GI Flashcards
how is liver failure recognised?
coagulopathy (INR > 1.5)
encephalopathy
what are the 2 types of liver failure
acute - sudden, healthy liver
chronic - background of cirrhosis
how is acute liver failure classified?
- hyperacute liver failure (within 7 days) - paracetamol overdose
- acute liver failure (within 8-21 days)
- subacute liver failure (within 4-26 weeks)
what is fulminant hepatic failure
- clinical syndrome
- result of massive necrosis of liver cells
- leads to severe liver function impairment
risk factors for hepatic failure
Hepatitis Infection
Mental Health Conditions (Suicide Risk)
Alcohol Abuse
Sex Worker
IVDU
differentials for liver failure
Chronic Liver Disease
Hepatitis
Hepatocellular Carcinoma
causes of hepatic failure
- infection - hep B and C
- drugs - paracetamol overdose, isoniazid (abx)
- Toxins
- Vascular conditions
- Specific conditions - alcohol abuse, fatty liver disease, primary biliary cholangitis, autoimmune hep, Wilson’s, alpha 1 anti-trypsin
what are the signs of chronic liver disease
leukonychia palmar erythema clubbing jaundice gynaecomastia spider naevi splenomegaly hepatomegaly caput medusa pedal oedema
signs of hepatic failure
hepatic encephalopathy - this is needed to be classified as liver failure pear drop breath asterixis/liver flap constructional apraxia jaundice
what are the signs of hepatic encephalopathy
confusion, altered GCS (see below)
asterix: ‘liver flap’
constructional apraxia: inability to draw a 5-pointed star
what bloods tests are needed for hepatic failure?
FBC - anaemia (GI bleed) and infection U&Es LFTs (deranged) coagulation - raised PT iron studies - high ferritin and transferin (haemochromatosis)
what antibodies will be high in autoimmune hep
IgG
what special tests would be requested for someone with suspected liver failure
ammonia CXR paracetamol viral serology ascitic tap
how to manage coagulopathy in hepatic failure (GI bleed)
vitamin K
FFP
blood
endoscopy
how to manage hepatic encephalopathy in hepatic failure
- lactulose (traps ammonia in colon)
- rifaximin (abx that kills nitrogen forming bacteria in gut)
- avoid drugs that constipate
how to manage ascites?
- fluid restriction
- low salt diet
- diuretics
what can you give to someone who has overdosed on paracetamol
N-acetylcysteine
what is hepatorenal syndrome and how is it treated
failure of liver leads to failure of kidneys (renal vasoconstriction)
kidneys become ischaemic and fail
what is an upper GI bleed
GI blood loss proximal to ligament of Treitz
oesophagus, stomach, duodenum
how would someone with upper GI bleed present
- Hematemesis
- ‘Coffee Ground’ Vomit (oxidation of blood by stomach acid)
- Melena (Black, tarry stools)
- tachycardic
- signs of shock, hypovolaemia
causes of upper GI bleeding
oesophagitis oesophageal varices oesophageal perforation Mallory-Weiss syndrome Booerhave's syndrome - alcoholics gastritis peptic ulcer duodenal ulcer gastric cancer
investigations for upper gi bleed
Blatchford score
bloods - urea (raised due to blood meal), anaemia (FBC), coagulation screen
endoscopy (once stabilised)
management of unstable patient with upper GI bleed
airway - high flow O2
2 large bore IV cannula -FBCm U&Es, LFTs, clotting, crossmatch (hypovolaemia, anaemia)
IV fluids
what is a lower GI bleed
GI bleed below the ligament of Trietz
bleeding from small intestine, large intestine, rectum, anus
causes of lower GI bleed
angiodysplasia of colon haemorrhoids *diverticular disease UC Crohn's (if colitis too but unlikely) colorectal cancer
clinical presentation of lower GI bleed
Haematochezia (fresh blood in stools, this may or may not be mixed with stool)
rarely melaena (as no digestive enzymes in colon)
haemorrhoid bleeding - paper and pan
investigations for lower GI bleed
bloods - FBC and WCC (anaemia and infection)
PR exam
colonoscopy
management of lower GI bleed
if severe bloody diarrhoea assume UC
treat with hydrocortisone
what is a hernia
Abnormal protrusion of abdominal contents through a weakness or defect along the abdominal wall. They can be acquired or congenital. The most common is inguinal.
what causes congenital hernias?
failure of process vaginalis to close after testicular descent
causes a indirect inguinal hernia
what causes acquired hernias
loss of mechanical integrity of abdo wall
due to a genetically weak abdo wall or damage to abdo muscles during surgery
types of hernia
reducible = contents of hernia freely return into the abdominal cavity
incarcerated = oedema and swelling of tissue, causes pain, non reducible, interruption to passage of contents -> obstruction
strangulated = progressive reduction in arterial flow to contents, erythema, ischemia, tissue necrosis
classification of hernias
Anterior hernia
- epigastric
- umbilical
- splegelian
- incisional
- parastomal
Groin hernia
- inguinal
- femoral
what are the 2 types of inguinal hernia?
direct - bowel pushes directly forward through posterior wall of inguinal canal
indirect - bowel passes through deep inguinal ring (can enter scrotum)
differences between direct and indirect inguinal hernias
direct - acquired, medial to epigastric vessels, common in old men
indirect - congenital, lateral to epigastric, born with it
where does a femoral hernia travel below and who is it more common in?
under inguinal ligament
common in females
which hernias have the highest risk of strangulation?
femoral
congenital inguinal hernia
how does umbilical hernia happen and what are the causes
through linea alba
born with it or increase in intra abdo pressure
how does an incisional hernia occur
through scar tissue of past surgical incision due to poor wound healing
what type of stoma does a parastomal hernia occur most common in
colostomy
which side does a hernia most commonly occur on?
right
what is the relationship between the pubic tubercle and inguinal and femoral hernias
inguinal hernias are above pubic tubercle (superomedial)
femoral hernias are below (inferolateral)
what are colorectal cancers?
malignancies arising from the beginning of the colon, caecum, through to the rectum
does not include anus or small bowel
what is the purpose of a loop colostomy
protect distal anastomoses after recent surgery - allows time for anastomoses to heal and become stronger before allowing faeces to travel through and leak
proximal loop colostomy are common
only temporary - can be reversed
risk factors for colorectal cancer
family hx hereditary syndromes - lynch and FAP IBD diet alcohol smoking DM
what is another name for lynch syndrome and what other cancer is it associated with
hereditary non polyposis colorectal carcinoma
endometrial
what is the clinical presentation for colorectal cancer
Common
- abdo mass (late sign)
- haematochezia - blood on stool
- constitutional sx
Right sided = often bleed → anaemia
- microcytic anaemia - fatigue, weight loss, pallor
- abdo pain
Left sided = obstruction
- bleeding and mucus on PR
- change in bowel habits - constipation
- tenesmus
- palpable mass on PR
who is the colorectal screening programme offered to
56-74
invited to test every 2 years
investigations for suspected CR cancer
- Bloods - FBC (microcytic anaemia), serum iron, transferrin saturation, TIBC, LFTs, clotting, CEA
- FIT test
- colonoscopy* with biopsy (for CR cancer)
- just colonoscopy for polyps
- CT pneumocolon
- barium enema
- CT abdo pelvis scan for staging (TNM)
- MRI liver
where do most colorectal cancers metastasise to?
where does rectal cancer metastasise to?
liver
lungs
what is diverticular disease
surgical problem which consists of herniation of the colonic mucosa through the muscular wall of the colon, usually in the sigmoid colon
It is known as diverticular disease if the patient experiences specific sx due to the presence of diverticula (diverticulosis).
what is the difference between diverticulum, diverticulosis, diverticulitis?
- Diverticulum - outpouching of colonic mucosa that has herniated through the muscularis propria and has come to lie in the subserosal fat outside the bowel wall
- Diverticulosis - a common disorder characterised by the presence of multiple outpouchings of the bowel wall (usually sigmoid colon), usually asymptomatic
- Diverticulitis - infection or inflammation of a diverticulum, presents acutely
risk factors for diverticular disease
- > 50
- FHx
- Low-fibre diet → raised intraluminal pressure
- Obesity
- Sedentary lifestyle
- Smoking
- NSAIDs
clinical presentation of diverticulosis
painless rectal bleeding
asymptomatic
clinical presentation of diverticular disease
altered bowel habit - constipation, diarrhoea
bloating
rectal bleeding
lower abdo pain
clinical presentation of diverticulitis
- L iliac fossa pain and tenderness (guarding)
- Fever (with raised WBC and CRP)
- Tachycardia
- Reduced bowel sounds
- Diarrhoea
- N&V
- Rectal bleeding
- Palpable abdominal mass
- Localised peritonitis
what happens in diverticulitis
caused when faecal matter impacts and obstructs the neck of the diverticulum (muscularis propria) → irritation and damage to the mucosa → body mounts an acute inflammatory response
investigations for diverticular disease
urinanalysis
bloods - FBC, faecal occult blood, U&Es, CRP
imaging CT and endoscopy
investigations for acute diverticulitis
bloods - FBC, CRP
imaging - CXR (erect) for perforation, CT
management of diverticular disease
avoid NSAIDs and codeine (give para)
offer antispasmodic
management for acute diverticulitis
IV abx - co-amox
liquid diet
analgesia
hartmann’s procedure - if perforated
