopsy
what other organs are commonly affected in IBD
eyes, skin, joints, hepatobiliary, kidney
what eye conditions are associated with IBD
episcleritis, uveitis, conjunctivitis
what skin conditions are associated with IBD
erythema nodosum, pyoderma grangrenosum
describe erythema nodosum
macula patches, often on shin, often painful
what joint conditions are associated with IBD?
ankylosing spondylitis
small joint arthritis
investigations done in suspected IBD
bloods - CRP, ESR, FBC
rule out colon cancer - imaging (AXR, CT, scopes)
stool cultures
PR exam
someone presenting with a palpable epigastric mass with a palpable lymph node at the supraclavicular fossa - what is the diagnosis to think about?
gastric cancer
what medication is known to cause peptic ulcerations
NSAIDs
4 common causes of haematemesis
gastric/duodenal ulcer
mallory weiss tear
esfgeal varicies
reflex esophagitis
what blood tests can be done to detect excess alcohol drinking?
elevated gamma-GT and raised MCV or blood/urine alcohol level
signs of wernicke’s encaphalopathy
ecephalopathy, delirium, ataxia, nystagmus
mediciation used in alcohol withdrawal
chlordiazepoxide
what is the most common reason for an LFT reading of ALT > 1000 ?
paracetamol overdose
what causes primary biliary cirrhosis?
autoimmune
symptoms of primary biliary cirrhosis?
puritis
+/- jaundice
hepatosplenomegaly
xanthelasma
describe the pain of biliary colic
severe pain in upper abdomen - comes and goes, and gets better after hours
can radiate to right shoulder
can be assoc with vomiting
investigations for suspected biliary colic?
history
US
LFTs -> increased ALP
absence of inflammatory markers
when to suspect cholecystitis over biliary colic?
when pain progresses over hours
systemic signs of inflammation (fever, fatigue etc)
murphy’s sign +ve
abnormal WCC, LFTs
US showing gallstone with distended GB
investigation in suspected pancreatitis
bloods - raised amylase, FBC, CRP, urea, LFTS, U&Es,
US
what does ecchymoses around the umbilicus and flank suggest?
cullen’s sign and Grey Turners - pancreatitis
why do LFTs often show obstructive pattern in alcoholic liver cirrhosis?
inra-hepatic obstruction
difference in symptoms of viral gastroenteritis and bacterial gastroenteritis?
bacterial GES is more severe, sometimes with bloody diarrhea, lasts longer
what is achlorhydria?
absence of hydrochloric acid in gastric secretions
why are PPIs a risk factor for gastroenteritis
reduced acidity in the stomach can allow bacteria/viruses to proliferate and cause disease
what MUST score should you refer to dietician?
2 or more
