GI Flashcards
Pathophysiology of alcoholic liver disease
Location of hepatic damage vs autoimmune
Alcohol- centrilobar, around the portal vein
autoimmune- peri-portal- around portal tracts
Signs of chronic liver disease
clubbing- associated with primary biliary sclerosis
palmar erythema
Dupuytren’s
spider naevi
gynacomastia
testicular atrophy
What is feminisation?
Signs of liver cell failure
jaundice
leuconychia
Bruising
ascites
encephalopathy
Pathophysiology of ascites
dysregulation of RAAS
increased hydrostatic
decreased oncotic
Signs of portal hypertension
varicies
ascites
splenomegaly
caput medusa- veins flowing down below umbilicus
IVC Obstruction vs Caput medusae
in IVC Obstruction blood flows up below the umbilicus, to bypass the IVC. In caput medusae, they flow down.
Causes of ascites
cirrhosisHypoalbuminaemic states
peritoneal secondaries
constrictive pericarditis
severe biventricular failure
hepatic Vein thrombosis
TB
ovarian tumours
Features of encephalopathy
falpping tremour- asterixis
confusion, irritability
constructional apraxia e.g. difficulty drawing 5 point star
coma
convulsions
fetor hepaticus
Severity of encephalopathy grading
Signs of shock
I SHOCKS
Increased RR- early sign
Sinus tachycardia
Hypotension
Oliguria
Cold
Klammy
Slow cap. Refill
plus confusion, cyanosis, acidosis
How does systemic inflammatory response cause hypotension?
Signs of peritonitis
TRAPPED
Tenderness
Reflex guarding
Absent bowel sounds
Pyrexia
Percussion pain
Extremely unwell
Distant-local sign - e.g. Rovsing’s sign
Causes of acute pancreatitis
I GET SMASHED
I: idiopathic
G: gallstones
E: ethanol (alcohol)
T: trauma
S: steroids
M: mumps (and other infections) / malignancy
A: autoimmune
S: scorpion stings/spider bites
H: hyperlipidaemia/hypercalcaemia/hyperparathyroidism (metabolic disorders)
E: ERCP
D: drugs
Acute Pancreatitis management
IV fluids, pain control, NG tube if vomiting
80% improve in 3 days
20% have more severe- nasogastric tube, IV antibiotics, ITU
What is ARDS?
’shock lung’
pulmonary oedema
due to leaking pulmonary capillaries due to cytokines storm
first organ to fail in multi-organ failure
Scoring of Acute Pancreatitis
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L
qSOFA score
Hypotension <100
techypnoea >22
altered mental state (GCS <15)
Sepsis six
BUFALO
blood cultures
Urine output
Fluids
antibiotics
lactate
oxygen
Symptoms of intestinal obstruction
Causes of intestinal obstruction
Small bowel vs large bowel on xray
Risks in AP resection
Parasacral plexus lies between sacrum and rectum
parasympathetic fibres are easily damaged
risk of erectile impotence in men, vaginal lubrication and anorgasmia in women
risk reduced by total mesorectal excision
Complications of a stoma
FOUL SHITS
fluid loss
odour
ulceration of skin
leakage
stenosis
herniation
Ischaemia
terminal ileum loss- failure to absorb bile salts and B12
sexual and psychological problems
Causes of haematemesis
peptic Ulcer disease
varices
oesophagitis
gastritis
mallory-weiss
malignancy
AVMs
H.pylori eradication
7 days tripple therapy
PPI (omeprazole), amoxicillin, carithromycin/ metronidazole
Blood tests in haematemesis
FBC- Anaemia/ thrombocytopenia
U&E- prerenal failure, risk of rebleed
clotting- INR
LFTs- Liver disease
Group & save/ cross match - 4-6 units if active bleeding
Why give Terri-resin in active bleeding varicies
constricts splanchnic bessels, restricting portal inflow
Glasgow blatchford score
The Blatchford score is calculated prior to endoscopy and is based on simple clinical and laboratory parameters. Its principal use is to identify low-risk patients’ who do not require any intervention (blood transfusion, endoscopic therapy, surgery). Approximately 20% of patients’ presenting with upper GI haemorrhage have a Blatchford score of zero. Such patients’ can largely be managed safely in the community, as the mortality in this group is ni
Rockall score
It is important to identify those patients who are at risk of ongoing bleeding and death.
The Rockall scoring system is used for risk categorisation based on simple clinical parameters. Rockall scores can be calculated both before and after endoscopy, but the post endoscopy Rockall score provides a more accurate risk assessment. It provides independent risk factors which have been shown to accurately predict the risk of rebleeding and mortality.³
With increasing age, there is an increased risk of death: ³
Mortality in those aged below 40 is negligible
Mortality increases to 30% in those aged over 90
Patients’ who have evidence of active bleeding and signs of shock have an 80% risk of death
Those with a non-bleeding visible vessel at endoscopy have a 50% chance of re-bleeding
Signs of a variceal rebleed
Tachycardia
decreased BP
decreased CVP
Decreased urine output
haematemesis
malena
Abdominal signs of chronic liver disease
Hepatomegaly/ small liver in late
ascites
splenomegaly
caput medusae
Blood tests to assess liver synthetic function
Albumin
INR
Liver function tests
AST/ALT- hepatocellular damage
ALP/gGT intra/extrahepatic
How is the severity of liver failure calculated?
Complications of liver cirrhosis
Grading of hepatic encephalopathy
Complications of gallstones
Biliary colic
cholecystitis
empyema
obstructive jaundice
cholangitis
gallbladder perforation
gallstone ileus
Complications of cholecystectomy
Death <1/1000
bile duct injury
bile leakage
jaundice due to retained ductal stoned
general surgical complications
Causes of bloody diarrhoea
UC
colorectal Ca
polyps
ischaemic colitis
pseudomembranous colitis
infective
Extraintestinal manifestations of IBD
What class of drug is used to maintain remission of UC?
aminosalicylates- active ingredient is 5ASA
mesalazine, sulfasalazine
Severity of UC attack scoring
Complications of UC
perforqrion
bleeding
malnutrition
toxic dilation of the colon
PSC
colon cancer risk increased
Causes of erythema nodosum
sarcoid
sterptococcal infection
TB
IBD
drugs- sulphonamides, OCP
Features of both UC and Crohns
young age
chronic
innapropriate activation of mucosal immune system
abdo pain and diarrhoea
may cause total colitis—> toxic mega colon
associated with extraintestinal manifestations e.g. iritis, arthritis, erythema nodosum, pyoderma gangrenosum
Features of Crohn’s disease
peak incidence in 20s (30s in UC)
transmural Disease with patchy distribution and non-caseating granulomas
mouth to anus
more likely to present with weight loss, ill health, Anaemia of chronic disease
Site of disease in Crohns
skip lesions
terninal ileum involvement —> malabsorption due to loss of bile salts
rectum commonly spared
strictures, typically in terminal ileum
peri-anal disease is common
Types of ulceration in Crohns disease
superficial- mucosal only- apthous
deep- mucosa and submucosa- fissures leading to cobblestone mucosa
transmural- full thickness, down to muscle layer, rose thorn ulcers
Features of Crohns
CAMPERS
Clubbing / Cobblestone
Apthous ulcers
Mass in RIF/ Malabsorption
Peri-anal Disease- skin tags, fistula, abscess
Erythema nodosum
Rosethorn ulcers/ Rectal sparing
Skip lesions/ Strictures
Features of UC
peak incidence 30s
diarrhoea, blood mucus
superficial mucosal ulceration
inflammatory cells extending into lumen of colonic glands ‘crypt abscesses’
pseudopolyps
Confined to colon (backwash ileitis)
recutm nearly always involved
risk of colonic carcinoma
IBD differentials
infection
pseudomembranous colitis
iscaemic colitis
radiation colitis
Severity grading of UC
mild- <4 stools per day, systemically well
moderate- >4 stools per day, systemically unwell
severe- >6 stools per day or systemically unwell
systemically unwell- tachycardia, fever, Anaemia, hypoalbuminaemia
borders of the inguinal canal
floor- inguinal ligament
roof- internal oblique
anterior- external oblique
posterior- transversalis
complications of hernias
incarceration, strangulation, obstruction
what is a Richter’s hernia?
only part of the bowel herniates –> strangulation without herniation
commoner in femoral hernias
mid inguinal point vs mid-point of the inguinal ligament
mid-inguinal point–> pubic symphysis to ASIS–> femoral pulse
mid point of the inguinal ligament–> pubic tubercle to ASIS–> deep inguinal ring
