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Finals Revision > GI > Flashcards

GI Flashcards

1
Q

Wilson’s Disease:

  • What is it? Genetics?
  • Symptoms? (liver, neuro, eyes, renal, haem, skin)
  • Ix? (3)
  • Rx?
A

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

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2
Q

How does loperamide work?

A

Reduction in gastric motility by stimulation of mu-opioid receptors

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3
Q

What type of drugs should be avoided in bowel obstruction?

A

Prokinetics e.g. metoclopramide

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4
Q

Can opioids e.g. morphine/penthidine be used in bowel obstruction?

A

Yes

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5
Q

Vit A deficiency?

A

Night blindness

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6
Q

Vit B1 deficiency?

A

Beri-Beri:

  • Wernicke-Korsakoff syndrome
  • Polyneuropathy
  • Heart failure
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7
Q

Vit B3 (niacin) deficiency?

A

Pellagra:

  • dermatitis
  • diarrhoea
  • dementia
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8
Q

Vit B6 (pyridine) deficiency?

A

Anaemia
Irratibility
Seizures

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9
Q

Vit B7 (biotin) deficiency?

A

Dermatitis

Seborrhoea (excessive sebum production from glands)

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10
Q

Vit B9 deficiency?

A

Folate

Megaloblastic anaemia
Foetal neural tube defects

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11
Q

Vit B12 deficiency?

A

Cyanocobalamin

Megaloblastic anaemia
Peripeheral neuropathy
Subacute combined degeneration of spinal cord

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12
Q

Vit C deficiency?

A

Scurvy

Gingivitis
Bleeding

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13
Q

Vit D deficiency?

A

Rickets

Osteomalacia

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14
Q

Vit E deficiency?

A

Mild haemolytic anaemia in newborns
Ataxia
Peripheral neuropathy

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15
Q

Vit K deficiency?

A

Haemorrhagic disease of newborn

Bleeding predisposition

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16
Q 
RUQ pain after food?
RUQ pain + fever?
RUQ pain + jaundice?
RUQ pain + fever + jaundice?
Epigastric pain (+tender) + vomiting?
A

Biliary colic

Acute cholecystitis

Choledocholithiasis

Ascending cholangitis (chariot’s triad)

Pancreatitis

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17
Q

Epigastric pain, non-bilious vomiting, inability to pass NG tube?

A

Gastric volvolus

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18
Q

Link between Crohn’s and Gall Stones?

A

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)

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19
Q

Which IBD subtype is helped by smoking?

A

UC

UC = Use Cigarettes

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20
Q

How to measure actual function of liver?

A

ABCDE

Albumin
Bilirubin
Clotting (PTT)
Distension (ascites)
Encephalopathy

(Child Pugh score for cirrhosis)

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21
Q

Where is protrusion in inguinal hernia?
Direct vs indirect inguinal hernia?
Why do inguinal hernias happen?
Indirect/direct protrude lateral/medial to what?

A

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

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22
Q

Femoral hernia:

  • Where is lump?
  • Who is it more common in?
  • Risk?
  • Rx?
A

Inferolateral to pubic tubercle

Women, esp multiparous

Incarceration

REFER - Surgery

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23
Q

Umbilical vs Paraumbilical hernias?

A

Umbilical - symmetrical bulge under umbilicus

Paraumbilical - asymmetrical bulge

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24
Q

Epigastric hernia - where?
Who?
Management?

A

Halfway between umbilicus and xipgysternum

20-30 y/o

Low priority - refer if painful

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25
Q

How commonly do incisional hernias occur post-abdo-op?

A

10%

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26
Q

Spigelian hernia other name?
Who?
Where is it?

A

Lateral ventral hernia

Elderly

Through the spigelian fascia (fascia between the rectus muscle medially and semilunar line laterally)

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27
Q

Congenital inguinal hernia:

  • cause?
  • who?
  • management?
A

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

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28
Q

Infantile umbilical hernia:

  • where is it?
  • who?
  • management?
A

Symmetrical bulge under the umbilicus

4-5 y/o, more common in afro-caribbean

Non-urgent, low risk of complications

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29
Q

Causes of acute appendicitis?

A

I GET SMASHED

Idiopathic

Gall stones
Ethanol
Trauma

Steroids
Mumps
Autoimmune (IgG4 or polyarteritis nodosa)
Scorpions
Hyper-triglyceride/calcaemia/Hypo-thermia
ERCP
Drugs

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30
Q

Drugs which cause pancreatitis? (4)

A

Mesalazine/Sulfasalazine (7x increased risk)
Valproate
Diuretics
Steroids

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31
Q

Budd-Chiari triad?
Risk factors?
Ix?

A

Triad:

  • sudden onset, severe abdo pain
  • ascites (high saag - transudate)
  • tender hepatomegaly

COCP, polycythaemia, pregnancy, thrombiphilia

USS with doppler

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32
Q

What metabolic abnormalities occur with referring syndrome? (3)
How to refeed?
Can it happen with TPN feeding?

A

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

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33
Q

Foul smelling, greasy stools in an alcoholic?

1st line Ix?

A

Chronic pancreatitis

CT pancreas - look for calcifications

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34
Q

Approach to treating dyspepsia with no red flags and no meds/food?

A

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

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35
Q

Dyspepsia:

- what warrants urgent referral?

A

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

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36
Q

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?
A

Cancer

Oesophagitis

Oesophageal candidiasis

Achalasia

Pharyngeal pouch

Systemic sclerosis

Myasthenia gravis

Globus hystericus

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37
Q

Ix of dysphagia?

A

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

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38
Q 
Symptoms of carcinoid syndrome?
What does the tumour secrete?
Ix?
Rx?
Where are they commonly found?
A

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

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39
Q

Grey-turner’s sign?

A

Sign of acute pancreatitis or retroperitoneal haemorrhage

Bruising at both flanks

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40
Q

When fever, constant RUQ pain, raised inflammatory markers, what points towards cholangitis rather than cholecystitis?

A

Jaundice or raised bili

Absence of Murphy’s sign

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41
Q

Management of cholangitis?

A

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

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42
Q 
What causes biliary colic?
What forms gall stones?
Where might pain radiate to?
Ix?
Management?
Most common complication?
A

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

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43
Q

Cholecystitis Ix?

Rx?

A

USS 1st line
If unclear then HIDA scan (cholescintigraphy) - cystic obstruction with inflammation or obstructing stone

IV abx
Laparoscopic cholecystectomy within 1 week

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44
Q

Management peptic ulcer?

Drugs that can cause ulcer?

A

Test for H pylori
If neg, PPI until healed

NSAIDs
SSRIs
Corticosteroids
Bisphosphonates

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45
Q

Peutz-Jehgers syndrome?

A

AD condition

Intestinal hamartomas - polyps (small bowel usually)

Pigmented lesions on lips, hands, soles, face, oral mucosa

Intussusception as a kid

GI bleeding

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46
Q

Why can TPN result in deranged LFT’s?

A

Cholestasis as nothing passing though bowel - causes slight raise in bili, AST and moderately raised ALP, gGT

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47
Q

Management of C Diff

A

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

48
Q

Man just returned from Thailand with non-bloody diarrhoea, abdominal cramps and nausea (no vomiting)?

A

Travellers diarrhoea - E. Coli

49
Q

What does USS show with cholangitis?

A

Dilated intrahepatic and extra hepatic bile ducts

50
Q

What is diarrhoea?
Acute and chronic?
Main DDx of each?
4 other things assoc w diarrhoea?

A

> 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

51
Q

Most common cause of gastroenteritis?
3 commonest bacterial causes?
3 commonest bacterial causes from food?
Most common cause of SBP?

A

Norovirus

Campylobacter
Salmonella
Shigella

Campylobacter
Clostridium perfingens
Yersinia

E coli

52
Q

What gastroenteritis pathogens have an incubation of:

  • 1-6 hrs?
  • 12-48 hrs?
  • 48-72 hrs?
  • > 7 days?
A

1-6: Staph Aureus, Bacillus Cereus

12-48: Salmonella, E Coli

48-72: Shigella, Campylobacter

> 7 days: Giardiasis, Amoebiasis

53
Q

Campylobacter pattern and what Gram stain?

A

Curved Gm -ve bacilli

Flu-like prodrome then bloody diarrhoea after eating contaminated farm animals/poultry

54
Q

Salmonella pattern and what Gram stain?

A

Gm -ve rod

Diarrhoea (potentially bloody) after eating undercooked meat/poultry

55
Q

Shigella pattern and what Gram stain?

A

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

56
Q

Typhoid/Enteric fever pattern and what Gram stain?

A

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

57
Q

Cholera pattern and what Gram stain?

A

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.

58
Q

C perfingens pattern and what Gram stain?

A

Gm +ve rod

Reheated gravy

59
Q

Bacillus cereus pattern and what Gram stain?

A

Gm +ve bacillus

Reheated rice

Can cause diarrhoeal or vomiting illness

60
Q

Cryptosporidium - what is it, gastroenteritis pattern, test, treatment?

A

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

61
Q

Giardiasis - what is it, gastroenteritis pattern, test, treatment?

A

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

62
Q

Amoebiasis - what is it, gastroenteritis pattern, liver pattern, tests, treatments?

A

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

63
Q

Enterobius vermicularis - what is it, symptom, test, treatment?

A

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

64
Q

Immediate resus of upper GI bleed?

Indications for surgery?

A
  • 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

65
Q

Most common site of upper GI bleed?

Can be severe bleed it…?

A

Posterior duodenum

Erodes into gasproduodenal artery

66
Q

4 main DDx for oesophageal bleed?

For gastric bleed?

A
  • 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
67
Q

4 main DDx for gastric bleeding?

A
  • 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.
68
Q

RF for cholangiocarcinoma?

4 features?

A

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)
69
Q

4 main causes of liver cirrhosis?
Diagnosis?
Monitoring?

A
  • 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
70
Q

Ix boerhaave syndrome?
Rx?
What to do if delayed?
Why does sepsis occur?

A

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

71
Q

RF for small bowel bacterial overgrowth syndrome (SBBOS/SIBO)?
Features?
Diagnosis?
Management?

A
  • 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

72
Q

How does thromboses haemorrhoid present?
What is seen on DRE?
Management?

A

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

73
Q

Levels of AA branches:

  • Coeliac?
  • SMA?
  • Renal?
  • Gonadal?
  • IMA?
  • Bifurcation?
A

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

74
Q

What is used to monitor colon cancer and response to treatment?

A

CEA

75
Q

What is CA19-9 elevated in?

A

Pancreatic cancer or cholngiocarcinoma

76
Q

On colonoscopy - pigmented lesions. Histologically: pigment-laden macrophages within mucosa. What is this?

A

Melanosis coli

Most commonly due to laxative abuse

77
Q

Spectrum of alcoholic liver disease?

A
  • 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
78
Q

Most common causes of lower abdo pain in young males?

A 
Appendicitis
Testicular problems (infection/torsion)

ALWAYS examine testicles of a male with RIF pain

79
Q

Diagnosis of malnutrition?

Management?

A
  • 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
80
Q

MUST score?

A

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
81
Q

NAFLD spectrum?

What is NASH?

A

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
82
Q

Ix NAFLD?

A

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
83
Q

What is dumping syndrome?

A

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

84
Q

Gastric MALT lymphoma main association?
If low grade main therapy?
Other assoc?

A 
H Pylori (95%) 
Good prognosis

If low grade, 80% regress with H Pylori eradication

Paraproteinaemia may also be present

85
Q

Management of inguinal hernias?

A

Routine referral for surgical repair (direct and indirect)

Generally mesh repair:
Unilateral - open
Bilateral - laparoscopic

Comps:
early - bruising
late - chronic pain, recurrence

86
Q

Bowel obstruction causes small and large?
Imaging?
Initial management?

A

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
87
Q

Lemon tinge to skin and altered sensation?

A

Pernicious anaemia

Lemon tinge - mixture of pallor and haemolytic (causing mild jaundice)

88
Q

C diff testing?

A

Stool antigen positive if have bacteria in bowel

Stool toxin positive if infection

Do not treat if loose stools but negative toxin

89
Q

What cancer is coeliac disease assoc w?

A

T cell lymphoma

Coeliac symptoms (fatigue, distension etc) with weight loss, night sweats, lymphadenopathy

90
Q

intestinal angina/chronic mesenteric ischaemia?

A

Classically a triad of:

  • colicky post-prandial abdo pain
  • weight loss
  • abdominal brut

Most common cause is atherosclerosis of arteries supplying GI tract

91
Q

Pilonidal sinus:

-

A

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
92
Q

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?

A

Prednisolone - alcoholic hepatitis

Black tarry stool likely from varices not gastric ulcer

93
Q

Who gets screened for hepatocellular carcinoma?

A

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

94
Q

Rectal ulcer?

A

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

95
Q

Important Ix for anyone with severe UC flare?

A

Abdo XR - for toxic megacolon

Transverse colon >6cm plus systemically unwell

Aggressive medical therapy for 24-72 hours, if no improvement then colectomy

96
Q

Autoimmune hepatitis - what else do females get?

What is seen on biopsy?

A

Amenorrhoea

Inflammation extending beyond limiting plate, ‘piecemeal necrosis’, bridging necrosis

97
Q

Management of abdominal wound dehiscence?

A
  • Cover with sterile saline-soaked gauze
  • IV broad-spec abx
  • Analgesia
  • IV fluids
  • Arrange return to theatre
98
Q

What are perianal skin tags assoc w?

A

Haemorrhoids and Crohn’s

99
Q

19 y/o with UC and neck pain and stiffness?

A

Ank Spond

HLA-B27 association. Often presents with thoracic or cervical kyphosis

100
Q

Urine colour, stool colour and pruritus in pre-hepatic, hepatic and post-hepatic jaundice?

A

Pre-hepatic:
- all normal

Hepatic:

  • Dark urine
  • normal stool, no itch

Post-hepatic:

  • Dark urine
  • Pale stool
  • Itch
101
Q

Woman has cholecystectomy then for months after has chronic diarrhoea and steatorrhoea - what is cause?

  • Ix?
  • Rx?
A

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

102
Q

SAAG cut offs for ascites and causes for each?

A

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
103
Q

Management of ascites?

A
  • 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

104
Q

Management of Barrett’s?

A

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
105
Q 
Indications for surgery in UC?
Surgical options in UC?
Restorative option?
Complications of this?
What other considerations when UC pts undergoing surgery?
A

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
106
Q

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?

A

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

107
Q

What is an acute and chronic anal fissure?
Location of these and when to refer?
Management options of acute?
Management options of chronic?

A

<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
108
Q

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?

A

Pancreatic pseudocyst

Initial management - conservative with simple analgesia (paracetamol, ibuprofen)

Usually resolve spontaneously in 12 weeks,

If not - surgical or endoscopic cystogastrotomy

109
Q

5 local complications of acute pancreatitis?

A

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

110
Q

Systemic complications of acute pancreatitis?

A

ARDS - 20% mortality

111
Q

Patients with SBP - what should they be given on discharge?

A

Spironolactone (reduce ascites)

Ciprofloxacin (prophylaxis for SBP)

112
Q

Pt presents with haematemesis and has background of galactorrhoea and unresponsive GORD. On blood test have hypercalcaemia. Cause?

A

MEN1

Pituitary - prolactinoma
Parathyroid - hypercalcaemia
Pancreas - gastrinoma

113
Q

Pt on immunosuppressants gets campylobacter, what is treatment?

A

Clarithromycin

Also used in severe infection (bloody stool, fever etc)

114
Q

anti-HCV (hep c) antibodies - are they still positive after infection?

A

Yes - 15% of HepC clear after acute infection

remember there is no vaccine as yet

115
Q

Management of alcoholic ketoacidosis?

A

IV saline and thiamine

116
Q

RUQ colicky pain radiating to back, with jaundice and cholestatic LFT’s following laparoscopic cholecystectomy?

A

CBD gallstones

117
Q

Ileocaecal resection for Crohn’s can result in which deficiency?

A

B12

Finals Revision (29 decks)

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