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Gen Surg / GI 2 Flashcards

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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
What are the risk factors for anal fissure?
constipation IBD STI - e.g. HIV, syphillis, herpes
26
What are the features of anal fissure?
painful, bright red PR bleeding
27
Where does the majority of anal fissures occur?
posterior midline
28
What condition must be considered if anal fissure is in an unusual location (e.g. lateral)?
Crohn's, other conditions
29
How is acute anal fissure managed?
soften stool - high fibre, high fluid intake - bulk-forming laxatives lubricants prior to defecation (e.g. petroleum jelly) topical anaesthetics analgesia
30
How is chronic anal fissure managed?
continue with management as in acute first line - topical GTN second line - botulinum toxin / surgery (sphincterotomy)
31
Where is haemorrhoidal tissue located?
3, 7, 11 o clock
32
What are the clinical features of haemorrhoids?
painless rectal bleeding pruritus pain - usually after thrombosed soiling (third and fourth degree)
33
What are the two main types of haemorrhoids?
internal external
34
What are internal haemorrhoids?
originate above the dentate line do not usually cause pain
35
What are external haemorrhoids?
originate below the dentate line prone to thrombosis may cause pain
36
What are the 4 grades of internal haemorrhoids?
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
How are haemorrhoids managed?
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
What is perianal abscess?
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
What is the epidemiology of perianal abscess?
most common type of anorectal abscess more common in men around 40 y.o.
40
What are the features of perianal abscess?
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
What are the causes of perianal abscess?
colonised by gut flora (e.g. E.coli)
42
How is perianal abscess investigated?
inspection of anus, DRE colonoscopy blood tests - potential cause (incl. HbA1c - underlying DM) MRI pelvis - gold standard
43
What conditions are associated with perianal abscesses?
Crohn's DM - impaired wound healing underlying malignancy
44
What are the most common underlying causes of fistulas?
Crohn's diverticular disease
45
What are the four main types of fistulas?
enterocutaneous enteroenteric / enterocolic enterovaginal enterovesicular
46
What is enterocutaneous fistula?
link between intestine and skin high (>500mL) output - duodenal / jejunal low (<500mL) output - colo-cutaneous - faeculent
47
How are fistulas managed?
conservative - best if no IBD or distal obstruction stoma - if skin involvement ocreotide - high output fistula TPN - for high jejunal / duodenal
48
What are the characteristic features of ulcerative colitis?
inflammation starts at rectum never spreads beyond ileocaecal valve continuous
49
What is the peak incidence (years) for ulcerative colitis?
15-25 55-65
50
What is the typical initial presentation in ulcerative colitis?
bloody diarrhoea urgency tenesmus LLQ pain extra-abdominal features
51
What are the extra-intestinal features of IBD?
arthritis - pauciarticular, assymetric erythema nodosum episcleritis osteoporosis
52
How is ulcerative colitis diagnosed?
colonoscopy + biopsy if severe colitis - avoid colonoscopy for risk of perforation - flexible sigmoidoscopy instead
53
What are the typical findings on colonoscopy in ulcerative colitis?
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
What features are typical for ulcerative colitis with barium enema?
loss of haustrations superficial ulceration, 'pseudopolyps' long standing disease: colon is narrow and short -'drainpipe colon'
55
What are some possible triggers for UC flares?
no identifiable trigger stress medications - NSAIDs - ATBs smoking cessation
56
How are UC flares classified?
mild moderate severe
57
What are mild UC flares?
Fewer than four stools daily, with or without blood No systemic disturbance Normal erythrocyte sedimentation rate and C-reactive protein values
58
What are moderate UC flares
Four to six stools a day, with minimal systemic disturbanc
59
What are severe UC flares?
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
When should patients with UC flares be admitted?
severe disease
61
What is the typical presentation of anal fissure?
intense pain post-defecation - lasts several hours bleeding - bright red, on wiping itching palpable / visible on examination
62
What examination, other than DRE, might be necessary in anal fissure? Why?
EUA - examination under anaesthesia due to intense pain
63
How can anal fissures be diagnosed, other than via DRE?
proctoscopy
64
What are some Dx for anal fissure?
haemorrhoids Crohn's UC anal cancer
65
What is the medical management of anal fissures?
treatment of underlying precipitating factors analgesia fibre intake, fluid intake stool-softening laxatives topical anaesthetic
66
What topical medication can be used in symptomatic patients with anal fissure?
topical lidocaine GTN cream - but gives headaches, so not used anymore diltiazem cream
67
When is surgical treatment used in anal fissures?
chronic fissure once medical management has failed
68
What is the initial invasive / surgical management option for anal fissures?
botox injections
69
What is the surgical management option for patients with anal fissure who do not respond to any previous treatment?
lateral sphincterectomy - division of internal anal sphincter muscle
70
What is the percentage of recurrence of anal fissures post surgery?
1-5%
71
How is perianal abscess managed?
ATB analgesia incision and drainage of abscess
72
What are the surgical management options for perianal abscess?
incision and drainage with intra-operative proctoscopy - to check for fistulas
73
What complication are perianal abscesses associated with?
perianal fistula formation
74
What is a perianal fistula?
abnormal connection between anal canal and perianal skin
75
What are most perianal fistulas associated with?
perianal abscess
76
Which group of patients is oesophageal cancer more common in?
males (3x more common in males than in females)
77
What are the two main types of oesophageal cancer?
squamous cell carcinoma adenocarcinoma
78
What are the typical symptoms of peptic ulcer perforation?
sudden onset epigastric pain - becomes generalised syncope
79
How is suspected peptic ulcer investigated?
erect CXR - free air under the diaphragm
80
What is Barrett's oesophagus?
metaplasia of lower oesophageal mucosa squamous epithelium is replaced by columnar epithelium
81
Barrett's oesophagus increases the risk of which cancer?
oesophageal adenocarcinoma
82
What are the risk factors for Barrett's oesophagus?
GORD male smoking obesity
83
How is Barrett's oesophagus managed?

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