GI 3 Flashcards
What is ascites?
accumulation of free fluid within the peritonieal cavity
What are causes of ascites?
local inflammation - peritonitis/intra-abdominal surgery, abdo cancers
low protein - hypoalbuminaemia, nephrotic syndrome, malnutrition
low flow - fluid cannot move forwards - cirrhosis, budd-chiari syndrome, cardiac failure
*high sodium diet, HCC, splanchnic vein thrombosis
How would ascites present?
abdominal swelling - over days or weeks
distended abdomen
fullness in the flanks and shifting fullness
mild abdo pain and discomfort
- if severe pain, investigate bacterial peritonitis
How would you investigate and manage ascites?
- shifting dullness
- diagnostic aspiration using ascitic tap - raised WCC, gram stain and culture, cytology
What can you suggest from protein measurement of the ascitic fluid from ascitic tap?
Transudate (low protein) - portal hypertension, contrictive pericarditis, cardiac failure, budd-chiari syndrome
exudate (high protein) - malignancy, peritonitis, pancreatitis, peritoneal tuberculosis, nephrotic syndrome
reduce sodium
Diuretic - aldosterone antagonist (K+ sparing)
drain fluid - 5 litres at a time
TIPS
What is the anatomical limits of the foregut? Where would the site of autonomic pain be?
Lower oesophagus to D2 (liver, spleen & gallbladder)
pain = epigastric
What is the anatomical limits of the midgut? Where would the site of autonomic pain be?
D2 to 2/3 across transverse colon (majority of abdomen)
pain = periumbilical
What is the anatomical limits of the hindgut? Where would the site of autonomic pain be?
transverse colon to upper rectum
pain = hypogastric
What are the main causes of peritonitis?
bacterial - gram-negative - E.coli and Klebsiella
gram-positive - staphylococcus aureus
chemical - bile, old clotted blood, (leakage of intestinal contents, ruptured ectopic)
How would peritonitis present?
perforation = sudden onset - acute severe abdo pain –> general collapse and shock
will want to stay still
rigid abdomen
How would you investigate peritonitis?
FBC -leucocytosis , anaemia (bleed)
Ascitic fluid - if ‘hazy, cloudy, bloody’, ascitic fluid absolute neutrophil count, fluid gram stain, fluid culture
Periscreen
standard urine leukocyte reagent strip test of ascitic fluid
blood culture
How would you manage peritonitis?
Cefotaxime + Vancomycin
Meropenem
albumin if there’s renal dysfunction
What is a volvulus? Where can it occur?
complete twisting of a loop of intestine around its mesenteric attachment
can occur at stomach, small intestine, caecum, transverse colon and sigmoid colon
sigmoid volvulus - commonest form
How would a volvulus present?
bilious vomiting
failure thrive
anorexia
constipation
bloody stools
abdo pain
malnutrition
immunodeficiency
What is the classical triad of GI obstruction?
Vomiting
Pain
Failed attempts to pass a NG tube
How would you investigate a volvulus?
X-ray - coffee bean sign (big fuck off coffee bean). Friman/Dahl sign
CT abdomen - whirl sign, bird beak sign
FBC
How would you manage a volvulus?
open laparotomy and Ladd procedure
cefoxitin
What are the different kinds of oesophageal tumours?
Squamous cell carcinoma - middle third (40%) and upper third (15%)
Adenocarcinoma - lower third and at the cardia (45%)
What are some risk factors for oesophageal squamous cell carcinoma?
alcohol
achalasia
tobacco
obesity
smoking
low fruit and veg
What are some risk factors for adenocarcinoma of the oesophagus?
Barrett’s oesophagus (reflux)
smoking tobacco GORD obesity diet low in Vit A & C
How would a oesophageal tumour present?
no physical signs until extremely advanced
if dysphagia to solids and liquids from the start this indicates BENIGN DISEASE
weight loss
lymphadenopathy
anorexia
pain due to impaction of food
signs from upper 1/3 of oesophagus
How would you investigate oesophageal cancer?
OGD with biopsy
metabolic profile - hypokalaemia, elevated creatinine and serum urea/nitrogen
How would you manage oesophageal cancer?
endoscopic resection with or without ablation
oesophagectomy
preoperative chemo and postop chemo
What types of gastric tumours are there?
adenocarcinoma
What are causes/risk factors of gastric tumours?
smoking
h.pylori
dietary factors - high salt and nitrates increase risk
non-starchy vegetables, fruit, garlic and low salt decrease risk
loss of p53
CDH1 gene
pernicious anaemia
How would carcinoma of the stomach present?
epigastric pain (indistinguishable from peptic ulcer disease)
nausea, anorexia
weight loss
vomiting frequent
dysphagia
anaemia from occult clood loss
liver, bone , brain and lung mets
palpable Virchow’s node
How would you investigate stomach carcinoma?
upper gastrointestinal endoscopy with biopsy
CT/MRI
How would you treat stomach cancer?
surgery
perioperative and postoperative chemoradiation
What is a colonic polyp? What sort of cell are they?
Abnormal growth of tissue projecting from the colonic mucosa
Adenomas
What are some forms of inherited colonic polyp?
Familial adenomatous polyposis (FAP) - AD mutation in the APC gene
Lynch syndrome - hereditary non-polyposis colon cancer (HNPCC) -AD mutation rapidly progress to colon cancer
What type of cancers are normally colorectal, where do they normally occur?
Usually adenocarcinoma
Occur in the distal colon
What are risk factors for colorectal carcinoma?
Increasing age
low fibre diet
saturated animal fat and red meat consumption
colorectal polyps
alcohol smoking
obesity
UC
fam Hx
How would a colorectal carcinoma present?
Right-sided - usually asymp. - mass, weight loss, low haemoglobin, abdo pain
Left-sided and sigmoid carcinoma - change in bowel habit with blood and mucus in stools, diarrhoea, constipation, thin/altered stools
Rectal carcinoma - rectal bleeding and mucus, thinner stools and tenesmus
What is an emergency presentation of colorectal carcinoma?
Obstruction
I) absolute constipation
ii) colicky abdo pain
iii) abdo distension
iv) vomiting (faeculent)
How would you investigate colorectal carcinoma?
FBC
Colonoscopy
Double- contrast barium enema
How would you treat a colorectal carcinoma?
local excision or radical excision
preoperative radiotherapy and chemotherapy
if surgery not suitable - cetuximab
What is the duke staging classification of colorectal cancer?
A - confined to the mucosa
B1 - tumor growth into the muscularis propria
B2 - tumour growth through muscularis propria and serosa
C1 - tumour spread to 1-4 regional lymph nodes
C2 tumour spread to more than 4 regional lymph nodes
D - distant metastases (liver, lung, bones)
How would you classify hernia?
Reducible - can be pushed back
Irreducible - cannot be pushed back (obstructed, incarcerated, strangulated)
What is the contents of the spermatic cord?
3 arteries - testicular, cremasteric and artery of Vas
3 veins - pampiniform plexus of testicular veins, cremasteric vein and vein of the Vas
3 nerves - ilioinguinal nerve, genitofemoral nerve, sympathetic nerve
3 others - vas deferens, lymph vessels, tunica vaginalis
What are risk factors for inguinal hernia?
Male Chronic Cough Constipation Urinary obstruction Heavy lifting Ascites Past abdo surgery
Whats the difference between a direct inguinal hernia and an indirect inguinal hernia?
Direct - less common, peritoneal sac through posterior wall, rarely strangulate, reduces easily
Indirect - more common, peritoneal sac enters inguinal canal through deep inguinal ring, can strangulate
How would you manage an inguinal hernia?
strangulated - surgical repair
open mesh or laparoscopic repair
What is a femoral hernia?
bowel comes through femoral canal below the inguinal ligament
likely to be irreducible and to strangulate due to the rigidity of the canals borders
What is a hiatus hernia? What are the different types?
Sliding hiatus hernia - where the gastro-oesophageal junction and part of the stomach slides up into the chest via the hiatus so that it lies above the diaphragm
rolling or para-oesophageal hiatus - gastro-oesophageal junction remains in the abdomen but part of the fundus of the stomach prolapses throught the hiatus
How would you treat a hiatus hernia?
IF hemmorhage and/or obstruction/volvulus - resus and urgent surgical repair
PPI and lifestyle changes
When would diarrhoea be considered chronic?
more than 2 weeks
What are the different mechanisms of diarrhoea? What are some causes for each?
Infective
Inflammatory
Osmotic - laxatives, generalised malabsorption
Secretory - enterotoxins, bile salts following ileal disease, resection or idiopathic bile acid malabsorption
Functional - IBS
What are the causes of infective diarrhoea ?
Children - rotavirus, E.coli, salmonella, shigella
Adults - norovirus, campylobacter jejuni (most common cause of bacteria diarrhoea)
What antibiotics can give rise to abx induced Clostridium Difficile?
In general, ones that start with C
Clindamycin
Ciprofloxacin
Co-amoxiclav
Cephalosporins
What are risk factors for C.diff diarrhoea?
elderly
abx
long hospital stay
immunocompromised
acid suppression (PPI or H2 receptor antagonist)
How would you investigate a possible C.Diff infection?
FBC - WBC increased
Stool guaiac - test for blood
Stool PCR - positive
Stool immunoassay for glutamate dehydrogenase - detects C.diff in bowel
How would you manage a C.diff infection?
Vancomycin
Isolate and barrier nurse
check for causative agent
Presentation of C. Diff? Complications?
3-9 days post antibiotics
High amount of green, foul smelling stool with crampy abdo pain
Complications – toxic megacolon, perforation, spread of infection
