GI Flashcards
commonest cause of LBO
colorectal carcinoma
commonest cause of SBO
adhesions
most common site of a carcinoid tumour
appendix
what does free air on abdo film suggest
perforation
when to refer for 2 wk wait suspected gastro cancer
(urgent endoscopy)
all px 55+ w weight loss + either:
- upper abdo pain
- reflux
- dyspepsia
ix + mx of perianal abscess
urgent MRI to see extent + to see if fistula
drainage via EUA (rectal exam under anaesthesia)
started on intravenous antibiotics e.g. ceftriaxone + metronidazole.
draining seton if complex
Familial adenomatous polyposis (FAP) features
Mutation in the adenomatous polyposis coli (APC) gene
AD
Px dev hundreds of adenomatous polyps in their teens - develop colorectal cancer by their 20s -> prophylactic proctocolectomy
High risk of developing duodenal cancer -> regular endoscopic surveillance.
Hereditary non-polyposis colorectal cancer (HNPCC)/Lynch syndrome features
mutation in the mismatch repair genes MLH1/MSH2
AD
80% risk of developing colorectal cancer by their 30s. Polyps turning to carcinoma occurs more rapidly.
There is increased risk of gastric, endometrial, breast, and prostate cancer.
Regular endoscopic surveillance.
triad of acute mesenteric ischaemia
severe abdo pain
unremarkable abdo exam
shock
what is achalasia
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus
i.e. LOS contracted, oesophagus above dilated.
Achalasia typically presents in middle-age and is equally common in men and women.
clinical presentation of achalasia
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
ix for achalasia
oesophageal manometry
- excessive LOS tone which doesn’t relax on swallowing
- most important diagnostic test
barium swallow
- shows grossly expanded oesophagus, fluid level , tapers at the lower oesophageal sphincter
- ‘bird’s beak’ appearance
chest x-ray
- wide mediastinum
- fluid level
tx of achalasia
pneumatic (balloon) dilation is increasingly the preferred first-line option
surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk
drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
what can c diff infection cause
pseudomembranous colitis
mx of c diff infection
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
ix c diff
is made by detecting C. difficile toxin (CDT) in the stool
C. difficile antigen positivity only shows exposure to the bacteria, rather than current infection
most common abx to lead to c diff
cephalosporins
first line diagnostic test for small bowel bacterial overgrowth syndrome
hydrogen breath testing
abx tx for small bowel bacterial overgrowth syndrome
rifaximin
what is the most common cause of infectious intestinal disease in the uk (give me a bacteria)
campylobacter jejuni
(gram -ve bacillus)
features of campylobacter jejuni
faecal-oral route
incubation period 1-6 days
- prodrome: headache, malaise
- diarrhoea: often bloody
- abdominal pain: may mimic appendicitis
how to differentiate CROHNS from UC
Crohns NESTS
N – No blood or mucus (these are less common in Crohns.)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor
Crohn’s is also associated with weight loss, strictures and fistulas.
get increased goblet cells
how to differentiate UC from CROHNS
U… C… CLOSE UP
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary sclerosing cholangitis
get crypt abscesses
mx of UC mild/moderate
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
mx of UC severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
maintaining remission of UC
Aminosalicylate (e.g. mesalazine oral or rectal) - topical is better if dis limited to rectum
Azathioprine
Mercaptopurine
inducing remission in crohns
First line are steroids (e.g. oral prednisolone or IV hydrocortisone).
If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance:
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
maintaining remission in crohns
1st line:
Azathioprine
Mercaptopurine
Alternatives:
Methotrexate
Infliximab
Adalimumab
electrolyte abnormalities in refeeding syndrome
Hypophosphataemia
hypokalaemia
hypomagnesaemia
what is haemochromatosis + what is its inheritance
AR disorder of iron absorption + metabolism -> iron accumulation
what is haemochromatosis inheritance like
AR
inheritance of mutations in the HFE gene on both copies of chromosome 6.
testing for haemochromatosis
ferritin (not as sensitive)
transferrin saturation
genetic testing for family members
mx of haemochromatosis 1st + 2nd line
venesection (try and keep transferrin sat , 50% + serum ferritin conc < 50 ug/l
Deferoxamine 2nd line
haemochromatosis presentation
iron overload usually becomes sx after 40yrs
presents later in females as menstruation eliminates some iron
Chronic tiredness
Joint pain
Pigmentation (bronze skin)
Testicular atrophy
Erectile dysfunction
Amenorrhoea (absence of periods in women)
Cognitive symptoms (memory and mood disturbance)
Hepatomegaly
comps of haemochromatosis
Secondary diabetes (iron affects the functioning of the pancreas)
Liver cirrhosis
Endocrine and sexual problems (hypogonadism, erectile dysfunction, amenorrhea and reduced fertility)
Cardiomyopathy (iron deposits in the heart)
Hepatocellular carcinoma
Hypothyroidism (iron deposits in the thyroid)
Chondrocalcinosis (calcium pyrophosphate deposits in joints) causes arthritis
what is wilson’s disease
copper build up
how to screen for Wilson’s disease
caeruloplasmin
first-line test for screening coeliac disease
tissue transglutaminase (TTG) antibodies (IgA)
endomyseal antibody (IgA) - needed to look for selective IgA deficiency, which would give a false negative coeliac result
test recommended for H. pylori post-eradication therapy
urea breath test
RFs that disrupt the mucus barrier -> peptic ulcers
Helicobacter pylori
Non-steroidal anti-inflammatory drugs (NSAIDs)
RFs that increase stomach acid -> peptic ulcer
Stress
Alcohol
Caffeine
Smoking
Spicy foods
risk of bleeding from a peptic ulcer is increased by what meds?
Non-steroidal anti-inflammatory drugs (NSAIDs)
Aspirin
Anticoagulants (e.g., DOACs)
Steroids
SSRI antidepressants
signs of upper GI bleeding
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count
peptic ulcer presentation
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
upper GI bleeding
iron def anaemia
how does eating affect ulcers
worsens the pain of gastric ulcers
the pain of duodenal ulcers improves immediately after eating but is worse 2-3 hrs later (when it gets to duo)
dx of peptic ulcers
endoscopy
During endoscopy, a rapid urease test (CLO test) can be performed to check for H. pylori. A biopsy is considered during endoscopy to exclude malignancy.
what do you see in bloods if there is an upper GI bleed
raised urea
histology of coeliac disease
villous atrophy
crypt hyperplasia
raised intra-epithelial lymphocytes
histology of crohn’s
inflammation in all layers from mucosa to serosa, goblet cells, granulomas
skip lesions
histology of UC
inflammation doesn’t reach below submucosa, crypt abscesses
continuous
what is the rockall score
used after endoscopy and utilises information such as the patient’s age, observations, comorbidities and the endoscopy result to provide an estimation of rebleeding risk and mortality
what is the Glasgow-Blatchford score
used before endoscopy to help assess patients with suspected upper GI bleeds who are deemed ‘lower risk’ and could be managed as outpatients (assesses likihood of them needing medical intervention)
most common site for UC
rectum
globus (feeling of something stuck in throat), hoarseness + no red flags dx?
+ what might be on endoscopy?
?laryngopharyngeal reflux (ie silent reflux)
erythema being seen on endoscopy
what is Globus hystericus
the sensation of a lump being stuck in the throat, with no physical findings present
how do you categorise mild, moderate and severe UC
mild = < 4 poos + minimal bleeding
moderate = 4-6
severe = 6+ , v bloody + systemic sx
Dukes’ classification
describes the extent of spread of colorectal cancer
A = confined to mucosa
B = invading bowel wall
C = lymph nodes mets
D = distant mets
do CT TAP (thorax, abdomen and pelvis)
Loop ileostomy
to divert stool away from the healing portion post-anterior resection. They are typically used when the intention is to later reverse the stoma and restore bowel continuity
ileostomy for small intestine
they are spouted to keep digested material away from the skin
end ileostomy
the end of the ileum, is brought to the surface of the abdomen to create an artificial opening called a stoma. An end ileostomy is usually undertaken following complete excision of the colon or when an ileocolic anastomosis is not planned
End colostomy
surgical procedure where one end of the colon is brought to the surface of the abdomen to create an artificial opening called a stoma. Colostomies are flush to the skin because the contents of the colon are less irritable to the skin
often permanent and not commonly used if anastomosis is planned.
most common type of colorectal cancer + location
adenocarcinoma
66% arise in colon (more proximal than distal), 30% rectum
what comprises the proximal colon
the ascending colon and the transverse colon
what comprises the distal colon
the descending colon and the sigmoid colon
what is an adenoma
type of polyp
precursor lesion in most cases of colon cancer
benign, dysplastic tumour of columnar cells or glandular tissue
where do colorectal tumours metastisize
LIVER (due to portal vein)
lung
RFs for colorectal carcinoma
Age (>60)
Male
low fibre diet
saturated fat + red meat
sugar
colorectal polyps, adenomas
alcohol + smoking
obesity
UC
FHx
genetic dis
what can reduce risk of colorectal carcinoma
veg
garlic
milk
exercise
low dose aspirin
colorectal carcinoma presentation
change in bowel habit
rectal bleeding
weight loss
abdo pain
iron def anaemia
rectal mass in rectal cancer?
abdo mass
the closer the cancer is to the anus the more visible blood + mucus will be
4 cardinal signs of obstruction
absolute constipation
colicky abdo pain
abdo distension
vomiting (faeculent)
sx + signs of right sided carcinoma (proximal colon)
usually asx until they present with iron def anaemia due to bleeding (so will present at more advanced stage)
palpable mass in right iliac fossa?
sx + signs of left sided carcinoma (distal colon)
change in bowel habit with blood + mucus in stools
alt constipation + diarrhoea
may be palpable mass in left iliac fossa or on PR exam
tenesmus (feeling you need a poo but empty)
when to refer for urgent ix suspected bowel cancer
> 40 unexplained weight loss + abdo pain
50 unexplained rectal bleeding
60 iron def anaemia or change in bowel habit
+ve FIT
what is the Faecal immunochemical tests (FIT)
look very specifically for the amount of human haemoglobin in the stool
when to use a FIT test
GP to help assess for bowel cancer in px who do not meet the criteria for a two week wait referral eg:
Over 50 with unexplained weight loss and no other symptoms
Under 60 with a change in bowel habit
Screening
bowel cancer screening programme
people aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy.
People with RFs - FAP, HNPCC or IBD are offered a colonoscopy at regular intervals
GS ix bowel cancer
colonoscopy w biopsy
when would you use CEA (carcinoembryotic antigen)
bowel cancer tumour marker
not gd for screening, but can monitor progression / relapse / prognosis
TNM cancer staging
T for Tumour:
TX – unable to assess size
T1 – submucosa involvement
T2 – involvement of muscularis propria (muscle layer)
T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa
T4 – spread through the serosa (4a) reaching other tissues or organs (4b)
N for Nodes:
NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to 1-3 nodes
N2 – spread to more than 3 nodes
M for Metastasis:
M0 – no metastasis
M1 – metastasis
right hemicolectomy
removal of the caecum, ascending and proximal transverse colon
Left hemicolectomy
removal of the distal transverse and descending colon
High anterior resection
removing the sigmoid colon (may be called a sigmoid colectomy)
Low anterior resection
removing the sigmoid colon and upper rectum but sparing the lower rectum and anus
Abdomino-perineal resection (APR)
removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
Hartmann’s procedure
usually an emergency procedure - removal of the rectosigmoid colon -> colostomy (permanent or reversed at a later date).
Common indications are acute obstruction by a tumour, or significant diverticular disease, or sigmoid colon perforation
Low Anterior Resection Syndrome
may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including:
Urgency and frequency of bowel movements
Faecal incontinence
Difficulty controlling flatulence
what is volvulus
a condition where the bowel twists around itself and the mesentery that it is attached to -> closed loop bowel obstruction
can cut off BS (mesenteric arteries) -> ischeamia -> necrosis + perf
types of volvulus + who
sigmoid
- more common
- older px
- cause is chronic constipation + lengthening of mesentery - sinks down + is overloaded w faeces
- associated with a high fibre diet and the excessive use of laxatives
caecal
- less common
- younger px
RFs volvulus
Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions
presentation volvulus
The signs and symptoms are akin to bowel obstruction, with:
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
ix volvulus
Abdo XR = coffee bean sign in sigmoid volvulus
GS = CT contrast
tx volvulus
initial management is the same as with bowel obstruction (nil by mouth, NG tube and IV fluids).
Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis).
- flexible sigmoidoscope inserted, px in L lateral position. A flatus/rectal tube left in place temporarily. Risk of recurrence (around 60%).
Surgical
what is ileus
condition affecting the small bowel, where the peristalsis temporarily stops.
what is pseudo-obstruction
a functional obstruction of the large bowel, where patients present with intestinal obstruction, but no mechanical cause is found
causes of ileus
Injury to the bowel
Handling of the bowel during surgery (most common ILEUS is following abdo surgery)
Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
ileus presentation
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
mx ileus
will usually resolve with treatment of the underlying cause
supportive
NBM
NG tube
IV fluids
mobilisation
TPN
most common section of bowel affected by diverticula
sigmoid colon
diverticulum
pouches or pockets in the bowel wall
Diverticulosis
presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms
Diverticulitis
inflammation and infection of diverticula
RFs diverticulosis
age
low fibre diet
obesity
NSAIDs (+ increases the risk of diverticular haemorrhage)
Diverticulosis sx
lower left abdominal pain, constipation or rectal bleeding
Diverticulosis mx
increased fibre in the diet
bulk-forming laxatives (e.g., ispaghula husk).
Stimulant laxatives (e.g., Senna) should be avoided.
Surgery where there are significant sx
Acute diverticulitis presentation
Pain and tenderness in the left iliac fossa / lower left abdomen
Fever
Diarrhoea
N&V
Rectal bleeding
Palpable abdominal mass (if an abscess has formed)
Raised inflammatory markers
mx of uncomplicated diverticulitis in primary care
Oral co-amoxiclav (at least 5 days)
Analgesia (avoiding NSAIDs and opiates, if possible)
Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
Follow-up within 2 days to review symptoms
diverticulitis hx tx
Nil by mouth or clear fluids only
IV antibiotics
IV fluids
Analgesia
Urgent investigations (e.g., CT scan)
Urgent surgery may be required for complications
Complications of acute diverticulitis
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
what is mesenteric ischaemia
chronic
acute
a lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia
Chronic (also called intestinal angina) is the result of narrowing of the mesenteric blood vessels by atherosclerosis
Acute is caused by a rapid blockage in blood flow through the superior mesenteric artery due to thrombus
3 main branches of the abdominal aorta that supply the abdominal organs
Coeliac artery
Superior mesenteric artery
Inferior mesenteric artery
triad for chronic mesenteric ischaemia
Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours) - as BS cannot keep up w demand
Weight loss (due to food avoidance, as this causes pain)
Abdominal bruit may be heard on auscultation
Chronic Mesenteric Ischaemia dx
CT angiography
Chronic Mesenteric Ischaemia mx
Reducing modifiable risk factors (e.g., stop smoking)
Secondary prevention (e.g., statins and antiplatelet medications)
Revascularisation to improve the blood flow to the intestines
- Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting)
- Open surgery (i.e endarterectomy, re-implantation or bypass grafting)
RF of acute mesenteric ischaemia
AF
- where a thrombus forms in the LA, then mobilises down the aorta to the superior mesenteric artery
acute mesenteric ischaemia presentation
acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.
acute mesenteric ischaemia ix
CT contrast
Metabolic acidosis
Raised lactate due to tissue hypoperfusion
acute mesenteric ischaemia tx
Need surgery
high mortality
what is GORD
stomach acid flows through the LOS + into oesophagus where it irritates the lining + causes sx
lining of oesophagus
squamous epithelial lining
lining of stomach
columnar epithelial lining
triggers of GORD
Greasy and spicy foods
Coffee and tea
Alcohol
NSAIDs
Stress
Smoking
Obesity
Hiatus hernia
GORD pres
Dyspepsia (indigestion):
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice
red flag upper GI features
Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
Weight loss
Upper abdominal pain
Reflux
Treatment-resistant dyspepsia
Nausea and vomiting
Upper abdominal mass on palpation
Low haemoglobin (anaemia)
Raised platelet count
what can an oesophago-gastro-duodenoscopy (OGD) be used to assess for
Gastritis
Peptic ulcers
Upper gastrointestinal bleeding
Oesophageal varices (in liver cirrhosis)
Barretts oesophagus
Oesophageal stricture
Malignancy of the oesophagus or stomach
what is a hiatus hernia
herniation of the stomach up through the diaphragm
where should the diaphragm opening be
at the lower oesophageal sphincter level and fixed in place
types of hiatus hernia
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax
mx of GORD
Lifestyle changes
Reviewing medications (e.g., stop NSAIDs)
Antacids (e.g., Gaviscon, Pepto-Bismol and Rennie) – short term only
Proton pump inhibitors (e.g., omeprazole and lansoprazole)
Histamine H2-receptor antagonists (e.g., famotidine)
Surgery
consider testing for H. pylori
lifestyle changes for GORD
Reduce tea, coffee and alcohol
Weight loss
Avoid smoking
Smaller, lighter meals
Avoid heavy meals before bedtime
Stay upright after meals rather than lying flat
surgery for reflux
laparoscopic fundoplication
- tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.
require oesophageal pH and manometry studies b4
test for h. pylori
offered for anyone w dyspepsia
(need 2 wks w no PPI)
Stool antigen test
Urea breath test using radiolabelled carbon 13
H. pylori antibody test (blood)
Rapid urease test performed during endoscopy (also known as the CLO test)
h. pylori eradication
triple therapy with a proton pump inhibitor (e.g., omeprazole) plus two antibiotics (e.g., amoxicillin and clarithromycin) for 7 days
don’t need to retest
what does h. pylori produce
ammonium hydroxide, which neutralises the acid surrounding the bacteria
+ toxins
what is barrett’s oesophagus
when the lower oesophageal epithelium changes from squamous to columnar epithelium (metaplasia)
caused by chronic acid reflux (may notice improvement in refluc after they dev it)
premalignant condition - big RF for dev of oesophageal adenocarcinoma
tx barrett’s oesophagus
Endoscopic monitoring for progression to adenocarcinoma
PPIs
Endoscopic ablation (e.g., radiofrequency ablation)
what is Zollinger-Ellison syndrome
rare condition where a duodenal or pancreatic tumour secretes excessive quantities of gastrin (stims acid secretion in stomach)
- severe dyspepsia
- diarrhoea
- peptic ulcers
assoc w MEN-1
what are haemorrhoids + what increases risk
enlarged anal vascular cushions often assoc w constipation + straining
They are also more common with pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing
classification of haemorrhoids
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
4th degree: prolapsed permanently
sx haemorrhoids
painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels
- blood not mixed w stool
sore itchy anus
feeling of lump
what exam for proper visualisation and inspection of haemorrhoids
Proctoscopy
mx haemorrhoids
Topical treatments can be given for sx relief and to help reduce swelling:
Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)
Anusol HC (also contains hydrocortisone – only used short term)
Germoloids cream (contains lidocaine – a local anaesthetic)
Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)
Prevention and treatment of constipation
Non-surgical treatments:
- rubber band ligation
Surgical
what are thrombosed haemorrhoids
caused by strangulation at the base of the haemorrhoid, resulting in thrombosis in the haemorrhoid
v painful
presentation thrombosed haemorrhoids
purplish, very tender, swollen lumps around the anus
PR examination is unlikely to be possible due to the pain.
mx thrombosed haemorrhoids
They will resolve with time, although this can take several weeks.
Consider admission if the px present within 72 hours with extremely painful thrombosed haemorrhoids - surgical management.
appendicitis presentation
abdo pain - starts off central + moves to RIF within first 24 hrs
palpation = tenderness at McBurney’s point (a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus), guarding,
rebound tenderness, percussion tenderness (suggesting peritonitis i.e. ruptured appendix)
appetite loss
N+V
low fever
what sign in appendicitis
Rovsing’s sign = palpation of the left iliac fossa causes pain in the RIF
dx appendicitis
clinical presentation + raised inflam markers
CT to confirm
USS in females to exc ovarian + gynae path
ddx of appendicitis
ectopic pregnancy - always do a serum or urine human chorionic gonadotropin (hCG)
ovarian torsion
Meckel’s diverticulum (malformation of distal ileum usually asx)
Mesenteric adenitis (inflamed abdo lymph nodes)
Complications of appendicectomy
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
complications of hernias
Incarceration - irreducible
Obstruction - V, abdo pain, absolute constipation
Strangulation -> ischaemia - surgical emergency
what is richter’s hernia
where only part of the bowel wall + lumen herniate through the defect
therefore they do not obstruct, but they can strangulate
what is Maydl’s Hernia
where two different loops of bowel are contained within the hernia
types of hernia repair
Tension-free repair - mesh over defect (more common)
Tension repair - suture defect
explain the 2 types of inguinal hernia
Indirect inguinal hernia
- bowel herniates through the inguinal canal (so deep ring + superficial ring)
- due to incomplete closure of the deep ring + processus vaginalis intact
- when reduced + pressure applied to deep inguinal ring the hernia will stay reduced
Direct inguinal hernia
- due to weakness in abdo wall at Hesselbach’s triangle
- hernia protrudes through this + exits inguinal canal through superficial ring
ddx for lump in inguinal region
Inguinal hernia
Femoral hernia
Lymph node
Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
Femoral aneurysm
Abscess
Undescended / ectopic testes
Kidney transplant
borders of Hesselbach’s triangle
medial = rectus abdominis muscle
lateral = inferior epigastric vessels
inferior = inguinal ligament
what is a femoral hernia + where
herniation of the abdominal contents through the femoral canal
femoral ring leaves only a narrow opening for femoral hernias so higher risk
below the inguinal ligament, at the top of the thigh
boundaries of femoral canal
F – Femoral vein laterally
L – Lacunar ligament medially
I – Inguinal ligament anteriorly
P – Pectineal ligament posteriorly
boundaries of femoral triangle
S – Sartorius muscle – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border
contents of the femoral triangle from lateral to medial across the top of the thigh
N – Femoral Nerve
A – Femoral Artery
V – Femoral Vein
Y – Y-fronts
C – Femoral Canal (containing lymphatic vessels and nodes)
what is a spigelian hernia
occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris
- the site of the spigelian fascia (aponeurosis between the muscles of the abdominal wall)
what is Diastasis Recti
widening of linea alba (connective tissue that separates the rectus abdominis muscle)
Rfs hiatus hernia
increasing age, obesity and pregnancy
presentation hiatus hernias
dyspepsia
tx hiatus hernia
Conservative (with medical treatment of GORD)
Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment
- laparoscopic fundoplication
RFs gastric cancer
h pylori
atrophic gastritis (chronic inflam + thinning of stomach lining)
diet
- salt and salt-preserved foods
- nitrates
smoking
blood group A
presentation gastic cancer
abdo pain
- vague, epigastric
- may present like dyspepsia
weight loss, anorexia
N+V
dysphagia
overt upper GI bleeding - minority
If lymphatic spread:
- left supraclavicular lymph node (Virchow’s node)
- periumbilical nodule (Sister Mary Joseph’s node)
dx gastric cancer
oesophago-gastro-duodenoscopy with biopsy
= signet ring cells]
CT for staging
RFs anal fissures
constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
features anal fissures
painful, bright red, rectal bleeding
usually in the posterior midline
what is an anal fissure
longitudinal or elliptical tears of the squamous lining of the distal anal canal
mx acute anal fissure (<6wks)
soften stool - high fibre diet + high fluid intake
- bulk forming laxatives
Lubricants
topical anaesthetics
analgesia
types of laxatives
Bulk-forming laxatives - usually start w these
- Fybogel
- methylcellulose
Osmotic laxatives
- lactulose
- macrogol
Stimulant laxatives
- senna
Poo-softener laxatives
mx of chronic anal fissure
1st line = topical glyceryl trinitrate (GTN)
If not effective after 8 wks refer
ctu acute mx
when to dx IBS
px has abdo pain relieved by defecation/assoc w altered bowel frequency stool form + 2 of:
- altered stool passage (straining, urgency, incomplete evacuation)
- abdominal bloating (more common in women than men), distension, tension or hardness
- symptoms made worse by eating
- passage of mucus
First-line pharmacological tx IBS
pain: antispasmodic agents
constipation: laxatives but avoid lactulose (linaclotide if no res)
diarrhoea: loperamide is first-line
2nd line pharmacological tx IBS
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg)
general diet advice for IBS
- have regular meals and take time to eat
- avoid missing meals or leaving long gaps between eating
- drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks
- restrict tea and coffee to 3 cups per day
- reduce intake of alcohol and fizzy drinks
- consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
- reduce intake of ‘resistant starch’ often found in processed foods
- limit fresh fruit to 3 portions per day
- for diarrhoea, avoid sorbitol
- for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
most common type of oesophageal cancer in UK
Adenocarcinoma
where is oesophageal adenocarcinoma found
Lower third - near the gastroesophageal junction
where is oesophageal squamous cell cancer
found
Upper two-thirds of the oesophagus
RFs oesophageal adenocarcinoma
GORD
Barrett’s oesophagus
smoking
obesity
RFs oesophageal squamous cell cancer
smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines
presentation oesophageal cancer
dysphagia
anorexia and weight loss
vomiting
other possible features include: odynophagia, hoarseness, melaena, cough
dx oesophageal cancer
Upper GI endoscopy with biopsy for dx
Endoscopic ultrasound for locoregional staging
CT CAP for initial staging
immunisation to give in coeliac disease + why
pnuemococcal (+ booster every 5 yrs)
as px often have a degree of functional hyposplenism
abdo XR diff between small and large bowel obstruction
haustra are found in large bowel obstructions
valvulae conniventes are found in small bowel obstructions
pneumonic to remember where each thing in the gut is absorbed
DUDE IM JUST FEELING ILL BRO
duodenum - iron
jejunum - folate
ileum - B12
