GI Flashcards
painless rectal bleeding
blood on stools - not mixed
anal itching/irritation
external small vascular lumps 2, 7, 11 o clock
haemorrhoids
haemorrhoids management
soften stools - dietary or laxatives
topical anaesthetic/steroids
rubber band ligation or sclerotherapy
very large haemorrhoids = surgery
painful bright rectal bleeding
sharp pain on passing stool
constipated
anal fissure
management of anal fissure
acute = soften stool with laxative and prescribe topical analgesics chronic = topical GTN - consider surgery or botulinum toxin
pain around anus, worse on sitting
pus-like discharge from the anus
hardened tissue around anus
sometimes systemic features
anorectal abscess
management of anorectal abscess
surgical incision and drainage
sometimes given Abx
skin irritation around the anus
contant throbbing pain - worse when sitting, moving, coughing or passing stool
smelly discharge near anus
rectal bleeding
hx of rectal abscess
rectal fistula
anal fistula tx
surgical - fistulotomy
painful, tender lump which may be fluctuant and have purulent discharge. There may be accompanying cellulitis
usually at the tailbone/coccyx /natal cleft
usually male between 16-40yrs
pilonodal disease
management of pilonodal disease
Incision and drainage
paracetamol for pain/fever
advise long term hygiene and hair removal techniques
often asymptomatic
rectal bleeding, diarrhoea, abdo pain and mucous discharge
dental problems
polyps
management of polyps
sulindac AND/OR tamoxifen
surgical - proctocolectomy with ileostomy or total colectomy with ileorectal anastomosis
persistent blood in stool persistent change in bowel habit persistent lower abdo pain , bloating or discomfort weight loss loss of appetite
colon cancer
management of colon cancer
surgery = cancerous section removed
chemo/radiotherapy
targeted therapies
colon/bowel cancer screening?
FIT & FOB when aged 60-74 = every 2 yrs home kit
commonly young pt 10-20yrs periumbilical pain/epigastric which radiated to RIF pain worse on coughing mild pyrexia anorexia nausea \+ve rovsing and psoas signs
acute appendicitis
management of acute appendicitis
laparoscopic appendectomy
prophylactic Abx and fluids
usually in infants 6-18months paroxysmal abdo pain (RUQ) vomiting red-currant jelly stool sausage shaped mass in RUQ
intussusception
investigations for intussusception
US = target like mass
Management for intussusception
reduction by air inflation and surgery
LIF abdo pain
fever, malaise
occasional rectal bleeding
Diverticulitis
management for diverticulitis
oral Abx, liquid diet and analgesia = mild cases
symptoms unsettled after 72hrs = admit to hospital and iV abx
what investigation done for diverticulitis
erect CXR = pneumoperitoneum (presence of air/gas in peritoneal cavity
abdominal pain
bloating
change in bowel habut
usually for 6 months
symptoms worsened by eating
passage of mucus
usually younger pts ~20-30ys
IBS
IBS management
first line - antispasmodics for pain, laxative if constiapted and loperamide if diarrhoea
second-line = low dose tricyclic eg: amitriptyline
can suggest
psychological interventions= CBT
management of faecal impaction in children
pulyethylene glycol 3350 + electrolytes / Movicol Paediatric Plain
add stimulant laxative
sudden onset of diarrhoea 3 or more times - sometimes with blood or mucus faecal urgency abdo pain/cramps sudden N&V bloating flatulence, weight loss
gastroenteritis
infectious diarrhoea
what Ix should be done in gastroenteritis
urea breath test for H.pylori
management of gastroenteritis
If H.pylori negative = PPI
hydrate
loperamide may help
avoid transmission
abdominal pain - often of sudden onset, severe and out-of-keeping with physical exam findings - sometimes post-prandial
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis
ischaemic bowel disease
Ix for ischaemic bowel disease
CT (wall thickening)
management of bowel ischaemia
intial resuscitation, iV fluids and oxygen
IV broad-spec Abx
surgery - urgent laparotomy
central diffuse abdo pain nausea and vomiting (bilious) constipation distended abdo 'tinkling bowel sounds'
recent surgery may predispose to adhesions
bowel obstruction
investigation for bowel obstruction
abdo X-ray = distended bowel loops
CT gives definitive diagnosis
management of bowel obstruction
nil by mouth, IV fluids, NG tube
some may require surgery
pain, distention of the abdomen, fever, rapid heart rate, and dehydration, altered mental status
toxic megacolon
management of toxic megacolon
IV fluids and Abx
colectomy
diarrhoea prominent weight loss ulcers, perianal disease skip lesions lesions from mouth to anus cobblestone appearance associated with gallstones granulomas and increase goblet cells all layers of submucosa inflamed
Crohn’s disease
bloody diarrhoea LLQ pain tenesmus continuous disease does not surpass the ileorectal valve crypt abscesses widespread ulceration and pseudopolyps lower goblet cells and granuloma
Ulcerative colitis
drainpipe colon, loss of haustrations
ulcerative colitis
management of ulcerative colitis
mild cases = topical rectal aminosalicylate (-salazines)
severe = hospital admission - IV steroid /cyclosporin
surgery if no improvement in 72hrs
maintaining = oral azathioprine/mercaptopurine
management of crohn’s
first line = glucocorticoids or budesonide
second line = aminosalicylates
can add oral azathioprine/mercaptopurine
eventual surgery
acidic taste in mouth persistent cough (at night) retrosternal pain sore throat dyspepsia halitosis
oesophagitis
investigations of oesophagitis
endoscopy and pH testing
management of oesophagitis
antacids PPI 12 months or H2Rs
keyhole surgery = tighten lower oesophageal sphincter
haematemesis melaena abdo pain dysphagia/odynophagia encephalopathy pallor, hypTN, signs of sepsis
oesophageal varices
management of oesophageal varices
vasoactive drugs - adrenaline
endoscopic band ligation
prophylactic antibiotics
progressive dysphagia heartburn food impaction chest pain weight loss persistent cough
oesophageal stricture
oesophageal stricture Ix
endoscopy, barium swallow, FBC and iron studies
management of oesophageal stricture
oesophageal dilation with endoscopy
and long term PPI use
Usually history of antecedent vomiting.
This is then followed by the vomiting of a small amount of blood.
little systemic disturbance or prior symptoms.
repeated vomiting after binge drinking, severe morning sickness and bulimia
mallory weiss tears
mallory weiss tear Ix
upper endoscopy
management of mallory weiss tears
initial resuscitation and correct fluid loss
change from squamous epithelium to columnar epithelium
usually asymptomatic
some GORD symptoms
barrett’s oesophagus
management of barrett’s oesophagus
endoscopic surveillance
and high dose PPI
resection - resection/ablation
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
achalasia/oesophageal dysmotility
investigations of achalasia/oesophageal dysmotility
oesophageal manometry
barium swallow = ‘birds beak appearance’
chest-X-ray = wide mediastinum
management of achalasia/oesophageal dysmotility
pneumatic (balloon) dilation first-line
surgical intervention with a heller cardiomyotomy
intra-sphincteric injection of botulinum toxin
retrosternal burning pain
dyspepsia
halitosis
acid brash
GORD
GORD Ix
24hr pH oesophageal monitoring
upper GI endoscopy
management of GORD
high dose PPI for 1 month
if no response = try H2RA or prokinetic
epigastric pain
nausea
dypepsia
hx of NSAID/aspirin use
peptic ulcer disease
ulcer relieved by eating
duodenal
ulcer worsened by eating
gastric ulcer
Ix for peptic ulcer disease
urea breath test for H.Pylori
management of peptic ulcer disease
H.pylori positive = eradication therapy
H.pylori negative = PPI till ulcer heals
dyspepsia
nausea and vomiting
anorexia and weight loss
dysphagia
usually more common in males and ~ 70s-80s
gastric cancer
diagnosis of gastric cancer
endoscopy with biopsy
staging = CT/endoscopic US
Management of gastric cancer
gastrectomy (5-10cm)
lymphadenectomy may also be carried out
chemo prior to and after surgery
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic
hypokalaemic
alkalosis
pyloric stenosis
diagnosis of pyloric stenosis
ultrasound
management of pyloric stenosis
Ramstedt pyloromyotomy
symptoms of peptic ulcer disease
generalised epigastric pain
syncope
peptic ulcer perforation
haematemesis
melena
hypotension
tachycardia
peptic ulcer haemorrhage
peptic ulcer haemorrhage management
Fist line = endoscopic intervention
IV PPI
if that fails = interventional angiography or surgery
hepatosplenomegaly - painful/tender fatigue jaundice loss of appetite nausea
GGT raised
AST:ALT >2 (>3 even stronger indication)
alcoholic liver disease
management of alcoholic liver disease
prednisolone (glucocorticoids) - acute episodes
pentoxifylline (sometimes used)
splenomegaly ascites hepatic encephalopathy/confusion lower conjugated bilirubin lowered production of coag factors and albumin jaundice pruritus bruising
cirrhosis
Ix for cirrhosis
liver biopsy
management
irreversible = prevent underlying cause
stop alcohol consumption
treat any infections
A yellow tinge to the skin or eyes (jaundice). Feeling tired. Muscle or joint aches and pains. Tummy (abdominal pain). A poor appetite. Feeling sick (nausea). Darker-coloured urine and pale-coloured stools. Headache. A high temperature (fever) in some cases
hepatitis
> 6months = chronic heaptitis
hepatitis B serology
HBsAg = acute hepatitis
IgM = acute
IgG = previous
Anti-HBs implies immunity
core antigen = chronic
surface antigen = acute
Hepatitis B management
pegylated interferon-a first line
anti-virals = tenofovir, entecavir and telbivudine
prevention with Hep B vaccine = 2, 3 and 4 months of age
a transient rise in serum aminotransferases / jaundice
fatigue
arthralgia
hx of IV drug use
Hep C hepatitis
management of Hep C hepatitis
currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir)
+/- ribavirin are used
jaundice
raised AFP
B symptoms
ascites, RUQ pain, hepatomegaly, pruritus, splenomegaly
hepatic cancer/neoplasm
Ix of hepatic neoplasm
CT/MRI
serial CT and aFP measurments
management of hepatic neoplasm
surgical resection
chemo/radiotherapy
tumour ablation
common hepatic neoplasms
cholangiocarcinoma and hepatocellular carcinoma
severe epigastric pain - radiates to back
vomiting common
low grade fever
cullen’s signs (periumbilical discolouration)
grey turner’s sign (flank discolouration)
ileus
hx of gallstones or excessive alcohol consumption
acute pancreatitis
Ix for acute pancreatitis
raised lipase, amylase
US/contrast induced CT
management of acute pancreatitis
fluid resus - aggressive hydration with crystalloids
IV opioids
enteral nutrition provided
if due to gallstones = cholecystectomy
necrosis = debridement and fine needle aspiration
epigastric pain worse 15-30 mins after a meal
steatorrhea
diabetes mellitus
chronic pancreatitis
Ix for chronic pancreatitis
pancreatic calcification on abdo X-ray or CT
faecal elastase
chronic pancreatitis management
pancreatic enzyme supplements
analgesia
antioxidants
painless jaundice pale stool, dark urine and pruritis anorexia weight loss epigastric and back pain steotorrhoea and DM
pancreatic cancer
Ix for pancreatic cancer
CT = double duct sign
can do US
management of pancreatic cancer
surgery - usually very little suitable for surgery
adjunctive chemotherapy
RUQ pain
fever
positive murphy’s sign
mildly deranged LFTs
Acute cholecystitis
Ix for Acute cholecystitis
Ultrasound
management for Acute cholecystitis
cholecystectomy (ideally within 48hrs)
RUQ pain - colicky
following fatty meal
Gallstones/cholethiasis
Ix for Gallstones/cholethiasis
US/MRCP
LFTs
management of Gallstones/cholethiasis
laparoscopic cholecystectomy
very unwell pt
RUQ pain
jaundice
cholangitis
herniation of part of the stomach above the diaphragm
GORD symptoms
hiatus hernia
management
lifestyle changes
PPI
Surgery
groin lump
superior and medial to the pubic tubercle
disappears on pressure or when the patient lies down
discomfort and ache: often worse with activity, severe pain is uncommon
usually in males
inguinal hernia
management of inguinal hernia
mesh repair is associated with the lowest recurrence rate
either open or laproscopic
ascites
abdominal pain
fever
usually hx of cirrhotic liver
peritonitis
diagnosis for peritonitis
paracentesis: neutrophil count > 250 cells/ul
management for peritonitis
IV cefotaxime
