GI Flashcards
What is a hernia
Protrusion of a viscus through a defect in the wall through its containing cavity
Main complications of hernias
irreducible
obstruction (bowel contents cant pass through)
incarcerated
strangulated
Rfs for inguinal hernia
Obesity, constipation, chronic cough, heavy lifting, male
Which inguinal hernia most likely to strangulate? where does this hernia go through? what about the other?
indirect (through deep inguinal ring) - these ones are more likely to strangulate!!!
Direct - though posterior wall of inguinal canal
What Ix can be done if unsure about a hernia
USS
Usual presentation of hernia
lump ± pain (?incarceration)
Non surgical mx of small hernia?
watch and wait
stop smoking, weight loss, diet
2 complications of mesh surgery for hernias
Recurrence within 5 years = 1%
Wound infection
Intestinal injury
presentation of femoral hernia
Lump in groin inferior and lateral to pubic tubercle
(*superior and lateral = inguinal)
Most common DDx of femoral hernia? how to differentiate OE?
Hydrocele - possible to get above on examination
Issue with femoral hernias ?
High strangulation rate (20% @ 3 months)
presentation of strangulated hernia?
Red, tender, tense, irreducible ± colicky abdo pain + vomit + distension (obstruction - a surgical emergency)
Red flags of dyspepsia? name 3
Wt loss, recurrent vomiting, dysphagia, chronic bleeding
ALARMS
Anaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena, Swallowing difficulty
most common causes of dyspepsia
Functional - without ulcers (70%)
Peptic ulcers
oesophagitis
Diagnosis of funcitional dyspepsia?
ROME criteria
6M Post-prandial fullness, early satiety, epigastric pain/burning + no struc
Name 2 drugs that cause dyspepsia
Nitrates
Bisphosphonates
Corticosteroids
NSAIDs
- Decrease mucus and bicarbonate secretion
How to PPIs work for dyspepsia?
decreases expression of H+/K+ antiporter on luminal membrane of parietal cells
Ix in dyspepsia?
FBC for alarm e.g. IDA
Test for h.pylori
Endoscopy (upper GI) if ALARMS or >55 (2 week wait)
Barium swallow may be useful
Lifestyle advice for dyspepsia
stop offending drugs, decrease tobacco, avoid aggravating foods, lose weight+ over the counter antacids
eg of a H2 receptor antagonist?
PPI?
ranitidine
Omeprazole
Stomach cells - what do they do?
Chief cells -
G-cells
Parietal cells
D-cells -
Goblet cells -
Chief cells - pepsinogen (to pepsin by HCl)
G-cells - gastrin (antrum)
Parietal cells - intrinsic factor and HCl (fundus + body)
D-cells - somatostatin (antrum)
Goblet cells - mucus + bicarbonate
What stops acid production?
somatostatin
describe h pylori
G - curved bacillus
Sx of PUD
Fullness, bloating, early satiety, epigastric pain/burning
Cause of PUD?
H.pylori through mucus layer
Ix for H pylori
C13 urea breath test - may be done in primary care
Stool antigen test + CLO test (pink with h.pylori)
Type of anaemia in PUD
iron deficiency
(bleeding + h pylori uses iron for own growth)
Mx of h pylori
PAC - 2 WEEKS
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
What things help protect against ulcers
Mucus, bicarbonate, prostaglandins
What arteries may be affected by PUD in duodenum ? stomach ?
duodenal cap, may erode gastroduodenal artery
Common at lesser curve of stomach , may erode L gastric artery
Differentiate pain caused by DU and GU
DU - post prandially (1-3 hours), which is relieved by eating
GU - on eating
If pain radiates to back with ulcers where might it be?
posterior duodenal ulcer as related pancreas
What may be cause of PUD if h pylori negative and recurrent ulcers?
Zollinger-Ellison syndrome
(gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers)
PUD ix? when for endoscopy? biopsy?
FBC - ID anaemia
H.pylori testing
Endoscopy ONLY IF first presentation >55 or ALARMS
Biopsy if NSAID and H.Pylori -ve as ?Zollinger-Ellison
mx of ulcer that is h pylori -ve NSAID induced
PPI or H2RA for 8 weeks
Comps of PUD
Haematemesis, melaena if erosion of large blood vessel
Acute abdomen and peritonism with perforation
What is GORD
Reflux of acid contents (bile - particularly caustic/acid) into oesophagus
What does GORD cause?
oesophagitis, ulceration, stricture formation or Barrett’s Oesophagus
Epithelial change in barretts?
metaplasia or squamous epithelium to glandular
Some Rfs for GORD
pregnancy
obesity
smoking, alcohol, coffee
3 things someone with GORD might present with?
Heartburn: burning feeling rising stomach to neck relieved by antacid. Related to meals, posture (lying down), straining
Water brash: excessive salivation
Acid brash: retrosternal discomfort - regurgitation of acid or bile
Odynophagia - painful swallowing related oesophagitis or stricture
Belching
Hoarseness
Cough - particularly at night
Gold standard Ix in GORD? other?
Gold standard is endoscopy
FBC to exclude anaemia
Barium swallow for hiatus hernia
Oeseophageal pH monitoring
±CXR
What would make you urgent refer for Ca with GORD?
ALARMSAnaemia, Loss of wt, Anorexia, Recent onset (if >55), Melaena (GI bleed), Swallowing difficulty
+ vomiting, Barrett’s oesophagitis, lump
Lifestyle Mx of GORD
reduce weight, stop smoking, reduce alcohol, raise bed at night, regular small meals,
Avoid causative drugs
Drugs that affect oesophageal motility?
nitrates, anticholinergics, TCA
Drugs that damage mucosa
NSAID
bisphosphonates
If you see oesophagitis on endoscopy what drug mx?
PPI 2/12
Surgical mx of GORD?
Laparoscopic fundoplication
Pres of a hiatus hernia? why?
GORD - oesophageal sphincter becomes less competent
Ix for hiatus hernia?
CXR
Barium study
Endoscopy
Mx of hiatus hernia
Lifestlye as GORD + PPI longterm + surgery e.g. gastropexy if refractory
Mx of oesophagitis
2/12 PPI
Name 2 PPIs
lansoprazole, omeprazole
2 key Ix for barretts?
Endoscope - proximal displacement
Biopsy - histological confirmation of columnarisation
Mx of low vs high grade barretts?
Low grade: Lifestyle as for GORD + long term PPI ± ablation
High grade: oesophagectomy
Cell type for Ca of oesophagus?
80% SCC (upper ⅔)
or adenocarcinoma (lower ⅓)
Red flags for presentation of oesophageal Ca?
Dysphagia (solids>liquids)
Vomiting
Anorexia and weight loss
Symptoms of GI related blood loss e.g. melaema
Symptoms of infiltration - intractable hiccups and persistent retrosternal pain
Upper ⅓ specific - hoarseness and cough - less common
Lymphadenopathy
name 3 Ix for oesophageal Ca
FBC, UE, LFT, glucose, CRP
*Endoscopy with brushing and biopsy of lesion
CXR for metastases
CT/MRI of chest and upper abdomen for staging
Double contrast barium swallow - for dysphagia
Bronchoscopy if hoarseness
DDx for dysphagia . name 3
Oesophageal: GORD, oesophagitis, oesophageal cancer (food sticking), pharyngeal cancer
Neurological: CVA, achalasia, diffuse oesophageal spasm, MS, MND
Others: pharyngeal pouch, external compression (mediastinal tumour), CREST or scleroderma
what is achalasia
Disorder of motility of lower oesophageal sphincter
- Smooth muscle layer has impaired peristalsis and sphincter fails to relax
3 Ix for achalasia? which is gold standard?
CXR
Barium swallow
Manometry - gold
[Tube passed into the oesophagus - measures pressure at rest / swallowing]
Seen on CXR of achalasia?
, vastly dilated oesophagus behind heart
Seen on barium swallow achalasia?
characteristic bird’s beak dilated oesophagus with distal narrowing
Drug mx of achalasia?
CCB/nitrates - botox injection
(reduce pressure in lower oesophageal sphincter)
Surgery for achalasia is normally endoscopic dilation - main comp?
perforation
Gi features of scleroderma?
Reflux oesophagitis, delayed gastric emptying, Watermelon stomach (- may cause GI bleeding / anaemia)
3 autoantibodies in scleroderma
Anti-topoisomerase 1
Anti-centromere antibody (ACA)
Anti-RNA polymerase III
Gi mx of scleroderma
lifestyle - like GORD
PPI
Pro-motility agents - metoclopramide or domperidone
Dilatation of oesophaeal strictures
3 DDx of upper GI bleed?
PUD, mallory weiss, malignancy, varicies
What to think if Haematemesis is bright red? coffee?
Bright red - fresh - above stomach, active haemorrhage
Altered - coffee ground - stomach or below
cause of mallory weiss?
Persistent vomiting/wretching
Ix of mallory weiss
Endoscopy, FBC including HCT to assess severirt
Renal function/urea for fluid replacement
Cross-match and blood group
2 comps of mallory weiss
aspiration pneumonia
Mediastinitis is perforation
Hypovolaemic shock / death
What are oesophageal varicies?
Dilated veins at junction between portal and systemic venous circulation account for 10% of UGI bleeds
What usually is the cause of oesophageal varicies?
chronic liver disease -> portal hypertension
Ix in varicies?
Endoscopy, FBC (Hb and HCT), clotting, renal function, LFT