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finals > GI > Flashcards

GI Flashcards

1
Q

commonest cause of LBO

A

colorectal carcinoma

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2
Q

commonest cause of SBO

A

adhesions

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3
Q

most common site of a carcinoid tumour

A

appendix

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4
Q

what does free air on abdo film suggest

A

perforation

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5
Q

when to refer for 2 wk wait suspected gastro cancer
(urgent endoscopy)

A

all px 55+ w weight loss + either:
- upper abdo pain
- reflux
- dyspepsia

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6
Q

ix + mx of perianal abscess

A

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

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7
Q

Familial adenomatous polyposis (FAP) features

A

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.

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8
Q

Hereditary non-polyposis colorectal cancer (HNPCC)/Lynch syndrome features

A

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.

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9
Q

triad of acute mesenteric ischaemia

A

severe abdo pain

unremarkable abdo exam

shock

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10
Q

what is achalasia

A

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.

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11
Q

clinical presentation of achalasia

A

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

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12
Q

ix for achalasia

A

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

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13
Q

tx of achalasia

A

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

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14
Q

what can c diff infection cause

A

pseudomembranous colitis

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15
Q

mx of c diff infection

A

first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole

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16
Q

ix c diff

A

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

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17
Q

most common abx to lead to c diff

A

cephalosporins

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18
Q

first line diagnostic test for small bowel bacterial overgrowth syndrome

A

hydrogen breath testing

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19
Q

abx tx for small bowel bacterial overgrowth syndrome

A

rifaximin

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20
Q

what is the most common cause of infectious intestinal disease in the uk (give me a bacteria)

A

campylobacter jejuni

(gram -ve bacillus)

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21
Q

features of campylobacter jejuni

A

faecal-oral route
incubation period 1-6 days

  • prodrome: headache, malaise
  • diarrhoea: often bloody
  • abdominal pain: may mimic appendicitis
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22
Q

how to differentiate CROHNS from UC

A

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

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23
Q

how to differentiate UC from CROHNS

A

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

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24
Q

mx of UC mild/moderate

A

First line: aminosalicylate (e.g. mesalazine oral or rectal)

Second line: corticosteroids (e.g. prednisolone)

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25
Q

mx of UC severe disease

A

First line: IV corticosteroids (e.g. hydrocortisone)

Second line: IV ciclosporin

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26
Q

maintaining remission of UC

A

Aminosalicylate (e.g. mesalazine oral or rectal) - topical is better if dis limited to rectum

Azathioprine
Mercaptopurine

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27
Q

inducing remission in crohns

A

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

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28
Q

maintaining remission in crohns

A

1st line:

Azathioprine
Mercaptopurine

Alternatives:

Methotrexate
Infliximab
Adalimumab

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29
Q

electrolyte abnormalities in refeeding syndrome

A

Hypophosphataemia
hypokalaemia
hypomagnesaemia

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30
Q

what is haemochromatosis + what is its inheritance

A

AR disorder of iron absorption + metabolism -> iron accumulation

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31
Q

what is haemochromatosis inheritance like

A

AR

inheritance of mutations in the HFE gene on both copies of chromosome 6.

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32
Q

testing for haemochromatosis

A

ferritin (not as sensitive)
transferrin saturation

genetic testing for family members

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33
Q

mx of haemochromatosis 1st + 2nd line

A

venesection (try and keep transferrin sat , 50% + serum ferritin conc < 50 ug/l

Deferoxamine 2nd line

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34
Q

haemochromatosis presentation

A

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

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35
Q

comps of haemochromatosis

A

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

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36
Q

what is wilson’s disease

A

copper build up

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37
Q

how to screen for Wilson’s disease

A

caeruloplasmin

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38
Q

first-line test for screening coeliac disease

A

tissue transglutaminase (TTG) antibodies (IgA)

endomyseal antibody (IgA) - needed to look for selective IgA deficiency, which would give a false negative coeliac result

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39
Q

test recommended for H. pylori post-eradication therapy

A

urea breath test

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40
Q

RFs that disrupt the mucus barrier -> peptic ulcers

A

Helicobacter pylori
Non-steroidal anti-inflammatory drugs (NSAIDs)

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41
Q

RFs that increase stomach acid -> peptic ulcer

A

Stress
Alcohol
Caffeine
Smoking
Spicy foods

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42
Q

risk of bleeding from a peptic ulcer is increased by what meds?

A

Non-steroidal anti-inflammatory drugs (NSAIDs)
Aspirin
Anticoagulants (e.g., DOACs)
Steroids
SSRI antidepressants

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43
Q

signs of upper GI bleeding

A

Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count

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44
Q

peptic ulcer presentation

A

Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
upper GI bleeding
iron def anaemia

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45
Q

how does eating affect ulcers

A

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)

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46
Q

dx of peptic ulcers

A

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.

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47
Q

what do you see in bloods if there is an upper GI bleed

A

raised urea

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48
Q

histology of coeliac disease

A

villous atrophy
crypt hyperplasia
raised intra-epithelial lymphocytes

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49
Q

histology of crohn’s

A

inflammation in all layers from mucosa to serosa, goblet cells, granulomas
skip lesions

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50
Q

histology of UC

A

inflammation doesn’t reach below submucosa, crypt abscesses
continuous

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51
Q

what is the rockall score

A

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

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52
Q

what is the Glasgow-Blatchford score

A

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)

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53
Q

most common site for UC

A

rectum

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54
Q

globus (feeling of something stuck in throat), hoarseness + no red flags dx?

+ what might be on endoscopy?

A

?laryngopharyngeal reflux (ie silent reflux)

erythema being seen on endoscopy

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55
Q

what is Globus hystericus

A

the sensation of a lump being stuck in the throat, with no physical findings present

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56
Q

how do you categorise mild, moderate and severe UC

A

mild = < 4 poos + minimal bleeding
moderate = 4-6
severe = 6+ , v bloody + systemic sx

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57
Q

Dukes’ classification

A

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)

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58
Q

Loop ileostomy

A

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

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59
Q

end ileostomy

A

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

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60
Q

End colostomy

A

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.

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61
Q

most common type of colorectal cancer + location

A

adenocarcinoma
66% arise in colon (more proximal than distal), 30% rectum

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62
Q

what comprises the proximal colon

A

the ascending colon and the transverse colon

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63
Q

what comprises the distal colon

A

the descending colon and the sigmoid colon

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64
Q

what is an adenoma

A

type of polyp
precursor lesion in most cases of colon cancer
benign, dysplastic tumour of columnar cells or glandular tissue

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65
Q

where do colorectal tumours metastisize

A

LIVER (due to portal vein)
lung

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66
Q

RFs for colorectal carcinoma

A

Age (>60)
Male
low fibre diet
saturated fat + red meat
sugar
colorectal polyps, adenomas
alcohol + smoking
obesity
UC
FHx
genetic dis

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67
Q

what can reduce risk of colorectal carcinoma

A

veg
garlic
milk
exercise
low dose aspirin

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68
Q

colorectal carcinoma presentation

A

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

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69
Q

4 cardinal signs of obstruction

A

absolute constipation
colicky abdo pain
abdo distension
vomiting (faeculent)

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70
Q

sx + signs of right sided carcinoma (proximal colon)

A

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?

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71
Q

sx + signs of left sided carcinoma (distal colon)

A

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)

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72
Q

when to refer for urgent ix suspected bowel cancer

A

> 40 unexplained weight loss + abdo pain
50 unexplained rectal bleeding
60 iron def anaemia or change in bowel habit
+ve FIT

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73
Q

what is the Faecal immunochemical tests (FIT)

A

look very specifically for the amount of human haemoglobin in the stool

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74
Q

when to use a FIT test

A

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

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75
Q

bowel cancer screening programme

A

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

76
Q

GS ix bowel cancer

A

colonoscopy w biopsy

77
Q

when would you use CEA (carcinoembryotic antigen)

A

bowel cancer tumour marker
not gd for screening, but can monitor progression / relapse / prognosis

78
Q

TNM cancer staging

A

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

79
Q

right hemicolectomy

A

removal of the caecum, ascending and proximal transverse colon

80
Q

Left hemicolectomy

A

removal of the distal transverse and descending colon

81
Q

High anterior resection

A

removing the sigmoid colon (may be called a sigmoid colectomy)

82
Q

Low anterior resection

A

removing the sigmoid colon and upper rectum but sparing the lower rectum and anus

83
Q

Abdomino-perineal resection (APR)

A

removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.

84
Q

Hartmann’s procedure

A

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

85
Q

Low Anterior Resection Syndrome

A

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

86
Q

what is volvulus

A

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

87
Q

types of volvulus + who

A

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

88
Q

RFs volvulus

A

Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions

89
Q

presentation volvulus

A

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

90
Q

ix volvulus

A

Abdo XR = coffee bean sign in sigmoid volvulus
GS = CT contrast

91
Q

tx volvulus

A

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

92
Q

what is ileus

A

condition affecting the small bowel, where the peristalsis temporarily stops.

93
Q

what is pseudo-obstruction

A

a functional obstruction of the large bowel, where patients present with intestinal obstruction, but no mechanical cause is found

94
Q

causes of ileus

A

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)

95
Q

ileus presentation

A

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)

96
Q

mx ileus

A

will usually resolve with treatment of the underlying cause

supportive
NBM
NG tube
IV fluids
mobilisation
TPN

97
Q

most common section of bowel affected by diverticula

A

sigmoid colon

98
Q

diverticulum

A

pouches or pockets in the bowel wall

99
Q

Diverticulosis

A

presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms

100
Q

Diverticulitis

A

inflammation and infection of diverticula

101
Q

RFs diverticulosis

A

age
low fibre diet
obesity
NSAIDs (+ increases the risk of diverticular haemorrhage)

102
Q

Diverticulosis sx

A

lower left abdominal pain, constipation or rectal bleeding

103
Q

Diverticulosis mx

A

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

104
Q

Acute diverticulitis presentation

A

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

105
Q

mx of uncomplicated diverticulitis in primary care

A

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

106
Q

diverticulitis hx tx

A

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

107
Q

Complications of acute diverticulitis

A

Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction

108
Q

what is mesenteric ischaemia

chronic

acute

A

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

109
Q

3 main branches of the abdominal aorta that supply the abdominal organs

A

Coeliac artery
Superior mesenteric artery
Inferior mesenteric artery

110
Q

triad for chronic mesenteric ischaemia

A

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

111
Q

Chronic Mesenteric Ischaemia dx

A

CT angiography

112
Q

Chronic Mesenteric Ischaemia mx

A

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)

113
Q

RF of acute mesenteric ischaemia

A

AF
- where a thrombus forms in the LA, then mobilises down the aorta to the superior mesenteric artery

114
Q

acute mesenteric ischaemia presentation

A

acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.

115
Q

acute mesenteric ischaemia ix

A

CT contrast

Metabolic acidosis
Raised lactate due to tissue hypoperfusion

116
Q

acute mesenteric ischaemia tx

A

Need surgery
high mortality

117
Q

what is GORD

A

stomach acid flows through the LOS + into oesophagus where it irritates the lining + causes sx

118
Q

lining of oesophagus

A

squamous epithelial lining

119
Q

lining of stomach

A

columnar epithelial lining

120
Q

triggers of GORD

A

Greasy and spicy foods
Coffee and tea
Alcohol
NSAIDs
Stress
Smoking
Obesity
Hiatus hernia

121
Q

GORD pres

A

Dyspepsia (indigestion):
Heartburn
Acid regurgitation
Retrosternal or epigastric pain
Bloating
Nocturnal cough
Hoarse voice

122
Q

red flag upper GI features

A

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

123
Q

what can an oesophago-gastro-duodenoscopy (OGD) be used to assess for

A

Gastritis
Peptic ulcers
Upper gastrointestinal bleeding
Oesophageal varices (in liver cirrhosis)
Barretts oesophagus
Oesophageal stricture
Malignancy of the oesophagus or stomach

124
Q

what is a hiatus hernia

A

herniation of the stomach up through the diaphragm

125
Q

where should the diaphragm opening be

A

at the lower oesophageal sphincter level and fixed in place

126
Q

types of hiatus hernia

A

Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax

127
Q

mx of GORD

A

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

128
Q

lifestyle changes for GORD

A

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

129
Q

surgery for reflux

A

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

130
Q

test for h. pylori

A

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)

131
Q

h. pylori eradication

A

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

132
Q

what does h. pylori produce

A

ammonium hydroxide, which neutralises the acid surrounding the bacteria
+ toxins

133
Q

what is barrett’s oesophagus

A

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

134
Q

tx barrett’s oesophagus

A

Endoscopic monitoring for progression to adenocarcinoma
PPIs
Endoscopic ablation (e.g., radiofrequency ablation)

135
Q

what is Zollinger-Ellison syndrome

A

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

136
Q

what are haemorrhoids + what increases risk

A

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

137
Q

classification of haemorrhoids

A

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

138
Q

sx haemorrhoids

A

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

139
Q

what exam for proper visualisation and inspection of haemorrhoids

A

Proctoscopy

140
Q

mx haemorrhoids

A

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

141
Q

what are thrombosed haemorrhoids

A

caused by strangulation at the base of the haemorrhoid, resulting in thrombosis in the haemorrhoid

v painful

142
Q

presentation thrombosed haemorrhoids

A

purplish, very tender, swollen lumps around the anus
PR examination is unlikely to be possible due to the pain.

143
Q

mx thrombosed haemorrhoids

A

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.

144
Q

appendicitis presentation

A

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

145
Q

what sign in appendicitis

A

Rovsing’s sign = palpation of the left iliac fossa causes pain in the RIF

146
Q

dx appendicitis

A

clinical presentation + raised inflam markers
CT to confirm

USS in females to exc ovarian + gynae path

147
Q

ddx of appendicitis

A

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)

148
Q

Complications of appendicectomy

A

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)

149
Q

complications of hernias

A

Incarceration - irreducible
Obstruction - V, abdo pain, absolute constipation
Strangulation -> ischaemia - surgical emergency

150
Q

what is richter’s hernia

A

where only part of the bowel wall + lumen herniate through the defect

therefore they do not obstruct, but they can strangulate

151
Q

what is Maydl’s Hernia

A

where two different loops of bowel are contained within the hernia

152
Q

types of hernia repair

A

Tension-free repair - mesh over defect (more common)
Tension repair - suture defect

153
Q

explain the 2 types of inguinal hernia

A

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

154
Q

ddx for lump in inguinal region

A

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

155
Q

borders of Hesselbach’s triangle

A

medial = rectus abdominis muscle
lateral = inferior epigastric vessels
inferior = inguinal ligament

156
Q

what is a femoral hernia + where

A

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

157
Q

boundaries of femoral canal

A

F – Femoral vein laterally
L – Lacunar ligament medially
I – Inguinal ligament anteriorly
P – Pectineal ligament posteriorly

158
Q

boundaries of femoral triangle

A

S – Sartorius muscle – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border

159
Q

contents of the femoral triangle from lateral to medial across the top of the thigh

A

N – Femoral Nerve
A – Femoral Artery
V – Femoral Vein
Y – Y-fronts
C – Femoral Canal (containing lymphatic vessels and nodes)

160
Q

what is a spigelian hernia

A

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)
161
Q

what is Diastasis Recti

A

widening of linea alba (connective tissue that separates the rectus abdominis muscle)

162
Q

Rfs hiatus hernia

A

increasing age, obesity and pregnancy

163
Q

presentation hiatus hernias

A

dyspepsia

164
Q

tx hiatus hernia

A

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

165
Q

RFs gastric cancer

A

h pylori
atrophic gastritis (chronic inflam + thinning of stomach lining)
diet
- salt and salt-preserved foods
- nitrates
smoking
blood group A

166
Q

presentation gastic cancer

A

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)

167
Q

dx gastric cancer

A

oesophago-gastro-duodenoscopy with biopsy
= signet ring cells]
CT for staging

168
Q

RFs anal fissures

A

constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes

169
Q

features anal fissures

A

painful, bright red, rectal bleeding
usually in the posterior midline

170
Q

what is an anal fissure

A

longitudinal or elliptical tears of the squamous lining of the distal anal canal

171
Q

mx acute anal fissure (<6wks)

A

soften stool - high fibre diet + high fluid intake
- bulk forming laxatives

Lubricants
topical anaesthetics
analgesia

172
Q

types of laxatives

A

Bulk-forming laxatives - usually start w these
- Fybogel
- methylcellulose

Osmotic laxatives
- lactulose
- macrogol

Stimulant laxatives
- senna

Poo-softener laxatives

173
Q

mx of chronic anal fissure

A

1st line = topical glyceryl trinitrate (GTN)
If not effective after 8 wks refer

ctu acute mx

174
Q

when to dx IBS

A

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

175
Q

First-line pharmacological tx IBS

A

pain: antispasmodic agents
constipation: laxatives but avoid lactulose (linaclotide if no res)
diarrhoea: loperamide is first-line

176
Q

2nd line pharmacological tx IBS

A

low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg)

177
Q

general diet advice for IBS

A
  • 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).
178
Q

most common type of oesophageal cancer in UK

A

Adenocarcinoma

179
Q

where is oesophageal adenocarcinoma found

A

Lower third - near the gastroesophageal junction

180
Q

where is oesophageal squamous cell cancer
found

A

Upper two-thirds of the oesophagus

181
Q

RFs oesophageal adenocarcinoma

A

GORD
Barrett’s oesophagus
smoking
obesity

182
Q

RFs oesophageal squamous cell cancer

A

smoking
alcohol
achalasia
Plummer-Vinson syndrome
diets rich in nitrosamines

183
Q

presentation oesophageal cancer

A

dysphagia
anorexia and weight loss
vomiting
other possible features include: odynophagia, hoarseness, melaena, cough

184
Q

dx oesophageal cancer

A

Upper GI endoscopy with biopsy for dx

Endoscopic ultrasound for locoregional staging
CT CAP for initial staging

185
Q

immunisation to give in coeliac disease + why

A

pnuemococcal (+ booster every 5 yrs)

as px often have a degree of functional hyposplenism

186
Q

abdo XR diff between small and large bowel obstruction

A

haustra are found in large bowel obstructions

valvulae conniventes are found in small bowel obstructions

187
Q

pneumonic to remember where each thing in the gut is absorbed

A

DUDE IM JUST FEELING ILL BRO

duodenum - iron
jejunum - folate
ileum - B12

finals (27 decks)

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