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Finals Revision > GI > Flashcards

GI Flashcards

1
Q

What investigations should be done in somebody presenting with GORD?

A

H-Pylori testing: urea breath test / stool antigen test

Endoscopy if: refractory, red flag symptoms, >55, dysphagia, low Hb

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2
Q

How do you manage GORD (not H-pylori) ?

A

Lifestyle change: stop smoking, weight loss, reduce alcohol, caffeine, stress, fizzy drinks, etc

Acid neutralising agents: gaviscon

PPI: Omeprazole / Lansoprazole - max 40mg per day

H2 antagonist: ranitidine - rarely used anymore

Surgical fundoplication in severe, refractory disease / structural causes

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3
Q

How is H-pylori treated?

A

Triple therapy:
7 day course
PPI + amoxicillin + clarithromycin

Metronidazole used in penicillin-allergic patients

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4
Q

What is the treatment for Barrett’s Oesophagus?

A

High dose PPI
Regular endoscopy monitoring
Ablation of high-risk tissue

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5
Q

What is Barrett’s Oesophagus?

A

Columnar cell metaplasia in the Oesophagus

Premalignant condition which can develop into Adenocarcinoma

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6
Q

What are the symptoms associated with peptic ulcers?

A 
GORD/heartburn
Retrosternal/epigastric abdominal pain
Nausea and vomiting
Coffee ground vomit
Acute abdomen
Melaena or iron deficiency anaemia
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7
Q

How does eating affect the pain associated with gastric and duodenal ulcers?

A

Gastric: worsens pain

Duodenal: initially helps pain, worsens later on

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8
Q

What are the complications of peptic ulcers?

A

Bleeding- most common with posterior ulcers
Perforation and peritonitis- most common with anterior ulcers
Scarring and stricturing of tissue -> pyloric stenosis

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9
Q

How are gastric ulcers managed?

A

Stop any causative medication
H-pylori management if +ve

If In-tact:
High-dose PPI 4-8w
Lifestyle change

If perforated:
IV PPI, antibiotics, fluids
NBM and NG tube
Surgical management e.g. patch
Surgical washout
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10
Q

What is the most common type of gastric cancer?

A

Adenocarcinoma

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11
Q

What are the risk factors for gastric cancer?

A 
H-pylori
Barrett's oesophagus
Smoking and alcohol consumption
Chronic GORD
Peptic ulcers
Family history
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12
Q

What are the symptoms of gastric cancer?

A

Dysphagia, early satiety
Nausea, vomiting, haematemesis/coffee-ground vomit, melena
Weight loss, fatigue, night sweats
Anaemia symptoms/unexplained anaemia, jaundice
Palpable mass, Virchow’s node

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13
Q

What is Zollinger-Ellison syndrome?

How is it diagnosed?

A

Gastrin-producing gastrinoma - usually malignant
Increasing acid production
Most commonly in pancreas and small intestine

Diagnosed by: serum gastrin, secretin provocation tests and imaging to confirm

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14
Q

What are the causes of upper GI bleed?

A 
Mallory weiss tear
Oesophageal varices
Gastric malignancy
Peptic ulcer
Coagulopathy/excess anticoagulation
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15
Q

What investigations should be done in upper GI bleed?

A

Bloods: FBC, U&E, LFT, group and save, coagulation studies (INR)

Urgent endoscopy

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16
Q

How would you manage a variceal bleed?

A

Group and save, cross match units of blood
Reverse any anticoagulation - vit K and prothrombin concentrate with warfarin
IV terlipressin
Urgent endoscopy- banding, balloon tamponade

TIPSS procedure- trans jugular intrahepatic portosystemic shunt
IV prophylactic antibiotics

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17
Q

What scoring system is used to quantify the risk of upper GI bleed?

A

Glasgow-Blatchford score

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18
Q

What is the Rockall score?

A

Score to calculate the risk of rebleeding and mortality after endoscopy for patients after having an acute upper GI bleed.
Helps determine whether patients require admission or are suitable for early discharge

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19
Q

What is the diagnostic criteria for IBS?

A
  1. Exclusion of other pathology: Normal FBC, ESR, CRP, faecal calprotectin, anti-TTG
    Cancer excluded or not suspected
  2. Pain/discomfort associated with change of bowel habit / relieved by opening bowels + 2 of:
    Abnormal stool consistence, bloating, PR mucus, symptoms worse after eating
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20
Q

What is the management for IBS?

A
  1. Lifestyle change: increased fluid intake, increased fibre, avoid alcohol, artificial sweeteners, stop smoking
    - > Dietician input may help, food/symptom diary
    - > trial of pro-biotics
  2. Pharmacological management:
    - > laxatives for constipation: avoid lactulose
    - > loperamide for diarrhoea
    - buscopan for abdominal cramps

Second line: TCAs
Third line: SSRIs

AVOID opiates

  1. CBT can be helpful for the psychosocial aspect of the condition
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21
Q

What pattern of inflammation is found in Crohn’s disease?

A

Transmural granulomatous inflammation
Can affect any part of the GI tract - most common in terminal ileum
Skip lesions
Abscess and fistula formation

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22
Q

What symptoms are associated with Crohn’s disease?

A

Abdominal pain and distension
Diarrhoea + PR mucus (less associated with blood)
Weight loss, fever, malaise, anorexia

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23
Q

What signs are associated with Crohn’s?

A 
Finger clubbing
Erythema nodosum
Skin tags, perianal abscesses
Abdominal mass
Anterior uveitis/enteropathic arthritis
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24
Q

How do you investigate suspected IBD?

A
  1. Bloods: FBC, U&E, LFT
    CRP/ESR, TFT, anti-TTG, haematinics (iron, B12, folate)
  2. Stool: Faecal calprotectin, MC+S
  3. Imaging: OGD and colonoscopy + biopsy
    Abdominal x-ray/CT: may show strictures, mucosal thickening, bowel dilation
  4. Truelove and Witts - criteria for severity of flare
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25
Q

What is the treatment for Crohn’s?

A

Inducing remission:
High dose oral prednisolone + PPI + bisphosphonate
+ azathioprine/mercaptopurine if not controlled

Maintaining remission:
Azathioprine + Infliximab most commonly

Surgical resection if severely affected

Symptomatic: loperamide, topical steroids
STOP SMOKING

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26
Q

What complications are associated with Crohn’s?

A 
Malnutrition
Small bowel obstruction
Abscess, fistula formation
Bowel perforation
Bowel cancer
Primary sclerosing cholangitis
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27
Q

What pattern of inflammation is associated with UC?

A

Continuous superficial inflammation- confined to mucosa
Starts at rectum and travels proximally
Limited to colon and rectum

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28
Q

What are the symptoms associated with UC?

A

Bloody diarrhoea, PR mucus
Abdominal pain and distension
Fever, weight loss, malaise, anorexia
Malnutrition, anaemia

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29
Q

What are the signs associated with ulcerative colitis?

A 
Finger clubbing
Anterior uveitis
Oral ulcers
Erythema nodosum
Pyoderma gangrenosum
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30
Q

How is UC managed?

A

Inducing remission:

  1. Rectal aminosalicylates
  2. Oral aminosalicylates
  3. High dose oral prednisolone + PPI + bone protection

Maintaining remission:

  1. Oral aminosalicylates
  2. Azathioprine

Surgical management:

  1. Resection of extremely diseased bowel
  2. In fulminant disease, panproctocolectomy -> permanent ileostomy/ileo-anal anastomosis (J pouch)
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31
Q

What complications are associated with UC?

A 
Toxic dilation (megacolon) >6cm
Perforation of bowel
Malnutrition
Anterior uveitis
Primary sclerosing cholangitis
Colon cancer
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32
Q

What are the antibodies associated with Coeliac disease?

A

Anti-TTG
Anti-endomysial

HLA-DQ2/DQ8

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33
Q

What are the symptoms associated with coeliac disease?

A 
FTT/weight loss in kids - buttock wasting etc
Bloating
Diarrhoea, nausea, vomiting
Abdominal pain
Symptoms of anaemia 
Dermatitis hepatiformis
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34
Q

How would you investigate somebody with suspected Coeliac disease?

A

Tests must be done while still eating gluten.

Bloods: FBC, U&E, CRP, ESR, Anti-TTG, IgA, haematinics

Endoscopy and duodenal biopsy: villous atrophy, crypt hypertrophy

If low IgA then normal anti-TTG does not exclude coeliac

Look for associated conditions: T1DM, thyroid disease, hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis

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35
Q

What are the complications of untreated coeliac disease?

A 
Malnutrition
Anaemia
Osteopenia/osteoporosis
Increased risk NHL, small bowel adenocarcinoma
Neuropathy
Vitamin deficiencies
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36
Q

What are the symptoms of appendicitis?

A

Central abdominal pain -> RIF pain
Nausea and vomiting
Abdominal distension, anorexia, N+V
Fever, tachycardia

37
Q

What are the signs of appendicitis on examination?

A

Abdominal distension and guarding of RIF
Tenderness at McBurney’s point
Rosving sign positive: palpation of LIF causes pain in RIF
Rebound and percussion tenderness -> peritonitis, may indicate rupture

38
Q

How is appendicitis diagnosed?

A

USS abdomen
CT abdo = highest diagnostic accuracy
Diagnostic laparoscopy in more unstable
Bloods: Raised WBC, CRP/ESR

39
Q

How would you manage somebody with appendicitis?

A

A-E assessment
IV access - bloods and IV fluids + NBM ready for surgery
IV antibiotics + analgesia + antiemetics
Appendicectomy (laparoscopic -> open if unstable/difficult operation)

40
Q

What are the 3 most common causes of bowel obstruction?

A

Adhesions, hernias, malignancy

Malignancy most common in large bowel, other 2 in small bowel
Other: volvulus, diverticulitis, stricture, intussusception

41
Q

What are the symptoms and signs of bowel obstruction?

A

Bilious vomiting
Abdominal pain and distension
Not opening bowels or passing wind

OE: tinkling bowel sounds -> absent bowel sounds, distended & tender abdomen

42
Q

What is the first line investigation in suspected bowel obstruction and how would you discriminate small vs large bowel?

A

Abdominal xray- dilation of bowel, may show clear obstruction, may show free air

small bowel: 3cm diameter, valvulae conniventes across entire diameter, usually more central
Large bowel: 6cm diameter, haustra not across entire width, usually more peripheral, more likely to see faeces

Typical abdominal X-ray features of small bowel obstruction include dilation of the small bowel (>3cm diameter) and much more prominent valvulae conniventes creating a ‘coiled-spring appearance‘.
Sigmoid volvulus: a characteristic ‘coffee bean’ appearance.
Caecal volvulus: often described as having a fetal appearance.

43
Q

What is the gold standard diagnostic test for bowel obstruction?

A

Contrast CT Scan

44
Q

How would you manage somebody with suspected bowel obstruction?

A 
A-E assessment
IV access (2 large bore cannula), NBM
Bloods incl. G&S + IV fluids
NG tube - bilious drainage 
AXR + erect CXR (free gas)
Contrast CT scan

If stable- treat cause
If unstable - surgical exploration and management

45
Q

What are the main causes of ileus?

A

Surgical handling of the bowel
Injury to the bowel
Inflammation/infection
Electrolyte imbalance affecting motility

46
Q

What are the symptoms of ileus?

A

Constipation
Abdominal pain and distension
Bilious vomiting/drainage from NG
No flatulence or bowel sounds

47
Q

What investigations should be done in ileus?

A

Bloods: electrolytes, magnesium, FBC

AXR / CT to rule out mechanical obstruction

48
Q

How do you manage a patient with ileus?

A 
NBM, NG with free drainage
IV fluids and nutrition
Mobilisation as much as possible
Correct any electrolyte abnormality
Reduce opioid analgesia
49
Q

How would you manage a patient with volvulus?

A

NBM + NG with free drainage
IV fluids and nutrition

Conservative: endoscopic decompression of the sigmoid colon, flatus tube

Surgical: laparotomy, Hartmann’s procedure in sigmoid, ileocaecal resection in caecal

50
Q

What would you expect to see on AXR in a patient with volvulus?

A

Sigmoid: coffee bean sign
Caecal: Foetus shape

51
Q

What are the three key complications of hernias? Define them.

A
  1. Incarceration- hernia becomes irreducible, leading to 2,3.
  2. Strangulation- incarcerated hernia becomes tight at the base, leading to loss of blood supply and ischaemia (surgical emergency)
  3. Bowel obstruction- hernia grows to block the passage of faeces through the bowel
52
Q

Where would you usually find an inguinal hernia?

A

Superomedial to the pubic tubercle

53
Q

What are the two types of inguinal hernia?

How are they defined?

A

Direct hernia: caused by weakness in Hesselbach’s triangle. Hernia not reduced by pressure on deep inguinal ring

Indirect inguinal hernia: herniates through inguinal canal. Pressure on the deep inguinal ring will reduce hernia.

54
Q

Where would you find a femoral hernia?

A

Inferolateral to the pubic tubercle

Herniation through the femoral canal via the femoral ring

55
Q

Where would you expect pain in an obturator hernia?

A

Medial thigh

56
Q

What is an incisional hernia?

A

Hernia through the incision of previous surgery or procedure.
Larger incision = greater risk.

57
Q

What is the management for abdominal hernias?

A
  1. Conservative: if small, not incarcerated/strangulated and wide neck - can leave alone
  2. Tension-free repair: Mesh attached to abdominal wall keeps protrusion within abdominal cavity
  3. Tension repair: surgical suturing of the muscles (rarely done)
58
Q

What is the most common site of hiatus hernias?

A

Through the oesophageal hiatus

59
Q

What are the symptoms of hiatus hernia?

A 
Dyspepsia / reflux
Bloating
Nausea
Bad breath
Belching
Dysphagia
60
Q

How are hiatus hernias diagnosed?

A

Erect CXR
CT scan
Endoscopy
Barium swallow study

61
Q

How are hiatus hernias managed?

A

If small and not very symptomatic - management of reflux symptoms

If large or symptomatic- surgical fundoplication

62
Q

What are the risk factors for haemorrhoids?

A 
Pregnancy
Obesity
Constipation 
Age
Increased IA pressure- coughing, weight lifting
63
Q

What are the symptoms of haemorrhoids?

A

May be asymptomatic
May be visible / palpable
Anal pain or itching, PR bleeding

64
Q

What are the different degrees of haemorrhoids?

A

1- no prolapse
2- prolapse on straining, return on relaxation
3- prolapse but can be pushed back in
4- permanently prolapsed

65
Q

What are the investigations for haemorrhoids?

A

Usually clinical diagnosis - external and internal PR examination

May be diagnosed by proctoscopy / flexible sigmoidoscopy

66
Q

How are haemorrhoids managed?

A
  1. Conservative- if few / asymptomatic can leave
  2. Medical: topical anaesthetic and steroid creams
  3. Non-surgical: banding/scleropathy/injection/diathermy
  4. Surgical: haemorrhoidectomy, artery embolisation/ligation
67
Q

What are the risk factors for diverticular disease?

A 
Age
Obesity
Low fibre diet
Constipation
NSAIDs
68
Q

What are the symptoms of diverticular disease?

A 
May be asymptomatic
May suffer LIF pain - often relieved by defecation
Constipation
PR bleeding
Weight loss in some
69
Q

How is diverticular disease diagnosed?

A

Flexible sigmoidoscopy

CT scan

70
Q

What is the management for diverticular disease?

A

High fibre diet
Increase fluid intake
Weight loss
Stool softeners/bulk-forming laxatives

AVOID stimulant laxatives

71
Q

What are the symptoms of acute diverticulitis?

A 
LIF pain
Fever
Diarrhoea, PR bleeding
Nausea and vomiting
May have palpable mass, peritonitis if perforated
72
Q

What are the investigations in acute diverticulitis?

A

Bloods: infection and inflammatory markers
Stool sample: rule out gastroenteritis / c.diff
CT abdo= gold std.

73
Q

How should diverticulitis be managed?

A 
1. Uncomplicated: 
5 day course oral co-amoxiclav
Oral analgesia- avoid NSAID and opiate
Clear fluids until symptoms resolve
2 day follow-up
  1. Complicated:
    NBM
    IV fluids, antibiotics, analgesia
    Urgent CT and surgical management
74
Q

What are the complications associated with diverticulitis?

A 
Bowel perforation
Abscess formation
Peritonitis
Haemorrhage
Bowel obstruction / ileus
Stricture/fistula formation
75
Q

What are the symptoms of acute mesenteric ischaemia?

A

Sudden onset, non-specific abdominal pain
Nausea and vomiting
Fever
Urgent need to move bowels

Symptoms of shock, peritonitis

76
Q

How is acute mesenteric ischaemia diagnosed?

A

ABG: metabolic acidosis and raised lactate

Contrast CT scan

US doppler

77
Q

How is acute mesenteric ischaemia managed?

A

Resuscitation
NBM
Surgery to remove any necrotic bowel
Endovascular/open thrombectomy or thrombus bypass

78
Q

What are the symptoms of chronic mesenteric ischaemia?

A

Colicky abdominal pain- usually comes on after eating and lasts 1-2 hours
Weight loss due to food avoidance
Abdominal bruit

79
Q

How is chronic mesenteric ischaemia diagnosed?

A

CT angiography

80
Q

How is chronic mesenteric ischaemia managed?

A
  1. Secondary prevention of CVD & reduce CV risk factors

2. Revascularisation

81
Q

What are the risk factors for colorectal cancer?

A

Increasing age, obesity
Family history
Smoking, alcohol consumption, red meat, low fibre diet
IBD,
FAP, HNPCC - both autosomal dominant conditions, need regular screening

82
Q

What are the symptoms of colorectal cancer?

A 
Change in bowel habit
Abdominal pain
PR bleeding/mucus
Weight loss, loss of appetite, unexplained iron-deficiency anaemia
Abdominal/rectal mass
83
Q

How is colorectal cancer investigated and diagnosed?

A

FIT testing (replaced faecal occult blood)
Bloods: FBC, U&E, CRP, CEA
Colonoscopy + biopsy = gold standard
CT colonoscopy in those who can’t tolerate colonoscopy
CT-TAP/PET staging

84
Q

What is the staging system used in colorectal cancer? (other than TNM)

A 
Duke's
A: confined to mucosa
B: spread through muscle
C: spread into lymph nodes
D: distant metastasis
85
Q

What are the different surgical techniques used in colorectal cancer?

A

Right hemicolectomy: caecum, ascending colon, proximal transverse
Left hemicolectomy: distal transvers, descending colon
High anterior resection: removal of sigmoid
Low anterior resection: removal of sigmoid and upper portion of the rectum
Abdominoperineal resection: removal of rectum, anus +/- some sigmoid - need permanent stoma

86
Q

What is the difference between an end and a loop colostomy/ileostomy?

A

Loop= temporary stoma where bowel is brought to skin surface and stoma made to allow distal portion and anastomosis to heal. Allows access to afferent and efferent limbs (proximal produces stool, distal produces mucus). These can be reversed in 3-6 months usually

End= distal part is sutured and left in the bowel. Can sometimes be reversed. Single lumen.

Alternatively ileoanal (J) pouch can be formed where a piece of ileum is brought along to act like rectum.

87
Q

How would you approach a patient with an acute abdomen?

A

A-E assessment
Full history and examination
IV access, O2 if needed and NBM in case need of surgery
NG tube if continuous vomiting, IV fluids as indicated
Bloods: FBC, U&E, LFT, CRP, lipase, troponin, calcium, group & save, glucose, B-HCG
ABG + blood cultures
Urine dip and pregnancy test in a woman
CT abdo with contrast
USS in A&E
ECG to rule out cardiac cause of epigastric pain

Need input from surgeons asap

88
Q

What are the two characteristic signs of retroperitoneal haemorrhage?

A

Cullen’s sign: bruising around the umbilicus

Grey-Turner’s sign: bruising around the flanks

89
Q

What are the signs on examination of peritonitis?

A 
Abdominal rigidity and guarding
Rebound tenderness
Percussion tenderness
Cough test elicits pain
Stretching leg elicit pains

Finals Revision (23 decks)

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