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5thyr > GI 2 > Flashcards

GI 2 Flashcards

1
Q

Who classically gets gallstones?

A

Fair, fat, fertile, female, forty

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2
Q

What are the main components of bile?

A

Cholesterol
Bile pigments from broken down Hb
Phospholipids

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3
Q

What are the main 2 different types of gallstones?

How are they different?

A

Cholesterol stones

  • 90% stones in UK
  • Large, often solitary
  • Caused by obesity

Pigment stones

  • Small, irregular
  • Friable (easily crumbled)
  • Caused by haemolysis, stasis and infection
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4
Q

What is Admirand’s triangle? (what increases your risk of stone)

A

Increased risk of stone if:

  • Low lecithin (essential fat)
  • Low bile salts
  • High cholesterol
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5
Q

How do gallstones present if they are symptomatic?

A

Asymptomatic (70%)

Symptoms include
- Colicky RUQ pain
•worse after eating
•refers to right shoulder
•pain as they are being passed through ducts (spasm of smooth muscle)
•lasts about 15 mins , resolves with analgesia

-May have nausea + vomiting

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6
Q

Managment of gallstones?

A

Gallstones

  • NBM
  • analgesia (IM Diclofenac)
  • IV fluids
  • Laperoscopic cholesystectomy (to reduce risk of comps)
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7
Q

Complications of gallstones?

A

Gallstone complications

  • Bilary colic (stuck in cystic duct or passing through CBD)
  • Cholecystitis (36%)
  • Cholangitis
  • Pancreatitis
  • Gall stone illeus
  • Carcinoma (dunno how)
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8
Q

What is acute cholecystitis?

What are the symptom and signs?

A

Acute cholecystitis
-gall stone stuck in cystic duct→INFLAMATION

Symptoms 
- RUQ/epigastric pain (more painful than simple binary colic)
   •refers to right shoulder 
   •colicky or constant 
   •worse when eating 
- Nausea Vomiting

Signs
- Fever- the presence of fever distinguishes from just biliary colic
- local peritonism- tender o/e with possible GB mass with guarding and some rigidity
○ MURPHY’S SIGN 2 fingers over RUQ and ask patient to breath in . (only +ve if the same test in the LUQ does not cause pain)

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9
Q

What are the signs of acute cholecystitis?

A

Acute cholecystitis

  • GB mass at RUQ (gall stone)
  • Murphy’s sign (palpate RUQ, breathe in, ↑pain)
  • NON peritonitic (may have “local peritonism”)
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10
Q

What is the best imaging for looking at gallstones?

A

USS is best for looking for gallstones

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11
Q

Investigations for acute cholesystis?

A

Cholecystitis investigations

  • FBC (high WCC)
  • LFTs (marginal elevation of ALP, bili and ALT possible - but highly elevated levels might be more suggestive of bile tract obstruction)
  • USS might show thick walls and shrunken GB, might see stones and might see a dilated CBD
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12
Q

Acute cholecystitis management?

A

Acute cholecystitis management

  • NBM
  • analgesia
  • IV fluids
  • IV antibiotics (guidelines) (cefuroxime)

Refer for laparoscopic cholecystectomywithin 1 week!

**if perforation: do open surgery

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13
Q

What is cholangitis?

What are the classic symptoms?

What is the treatment?

A

Cholangitis

  • Stone in the common bile duct (no bile can get through)
  • This is similar to cholecystitis PLUS JAUNDICE
  • It’s bad! likely septicaemia!
  • Infection of the gall bladder

-CHARCOT’S TRIAD:
•RUQ pain
•Fever and rigors
•Jaundice

Treatment

  • IV antibiotics (guidelines)
  • ERCP to drain GB
  • cholesystectomy if due to stones
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14
Q

Compare the below things for bilary colic/cholysistis/cholangitis.

Location of stone 
RUQ pain
Blood results 
Murphys sign 
Jaundice?
Fever?
Treatment
A

Location of stone

  • bilary colic: in gall bladder
  • cholysistis: in cystic duct (neck of gallbladder)
  • cholangitis: in common bile duct (obstructing bile flow)

RUQ pain

  • bilary colic: yes
  • cholysistis: yes
  • cholangitis: yes

Blood results

  • bilary colic: normal
  • cholysistis: ↑WCC
  • cholangitis: ↑WCC

Murphys sign

  • bilary colic: -ve
  • cholysistis: +ve
  • cholangitis: Can be +ve

Jaundice?

  • bilary colic: no
  • cholysistis: no
  • cholangitis: yes

Fever?

  • bilary colic: no
  • cholysistis: yes
  • cholangitis: yes
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15
Q

Compare the treatments for bilary colic/cholysistis/cholangitis.

A 
Bilary colic:
Laparoscopic cholecystectomy (timing depends on clinical picture)

Acute cholysystitis:
Refer for laparoscopic cholecystectomywithin 1 week!

Cholangitis:

  • IV antibiotics (guidelines)
  • ERCP to drain GB
  • cholesystectomy if due to stones
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16
Q

What is the managment for chronic cholesystis?

A

Do an USS

-if USS shows dilated CBD with stones do an ERCP + sphincterotomy before laparoscopic cholecystectomy

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17
Q

What are the 2 types on inguinal hernias?

Which ones are more often strangulated?

A

Inguinal Hernias (75% of abdominal wall hernias)

Indirect (most common 80%)

  • internal ring → external inguinal ring
  • can strangulate

Direct (less common 20%)

  • directly through posterior wall of inguinal canal
  • rarely strangulate

*located SUPERO MEDIAL to pubic tubercle

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18
Q

What are the risk factors for inguinal hernias?

A

Risk factors-Inguinal hernias

  • MALES (8:1)
  • chronic cough
  • obesity
  • constipation/urinary obs
  • heavy lifting
  • prev abdo surg
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19
Q

How do you tell the difference between direct and indirect inguinal hernias

A
  • *telling the difference**
  • occlude the deep (internal) inguinal ring
  • ask them to cough or stand
  • if the hernia disappears it is indirect (if it stays its direct)

In reality, its determined during surgical repair:

  • Indirect are LATERAL to inferior epigastric vessels
  • Direct are MEDIAL to inferior epigastric vessels
20
Q

Presnetation of inguinal hernia?

A
  • Intermittent swelling in groin or scrotum
  • Firm + tender
  • Mass especially during coughing (↑IA pressure)
  • Sudden pain – unlikely to be severe
  • Vomiting + Irritability
  • Thickened spermatic cord (M) or round ligament (F)
21
Q

Management of inguinal hernias?

A

-Obviously tell them to lose weight if overweight

SURGERY (to prevent strangulation)
-Mesh repair (Lichtenstein repair - best) (polypropylene mesh reinforces posterior wall

22
Q

Investigations for inguinal hernia

A

Inguinal hernia is a clinical diagnosis

-do USS if its unclear

23
Q

What would indicate hernia strangulation?

What is the management?

A

Hernia strangulation

  • pain out of proportion to clinical features
  • red/tender/tense mass
  • vomiting/ colicky abdominal pain/ distention
  • deranged biochemical results

Management: urgent surgical exploration

24
Q

What are 2 complications of inguinal hernias?

A

Inguinal hernias
-Irreducible/incarcerated hernia – occurs chronically over time as hernia enlarges + fibrous adhesions form → strangulation (compromises vasc supply) → small bowel obstruction (common complication of hernias)

Hydrocele – patent processus vaginalis (which is narrow enough to prevent formation of inguinal hernia), may still allow peritoneal fluid around scrotum 
-painless scrotal swelling
-non-tender 
-bilateral blue 
-transilimination
SELF LIMITING
25
Q

What is a femoral hernia

What is the treatement?

A

Femoral Hernia

  • Bowel segment enters femoral canal → often irreducible → strangulation (due to rigid boarders of canal)
  • RF: FEMALES
  • Repair – EVERYONE, due to high risk of strangulation
26
Q

Femoral hernia

  • what do they look like?
  • where are they located?
A

Femoral hernia

  • DOWNWARD POINTINGmass in upper medial thigh or above inguinal ligament
  • Neck of hernia felt INFERO-LATERAL to pubic tubercle
  • Made worse on cough/standing (clinical diagnosis)
27
Q

What is an incisional hernia?

What is the managment is an incisional hernia?

A

Incisional hernia
-hernia that occurs through a previously made incision in the abdominal wall (clinical diagnosis)

Management is decided on a case-by-case basis, however if suitable most patients will warrant surgical intervention

28
Q

What genes are linked to coeliac disease?

A

HLA-DQ2 (95%)

HLA-DQ8

29
Q

When should coeliac disease be suspected?

A

Anaemia (iron or B12 deficiency)
Weight loss
Diarrhoea (steatorrhoea)

30
Q

What is seen on histology of coeliac disease?

A

Villous atrophy

Crypt hyperplasia

31
Q

What are some manifestations of coeliac disease?

A
  • Fe+ (duodenum) or Folate (jejunum) deficiency → fatigue and angular stomatitis
  • B12 deficiency - peripheral neuropathy, ataxia
  • Aphthous ulcers
  • Osteoporosis
  • Muscle wasting (buttocks) + Arthralgia
  • Dermatitis herpetiformis – classic skin (75%)

*look for other autoimmune conditions (Type 1 DM or autoimmune thyroid disease)

32
Q

What ages get coeliac?

A

Coeliac disease peaks in childhood and age 50-60yrs

33
Q

How do you diagnose coeliac disease?

A

All tests must be done whilst eating a gluten-containing diet

  1. Total IgA and IgA tissue transglutaminase = 1st choice
  2. If the first test was only weakly positive, test IgA EMA (endomysial antibodies)
  3. If IgA is deficient, test IgG
34
Q

What is mirrizi syndrome?

How does it present?

A

Mirrizi syndrome

  • extrinsic compression of CBD (cholesystitis)
  • presents like cholangitis (fever, jaundice, RUQ)
35
Q

What is the main symptom of rectal prolapse?

Risk factors for rectal prolapse?

A

Incontinance (75%)

Risk factors: prolongs starring/coughing/chronic neuro/psych disorders

36
Q

What investigations would you do for a rectal prolapse?

A
  1. PR exam- protruding mass (w/ concentric rings of mucosa), rectal ulcers, ↓anal tone
  2. Barium enema/Colonoscopy – evaluate colon prior to surgery to exclude other lesion
  3. Stool microscopy/cultures -GI parasitic infection can cause
  4. Sweat test – CF screening (common due to hard stool sand cough)
37
Q

Treatment for rectal prolapse?

A

Conservative

  • Stool softeners (docusate/lactulose)
  • Manually reduce it

Surgery to fix!!

38
Q

What are haemorrhoids?

A
  • Straining/gravity can cause anal cushions to dilate
  • This causes piles (vascular balls)
  • Prone to trauma and bleeds readily
39
Q

Symptoms of haemorrhoids?

A

Haemorrhoids

  • Painless Rectal Bleed
    • bright red
    • often coats stool
    • noticed dripping in toilet post defecation
  • Symptoms of anaemia
  • Pruritis of anal area
  • Mucous discharge
  • Rectal fullness or discomfort
40
Q

Investigations for haemorrhoids?

A
  1. Abdo and PR exam
    (internal haemorrhoids are not palpable)
  2. Proctoscopy – visualise internal haemorrhoids + other causes for bleeding
  3. Sigmoidoscopy – visualise high rectal pathology if 50+
41
Q

Treatment for haemorrhoids?

A

For 1st degree haemorrhoids-stay in rectum

  • ↑Fluid + Fibre
  • topical analgesics
  • stool softeners (docusate/lactulose)
  • anusol packs (shrink them)

For 2nd-3rd degree (and refractory 1st degree)
-Rubber band ligation

Can also have surgery (most effective)

42
Q

Treatment for perianal absess?

A

Insicion and drainage under GA

more common in chrons

43
Q

What is anal fissure?

Treatment for anal fissure?

A
  • Painful tear normally caused by straining
  • 5% lidocaine ointment and GTN ointment (or topical diltiazem)

ENCOURAGE BLOOD SUPPLY>HEAL

44
Q

How does lactulose work?

Classic side effect?

A
  • stool softener
  • Non-absorbable sugar - stays in the digestive tract
  • Causing retention of water through osmosis (softer stool)

side effect: bloating

45
Q

How does senna work?

Classic side effect of long term use?

A
  • stimulant
  • act directly as irritants on the colonic wall to induce fluid secretion and colonic motility

side effect: melanosis coli.

46
Q

Which laxative can cause hyperkaleamia?

A

Potassium salts mixed with movicol-so can cause hyperkaleamia

47
Q

Which laxative can cause orange urine?

A

Co-Danthrusate

5thyr (18 decks)

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