GI Flashcards
Wilson’s Disease:
- What is it? Genetics?
- Symptoms? (liver, neuro, eyes, renal, haem, skin)
- Ix? (3)
- Rx?
Autosomal recessive - excess copper deposition in tissues, usually presents 10-25 y/o
Liver: hepatitis, cirrhosis, asterixis
Neuro: Basal ganglia degeneration, speech & behavioural problems (psychiatric often first presentation), dementia, parkinsonism
Eyes: Kayser-Fleischer rings, green-brown rings at periphery of iris
Renal: tubular acidosis
Haem: haemolysis
Skin: blue nails
Slit lamp for eyes
Low caeruloplasmin
Low total serum copper but increased free copper
Rx: penicillamine
How does loperamide work?
Reduction in gastric motility by stimulation of mu-opioid receptors
What type of drugs should be avoided in bowel obstruction?
Prokinetics e.g. metoclopramide
Can opioids e.g. morphine/penthidine be used in bowel obstruction?
Yes
Vit A deficiency?
Night blindness
Vit B1 deficiency?
Beri-Beri:
- Wernicke-Korsakoff syndrome
- Polyneuropathy
- Heart failure
Vit B3 (niacin) deficiency?
Pellagra:
- dermatitis
- diarrhoea
- dementia
Vit B6 (pyridine) deficiency?
Anaemia
Irratibility
Seizures
Vit B7 (biotin) deficiency?
Dermatitis
Seborrhoea (excessive sebum production from glands)
Vit B9 deficiency?
Folate
Megaloblastic anaemia
Foetal neural tube defects
Vit B12 deficiency?
Cyanocobalamin
Megaloblastic anaemia
Peripeheral neuropathy
Subacute combined degeneration of spinal cord
Vit C deficiency?
Scurvy
Gingivitis
Bleeding
Vit D deficiency?
Rickets
Osteomalacia
Vit E deficiency?
Mild haemolytic anaemia in newborns
Ataxia
Peripheral neuropathy
Vit K deficiency?
Haemorrhagic disease of newborn
Bleeding predisposition
RUQ pain after food? RUQ pain + fever? RUQ pain + jaundice? RUQ pain + fever + jaundice? Epigastric pain (+tender) + vomiting?
Biliary colic
Acute cholecystitis
Choledocholithiasis
Ascending cholangitis (chariot’s triad)
Pancreatitis
Epigastric pain, non-bilious vomiting, inability to pass NG tube?
Gastric volvolus
Link between Crohn’s and Gall Stones?
Crohn’s commonly causes inflammation in terminal ileum, where bile salts are reabsorbed
Less bile salts being reabsorbed causes pigment gall stones
(Crohn’s = Stones; UC = PSC)
Which IBD subtype is helped by smoking?
UC
UC = Use Cigarettes
How to measure actual function of liver?
ABCDE
Albumin Bilirubin Clotting (PTT) Distension (ascites) Encephalopathy
(Child Pugh score for cirrhosis)
Where is protrusion in inguinal hernia?
Direct vs indirect inguinal hernia?
Why do inguinal hernias happen?
Indirect/direct protrude lateral/medial to what?
Superomedial to pubic tubercle
Direct - lump reappears when coughing when covering the deep inguinal ring
Indirect DOES NOT reappear (indirect stays inside)
Hole in internal oblique and transversus muscles
Indirect = lateral to inferior epigastric artery Direct = medial to it
Low priority - refer if painful - risk of strangulation minimal
Femoral hernia:
- Where is lump?
- Who is it more common in?
- Risk?
- Rx?
Inferolateral to pubic tubercle
Women, esp multiparous
Incarceration
REFER - Surgery
Umbilical vs Paraumbilical hernias?
Umbilical - symmetrical bulge under umbilicus
Paraumbilical - asymmetrical bulge
Epigastric hernia - where?
Who?
Management?
Halfway between umbilicus and xipgysternum
20-30 y/o
Low priority - refer if painful
How commonly do incisional hernias occur post-abdo-op?
10%
Spigelian hernia other name?
Who?
Where is it?
Lateral ventral hernia
Elderly
Through the spigelian fascia (fascia between the rectus muscle medially and semilunar line laterally)
Congenital inguinal hernia:
- cause?
- who?
- management?
Failure of closure of processus vaginalis
1% in term babies but more common in preterm - more common in boys
Surgery soon after diagnosis - high risk of incarceration
Infantile umbilical hernia:
- where is it?
- who?
- management?
Symmetrical bulge under the umbilicus
4-5 y/o, more common in afro-caribbean
Non-urgent, low risk of complications
Causes of acute appendicitis?
I GET SMASHED
Idiopathic
Gall stones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (IgG4 or polyarteritis nodosa)
Scorpions
Hyper-triglyceride/calcaemia/Hypo-thermia
ERCP
Drugs
Drugs which cause pancreatitis? (4)
Mesalazine/Sulfasalazine (7x increased risk)
Valproate
Diuretics
Steroids
Budd-Chiari triad?
Risk factors?
Ix?
Triad:
- sudden onset, severe abdo pain
- ascites (high saag - transudate)
- tender hepatomegaly
COCP, polycythaemia, pregnancy, thrombiphilia
USS with doppler
What metabolic abnormalities occur with referring syndrome? (3)
How to refeed?
Can it happen with TPN feeding?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia (predisposes torsades de pointes)
If someone hasn’t eaten for >5 days, aim to re-feed at no more than 50% of requirements for first 2 days
Yes
Foul smelling, greasy stools in an alcoholic?
1st line Ix?
Chronic pancreatitis
CT pancreas - look for calcifications
Approach to treating dyspepsia with no red flags and no meds/food?
Full dose PPI for 1 month
If response then low dose treatment PRN
If no recovery - take 2 weeks off then test for H Pylori using urea breath test or stool antigen
If negative then double dose PPI may be trialled for 1 month
Then can try other drugs like Ranitidine (H2 antagonist) or Metoclopramide (pro-kinetic)
No need to test for cure but if done then urea breath test
Dyspepsia:
- what warrants urgent referral?
URGENT:
Dysphagia + dyspepsia
Palpable abdo mass
> 55 with weight loss AND dyspepsia, reflux or upper abdomen pain
NON-URGENT:
Haematemesis
Treatment resistant dyspepsia
Upper abdo pain + low Hb
Raised platelet count or nausea and vom with weight loss/reflux/pain
Dysphagia:
- weight loss, vomiting with eating, GORD?
- Heartburn, odynophagia, no systemic?
- HIV or steroid inhalers?
- solids+liquids, heartburn, regurgitate food, aspiration pneumonia?
- older man, midline lump in neck, regurgitates food, aspiration pneumonia, bad breath?
- Raynaud’s, talengiectasia, stiff fingers, difficulty breathing?
- Ptosis, muscle weakness at end of day, difficulty swallowing solids+liquids?
- anxiety, intermittent symptoms, painless?
Cancer
Oesophagitis
Oesophageal candidiasis
Achalasia
Pharyngeal pouch
Systemic sclerosis
Myasthenia gravis
Globus hystericus
Ix of dysphagia?
All patients require OGD
After this, if motility disorder suspected (e.g. spasm) then fluoroscopic swallow study
Manometry/ambulatory oesophageal pH for achalasia along with fluoroscopic swallow
Symptoms of carcinoid syndrome? What does the tumour secrete? Ix? Rx? Where are they commonly found?
Flushing
Diarrhoea
Bronchospasm
Hypotension
Can release ACTH - cushingoid symptoms and hypokalaemia
Can release GHRH - acromegaly
Secretes serotonin into bloodstream - can develop pellagra as dietary tryptophan is diverted to make serotonin by tumour (common precursor with Niacin)
Ix: urinary 5-HIAA
Plasma chromogranin A
Management: Octreotide
Cryoheptadine may help diarrhoea
Liver and lung
Grey-turner’s sign?
Sign of acute pancreatitis or retroperitoneal haemorrhage
Bruising at both flanks
When fever, constant RUQ pain, raised inflammatory markers, what points towards cholangitis rather than cholecystitis?
Jaundice or raised bili
Absence of Murphy’s sign
Management of cholangitis?
IV broad spec antibiotics (most common cause E coli)
ERCP after 24-48 hours to relieve any obstruction
commonly gall stones seen on USS and fever not reducing
What causes biliary colic? What forms gall stones? Where might pain radiate to? Ix? Management? Most common complication?
Gall stone passing through bile ducts - pain occurs due to gall bladder contracting against stone, nausea and vomiting common
Increased cholesterol, decreased bile salts and biliary stasis
shoulder/interscapular region
USS
Elective cholecystectomy
Acute cholecystitis
Cholecystitis Ix?
Rx?
USS 1st line
If unclear then HIDA scan (cholescintigraphy) - cystic obstruction with inflammation or obstructing stone
IV abx
Laparoscopic cholecystectomy within 1 week
Management peptic ulcer?
Drugs that can cause ulcer?
Test for H pylori
If neg, PPI until healed
NSAIDs
SSRIs
Corticosteroids
Bisphosphonates
Peutz-Jehgers syndrome?
AD condition
Intestinal hamartomas - polyps (small bowel usually)
Pigmented lesions on lips, hands, soles, face, oral mucosa
Intussusception as a kid
GI bleeding
Why can TPN result in deranged LFT’s?
Cholestasis as nothing passing though bowel - causes slight raise in bili, AST and moderately raised ALP, gGT
Management of C Diff
1st line - oral metronidazole
2nd line - if severe or not responding/recurrence - oral vancomycin
3rd line - if life threatening e.g. sepsis/toxic megacolon - oral vancomycin + IV metronidazole
Man just returned from Thailand with non-bloody diarrhoea, abdominal cramps and nausea (no vomiting)?
Travellers diarrhoea - E. Coli
What does USS show with cholangitis?
Dilated intrahepatic and extra hepatic bile ducts
What is diarrhoea?
Acute and chronic?
Main DDx of each?
4 other things assoc w diarrhoea?
> 3 loose/watery stools per day
Acute <14 days
Chronic >14 days
Acute:
- gastroenteritis
- diverticulitis (LLQ pain, fever)
- broad spec abx (c dif)
- Constipation causing overflow - Hx of alternating diarrhoea and constipation, may lead to faecal incontinence in elderly
Chronic:
- IBS - abdo pain, bloating, constipation/diarrhoea
- UC - bloody diarrhoea, cramp, weight loss, tenesmus, urgency
- Crohn’s - cramp, rarely blood, malabsorption, mouth ulcers, perianal disease, intestinal obstruction
- Colorectal Ca - depends on site - rectal bleeding, anaemia, weight loss, anorexia
- coeliac - in kids failure to thrive, diarrhoea, abdominal distension; in adults - lethargy, anaemia, diarrhoea, weight loss
Thyrotoxicosis
Laxative abuse
Appendicitis
Radiation enteritis
Most common cause of gastroenteritis?
3 commonest bacterial causes?
3 commonest bacterial causes from food?
Most common cause of SBP?
Norovirus
Campylobacter
Salmonella
Shigella
Campylobacter
Clostridium perfingens
Yersinia
E coli
What gastroenteritis pathogens have an incubation of:
- 1-6 hrs?
- 12-48 hrs?
- 48-72 hrs?
- > 7 days?
1-6: Staph Aureus, Bacillus Cereus
12-48: Salmonella, E Coli
48-72: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
Campylobacter pattern and what Gram stain?
Curved Gm -ve bacilli
Flu-like prodrome then bloody diarrhoea after eating contaminated farm animals/poultry
Salmonella pattern and what Gram stain?
Gm -ve rod
Diarrhoea (potentially bloody) after eating undercooked meat/poultry
Shigella pattern and what Gram stain?
Gm -ve bacilli
Occurs in outbreaks, especially in schools and nurseries - abdominal pain, bloody diarrhoea, vomiting
Never invades further than gut wall - pus and blood in stools
Typhoid/Enteric fever pattern and what Gram stain?
Gram negative rods - Salmonella Typhi/Salmonella Paratyphi A, B + C
Febrile illness, headache then diarrhoea. Rose spots on abdo. Often causes constipation instead of diarrhoea. 1% become chronic carriers in gall bladder. Incubation 6-30 days.
From contaminated water/pools in developing world
Abx -> azithromycin
Cholera pattern and what Gram stain?
Vibrio cholerae - small Gm -ve bacillus
Produces an exotoxin that causes fluid loss from small intestine - rice water stools - profuse diarrhoea. Outbreaks in refugee camps.
Fluid/electrolyte replacement essential.
C perfingens pattern and what Gram stain?
Gm +ve rod
Reheated gravy
Bacillus cereus pattern and what Gram stain?
Gm +ve bacillus
Reheated rice
Can cause diarrhoeal or vomiting illness
Cryptosporidium - what is it, gastroenteritis pattern, test, treatment?
Protozoal infection (commonest protozoal infection in UK)
Cysts are ingested from animal sources or contaminated water or swimming pools (resistant to chlorine)
Diarrhoea - esp severe in HIV
Red spores seen on Ziehl-Neelson stain of stool
Symptomatic
Giardiasis - what is it, gastroenteritis pattern, test, treatment?
Single parasite - protozoa
Often asymptomatic
Abdo pain, flatulence, non-bloody CHRONIC diarrhoea, malabsorption and lactose intolerance can occur. Also resistant to chlorine so can get in pools.
(returned from holiday 3 weeks ago, has been opening bowels 5 times a day, crampy, bloating - stools float and are greasy (fat malabsorption))
- Stool microscopy for trophozoite and cysts usually negative
- duodenal fluid aspirate or ‘string tests’ sometimes needed
Metronidazole
Amoebiasis - what is it, gastroenteritis pattern, liver pattern, tests, treatments?
Protozoal infection - estimated 10% of world chronically infected. Can cause severe dysentry or colonic/liver abscesses
Dysentry:
- profuse, bloody diarrhoea,
- Stool may show trophozoites if examined within 15 mins (hot stool)
- Rx - metronidazole
Liver abscess:
- Single mass in right lobe usually (may be multiple). ‘anchovy sauce’
- Fever, RUQ pain
- Serology +ve 90%
Cystic stage: luminal amoebicide
Invasive stage: metronidazole and tinidazole
Enterobius vermicularis - what is it, symptom, test, treatment?
Threadworm - tiny white worms that look like small pieces of white thread in stool
Seen in school kids and will often infect relatives
Eggs ingested, live in caecum/colon, hatch, females lay eggs at perianal area, scratch bottom, re-ingest if poor hand hygiene
Symptom - perianal itch, esp at night
Test - worms seen in stool, sellotape perianal area and send to lab. Usually just treated empirically
Rx: mebendazole single dose - treat family members
Immediate resus of upper GI bleed?
Indications for surgery?
- Bloods, X-match, clotting etc
- Terlipressin if suspected varices
- Endoscopy within 24 hours, ideally immediately, for band ligation/sclerotherapy (varices) or adrenaline/thermal/mechanical treatment (ulcer/gastritis/oesophagitis)
- If varices and bleeding prevents endoscopy -> sengstaken-blakemore tube
- If erosive gastritis/oesophagitis -> 3 days IV PPI
- Diffuse erosive gastritis may require gastrectomy
Surgery if:
- bleeding point that cannot be stopped endoscopically
- recurrent bleed
known CVD with poor response to hypotension
Most common site of upper GI bleed?
Can be severe bleed it…?
Posterior duodenum
Erodes into gasproduodenal artery
4 main DDx for oesophageal bleed?
For gastric bleed?
- Oesophagitis - small volume fresh blood, streaking of vomit, usually resolves spontaneously. Hx of PPi.
- Cancer - small volume of blood unless terminal erosion. Dysphagia, weight loss.
- Mallory weiss
- Varices
4 main DDx for gastric bleeding?
- Cancer - may be frank aematemesis or altered blood mixed with vomit. Dyspepsia, weight loss, malaena.
- Dieulafoy lesion - no prodromal features, haematemesis, malaena. AVM can cause significant haemorrhage. Prominent arteries seen on lesser curvature of stomach.
- Diffuse erosive gastritis - haematemesis and epigastric discomfort. Usually NSAID/alcohol. May be large volume
- Ulcer - small volume bleeds, usually presents as Fe def anaemia. May cause haemorrhage/haematemesis if erodes into artery.
RF for cholangiocarcinoma?
4 features?
PSC and gall bladder calcification (after chronic gall stones)
- persistent colic symptoms
- anorexia, weight loss, jaundice
- palpable mass RUQ (courvoisier sign)
- periumbilical lymphadenopathy (sister mary joseph nodules) and left supraclavicular adenopathy (virchow node)
4 main causes of liver cirrhosis?
Diagnosis?
Monitoring?
- Alcohol, Hep B, Hep C, NAFLD
- Transient elastography (Fibroscan) 1st line, biopsy if not
Monitoring:
- OGD to check for varices on diagnosis
- Liver USS every 6 months + AFP to check for hepatocellular carcinoma
Ix boerhaave syndrome?
Rx?
What to do if delayed?
Why does sepsis occur?
CT contrast swallow
Thoracotomy with lavage
If <12 hours repair is feasible
If >12 hours best managed by T-tube insertion to create a controlled fistula between oesophagus and skin
Sepsis from mediastinitis
RF for small bowel bacterial overgrowth syndrome (SBBOS/SIBO)?
Features?
Diagnosis?
Management?
- Neonates with GI abnormalities
- Scleroderma (from dysmotility)
- Diabetes mellitus (also from gastroparesis)
Features similar to IBS:
- chronic diarrhoea
- bloating, flatulence
- abdo pain
Diagnosis:
- H breath test
- Small bowel aspiration and culture (rarely used as invasive)
- Sometimes give abx as a diagnostic trial
Management:
- underlying condition
- abx: Rifaximin
Co-amox or metronidazole alternatives
How does thromboses haemorrhoid present?
What is seen on DRE?
Management?
Hx of painless fresh blood PR then all of a sudden sore, may notice lump. Pain esp when passing stool.
DRE - purple, oedematous lump that is tender, subcutaneous and perianal.
If <72 hrs - refer for excision
If >72 hrs - stool softeners, analgesia, ice packs
Symptoms normally settle in 10 days
Levels of AA branches:
- Coeliac?
- SMA?
- Renal?
- Gonadal?
- IMA?
- Bifurcation?
Coeliac - T12
SMA - L1
Renal - L1/L2 (leave laterally - right renal artery goes behind IVC)
Gonadal - L2 - leave laterally
IMA - L3
Bifurcation to common iliacs - L4
What is used to monitor colon cancer and response to treatment?
CEA
What is CA19-9 elevated in?
Pancreatic cancer or cholngiocarcinoma
On colonoscopy - pigmented lesions. Histologically: pigment-laden macrophages within mucosa. What is this?
Melanosis coli
Most commonly due to laxative abuse
Spectrum of alcoholic liver disease?
- alcoholic fatty liver disease
- alcoholic hepatitis
- cirrhosis
Ix:
- gGT elevated
- AST:ALT ratio >2, if >3 suggestive of alcoholic hepatitis
Rx:
- prednisone in acute alcoholic hepatitis
- pentoxyphylline also used sometimes
Most common causes of lower abdo pain in young males?
Appendicitis Testicular problems (infection/torsion)
ALWAYS examine testicles of a male with RIF pain
Diagnosis of malnutrition?
Management?
- BMI <18.5
- unintentional weight loss >10% in 3-6 months
- BMI <20 and unintentional weight loss >5% in 3-6 months
Management of malnutrition:
- dietician
- food first rather than just supplements
- take oral nutritional supplements between meals if prescribed
MUST score?
Step 1:
- BMI <20 = 0
- 18.5-20 = 1
- <18.5 = 2
Step 2: unplanned weight loss in 3-6 months <5% = 0 5-10% = 1 >10% = 2
Step 3:
if patient is acutely ill and there has been/is likely to be no nutritional intake for >5 days = 2
0 = low risk 1 = med risk - observe 2 = high risk - treat
NAFLD spectrum?
What is NASH?
Steatosis - fat in liver
Steatohepatitis - fat with inflammation
Fibrosis and cirrhosis
NASH:
Similar to the changes in alcoholic hepatitis but absence of alcohol abuse
Assoc: obesity, T2DM, hyperlipidaemia, jejunal bypass, sudden weight loss/starvation
Features:
- usually asymptomatic
- hepatomegaly
- ALT>AST
- ALP may be raised as well with increased bile and decreased albumin
- increased echogenicity on USS
Ix NAFLD?
USS - can often be an incidental finding
If changes seen:
Enhanced liver fibrosis blood test
- pro collagen II
- tissue inhibitor metalloproteinase 1
If ELF not available:
- Fibroscan for fibrosis
- FIB4 score
Management:
- Lifestyle change and weight loss
- potentially metformin/TZD
- monitor
What is dumping syndrome?
It can happen following gastric bypass surgeries
Sudden hyperosmolar load rapidly entering proximal jejunum causes water to enter lumen from cells
This causes distension (crampy pain), diarrhoea, and vertigo
Gastric MALT lymphoma main association?
If low grade main therapy?
Other assoc?
H Pylori (95%) Good prognosis
If low grade, 80% regress with H Pylori eradication
Paraproteinaemia may also be present
Management of inguinal hernias?
Routine referral for surgical repair (direct and indirect)
Generally mesh repair:
Unilateral - open
Bilateral - laparoscopic
Comps:
early - bruising
late - chronic pain, recurrence
Bowel obstruction causes small and large?
Imaging?
Initial management?
Small: adhesions, hernias
Large: tumours, volvolus, diverticular disease
1st line AXR
- small bowel >3cm
- large bowel >6.5cm
- caecum >10-12cm
Definitive: CT
Management:
- NBM, IV fluids, NG tube with drainage
- if peritonitis - emergency surgery, IV antibiotics - irrigation and resection of any necrotic bowel
- if no adverse features - can try conservative management to see if resolution in 72 hours - if not -> surgery
- 75% will require surgery
Lemon tinge to skin and altered sensation?
Pernicious anaemia
Lemon tinge - mixture of pallor and haemolytic (causing mild jaundice)
C diff testing?
Stool antigen positive if have bacteria in bowel
Stool toxin positive if infection
Do not treat if loose stools but negative toxin
What cancer is coeliac disease assoc w?
T cell lymphoma
Coeliac symptoms (fatigue, distension etc) with weight loss, night sweats, lymphadenopathy
intestinal angina/chronic mesenteric ischaemia?
Classically a triad of:
- colicky post-prandial abdo pain
- weight loss
- abdominal brut
Most common cause is atherosclerosis of arteries supplying GI tract
Pilonidal sinus:
-
In natal cleft after puberty superior to coccyx.
- opening of sinus is lined by epithelium but wall mostly made of granulation tissue
- hairs become trapped creating sinuses causing inflammation and abscess which can discharge
- occurs mostly in especially hirsute people
- Treatment difficult - Bascom procedure with excision of pits and wide excision of natal cleft
54 y/o with enlarging abdomen, yellowing eyes and skin, Hx alcohol, angular stomatitis, enlarged liver, LUQ dull ache, one episode of black tarry stool a couple of weeks ago - initial Rx?
Prednisolone - alcoholic hepatitis
Black tarry stool likely from varices not gastric ulcer
Who gets screened for hepatocellular carcinoma?
Cirrhosis secondary to Hep B/C or haemochromatosis or alcoholism
USS every 6 months
AFP also useful for screening for HCC
Synthetic function better for screening for cirrhosis
Rectal ulcer?
Bleeding passing a small amount of blood with defaecation
Indurated area at anal verge
Hx of constipation/straining
Ix: endoscopy
potentially defecting proctogram
ano-rectal manometry
Important Ix for anyone with severe UC flare?
Abdo XR - for toxic megacolon
Transverse colon >6cm plus systemically unwell
Aggressive medical therapy for 24-72 hours, if no improvement then colectomy
Autoimmune hepatitis - what else do females get?
What is seen on biopsy?
Amenorrhoea
Inflammation extending beyond limiting plate, ‘piecemeal necrosis’, bridging necrosis
Management of abdominal wound dehiscence?
- Cover with sterile saline-soaked gauze
- IV broad-spec abx
- Analgesia
- IV fluids
- Arrange return to theatre
What are perianal skin tags assoc w?
Haemorrhoids and Crohn’s
19 y/o with UC and neck pain and stiffness?
Ank Spond
HLA-B27 association. Often presents with thoracic or cervical kyphosis
Urine colour, stool colour and pruritus in pre-hepatic, hepatic and post-hepatic jaundice?
Pre-hepatic:
- all normal
Hepatic:
- Dark urine
- normal stool, no itch
Post-hepatic:
- Dark urine
- Pale stool
- Itch
Woman has cholecystectomy then for months after has chronic diarrhoea and steatorrhoea - what is cause?
- Ix?
- Rx?
Too much bile progresses into large bowel causing excess loss of water and salts in stool. This results in bile-acid malabsorption, causing steatorrhoea and eventually vit ADEK malabsorption
Other causes = bile overproduction, Crohn’s, SIBO
Ix = SeHCAT - nuclear medicine selenium test
Management = cholestyramine - binds bile acids promoting their reabsorption
SAAG cut offs for ascites and causes for each?
Serum-ascites albumin gradient
> 11g/L = portal hypertension
- cirrhosis/liver failure/liver mets
- RVF, constrictive pericarditis
- Budd chiari, portal vein thrombosis, myxoedema
<11g/L = non-hepatic circulation causes
- hypoalbuminaemia (nephrotic syndrome/severe malnutrition)
- peritoneal carcinoma
- TB peritonitis
- pancreatitis
- bowel obstruction
- serositis in connective tissue disease
Management of ascites?
- Reduce dietary sodium
- Fluid restriction is recommended if Na <125mmol/L
- Spironolactone
- > loop diuretics may be added if no response
- drainage if tense ascites - large volume (>5L) requires human albumin cover
- Large volume assoc w recurrence, hepatorenal syndrome, dilution hyponatraemia, high mortality
Prophylactic abx needed with a quinolone if cirrhosis and ascites with <15g/L protein until ascites resolved
TIPPS sometimes
Management of Barrett’s?
Endoscopic surveillance every 3-5 years with biopsies
High dose PPI (prevents progression but no regression)
If dysplasia of any grade found:
- endoscopic mucosal resection
- radiofrequency ablation
Indications for surgery in UC? Surgical options in UC? Restorative option? Complications of this? What other considerations when UC pts undergoing surgery?
Elective - maximal therapy or prolonged courses of steroids. Also if presence of dysplastic change as longstanding UC is high risk
Emergency - not responding to treatment
- in emergency usually a subtotal colectomy (leaving rectum in place)
- if medically stable panproctocolectomy can be done if whole bowel affected
- ileoanal pouch can be formed as a restorative measure to avoid stoma - this can only be done with rectum in place and not following proctectomy (can be done at time of panproctocolectomy)
Comps: anastamostic dehiscence, pouchitis, poor functioning with seepage/soiling
- High DVT risk - thromboprophylaxis
Indications for surgery in Crohn’s?
What is there a risk of in surgery for Crohn’s?
Staging of Crohn’s?
Treatment of complex perianal fistula?
Treatment of perianal/rectal Crohn’s?
Why are ileoanal pouches not recommended?
Most common surgery for Crohn’s?
Fistulae, abscess formation, strictures
Excessive small bowel resection can result in short bowel syndrome - stricturoplasty can prevent this
Staging - MRI and colonoscopy
Complex perianal fistula - seton sutures
Proctectomy
Ileoanal pouch = high risk of fistula, not recommended
Ileocaecal resection - terminal ileum most common site
What is an acute and chronic anal fissure?
Location of these and when to refer?
Management options of acute?
Management options of chronic?
<6 weeks = acute
>6 weeks = chronic
- Usually in midline (90% posterior, 10% anterior)
- If lateral, look for other causes (e.g. Crohn’s, cancer)
- Refer to colorectal surgeons under 2 week pathway if lateral figure with weight loss and stool changes
Acute:
- high fibre diet
- 1st line med - bulk-forming laxative (lspaghula husk)
- 2nd line - lactulose
To help defaecation:
- petroleum jelly
- topical anaesthetic
- analgesia
Chronic:
- continue above techniques
- topical GTN
- if not effective after 8 weeks, refer for sphincterotomy/botulinum injection
Abdo pain radiating to back 4 weeks after acute pancreatitis, mild epigastric tenderness on palpation, CT shows retrogastric fluid collection that is surrounded by granulation tissue - what is it?
Initial management?
When does it normally resolve?
If it doesn’t resolve?
Pancreatic pseudocyst
Initial management - conservative with simple analgesia (paracetamol, ibuprofen)
Usually resolve spontaneously in 12 weeks,
If not - surgical or endoscopic cystogastrotomy
5 local complications of acute pancreatitis?
Pancreatic pseudocyst - collection of fluid surrounded by fibrous/granulation tissue, 4 weeks after acute, mostly retrogastric, resolve in 12 weeks
Peripancreatic fluid collection - near pancreas, lack of fibrous/granulation tissue, may resolve or develop into pseudocyst/abscess, most resolve
Necrosis - manage sterile necrosis conservatively, perform FNA if infection suspected
Abscess - pus in pancreas but absence of necrosis, usually as a result of infected pseudocyst - drainage
Haemorrhage - infected necrosis invading vascular structure - grey-turner’s sign if retroperitoneal
Systemic complications of acute pancreatitis?
ARDS - 20% mortality
Patients with SBP - what should they be given on discharge?
Spironolactone (reduce ascites)
Ciprofloxacin (prophylaxis for SBP)
Pt presents with haematemesis and has background of galactorrhoea and unresponsive GORD. On blood test have hypercalcaemia. Cause?
MEN1
Pituitary - prolactinoma
Parathyroid - hypercalcaemia
Pancreas - gastrinoma
Pt on immunosuppressants gets campylobacter, what is treatment?
Clarithromycin
Also used in severe infection (bloody stool, fever etc)
anti-HCV (hep c) antibodies - are they still positive after infection?
Yes - 15% of HepC clear after acute infection
remember there is no vaccine as yet
Management of alcoholic ketoacidosis?
IV saline and thiamine
RUQ colicky pain radiating to back, with jaundice and cholestatic LFT’s following laparoscopic cholecystectomy?
CBD gallstones
Ileocaecal resection for Crohn’s can result in which deficiency?
B12
