Gen Surg / GI 2 Flashcards

1
Q

What is primary biliary cholangitis?

A

chronic liver disorder
typically in middle aged females
damage of interlobular bile ducts
progressive cholestasis

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2
Q

What conditions is primary biliary cholangitis associated with?

A

Sjogren’s syndrome
rheumatoid arthritis
systemic sclerosis
thyroid disease

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3
Q

What are the clinical features of primary biliary cholangitis?

A

early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus
cholestatic jaundice
hyperpigmentation, especially over pressure points
around 10% of patients have right upper quadrant pain
xanthelasmas, xanthomata
also: clubbing, hepatosplenomegaly

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4
Q

What is a possible late complication of primary biliary cholangitis?

A

liver failure
cirrhosis → portal hypertension → ascites, variceal haemorrhage
osteomalacia and osteoporosis
significantly increased risk of hepatocellular carcinoma (20-fold increased risk)

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5
Q

How is primary biliary cholangitis diagnosed?

A

immunology
- AMA M2 (anti-mitochondrial antibodies)
- raised serum IgM
imaging
- to exclude biliary obstruction

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6
Q

How is primary biliary cholangitis managed?

A

first line - ursodeoxycholic acid - slows disease progression, improves symptoms

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7
Q

What is the M rule in primary biliary cholangitis?

A

IgM
anti-mitochondrial antibodies M2
middle aged females

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8
Q

What patients typically present with autoimmune hepatitis?

A

young females
with other autoimmune conditions

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9
Q

What is the main cause of chronic pancreatitis?

A

alcohol excess

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10
Q

Which pancreatic function is affected in chronic pancreatitis?

A

both endocrine and exocrine

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11
Q

What are some non-alcohol related causes of chronic pancreatitis?

A

genetic - cystic fibrosis, haemochromatosis
ductal obstruction - annular pancreas, tumours, stones

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12
Q

What are the features of chronic pancreatitis?

A

pain - worse 15-30 mins following a meal
steatorrhoea - too much fat in stool - onset 5-25 years after onset of pain
DM - 20 years after onset of symptoms

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13
Q

How is chronic pancreatitis investigated?

A

abdo XR - calcification
CT - calcification
functional tests - faecal elastase

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14
Q

How is chronic pancreatitis managed?

A

pancreatic enzyme supplements
analgesia
antioxidants

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15
Q

What is primary sclerosis cholangitis?

A

inflammation and fibrosis of intra and extra-hepatic bile ducts

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16
Q

What condition is primary sclerosing cholangitis mostly associated with?

A

ulcerative colitis

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17
Q

What are the features of primary sclerosing cholangitis?

A

cholestasis - jaundice, raised ALP and bilirubin
RUQ pain
fatigue

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18
Q

How is primary sclerosing cholangitis diagnosed?

A

ERCP / MRCP - ‘beaded’ appearance of biliary tree (strictures)

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19
Q

How does pancreatic cancer present?

A

painless jaundice - pale stools, dark urine
cholestatic LFTs
abdominal mass - hepatomegaly (mets), gallbladder, epigastric mass
non-specific constitutional symptoms
loss of exocrine function - steatorrhoea
loss of endocrine function - DM
atypical back pain (mets?)
migratory thrombophlebitis

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20
Q

How is pancreatic cancer investigated?

A

USS
high res CT - double duct sign (simultaneous dilaatation of CBD and pancreatic duct)

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21
Q

How is pancreatic cancer managed?

A

Whipple’s resection - pancreaticoduodenectomy
adjuvant chemo
ERCP + stent

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22
Q

What is anal fissure?

A

tear in the mucosal lining of the anal canal

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23
Q

What is acute anal fissure?

A

less than 6 weeks

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24
Q

What is chronic anal fissure?

A

more than 6 weeks

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25
Q

What are the risk factors for anal fissure?

A

constipation
IBD
STI - e.g. HIV, syphillis, herpes

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26
Q

What are the features of anal fissure?

A

painful, bright red PR bleeding

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27
Q

Where does the majority of anal fissures occur?

A

posterior midline

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28
Q

What condition must be considered if anal fissure is in an unusual location (e.g. lateral)?

A

Crohn’s, other conditions

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29
Q

How is acute anal fissure managed?

A

soften stool
- high fibre, high fluid intake
- bulk-forming laxatives
lubricants prior to defecation (e.g. petroleum jelly)
topical anaesthetics
analgesia

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30
Q

How is chronic anal fissure managed?

A

continue with management as in acute
first line - topical GTN
second line - botulinum toxin / surgery (sphincterotomy)

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31
Q

Where is haemorrhoidal tissue located?

A

3, 7, 11 o clock

32
Q

What are the clinical features of haemorrhoids?

A

painless rectal bleeding
pruritus
pain - usually after thrombosed
soiling (third and fourth degree)

33
Q

What are the two main types of haemorrhoids?

A

internal
external

34
Q

What are internal haemorrhoids?

A

originate above the dentate line
do not usually cause pain

35
Q

What are external haemorrhoids?

A

originate below the dentate line
prone to thrombosis
may cause pain

36
Q

What are the 4 grades of internal haemorrhoids?

A

1 - do not prolapse out of the anal canal
2 - prolapse on defecation, reduce spontaneously
3 - can be manually reduced
4 - cannot be reduced

37
Q

How are haemorrhoids managed?

A

soften stools - high fibre and fluid intake
topical local anaesthetics and steroids
rubber band ligation
surgery - for large symptomatic haemorrhoids
doppler guided haemorrhoidal artery ligation
stapled haemorrhoidoplexy

38
Q

What is perianal abscess?

A

collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter
origin - plugging of anal ducts

39
Q

What is the epidemiology of perianal abscess?

A

most common type of anorectal abscess
more common in men
around 40 y.o.

40
Q

What are the features of perianal abscess?

A

pain around anus, worse on sitting
swollen, hardened tissue in anal region
pus-like discharge from anus, possible bleeding
systemic infection - if abscess long-standing -> sepsis!

on examination - erythematous, tender swelling

41
Q

What are the causes of perianal abscess?

A

colonised by gut flora (e.g. E.coli)

42
Q

How is perianal abscess investigated?

A

inspection of anus, DRE
colonoscopy
blood tests - potential cause (incl. HbA1c - underlying DM)
MRI pelvis - gold standard

43
Q

What conditions are associated with perianal abscesses?

A

Crohn’s
DM - impaired wound healing
underlying malignancy

44
Q

What are the most common underlying causes of fistulas?

A

Crohn’s
diverticular disease

45
Q

What are the four main types of fistulas?

A

enterocutaneous
enteroenteric / enterocolic
enterovaginal
enterovesicular

46
Q

What is enterocutaneous fistula?

A

link between intestine and skin
high (>500mL) output
- duodenal / jejunal
low (<500mL) output
- colo-cutaneous - faeculent

47
Q

How are fistulas managed?

A

conservative - best if no IBD or distal obstruction
stoma - if skin involvement
ocreotide - high output fistula
TPN - for high jejunal / duodenal

48
Q

What are the characteristic features of ulcerative colitis?

A

inflammation starts at rectum
never spreads beyond ileocaecal valve
continuous

49
Q

What is the peak incidence (years) for ulcerative colitis?

A

15-25
55-65

50
Q

What is the typical initial presentation in ulcerative colitis?

A

bloody diarrhoea
urgency
tenesmus
LLQ pain
extra-abdominal features

51
Q

What are the extra-intestinal features of IBD?

A

arthritis - pauciarticular, assymetric
erythema nodosum
episcleritis
osteoporosis

52
Q

How is ulcerative colitis diagnosed?

A

colonoscopy + biopsy
if severe colitis - avoid colonoscopy for risk of perforation
- flexible sigmoidoscopy instead

53
Q

What are the typical findings on colonoscopy in ulcerative colitis?

A

red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent

54
Q

What features are typical for ulcerative colitis with barium enema?

A

loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’

55
Q

What are some possible triggers for UC flares?

A

no identifiable trigger
stress
medications
- NSAIDs
- ATBs
smoking cessation

56
Q

How are UC flares classified?

A

mild
moderate
severe

57
Q

What are mild UC flares?

A

Fewer than four stools daily, with or without blood

No systemic disturbance

Normal erythrocyte sedimentation rate and C-reactive protein values

58
Q

What are moderate UC flares

A

Four to six stools a day, with minimal systemic disturbanc

59
Q

What are severe UC flares?

A

More than six stools a day, containing blood

Evidence of systemic disturbance, e.g.
fever
tachycardia
abdominal tenderness, distension or reduced bowel sounds
anaemia
hypoalbuminaemia

60
Q

When should patients with UC flares be admitted?

A

severe disease

61
Q

What is the typical presentation of anal fissure?

A

intense pain post-defecation - lasts several hours
bleeding - bright red, on wiping
itching

palpable / visible on examination

62
Q

What examination, other than DRE, might be necessary in anal fissure? Why?

A

EUA - examination under anaesthesia
due to intense pain

63
Q

How can anal fissures be diagnosed, other than via DRE?

A

proctoscopy

64
Q

What are some Dx for anal fissure?

A

haemorrhoids
Crohn’s
UC
anal cancer

65
Q

What is the medical management of anal fissures?

A

treatment of underlying precipitating factors
analgesia
fibre intake, fluid intake
stool-softening laxatives
topical anaesthetic

66
Q

What topical medication can be used in symptomatic patients with anal fissure?

A

topical lidocaine
GTN cream - but gives headaches, so not used anymore
diltiazem cream

67
Q

When is surgical treatment used in anal fissures?

A

chronic fissure
once medical management has failed

68
Q

What is the initial invasive / surgical management option for anal fissures?

A

botox injections

69
Q

What is the surgical management option for patients with anal fissure who do not respond to any previous treatment?

A

lateral sphincterectomy - division of internal anal sphincter muscle

70
Q

What is the percentage of recurrence of anal fissures post surgery?

A

1-5%

71
Q

How is perianal abscess managed?

A

ATB
analgesia
incision and drainage of abscess

72
Q

What are the surgical management options for perianal abscess?

A

incision and drainage
with intra-operative proctoscopy - to check for fistulas

73
Q

What complication are perianal abscesses associated with?

A

perianal fistula formation

74
Q

What is a perianal fistula?

A

abnormal connection between anal canal and perianal skin

75
Q

What are most perianal fistulas associated with?

A

perianal abscess

76
Q
A