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Phase 2a Annabel > GI > Flashcards

GI Flashcards

1
Q

Whata are the 2 main types of inflammatory bowel disease (IBD?)

A

Ulcerative colitis (UC)
Crohn’s disease (CD)

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2
Q

Where does UC affect?

A

ONLY the colon
Mucosa

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3
Q

Where does CD affect?

A

Any part of the GI tract- mouth to anus
Transmural

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4
Q

Define transmural

A

Affects all layers

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5
Q

Define ulcerative colitis

A

Chronic relapsing-remitting non-infectious inflammatory disease of the colon

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6
Q

What are the 4 types of UC?

A

Ulcerative proctitis
Proctosigmoiditis
Left sided colitis
Extensive colitis

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7
Q

Define ulcerative proctitis

A

Inflammation limited to rectum

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8
Q

Define proctosigmoiditis

A

Inflammation involving rectum and sigmoid colon

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9
Q

Define left sided colitis

A

Inflammation doesnt extend proximally above splenic flexure

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10
Q

Define extensive colitis

A

Inflammation extends proximally beyond splenic flexure, including pancolitis (entire colon)

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11
Q

Where does inflammation begin in UC?

A

Starts at rectum -> sigmoid -> proximal colon

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12
Q

What layers are affected by inflammation in UC?

A

Just the mucosa

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13
Q

What ethnic group are most prone to IBD?

A

Jewish people

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14
Q

What gene is associated with UC?

A

HLAB27

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15
Q

Who is commonly affected by UC?

A

Highest in Europe, UK, North America
Males=females
15-30
Some family history
No appendectomy

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16
Q

Does smoking increase the risk of UC?

A

No- smoking decreases risk!

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17
Q

What are 3 risk factors of UC?

A

Family history
NSAIDs
Chronic stress and depression

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18
Q

What are the signs and symptoms of UC?

A

Pain in lower left quadrant and when defecating
Diarrhoea with blood or mucus
Fever, tachycardia
Extraintestinal signs
Weight loss

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19
Q

What are the extraintestinal signs of IBD?

A

A PIE SAC

Ankylosing spondylitis
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Aphthous ulcers/ amyloidosis
Clubbing

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20
Q

What is pyoderma gangrenosum?

A

Ulcerated patches on skin (usually legs) which is very painful and has a purple edge

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21
Q

What is iritis?

A

Swelling and irritation of the iris

AKA anterior uveitis

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22
Q

What is erythema nodosum?

A

Swollen fat under skin causing red bumps on the skin

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23
Q

What is sclerosing cholangitis?

A

Disease of the bile ducts causing scarring

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24
Q

What are aphthous ulcers?

A

Canker sores- small shallow lesions in the soft tissue of the mouth or gums

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25
Q

How is UC diagnosed?

A

GS: colonoscopy with mucosal biopsy
Positive faecal calprotectin
Inflammatory markers: raised WCC, ESR and CRP

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26
Q

How is UC graded?

A

Truelove and Witt’s Criteria

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27
Q

What are the 3 levels of Truelove and Witt’s Criteria?

A

Mild: <4 stools per day
Moderate: 4-6 stools per day
Severe: <6 stools

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28
Q

What are 2 differential diagnoses of UC?

A

Crohn’s disease
Infective colitis
Pseudomembranous colitis
Microscopic colitis

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29
Q

How is UC treated?

A

Aminosalicylate/ 5-ASA
Moderate: 5-ASA and corticosteroid (Prednisolone)
Moderate-severe: fluid resus, IV steroid, anti-TNF

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30
Q

What are 3 5-ASAs?

A

*Mesalazine
Sulfasalazine
Olsalazine

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31
Q

How do 5-ASAs work?

A

Inhibit prostaglandins to reduce inflammation

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32
Q

What is an example of a glucocorticoid?

A

Prednisolone

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33
Q

What 3 drugs can be used to treat UC with severe systemic features?

A

Ciclosporin
Hydrocortisone
Infliximab

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34
Q

How is remission maintained in UC?

A

Azathioprine

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35
Q

How is UC cured?

A

Colectomy (rectum fused to ileum)
Partial colectomy

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36
Q

What is a severe complication of UC?

A

Toxic mega colon

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37
Q

What gene is associated with Crohn’s disease?

A

NOD-2

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38
Q

Define Crohn’s disease

A

Chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of the GI tract

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39
Q

What are skip lesions?

A

Regions of unaffected bowel between areas of active disease

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40
Q

Do skip lesions occur in UC or Crohns?

A

Crohn’s

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41
Q

What region of the GI tract is most commonly affected by Crohn’s?

A

Terminal ileum and proximal colon

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42
Q

Who is most commonly affected by Crohn’s?

A

North Europe, UK, USA
Not Asian
Females
1/5 have close relatives with CD
20-40 presentation

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43
Q

Is UC or Crohn’s more common?

A

UC

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44
Q

What are 3 risk factors of Crohn’s?

A

Genetic association
Smoking
Stress and depression
Good hygiene
Appendectomy

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45
Q

What are the symptoms of Crohns?

A

Pain in right lower quadrant
Urgent diarrhoea and pain
Gallstones
Weight loss and anorexia
Extraintestinal signs

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46
Q

What are 3 complications of Crohn’s?

A

Perforation and bleeding
Fistula formation
Malabsorption
Small bowel obstruction
Colorectal cancer

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47
Q

What are 3 differential diagnoses for Crohns?

A

Chronic diarrhoea
Salmonella
Rotavirus

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48
Q

What is another disease associated with the HLA B27 gene?

A

Ankylosing spondylitis
Psoriatic arthritis

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49
Q

How is Crohns diagnosed?

A

Colonoscopy and biopsy
Exclude campylobacter ect

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50
Q

What are some features of UC on colonoscopy?

A

Inflammatory infiltrate
Goblet cell depletion
Crypt abscesses
Mucosal ulcers

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51
Q

What are some signs of Crohns on colonoscopy?

A

Skip lesions
Granulomas
Cobblestone appearance

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52
Q

Outline the pathophysiology of Crohns

A

Faulty epithelium -> pathogens enter -> inflammation -> granulomas -> skip lesions and cobblestone appearance

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53
Q

How is Crohn’s treated?

A
  1. Prednisolone (mild) or IV hydrocortisone (severe)
  2. +5-ASA
  3. Infliximab
  4. Surgery
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54
Q

Will surgery cure Crohns?

A

No

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55
Q

How is remission for Crohns maintained?

A

Azathioprine +/- methotrexate

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56
Q

What are 3 differences between Crohns and UC?

A
  1. UC affects only colon, CD is whole GI tract
  2. UC affects whole part, CD has skip lesions
  3. CD penetrates the whole linings of the GI tract, UC only mucosa
  4. Smoking can prevent UC, but cause CD
  5. CD has granulomas, UC doesnt
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57
Q

Define irritable bowel syndrome (IBS)

A

Functional bowel disorder with a group of abdominal symptoms for which no organic cause can be found

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58
Q

Who is affected by IBS?

A

1/5 in UK!
Females > males
20-30

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59
Q

What are 3 things that can exacerbate IBS?

A

Stress
Food
Gastroenteritis
Menstruation

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60
Q

What are 3 causes of IBS?

A

Stress and anxiety
Stress and trauma
GI infection
Sexual, psychical and verbal abuse
Eating disorders

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61
Q

What are the 3 types of IBS?

A

IBS-C: constipation
IBS-D: diarrhoea
IBS-M: mixed- constipation and diarrhoea

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62
Q

What are 2 differential diagnoses of IBS?

A

IBD
Coeliac
GI infection
Lactose intolerance

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63
Q

What are the clinical presentations of IBS?

A

ABC:

A- Abdominal pain or discomfort (Relieved by defecation)
B- bloating
C- changes in bowel habit

Altered stool form and frequency

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64
Q

How is IBS diagnosed?

A

Rule out differentials: faecal caprotectin, anti-tTG, inflammation

Rome IV criteria

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65
Q

What does faecal calprotectin indicate?

A

IBD

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66
Q

What is Rome IV criteria?

A

Recurrent abdominal pain for at least 1 day a week for 3 months
AND 2 of:
Relieved by defecation
Changes in bowel appearance
Changes in bowel frequency

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67
Q

How is IBS managed conservatively?

A

Low FODMAP diet
Education and reassurance
Avoid caffeine and alcohol

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68
Q

How is IBS treated medically?

A
  1. Diarrhoea= loperamide, constipation = laxative (eg. Senna) and antispasmodics
  2. TCA - eg. Amitriptyline
  3. SSRA
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69
Q

What are 2 antispasmodics?

A

Mebeverine
Buscopan

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70
Q

What is a low FODMAP diet?

A

Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols

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71
Q

What are 3 differences between IBD and IBS?

A
  1. IBS normal on investigations
  2. IBS has no symptoms outside of GI tract
  3. IBS has no blood in stools
  4. IBS does not involve weight loss
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72
Q

Define coeliac disease

A

T cell mediated autoimmune disease of the small bowel where gluten causes inflammation

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73
Q

What part of gluten causes coeliac disease inflammation?

A

Prolamin which is an alcohol soluble protein

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74
Q

Outline the pathophysiology of coeliac

A

Prolamins bind to IgA and interact with ttg-> formation of IgA, IgA anti-ttg and EMA antibodies -> villous atrophy

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75
Q

What are 2 antibodies associated with coeliac?

A

Anti-TTG
Anti-EMA (more specific)

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76
Q

What part of the bowel is typically most affected by coeliac?

A

Jejunum

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77
Q

What 2 genes are associated with coeliac?

A

HLA-DQ2 (90%)
HLA-DQ8

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78
Q

What are 3 risk factors for coeliac disease?

A

Autoimmune disease eg. DMT1 and thyroid disease
Breastfeeding
Family history
IgA deficiency

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79
Q

What type of hypersensitivity reaction is involved in coeliac?

A

Type 4

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80
Q

What are the 3 effects of coeliac on the small intestine?

A

Villous atrophy
Crypt hyperplasia
Intraepithelial lymphocytes

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81
Q

What are the signs and symptoms of coeliac?

A

Dermatitis herpetiformis on elbows, knees and buttocks
Malabsorption (anaemia, weight loss, failure to thrive)
Angular stomatitis
Steatorrhoea
Osteomalacia

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82
Q

What is dermatitis herpetiformis?

A

Raised red patches cause by IgA deposition which can burst on scratching

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83
Q

What is angular stomatitis?

A

Inflammation on corners of mouth

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84
Q

What is steatorrhoea?

A

Fatty/smell stools

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85
Q

How is coeliac diagnosed?

A
  1. IgA levels: Raised anti-tTG
  2. Raised anti-EMA
    Biopsy
    Maintain gluten diet for 6< weeks before test
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86
Q

What is the gold standard diagnosis for coeliac?

A

Endoscopy and duodenal biopsy

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87
Q

Where is iron, folate and B12 absorbed?

A

Dude Is Just Feeling Ill Bro

Duodenum = Iron
Jejunum = folate
Ileum = B12

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88
Q

How is coeliac treated?

A

Lifelong gluten free diet :(
Replace mineral and vitamin deficiency

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89
Q

What are 2 complications of coeliac?

A

Osteoporosis
Anaemia
Non-responsive coeliac (not improved by no gluten)
T- cell lymphoma

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90
Q

Define tropical sprue

A

Severe malabsorption with diarrhoea and malnutrition after tropical travel

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91
Q

What is the onset of tropical sprue?

A

Can occur days or years after visit to tropics

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92
Q

What are the clinical presentations of tropical sprue?

A

Villous atrophy
Diarrhoea
Anorexia and weight loss

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93
Q

How is tropical sprue diagnosed?

A

Jejunal tissue biopsy shows incomplete villous atrophy

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94
Q

How is coeliac and tropical sprue differentiated on biopsy?

A

Tropical sprue= INCOMPLETE villous atrophy
Coeliac= COMPLETE villous atrophy

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95
Q

How is tropical sprue treated?

A

Drink treated water
Antibiotics: tetracycline for 6 months

Very good prognosis

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96
Q

Define gastritis

A

Inflammation of the stomach musocal lining

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97
Q

What are 3 causes of gastritis?

A

autoimmune
H. Pylori
NSAIDs
Alcohol
Stress

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98
Q

How does H.pylori cause gastritis?

A

Severe inflammation -> mucus degradation and increased permeability -> ammonia forms from urea -> toxic to mucosa -> less mucus produced

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99
Q

How do NSAIDs cause gastritis?

A

COX inhibitors inhibit prostaglandin-> inhibits mucous secretion -> gastritis

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100
Q

What are the clinical presentations of gastritis?

A

Epigastric pain with diarrhoea
N+V
Abdo bloating
Dyspepsia

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101
Q

What are 2 differential diagnoses of gastritis?

A

PUD
GORD
Gastric lymphoma
Gastric carcinoma

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102
Q

How is gastritis diagnosed?

A

Endoscopy and biopsy
H. Pylori urea breath test and stool antigen test

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103
Q

Why is CO2 high in a urea breath in H.pylori infection?

A

H.Pylori produces urease which converts urea to ammonia and CO2

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104
Q

How is gastritis treated?

A

Triple therapy: PPI and 2 Abx

PPI + amoxicillin (1g) + clarithomycin (500mg)

Stop NSAIDS and alcohol

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105
Q

What are 2 complications of gastritis?

A

Peptic ulcers
Bleeding and anaemia
Gastric cancer
MALT lymphoma

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106
Q

Define GORD

A

Reflux of gastric contents into the oesophagus due to lower oesophageal sphincter (LOS) relaxation

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107
Q

What are the causes of GORD?

A

Increased intraabdominal pressure (obese, pregnancy)
Hiatal hernia
Drugs
Scleroderma

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108
Q

What are the risk factors for GORD?

A

Obese or pregnancy
Smoking
NSAIDs, caffeine, alcohol
Male sex

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109
Q

What is the MC hiatus hernia?

A

Sliding: GOj and part of stomach slides into the chest
80%

Other = rolling- fundus collapses

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110
Q

What are the clinical presentations of GORD?

A

Dyspepsia/indigestion
Belching
Bile regurgitation/acid brash
Cough
Sinusitis

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111
Q

When are symptoms worsened in GORD?

A

Hot drinks and alcohol
Bending, stooping, lying down

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112
Q

What are the red flags in GI for urgent referral?

A

ALARMS

Anaemia (internal bleed)
Loss of weight
Anorexia
Recent onset
Melaena or haematemesis
Swallowing issues/dysphagia

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113
Q

What is the difference between haematemesis and haemoptysis?

A

Haematemesis is coughing up blood from GI
Haemoptysis is coughing up blood from respiratory system

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114
Q

What are 2 differential diagnoses of GORD?

A

CAD
Biliary colic
PUD
Malignancy

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115
Q

How is GORD diagnosed?

A

Usually made without investigation if no ALARM symptoms and go straight to treatment

If ALARM:
Endoscopy
FBC
Barium swallow
24h oesophageal pH

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116
Q

How is GORD treated conservatively?

A

Weight loss
Stop smoking
Small regular meas
Avoid hot drinks, alcohol, citrus, eating <3 hours before bed

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117
Q

How is GORD treated pharmacologically?

A
  1. PPI
  2. H2 receptor antagonist
    OTC:
    Antacids
    Alginates
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118
Q

What is an example of an antacid?

A

Magnesium trisilicate

Form a gel or foam raft to reduce reflux

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119
Q

What is an example of an alginate?

A

Gaviscon

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120
Q

What are 2 PPIs?

A

Lansoprazole
Omeprazole

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121
Q

What is an example of a H2 receptor antagonist?

A

Cimetidine
Ranitidine

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122
Q

What surgery can be used to treat severe GORD?

A

Nissan fundoplication

Fundus can be wrapped around oesophagus to increase resting LOS pressure

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123
Q

What are 2 complications of GORD?

A

Oesophageal stricture
Barretts oesophagus

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124
Q

What is oesophageal stricture?

A

Inflammation of oesophagus due to acid exposure
Presents as gradually worsening dysphagia

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125
Q

How is oesophageal stricture treated?

A

Endoscopic dilation
Long term PPIs

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126
Q

Define Barrett’s oesophagus

A

Metaplasia of stratified squamous -> simple columnar epithelium

ALWAYS hiatus hernia

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127
Q

What is the complication of Barrett’s oesophagus?

A

Increased risk of oesophageal adrenocarcinoma

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128
Q

How is Barrett’s oesophagus diagnosed?

A

Upper GI endoscopy and biopsy
Shows metaplasia >1cm from GOJ

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129
Q

Define peptic ulcer

A

A break in the superficial epithelial cells down to the muscularis mucosa of the stomach or duodenum

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130
Q

What are the 2 types of peptic ulcers?

A

Duodenal ulcers
Gastric ulcers

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131
Q

What is the MC type of peptic ulcers?

A

Duodenal ulcers

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132
Q

What is the MC site of gastric ulcers?

A

Lesser curvature

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133
Q

What are 3 causes of gastric ulcers?

A

H. Pylori (70-80%)
NSAIDs
Zollinger Ellison syndrome

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134
Q

What is Zollinger Ellinson syndrome?

A

Gastrin secrete tumour

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135
Q

What are the symptoms of gastric ulcers?

A

Epigastric pain
Worse quickly after eating
Weight loss

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136
Q

How is PUD diagnosed?

A

No red flags: C-urea breath test and stool antigen test
Red flags: urgent endoscopy and biopsy

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137
Q

What are the causes of peptic ulcer disease (PUD)?

A

H. Pylori infection
NSAIDs
Increased acid secretion
Smoking
Delayed emptying
Blood group O

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138
Q

How does H.pylori cause PUD?

A

Secretes urease -> urea converted to ammonia -> toxic to mucosa -> decreased mucus -> inc inflammation -> inc acid production

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139
Q

What is the most common site of duodenal ulcers?

A

D1 and D2 posterior wall

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140
Q

What is the MC cause of PUD?

A

H.Pylori

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141
Q

What are the symptoms of duodenal ulcers?

A

Epigastric pain
eating can alleviate pain
Pain ~4 hours after eating
Weight gain

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142
Q

What may cause a false negative result for H.Pylori?

A

PPI not stopped for 2 weeks before test!

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143
Q

How is PUD treated if H.pylori positive?

A

PPI + 2 Abx

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144
Q

What is the major complication of PUD?

A

Erodes into an artery and causes a bleed

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145
Q

How is PUD treated if H.Pylori negative?

A
  1. PPI
  2. H2 antagonist
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146
Q

How is an active PUD bleed treated?

A

ABC
1. Endoscopy to diagnose and treat
2. If fails, interventional angiography or surgery
Consider PPI

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147
Q

What are 3 complications of PUD?

A

Haemmorages
Perforation
Duodenal on posterior wall = pancreatitis
Malignancy

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148
Q

What does pain worsening after eating indicate?

A

Gastric ulcer

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149
Q

What does pain improving shortly after eating indicate?

A

Duodenal ulcer

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150
Q

What artery may be perforated in a gastric ulcer?

A

Left gastic artery

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151
Q

What artery may be perforated in a duodenal ulcer?

A

Gastroduodenal

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152
Q

What is a Mallory-Weiss tear?

A

Linear mucosal tear at gastric part of GOJ occuring due to a sudden increase in intra-abdominal pressure

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153
Q

What is usually seen before a Mallory Weiss tear?

A

Bout of coughing or retching
Alcoholic “dry heaves”

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154
Q

What are 2 causes of Mallory Weiss tears?

A

Forceful vomiting (bulimia and alcohol)
Chronic coughing
Weightlifting
Hiatus hernia

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155
Q

Who is commonly affected by Mallory Weiss tears?

A

Males
20-50

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156
Q

What are 3 risk factors of Mallory Weiss tears?

A

Alcoholism
Forceful vomiting
Male
Eating disorder
NSAID abuse

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157
Q

What are the clinical presentations of a Mallory Weiss tear?

A

Vomiting
Haematemesis after vomiting
Retching
Postural hypotension
Dizziness

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158
Q

What are 2 differential diagnoses of Mallory Weiss tear?

A

Gastroenteritis
Peptic ulcers
Cancer
Oesophageal varices

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159
Q

How is Mallory Weiss tear diagnosed?

A

Endoscopy

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160
Q

How is Mallory Weiss tear treated?

A

Most bleeds are minor, heal in 24 hours
Very rare but surgery can be required to sew the tear up

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161
Q

What are gastrooesophageal varices?

A

Enlarged veins protruding into lumen which have a risk of rupture causing GI bleeding

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162
Q

What are the causes of gastrooesophageal varices?

A

HTN in portal system in liver
Prehepatic: thrombosis
Intrahepatic: cirrhosis, sarcoid
Postheparic: R heart failure

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163
Q

What are 3 risk factors for gastrooesophageal varices?

A

Cirrhosis
Portal HTN
Schistosomiasis infection
Alcoholism

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164
Q

What are the 2 MC sites of gastrooesophageal varices?

A

Lower oesophags
Gastric cardia

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165
Q

What are the clinical presentations of ruptured gastrooesophageal varices?

A

Haematemesis- A LOT!
Abdo pain
Shock
Pallor
Hypotension

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166
Q

How is a ruptured gastrooesophageal varices diagnosed?

A

Endoscopy

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167
Q

How is a ruptured gastrooesophageal varices treated?

A
  1. ABCDE
  2. Vasopressin (Terlipressin)
  3. Transfusion
  4. Surgery
168
Q

What surgeries are used to treat gastrooesophageal varices (ie preventing bleeds)?

A

Variceal banding
Balloon tamponade
TIPS (shunt between systemic and portal system in liver)

169
Q

How are gastrooesophageal varices prevented?

A

Propranolol
Variceal banding
Liver transplant

170
Q

What are the 3 general symptoms of an upper GI bleed?

A

Haematemesis
Melena
Coffee ground vomiting

171
Q

What is melena?

A

Digested blood = black stools

172
Q

What is the general symptom of a lower GI bleed?

A

Haematochezia

173
Q

What is haematochezia?

A

Fresh red blood in stools

174
Q

Define achalasia

A

Oesophageal aperistalsis and impaired relaxation of the LOS

175
Q

What is affected by achalasia?

A

Degeneration of ganglions in myenteric plexus in muscularis externa

176
Q

What causes achalasia?

A

Idiopathic- cause unknown

177
Q

Outline the pathophysiology of achalasia

A

Nerves of LOS are degenerated -> LOS fails to relax -> obstruction

178
Q

Define dysphagia

A

Difficulty swallowing

179
Q

What are 3 symptoms of achalasia?

A

Non-progressive dysphagia - both solids and liquids
Regurgitation of food -> aspiration pneumonia
Spontaneous chest pain due to oesophageal spasm

180
Q

How is achalasia diagnosed?

A

Endoscopy
Barium swallow
Manometry (GS)

181
Q

What is the sign of achalasia on barium swallow?

A

“Birds beak sign”

182
Q

What is manometry used to measure?

A

Senses the pressure and constriction of muscles in the esophagus as you swallow

183
Q

How is achalasia treated?

A

Nitrates or CBB to relax LOS
Surgery can be curative- endoscopic balloon to open LOS or cardiomyotomy
Botox into LOS
Smaller but more frequent meals

184
Q

What is the main complication of achalasia?

A

Increased risk of squamous carcinoma of oesophagus

185
Q

What are the 3 types of bowel ischemia?

A

Acute mesenteric ischemia
Chronic mesenteric ischaemia
Ischemic colitis

186
Q

Define acute mesenteric ischemia

A

EMERGENCY

Blockage of the mesenteric arteries or veins causing bowel ischaemia

187
Q

What are 3 causes of acute mesenteric ischaemia?

A

Superior mesenteric (SMA) thrombosis (MC)
SMA embolism
Mesenteric vein thrombosis

188
Q

What are the 3 symptoms of acute mesenteric ischaemia?

A

Acute severe abdominal pain around right iliac fossa
No abdo signs but maybe cardiac issues -> AF or aneurysm
Rapid hypovolaemia -> shock

189
Q

How is acute mesenteric ischaemia diagnosed?

A
  1. CT angiography
    Bloods: metabolic acidosis and raised Hb
    GS: colonoscopy
190
Q

How is acute mesenteric ischaemia treated?

A

Antibiotics
IV heparin
Surgery

191
Q

What are 2 complications of acute bowel ischaemia?

A

Septic peritonitis
Systemic inflammatory response syndrome (SIRS) -> organ dysfunction

192
Q

Define chronic mesenteric ischemia

A

Narrowing of GI blood vessels causing decreased supply to bowel

similar mechanism to angina

193
Q

What are the symptoms of chronic mesenteric ischaemia?

A

Postprandial pain (colicky abdo after eating)
Weight loss
Abdominal bruit

194
Q

How is chronic mesenteric ischaemia diagnosed?

A

CT contrast/ Angiography

195
Q

How is chronic mesenteric ischaemia treated?

A

Lifestyle changes
Secondary prevention (same as cardio)
Surgery (ie stent)

196
Q

What region is most commonly affected by ischaemic colitis (CMI limited to bowel)?

A

Splenic flexure- areas supplied by IMA

197
Q

Who is affected by ischaemic colitis?

A

Usually older people
Atherosclerosis patients
Women taking pill

198
Q

What are 3 causes of ischaemic colitis?

A

Thrombosis
Emboli
Drugs (eg. Oestrogen)
Coagulation disorders
Idiopathic

199
Q

What are the 3 symptoms of ischaemic colitis?

A

Sudden onset of lower LEFT abdominal pain
Passage of bright red blood (maybe with diarrhoea)
Could be signs of shock

200
Q

How is ischaemic colitis diagnosed?

A

Urgent CT angiography
Colonoscopy and biopsy
Barium enema

201
Q

How is ischaemic colitis treated?

A

More conservative than mesenteric ischaemia
Fluid replacement
Antibiotics
Most recover- if gangrenous SURGERY AND RESUS

202
Q

What is the most common surgical emergency?

A

Acute appendicitis

203
Q

Define appendicitis

A

Inflammed appendix, usually due to obstruction

204
Q

Where is the appendix located?

A

McBurney’s point
2/3 between the umbilicus and ASIS

205
Q

Outline the epidemiology of appendicitis

A

Males > females
10-20 but can occur at any age

206
Q

What are 3 causes of appendicitis?

A

Faecolith (poo stone)
Lymphoid hyperplasia
Filarial worms

207
Q

Outline the pathophysiology of appendicitis

A

Lumen obstructed -> invasion of gut organisms -> inflammation -> rupture -> infected and faecal matter enters peritoneum -> peritonitis

208
Q

What are the symptoms of appendicitis?

A

Periumbilical pain -> RIF
Anorexia
Nausea and vomiting
Pyrexia

209
Q

What are 3 differential diagnoses of appendicitis?

A

Ectopic pregnancy
UTI
Diverticulitis
Perforated ulcer
Food poisoning

210
Q

What are the 6 signs of appendicitis on examination?

A

Rovsing’s sign
Psoas sign
Obturator sign
Mcburneys sign
Abdominal guarding
Rebound tenderness

211
Q

What is Rovsings sign?

A

palpating left lower quadrant -> right lower quadrant pain

212
Q

What is obturator sign?

A

Pain with internal rotation of right hip

213
Q

What is Psoas sign?

A

Pain on extension of right hip

214
Q

What is abdominal guarding?

A

Abdominal muscle tightening during palpation -> peritoneal irritation

215
Q

What is rebound tenderness?

A

Blumbergs sign
Rebound tenderness upon palpation and quick release

216
Q

How is appendicitis diagnosed?

A

Usually clinical- don’t delay surgery

Abdominal contrast CT (GS)
Ultrasound
Elevated CRP and ESR
Pregnancy and urinalysis (exclude pregnancy and UTI)

217
Q

How is appendicitis treated?

A

Abx and appendectomy

218
Q

What are the complications of appendicitis?

A

Perforation
Appendix mass
Appendix abscess
Peritonitis

219
Q

Define diverticulum?

A

Outpouching of the gut wall usually at sites of entry of perforating arteries

220
Q

Define diverticulosis

A

Asymptomatic diverticulum

221
Q

Define diverticular disease

A

Diverticula are symptomatic

222
Q

Define diverticulitis

A

Inflammation of a diverticulum

223
Q

What percentage of diverticula are symptomatic?

224
Q

Where are diverticula commonly found?

A

Sigmoid colon

225
Q

What are the risk factors of diverticula?

A

Low fibre diet
Obesity
Smoking
NSAIDs
Old age

226
Q

Outline the pathophysiology of diverticulitis

A

High pressures in colon -> diverticula-> faecal matter and bacteria gather -> inflammation and rupture of vessels -> diverticulitis

227
Q

What are the symptoms of diverticular disease?

A

BBL

Bowel habits changed
Bloating and flatulence
Left lower quadrants pain

228
Q

What are the symptoms of diverticulitis?

A

BBL and
Fever
Blood in stool

229
Q

How is diverticular disease diagnosed?

A

GS: contrast CT scan
Colonoscopy (bleeding)
Inflammatory markers in blood

230
Q

What are 2 differential diagnoses of diverticular disease?

A

IBS
Appendicitis
Gastroenteritis

231
Q

What are the complications of diverticular disease?

A

Perforation
Fistula formation
Intestinal obstruction
Bleeding
Mucosal inflammation

232
Q

How is diverticular disease treated?

A

High fibre diet
Antispasmodics
Bulk forming laxatives

233
Q

How is diverticulosis treated?

A

Nothing
Watch and wait

234
Q

How is diverticulitis treated?

A

Abx
IV fluids and Abx
Sometimes surgical resection

235
Q

What is Meckels diverticulum?

A

Paediatric disorder- failure of obliteration of vitelline duct

236
Q

What are the features of Meckels diverticulum?

A

2 years old
2 inches long
1/2 have symptoms
2ft from umbilicus

237
Q

How is Meckels diverticulum diagnosed?

A

Technitium scan
CT

238
Q

How is Meckels diverticulum treated?

A

50% wont need treatment
50% need diverticulectomy

239
Q

Define intestinal obstruction

A

Arrest/blockage of onward movement of intestinal contents

240
Q

Define pseudomembranous colitis

A

Inflammation of the colon due to overgrown of clostridium difficult

241
Q

What are 3 risk factors of pseudomembranous colitis?

A

RECENT ANTIBIOTIC USE
Older age
IBD
PPI
Staying at hospital or care home
CMV infection

242
Q

What are the investigations and findings of pseudomembranous colitis?

A

Owl eyes inclusion body on histology (CMV)
Yellow plaques on colonoscopy
Stool sample (C. Difficile infection)

243
Q

How is pseudomembranous colitis treated?

A

Stop causative agent
Abx effective against C.Difficile (vancomycin)
Hydration and electrolyte replacement

Recurrent = faecal microbiotia transplant

244
Q

What are the 3 types of bowel obstruction?

A

Small bowel obstruction
Large bowel obstruction
Pseudo-obstruction

245
Q

What is the most common bowel obstruction?

A

Small bowel obstruction

246
Q

What are 4 causes of SBO?

A

Adhesions (MC) and often due to surgery
Hernias
Crohns
Malignancy

247
Q

What are the symptoms of SBO?

A

Vomiting then constipation
tinkling bowel sounds
Colicky higher abdo pain
Abdo distension

248
Q

What is the 1st line for bowel obstruction diagnosis?

A

Abdo X-ray: dilated bowel loops and transluminal liquid/gas shadows

249
Q

What is the gold standard diagnosis for bowel obstruction?

A

CT abdomen and pelvis with contrast

250
Q

What are the signs of SBO on abdo X-ray?

A

Coiled spring appearance

250
Q

How is bowel obstruction treated?

A

Drip and suck

IV fluid
Nil-by-mouth
NG tube
Analgaesia, antiemetics and Abx

250
Q

How is bowel obstruction treated surgically?

A

Needed for most LBO

Laparotomy to remove obstruction
Adhesions = adhesiolysis
Hernia repair
Bowel resection

251
Q

What are 4 causes of LBO?

A

Malignancy (90%)
Strictures
Sigmoid Volvus

252
Q

What are the signs of LBO on X-ray?

A

Sigmoid volvulus = coffee bean appearance
Dilation of large bowel >6cm
Dilation of caecum >9cm

253
Q

What are the symptoms of LBO?

A

Constipation then vomiting (bilious then faecal)
Severe abdo distension
Absent bowel sounds

254
Q

What are 3 differences between LBO and SBO?

A

1.SBO colicky pain, LBO continous
2. SBO mainly causes by adhesions, LBO mainly by malignancy
3. SBO = vomiting -> constipation, LBO = constipation -> vomiting
4. LBO more severe distension
5. SBO has tinkling bowel sounds

255
Q

What is colicky pain?

A

sharp, localized gastrointestinal or urinary pain that can arise abruptly
tends to come and go in spasms

256
Q

What is sigmoid volvulus?

A

Sigmoid colon twists around mesentery

257
Q

What are the complications of bowel obstruction?

A

Perforation -> peritonitis -> sepsis
Dehydration
Infarction and necrosis
Electrolyte disturbance

258
Q

Define pseudoobstruction

A

Aka ogilvie syndrome
Colonic dilation in the absence of mechanical obstruction

259
Q

Outline the pathophysiology of pseudo obstruction

A

Parasympathetic nerve dysfunction-> absent smooth muscle function

260
Q

What are 2 complications of pseudoobstruction?

A

Bowel ischaemia
Perforation

261
Q

What are 3 causes of pseudoobstruction?

A

Almost always a complication of something

Paralytic ileus (post operative)
CCB, opioids
Neurological- Parkinson’s, MS
Trauma

262
Q

How is pseudoobstruction diagnosed?

A

Abdo X-ray shows megacolon dilation
GS: CT of abdomen and pelvis with contrast
-No transition zone

263
Q

How is pseudoobstruction treated?

A

Drip and suck
IV neostigmine
Surgical decompression if bad

264
Q

Define diarrhoea

A

3+ watery loose stools a day which are 5-7 on Bristol stool chart

265
Q

How long does acute diarrhoea last?

266
Q

How long does subacute diarrhoea last?

267
Q

Define chronic diarrhoea

268
Q

What is the MC of diarrhoea in children >3?

269
Q

What is the most common cause of diarrhoea in adults?

270
Q

What are 3 places that can harbour norovirus?

A

Cruise ship
Restaurant
Hospital

271
Q

What bacteria is associated with diarrhoea on antibiotics?

A

C. Difficile

272
Q

What are 3 antibiotics that can cause C.Difficile?

A

Antibiotics starting with C

Clindamycin
Co-amoxiclav
Ciprofloxacin

273
Q

What are some non infective causes of diarrhoea?

A

IBD
Coeliac
Hyperthyroidism
Inflammation or malignancy

274
Q

What are 3 causes of bacterial diarrhoea?

A

C. Diff
Campylobacter
E. Coli

275
Q

What is the most common cause of diarrhoea?

A

Viral diarrhoea (gastroenteritis)

276
Q

What are 2 infective non-viral non-bacterial causes of diarrhoea?

A

Worms
Giardiasis (MC parasitic diarrhoea)

277
Q

Define tenesmus

A

Need to defecate even though bowels are empty

278
Q

What are the symptoms of travellers diarrhoea?

A

Fever
N+V
Tenesmus
Bloody stools

279
Q

How is travellers diarrhoea treated?

A

Usually self limiting 3-5 days

280
Q

What are 3 drugs that can cause diarrhoea?

A

Laxatives
Abx
Chemo
Metformin
PPI
SSRI

281
Q

What are 3 processes that can lead to diarrhoea?

A

Increased osmotic load
Increased secretion
Inflammation

282
Q

What are the red flag symptoms of diarrhoea?

A

Blood
Recent antibiotics
Weight loss
Dehydration
Nocturnal symptoms

283
Q

How is diarrhoea managed?

A

Fluids and diuralite
Viral usually self limiting
Abx cause = probiotics
Loperamide and codeine phosphate

284
Q

What is giardiasis?

285
Q

How is giardiasis spread?

A

Faeco orally

286
Q

What are the symptoms of giardiasis?

A

Explosive, watery, non-bloody diarrhoea

287
Q

How is giardiasis diagnosed?

A

Stool microscopy

288
Q

How is giardiasis treated?

A

Metronidazole

289
Q

What is the complication of giardiasis?

A

New onset lactose intolerance

290
Q

What are2 features of H.pylori?

A

Gram negative
Low virulence commensal

291
Q

What are 4 effects of H.pylori?

A

Decreased somatostatin
Increased gastric acid
Urease —> ammonia generation
Decreased HCO3 secretion

292
Q

What are 3 complications of H.Pylori?

A

PUD (MC)
Gastritis
Gastric carcinoma

293
Q

How is H.pylori infection diagnosed?

A

Stool test
Urea breath test

294
Q

How is H.Pylori infection treated?

A

Triple therapy

PPI + amoxicillin + clarithomycin

295
Q

What are 3 qualities of E.Coli?

A

Gram negative
Often commensal
Some strains virulent

296
Q

What are 3 types of diarrhoea?

A

Watery
Steatorrhoea
Inflammatory

297
Q

What are 3 types of E. Coli that cause watery diarrhoea?

A

ETEC
EAEC
EPEC
(TAP)

298
Q

What type of E. Coli causes bloody diarrhoea?

299
Q

How is E.coli diagnosed?

A

MacConkey agar as lactose fermenting

300
Q

How is E.coli treated?

A

Amoxicillin

301
Q

What are 3 qualities of C.Difficile?

A

Gram positive
Spore forming bacteria
Highly infectious

302
Q

What does C.Difficile cause?

A

Pseudomembranous colitis

303
Q

Outline the mechanism of C.Difficile causing diarrhoea

A

Normal flora killed by Abx -> c. Difficile replaces it -> severe diarrhoea -> dehydration

304
Q

How is C.Difficile treated?

A

Stop antibiotics
Vancomycin

305
Q

How is campylobacter jejuni diagnosed?

A

CCDA (charcoal cefazolin sodium deoxycholate agar)
PCR

306
Q

What causes campylobacter?

A

Undercooked chicken after BBQ

307
Q

How is campylobacter treated?

A

Usually self limiting

308
Q

How is salmonella diagnosed?

A

Pink with black centre on XLD

309
Q

How is shingella diagnosed?

A

Pink on XLD

310
Q

What are the 2 types of oesophageal cancer?

A

Adenocarcinoma (AC)
Squamous cell carcinoma (SSC)

311
Q

What oesophageal cancer is most common in the developed world?

A

Adenocarcinoma

312
Q

What part of the oesophagus is affected by AC?

313
Q

What part of the oesophagus is affected by SCC?

314
Q

What are 5 risk factors of AC?

A

*Barretts oesophagus
*GORD
*Caucasian
Obesity
Smoking
Older age
Males
Hernia

315
Q

What are 5 risk factors of SCC?

A

*Smoking
*Alcohol
*BAME
Hot food and drinks
Achalasia

316
Q

What are the symptoms of oesophageal cancer?

A

ALARMS

With PROGESSIVE swallowing difficulty (solids -> liquids)

317
Q

What is an extra symptom of SCC?

A

Hoarse voice or cough

318
Q

What is the difference between dysphagia in achalasia and oesophageal cancer?

A

Progressive = cancer
All at once = achalasia

319
Q

What warrants a 2 week endoscopy referral for oesophageal cancer?

A

Dysphagia
>55 or 55 with weight loss and 1 of the following:
- Upper abdo pain
- Reflux
- Dyspepsia

320
Q

What are 3 differential diagnoses of oesophageal cancer?

A

Achalasia
Strictures
Barretts oesophagus

321
Q

How is oesophageal cancer diagnosed?

A

Upper GI endoscopy and biopsy
CT/PET of chest and abdomen for staging and metastases

322
Q

How is oesophageal cancer treated?

A

Fit = chemo, radio, surgical resection
Unfit = palliative care- 5 year survival is 25%

323
Q

What is the most common cause of gastric cancer (histology)?

A

Adenocarcinomas

324
Q

What are the 2 types of gastric cancer?

A

Type 1: intestinal type
Type 2: diffuse type

325
Q

What is the MC type of gastric cancer?

A

Type 1/intestinal type

326
Q

What is the MC location of type 1 gastric cancer?

A

Antrum
Lesser curvature

327
Q

Outline the pathophysiology of type 1 gastric cancer

A

Inflammation -> chronic gastritis -> atrophic gastritis -> intestinal metaplasia and dysplasia

328
Q

Outline the pathophysiology of type 2 gastric cancer

A

Development of linitis plastica (leather bottle stomach)

329
Q

What are the prognoses of gastric cancer?

A

Type 1: good
Type 2: bad- 5 year survival of 3-10%

330
Q

What is the MC location of type 2 gastric cancer?

A

Cardia- but diffuse so affects anywhere in the stomach

331
Q

What are the risk factors of type 1 gastric cancer?

A

Male
Older age
H. Pylori infection
Gastritis
Smoking

332
Q

What are the risk factors of type 2 gastric cancer?

A

Female
Younger age
Genetics
Blood type A

333
Q

What gene is associated with gastric cancer?

A

CDH-1 mutation

334
Q

What is the histological appearance of type 1 gastric cancer?

A

Well differentiated tubular cells

335
Q

What is the histological appearance of type 2 gastric cancer?

A

Poorly differentiated
Signet ring cells

336
Q

What are the symptoms of gastric cancer?

A

Virchow’s node
ALARMS
Severe Epigastric pain
Progressive dysphagia

337
Q

Where is gastric cancer most common in?

A

Eastern Asia, Eastern Europe and South America

338
Q

How is gastric cancer diagnosed?

A

Upper GI endoscopy and biopsy
Endoscopic ultrasound
CT/MRI of chest and abdomen for staging

339
Q

What is Virchow’s node?

A

Node above left clavicle

340
Q

How is gastric cancer treated?

A

Surgical resection (subtotal or total gastrectomy)
ECF chemotherapy and radiotherapy

341
Q

How common are small intestine tumours?

A

~1% of malignancies

342
Q

What is the MC tumour of the small intestine?

A

Adenocarcinoma

343
Q

Define colon polyp

A

Abnormal growth of tissue projecting from the colonic mucosa INTO the lumen

344
Q

What is the most common precursor lesion in colon cancer?

345
Q

Why are polyps removed?

A

Can develop into cancer

346
Q

What are he 2 types of inherited polyps?

A

Familial adenomatous polyposis (FAP)
Hereditary non-polyposis colon cancer/ Lynch syndrome (HNPCC)

347
Q

What are the MC sites of colon cancer?

A

Sigmoid colon
Rectum

348
Q

What gene is mutated in FAP?

349
Q

What occurs in FAP?

A

Presence of hundreds-thousands of colorectal and duodenal adenomas

350
Q

What age does FAP present?

A

Adenomas develop at 16
Cancer develops at 30

351
Q

How is FAP managed?

A

Prophylactic colectomy and ileorectal anastomosis

352
Q

What occurs in HNPCC?

A

Polyps formed in the colon and can rapidly progress to colon cancer

353
Q

What genes are affected by HNPCC?

A

Mutation in DNA mismatch repair genes
hMSH2 or hMSH1

354
Q

Why does the gene mutation in HNPCC lead to cancer?

A

The genes maintain stability of DNA in replication so defect causes altered DNA sequences in replication therefore making cancer more probable

355
Q

What are the risk factors of colon cancer?

A

Family history of bowel cancer or FAP/HNPCC
IBD
Obesity
Smoking and alcohol
Low fibre and high sugar

356
Q

What are the common sites of bowel cancer metastasis?

A

Lung
Liver

357
Q

What are the symptoms of colon cancer?

A

ALARMS
Changes in bowel habit
Anaemia
Tenesmus
PR bleed
Abdo pain

358
Q

When should a 40 year old be referred for suspected colon cancer?

A

Abdo pain and unexplained weight loss

359
Q

When should a 50 year old be referred for suspected colon cancer?

A

Rectal bleeding

360
Q

When should a 60< year old be referred for suspected colon cancer?

A

Changes in bowel habit OR iron deficiency anaemia

361
Q

How is bowel cancer screened for?

A

Faecal immunochemical test (FIT)

362
Q

Who is screened for bowel cancer?

A

60-74 every 2 years

363
Q

How is bowel cancer diagnosed?

A

1st: FIT test
GS: colonoscopy and biopsy

Sigmoidoscopy, CT colonography, CT TAP (thorax, abdo, pelvis)

364
Q

How is Bowel cancer classified?

A

Dukes classification
TNM classification

365
Q

What does A on Dukes classification indicate?

A

Limited to bowel wall (not past mucosa)

366
Q

What does B on Dukes classification indicate?

A

Extending through bowel wall

367
Q

What does C on Dukes classification indicate?

A

Regional lymph node infiltration

368
Q

What does D on Dukes classification indicate?

A

Distant metastasis

369
Q

What is infiltrated in T1 bowel cancer?

370
Q

What is infiltrated in T2 bowel cancer?

A

Smooth muscle

371
Q

What is infiltrated in T3 bowel cancer?

372
Q

What is infiltrated in T4 bowel cancer?

A

Penetrates surface visceral peritoneum

373
Q

How is bowel cancer monitored ?

A

CEA (carcinoembryonic antigen) to monitor therapeutic intervention

374
Q

How is colon cancer treated?

A

Surgery
Chemo ect

375
Q

What is Zenker’s diverticulum?

A

Pharyngeal pouch- food goes down this mouth instead of oesophagus

376
Q

What are the symptoms of Zenkers diverticulum?

A

Smelly breath
Regurgitation and aspiration of food

377
Q

Define haemorrhoids/piles

A

Disrupted and dilated anal cushions due to swollen veins around the anus

378
Q

What are 3 causes of haemorrhoids?

A

Constipation with prolonged straining
Diarrhoea
Gravity due to posture
Congestion (tumour, pregnancy)
Anal intercourse

379
Q

Who is most commonly affected by haemorrhoids?

A

Males = females
45-65 but increases with age

380
Q

Outline the pathophysiology of haemorrhoids

A

Anal visions become bulky and loose -> form piles -> can protrude through anus -> become congested and hypertrophy -> protrude even more

381
Q

What are the 2 types of haemorrhoids?

A

Internal
External

382
Q

Where do internal haemorrhoids occur?

A

Above dentate line (internal rectal plexus)

383
Q

What are the 4 degrees of internal haemorrhoids?

A

1st: remain in rectum
2nd: prolapse through anus on defecation but reduce spontaneously
3rd: prolapse but can be manually reduced
4th: remain permanently prolapsed

384
Q

Where do external haemorrhoids occur?

A

Below dentate line/internal rectal plexus
Can be visible externally

385
Q

Are haemorrhoids painful?

A

Internal: less painful as no sensory nerve- can be described as “incomplete defecation”
External: extremely painful- sensory nerve
- Patient can not sometimes sit down :(

386
Q

What are the clinical presentations of haemorrhoids?

A

Bright red fresh PR bleeding
Mucus discharge
Pruritus ani
Constipation

387
Q

What is pruritus ani?

388
Q

How are haemorrhoids diagnosed?

A

External examination
Digital rectal examination (DRE)
Proctoscopy

389
Q

What are 3 differential diagnoses of haemorrhoids?

A

Perianal haematoma
Anal fissure
Abscess
Tumour

390
Q

How are 1st degree haemorrhoids treated?

A

1st line: increases fluid and fibre
Topical analgesic and stool softening

391
Q

How are 2nd and 3rd degree haemorrhoids treated?

A

Rubber band ligation
Infrared coagulation
Bipolar diathermy

392
Q

How are 4th degree haemorrhoids treated?

A

Excisional haemorrhoidectomy
Ligation

393
Q

Define anal fistula

A

Abnormal connection between the anal canal and skin

394
Q

What are 3 causes of anal fistula?

A

Perianal abscess
Crohn’s ulcerations
TB

395
Q

What are the symptoms of an anal fistula?

A

Throbbing pain worsened by sitting
Pruritus ani
Bloody/mucus discharge

396
Q

How are anal fistulas diagnosed?

A

Endoanal ultrasound

397
Q

How are anal fistulas treated?

A

Surgery- fistulotomy and excision
Drain abscesses if needed

398
Q

Define anal fissure

A

Tear in anal canal below the dentate lining, causing pain on defecation

399
Q

What are 3 causes of an anal fissure?

A

Hard stool/ constipation
Childbirth (will be anterior)
IBD

400
Q

What are the symptoms of an anal fissure?

A

Extreme pain especially on defecation
Bleeding
Extreme pruritus ani

401
Q

How is an anal fissure diagnosed?

A

Usually history
GS: Perianal inspection

402
Q

How are anal fissures treated?

A

Increase dietary fibre
Lidocaine + GTN ointment
Botox (2nd line)
Surgery (rare)

403
Q

Define Perianal/anorectal abscess

A

Collection of stool and bacteria in anal tissue causing infection

404
Q

What is the MC cause of perianal abscess?

405
Q

What are the symptoms of perianal abscess?

A

Painful swelling
Tender
Discharge
Fever

406
Q

How is perianal abscess diagnosed?

A

Endoanal ultrasound

407
Q

How are perianal abscesses treated?

A

Surgical excision
Drainage and Abx

408
Q

Define pilonidal sinus/abscess

A

Hair follicles get stuck under the skin in the natal cleft (bum crack) causing irritation and inflammation
- forms sinuses and abscesses

409
Q

Outline the epidemiology of pilonidal abscesses

A

Much more common in males
20-30

410
Q

What are the risk factors of pilonidal sinus?

A

Obese Caucasians
Asia, Middle East, Mediterranean
Lots of body hair
Sedentary occupation
Family history

411
Q

What are the symptoms of pilonidal sinus?

A

Painful swelling
Pus and foul smell from abscess
Systemic infection signs

412
Q

How are pilonidal sinuses treated?

A

Excession of sinus tract and primary closure
Pus drainage
Abx

413
Q

What is the major complication of campylobacter induced gastritis?

A

Guillian Barre

414
Q

Define ischemic colitis

A

mesenteric ischemia limited to the colon

Phase 2a Annabel (12 decks)

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