GI 2 Flashcards
Who classically gets gallstones?
Fair, fat, fertile, female, forty
What are the main components of bile?
Cholesterol
Bile pigments from broken down Hb
Phospholipids
What are the main 2 different types of gallstones?
How are they different?
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
What is Admirand’s triangle? (what increases your risk of stone)
Increased risk of stone if:
- Low lecithin (essential fat)
- Low bile salts
- High cholesterol
How do gallstones present if they are symptomatic?
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
Managment of gallstones?
Gallstones
- NBM
- analgesia (IM Diclofenac)
- IV fluids
- Laperoscopic cholesystectomy (to reduce risk of comps)
Complications of gallstones?
Gallstone complications
- Bilary colic (stuck in cystic duct or passing through CBD)
- Cholecystitis (36%)
- Cholangitis
- Pancreatitis
- Gall stone illeus
- Carcinoma (dunno how)
What is acute cholecystitis?
What are the symptom and signs?
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)
What are the signs of acute cholecystitis?
Acute cholecystitis
- GB mass at RUQ (gall stone)
- Murphy’s sign (palpate RUQ, breathe in, ↑pain)
- NON peritonitic (may have “local peritonism”)
What is the best imaging for looking at gallstones?
USS is best for looking for gallstones
Investigations for acute cholesystis?
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
Acute cholecystitis management?
Acute cholecystitis management
- NBM
- analgesia
- IV fluids
- IV antibiotics (guidelines) (cefuroxime)
Refer for laparoscopic cholecystectomywithin 1 week!
**if perforation: do open surgery
What is cholangitis?
What are the classic symptoms?
What is the treatment?
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
Compare the below things for bilary colic/cholysistis/cholangitis.
Location of stone RUQ pain Blood results Murphys sign Jaundice? Fever? Treatment
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
Compare the treatments for bilary colic/cholysistis/cholangitis.
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
What is the managment for chronic cholesystis?
Do an USS
-if USS shows dilated CBD with stones do an ERCP + sphincterotomy before laparoscopic cholecystectomy
What are the 2 types on inguinal hernias?
Which ones are more often strangulated?
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
What are the risk factors for inguinal hernias?
Risk factors-Inguinal hernias
- MALES (8:1)
- chronic cough
- obesity
- constipation/urinary obs
- heavy lifting
- prev abdo surg
How do you tell the difference between direct and indirect inguinal hernias
- *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
Presnetation of inguinal hernia?
- 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)
Management of inguinal hernias?
-Obviously tell them to lose weight if overweight
SURGERY (to prevent strangulation)
-Mesh repair (Lichtenstein repair - best) (polypropylene mesh reinforces posterior wall
Investigations for inguinal hernia
Inguinal hernia is a clinical diagnosis
-do USS if its unclear
What would indicate hernia strangulation?
What is the management?
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
What are 2 complications of inguinal hernias?
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
What is a femoral hernia
What is the treatement?
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
Femoral hernia
- what do they look like?
- where are they located?
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)
What is an incisional hernia?
What is the managment is an incisional hernia?
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
What genes are linked to coeliac disease?
HLA-DQ2 (95%)
HLA-DQ8
When should coeliac disease be suspected?
Anaemia (iron or B12 deficiency)
Weight loss
Diarrhoea (steatorrhoea)
What is seen on histology of coeliac disease?
Villous atrophy
Crypt hyperplasia
What are some manifestations of coeliac disease?
- 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)
What ages get coeliac?
Coeliac disease peaks in childhood and age 50-60yrs
How do you diagnose coeliac disease?
All tests must be done whilst eating a gluten-containing diet
- Total IgA and IgA tissue transglutaminase = 1st choice
- If the first test was only weakly positive, test IgA EMA (endomysial antibodies)
- If IgA is deficient, test IgG
What is mirrizi syndrome?
How does it present?
Mirrizi syndrome
- extrinsic compression of CBD (cholesystitis)
- presents like cholangitis (fever, jaundice, RUQ)
What is the main symptom of rectal prolapse?
Risk factors for rectal prolapse?
Incontinance (75%)
Risk factors: prolongs starring/coughing/chronic neuro/psych disorders
What investigations would you do for a rectal prolapse?
- PR exam- protruding mass (w/ concentric rings of mucosa), rectal ulcers, ↓anal tone
- Barium enema/Colonoscopy – evaluate colon prior to surgery to exclude other lesion
- Stool microscopy/cultures -GI parasitic infection can cause
- Sweat test – CF screening (common due to hard stool sand cough)
Treatment for rectal prolapse?
Conservative
- Stool softeners (docusate/lactulose)
- Manually reduce it
Surgery to fix!!
What are haemorrhoids?
- Straining/gravity can cause anal cushions to dilate
- This causes piles (vascular balls)
- Prone to trauma and bleeds readily
Symptoms of haemorrhoids?
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
Investigations for haemorrhoids?
- Abdo and PR exam
(internal haemorrhoids are not palpable) - Proctoscopy – visualise internal haemorrhoids + other causes for bleeding
- Sigmoidoscopy – visualise high rectal pathology if 50+
Treatment for haemorrhoids?
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)
Treatment for perianal absess?
Insicion and drainage under GA
more common in chrons
What is anal fissure?
Treatment for anal fissure?
- Painful tear normally caused by straining
- 5% lidocaine ointment and GTN ointment (or topical diltiazem)
ENCOURAGE BLOOD SUPPLY>HEAL
How does lactulose work?
Classic side effect?
- stool softener
- Non-absorbable sugar - stays in the digestive tract
- Causing retention of water through osmosis (softer stool)
side effect: bloating
How does senna work?
Classic side effect of long term use?
- stimulant
- act directly as irritants on the colonic wall to induce fluid secretion and colonic motility
side effect: melanosis coli.
Which laxative can cause hyperkaleamia?
Potassium salts mixed with movicol-so can cause hyperkaleamia
Which laxative can cause orange urine?
Co-Danthrusate
