GI Flashcards
What is boerhaave’s syndrome
Oesophageal wall rupture due to vomiting.
What area of the GIT does crohn’s affect
Anywhere from mouth to anus.
Syx of Crohn’s disease
Abdo pain Loss of appetite Weight loss Diarrhoea Passage of blood / mucus rectally
Most common cause of painless rectal bleeding
Haemorrhoids
Syx of an anal fissure
Streaks of blood on toilet paper
Pain on defecation
What is cholestyramine and what is it used for?
Bile acid sequestrant
Used in primary biliary cirrhosis
What is goodpastures syndrome
Anti-glomerular basement antibody disease
Leading to glomerulonephritis and lung haemorrhage
What is primary sclerosing cholangitis
Disease of bile ducts.
Progressive inflammation and fibrosis of intra and extra-hepatic bike ducts.
Symptoms of primary sclerosing cholangitis
Fatigue Jaundice Pruritus Malabsorption + steatorrhoea Dark urine RUQ pain (hepatomegally) Weightloss Fever / rigors
Diagnosis of primary sclerosing cholangitis
Raised bilirubin
Raised alkaline phosphatase / GGT
Endoscopic retrograde cholangiopancreatography
80% have p-ANCA
What is Primary biliary cirrhosis
Chronic inflammatory liver disease
Progressive destruction of intrahepatic bile ducts
Probably autoimmune
Symptoms of Primary biliary cirrhosis
Pruritus Fatigue Weightloss Arthralgia Jaundice RUQ pain (hepatomegally) Xanthelasma Hyperpigmentation
What is biliary colic
Severe RUQ/epigastic pain - radiate to scapula Related to cholecystitis and gallstones Lasts several hours May be precipitated by fatty meal \+/- n+v
What is cholangitis
Infection of the common bile duct
What is Wilson’s disease
Autosomal recessive condition leading to reduced biliary excretion of copper
Accumulates in liver and brain
Management of Wilson’s disease
Penicillamine = chelating agent
Symptoms of Wilson’s disease
Liver infiltration –> jaundice, easy bruising, variceal bleeding, encephalopathy
Neuro –> dyskinesia, rigidity, tremor, dysarthria, dementia, ataxia
Psych syx
Signs of hepatocellular carcinoma
Weightloss Lymphadenopathy Nodular hepatomegally Jaundice Ascites (Liver bruit)
Signs of alcohol excess
Malnourished Palmar erythema Dupuytrens contracture Facial telangiectasia Parotid enlargement Spider naevi Gynaecomastia Testicular atrophy Hepatomegally Easy bruising
Symptoms of alcoholic hepatitis?
Mild illness Nausea Malaise Epigastric or R hypochondrium pain Low-grade fever Jaundice Ascites Peripheral oedema GI bleed
When do Kayser fleischer rings occur?
Wilsons disease
Clinical features of pancreatitis?
Epigastric pain radiating to the back Nausea and vomiting Previous episodes Known gallstones (Tachycardia, Hypotension)
Standard diagnostic test for pancreatitis?
Serum amylase
What is courvoisiers law?
In painless jaundice palpable gallbladder is unlikely to be gallstones
What is a choledocholithiasis
Gallstone in the common bile duct
Risk factors for hepatocellular carcinoma?
Increasing age
Male
Hepatitis B
Cirrhosis
Risk factors for developing acute cholangitis
Choledocholithiasis
Biliary stricture
Tumours
ERCP
Treatment of acute cholangitis
Antibiotic
Remove cause
What is Charcots triad
Fever, jaundice and abdominal pain
Associated with acute cholangitis
What is the acute cholangitis
Bacterial infection in conjugation with obstruction of the biliary tree
Commonly due to gallstones
Symptoms of acute cholangitis?
Epigastric pain Right upper quadrant pain Vomiting Fever Peritonism
What is Gilbert’s syndrome?
Raised unconjugated bilirubin
More marked in fasting or illness
Autosomal recessive
No long-term sequelae
Features of an amoebic liver abscess
Entamoeba histoltica
90% Are solitary
Commonly involves right liver lobe
Treated by aspiration
Types of pancreatic Cancer
80% = adenocarcinoma Rest = adenosqamous And mucinous cystadenocarcinoma
75% in head/neck of pancreas
15% in body
10% in tail
Symptoms of pancreatic cancer
Anorexia
Weight loss
Malaise
Later jaundice and epigastric pain
Symptoms of acute pancreatitis
Severe epigastric pain radiating to the back Relieved by sitting forward Worse on movement Anorexia Nausea and vomiting
What is Cullens sign?
Discolouration around the umbilicus inpatients with acute pancreatitis
What is grey-turners sign?
Bruising of the flanks
Can occur in a severe attack of acute pancreatitis
Features of amoebiasis
Pain
Bloody diarrhoea.
Flask-shaped ulcers on colon
PAS +ve trophozites + ingested RBC
Features of congenital toxoplasmosis
Jaundice Hepatomegally Hydrocephalus Choroidoretinitis necrosis of brain, liver, heart, lung, retina
Features of toxoplasmosis in adults
Sub clinical infection
Mild lymphadenopathy
Weightloss plus anaemia in a patient with a change in bowel habit and PR bleeding suggests what?
Colorectal carcinoma
Paroxysmal Flushing, wheezing, abdominal pain, diarrhoea and bronchospasm suggests what?
Carcinoid syndrome
What is a Hartman’s procedure?
Primary resection of a lesion leaving a temporary colostomy and oversewing the rectum.
For later re-anastomosis.
Emergency procedure.
Complications of stomas
Fluid loss Odour Skin ulceration Leaking Stenosis Herniation Prolapse Ischaemia Psychosocial / sexual
Where do haustrae occur
Large bowel
Not full width
Where do valvulae coniventes occur?
Small bowel
Complete width
Symptoms of intestinal obstruction
Pain
Vomiting
Distension
Absolute constipation - no flatus or faeces
Causes of bowel obstruction
Adhesions Hernias Tumours Gall stone ileus Sigmoid or caecal volvulus
Features of spontaneous bacterial peritonitis in a patient with ascites
Generalised abdominal pain Worsening ascites Vomiting Fever Rigor
Most common causative organisms in spontaneous bacterial peritonitis
E. coli
Klebsiella
Portal hypertension causes varices where
Oesophagus
Rectum
Umbilical veins
Management of Oesophageal variceal bleeding
Therapeutic endoscopy
Banding or sclerosis of varices
If unresponsive haemostasis is achieved with balloon tamponade
= sengstaken-blakemore tube
Secondary prophylactic measures to reduce the risk of variceal rebleeding
Elective endoscopic variceal banding/sclerotherapy
Propranolol to reduce portal Venous pressure
Clinical features of hepatic encephalopathy
Reversed sleep pattern Asterixis Constructional apraxia Agitation Reduced consciousness Coma Death
Precipitants of hepatic encephalopathy
High protein diet Upper GI bleeding Hypokalaemia Alcohol Benzodiazepines Diuretics
Treatment of hepatic encephalopathy
Correct underlying cause
Low protein diet
nurse patient in light room
Lactulose (osmotic laxative)
What is hepatorenal syndrome
Acute renal failure despite normal kidneys in a patient with cirrhosis and portal hypertension
What is the odynophagia
Pain on Swallowing
Symptoms of GORD
Heartburn
regurgitation
dysphagia
(Atypical symptoms= Retrosternal chest pain, hoarseness, hiccups, ear pain, loss of dental enamel, night sweats, chronic wheeze, globus sensation, hypersalivation, halitosis)
Complications GORD
Oesophageal inflammation Erosions Ulceration Stricture Metaplasia of lower oesophagus (Barrett's oesophagus)
Management GORD
Lifestyle - Weight loss, smoking cessation, avoid late night meals, avoid spicy food, elevate head of bed
Medical - Ranitidine (H2 antagonist), omeprazole (PPI), metoclopramide (Prokinetic)
Surgical - fundoplication
Most common causes of small-bowel obstruction
Post-op adhesions
Incarcerated hernia
Malignancy
Less common (diverticulitis, gallstone ileus, IBD)
What is familial adenomatous polyposis
Autosomal dominant
Hundreds of adenomatous polyps in early adulthood
Malignant transformation by age 50
What causes pseudomembranous colitis
Overgrowth of clostridium difficile
Most occurs following antibiotic use
Treatment is oral Metronidazole
Complications of diverticular disease
Diverticulitis Abscess formation Fistula Bleeding Perforation
Features of anorectal abscesses
Constant throbbing pain
Discharge of pus per rectum
Rectal lump/nodule
What type of stoma has a spout
Ileostomy
What is an end colostomy and when is it used
End colostomy is required after abdomino-perineal resection of a low rectal or anal canal tumour.
It has a single opening.
Usually found in the left iliac fossa - contents will be solid.
What is a Hartman’s procedure and when is it used
Hartman’s procedure is done after emergency resection of rectosigmoid lesions
When primary anastomosis is unfavourable.
The diseased segment is resected, the proximal end of bowel is made into an end colostomy.
The distal segment of bowel / rectal stump, is oversewn to remain closed.
Secretions from the rectal stump still pass through the anus.
Later once inflammation settled the two ends are rejoined.
How can you tell the difference between Hartman’s procedure and an AP resection
Digital rectal examination - AP. procedure leave no rectum
What is an end Ileostomy and when is it used
End ileostomy is an end stoma using distal ileum.
Often created after resection of the colon and rectum, e.g for IBD.
Ileostomies usually found in RIF
Contents will be liquid.
Once outside abdominal wall - small bowel is everted to create a spout to protect the abdominal wall skin from the irritation.
What is a defunctioning ileostomy and why is it used
Defunctioning ileostomy is a temporary stomas created to protect distal anastomosis at risk of leakage or breakdown.
Allows bowel time to rest.
Commonly used in difficult low rectal anastomoses and in emergency resections.
Reversal of the temporary stoma at about 3-4 months.
What is a loop stoma and when is it used
Temporary stomas are usually loop stomas.
E.g. Defunctioning stomas
A loop of bowel is brought to the surface.
The loop is supported by a ‘bridge’ beneath it (between bowel and skin) to prevent the loop slipping back in.
The bridge is removed after a few days once wound healed.
Bowel wall is partially cut to create two openings: an afferent limb and an efferent limb.
The afferent limb leads to the functioning part of the bowel and allows stool and gas to pass out.
The efferent limb leads into the non-functioning part of bowel and secretes mucus. This is the mucous stoma.
What is a urostomy and when is it used?
Urostomies are used for diversion of the urinary system.
Used for bladder cancers, urinary incontinence not anemable to other treatments, and neuropathic bladders.
Requires an ileal conduit = a segment of ileum open at 1 end + closed at the other.
Ureters are implanted into this.
The open end is used to create a spout similar to an ileostomy
It allows urine collection in a stoma bag.
Classic presentation of acute pancreatitis
Epigastric pain
Radiating to the back
Hx of gallstones, alcohol
Causes of raised serum amylase in an acute abdomen
Acute pancreatitis
Perforation
Cholecystitis
What is murphy’s sign
Place hand on RUQ and ask patient to breathe in. Causes pain as gallbladder contacts hand. –> arrest of inspiration.
Repeat on LUQ.
+ve = pain on RUQ palpation and not on L.
Indicates acute cholecystitis
Presentation of small bowel obstruction
Early onset vomiting - bilious not faceculant
Late onset distension
Abdominal pain - colicky
Presentation of large bowel obstruction
Early onset distension
Late onset vomiting - faeculant
Abdominal pain - colicky
Presentation of a duodenal ulcer
Epigastic pain relieved by eating or milk
Worse at night
Presentation of a gastric ulcer
Epigastric pain worse on eating
RF for duodenal ulceration
H. Pylori
Chronic NSAID use
Classic presentation of appendicitis
Central colicky abdominal pain
Shifts to RIF once peritoneum inflamed
Rebound tenderness
Is it crohn’s or UC that is transmural
Crohn’s
Crohn’s can occur anywhere from mouth to anus but which area does it favour
Terminal ileum
Surgical repair of a AAA is indicated at what diameter?
> 5.5cm
Presentation of gastric carcinoma
Persistent dyspepsia Mass above L clavicle Weight loss Fatigue (anaemia) Ascites if advanced
Right sided colon cancers (caecum / ascending colon) commonly present with…
Weight loss
Anaemia
RIF mass
Left sided colon cancers (sigmoid / rectum) commonly present with…
Change in bowel habit
PR bleeding
In a patient >40yo presenting with features of acute appendicitis it is important to consider the diagnosis of….
Caecal carcinoma
Features of a pancreatic pseudocyst
Abdominal discomfort
Nausea
Early satiety
Usually due to acute or chronic pancreatitis
Causes of a hard liver edge
Liver metastasis
Hepatocellular carcinoma
Conditions causing macronodular cirrhosis (Viral hepatitis B or C. Wilson’s disease. Alpha-1-antitrypsin deficiency)
Presentation of haemochromatosis
Lethargy Arthralgia Features of chronic liver disease Bronze diabetes (Dilated cardiomyopathy)
Classical patient with haemochromatosis
Male
Middle aged
Inheritance of haemochromatosis
Type 1 = autosomal recessive
Mutation of HFE gene
Disorder of iron metabolism
Signs of chronic liver disease
Spider naevi Gynaecomastia Testicular atrophy Clubbing Leuconychia Dupuytrens contracture Palmar erythema Parotid enlargement
What is a green-ish brown ring at the corneo-scleral junction best seen with a slit lamp called. And when does it occur
Kaiser-fleischer ring
Pathognomonic of Wilson’s disease
Management of Wilson’s disease
Long term penicillamine
Copper-chelating agent
When is alkaline phosphatase raised
Biliary tract diseases
When is serum bilirubin raised
Hepatic and post hepatic disease
When are alanine transaminase and aspartate transaminase raised
Hepatocellular disease
When is alkaline phosphatase raised
Biliary tract diseases
When is serum bilirubin raised
Hepatic and post hepatic disease
When are alanine transaminase and aspartate transaminase raised
Hepatocellular disease
Features of crigler-Najjar syndrome
Congenital hyperbillirubinaemia
Unconjugated jaundice
Causes severe brain damage in early years
Intermittent RUQ pain exacerbated by fatty foods is likely to be due to…
Biliary tract obstruction
Commonly due to gallstones
Diagnostic test for Wilson’s disease
Ceruloplasmin level (low)
Diagnostic test for hereditary haemochromatosis
Raised ferritin
Reduced total iron binding capacity
What antibody is commonly found in primary biliary cirrhosis?
Antimitochondrial antibody
Diagnostic tests for primary biliary cirrhosis
+ve for anti-mitochondrial antibody
Hepatic USS
ERCP
Management of primary biliary cirrhosis
Symptomatic relief
Cholestyramine to treat pruritus
ursodeoxycholic acid for ascites and jaundice
Liver transplant (or death within 2 years of jaundice onset)
What may precipitate episodes of carcinoid syndrome
Stress
Caffeine
Alcohol
Management of proctitis in UC
Steroid foam enema
Mesalazine suppositories
Management of UC
- Aminosalicylates: - Mesalazine (= 1st line for induction + maintenance of remission in mild cases - topical then oral), olsalazine, balsalazide, sulfasalazine (more SE)
- Corticosteroids: induce remission in relapses. No role in maintenance. Topical - suppository, liquid, foam enema. Oral or iv.
- Thiopurines: - Azathioprine (if intolerant of steroids).
- Ciclosporin: salvage therapy - severe refractory colitis.
- Infliximab: effective in inducing remission in refractory to conventional treatment
- Stool bulking agents: - distal transit is rapid but proximal transit is slowed –> proximal constipation.
Causes of pancreatitis
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion / snake
Hyperlipidaemia / hypercalcaemia / hypothyroidism
ERCP / embolism
Drugs (azathioprine, steroids, Thiazide diuretic, COCP)
Pregnancy
What causes pain in pancreatitis
Autodigestion of the pancreas by trypsin.
Fat necrosis by lipases
Presentation of acute pancreatitis
Acute onset epigastric pain Radiates to the back Severe and constant Relieved by sitting forwards Nausea and vomiting Fever \+/- Shock \+/- Peritionitis
Intermittent RUQ pain exacerbated by fatty foods is likely to be due to…
Biliary tract obstruction
Commonly due to gallstones
What x-ray feature may suggest acute pancreatitis
Sentinel loop of small bowel on a-Xr
Due to localised ileus
Symptoms of irritable bowel syndrome
Abdominal pain - relieved by defection
Bloating
Change in bowel habit
(Diagnosis of exclusion)
What are gallstones made of
<10%-pure pigment (Bilirubin breakdown products)
75% - Cholesterol
15% - Mixed
What percent of gallstones are radiopaque
10%
Predisposing factors to gallstone formation
Female obesity Haemolytic anaemia Hyperlipidaemia Crohn's (Lithogenic bike - innate tendency to form stones)
Complications of gallstones
Chronic cholecystitis Biliary colic Acute cholecystitis (empyema/biliary peritonitis/abscess) Mucocele Gallbladder carcinoma Obstruction of the common bile duct --> jaundice Cholangitis Pancreatitis Gallstone ileus
Features of mesenteric ischaemia
Severe central abdominal pain that occurs soon after eating
Causes of pre-hepatic jaundice
Increased bile production- Haemolysis
- hereditary spherocytosis
- haemolytic transfusion reactions
- thalassaemia
- pernicious anaemia
Gilbert’s syndrome (underactive conjugating enzyme)
Crigler-Najjar syndrome (rare autosomal recessive disorder of bilirubin metabolism)
Features of peutz-jeghers syndrome
Multiple blue-black Freckles around the lips nose oral mucosa and fingers.
GI hamartomatous polyps (benign)
Polyps predispose to GI bleeding and intussusception
Syx of diverticulitis
Central domino pain, localises to LIF Vomiting Diarrhoea Fever Local guarding Leucocytosis Risk of perforation or fistula formation
Hepatic causes of jaundice
- Viral hepatitis - A / B / leptospirosis / brucellosis / Coxiella burnetii/ glandular fever
- Alcoholic hepatitis.
- Autoimmune hepatitis
- Drug-induced hepatitis: paracetamol, rifampicin, isoniazid, allopurinol, amitryptilline, amiodarone, phenytoin
- Hepatotoxic chemicals: phosphorous, carbon tetrachloride, phenol.
- Decompensated cirrhosis.
Is hepatic jaundice Unconjugated or conjugated
Mixed
What is the mechanism behind hepatic jaundice?
Impaired bile conjugation and excretion
Isolated hyperbilirubinaemia in an asymptomatic patient indicates what
Gilbert’s syndrome
What is achalasia
+ features
Progressive failure of relaxation of the lower oesophagus. Degeneration of the ganglia.
Dilated, tortuous, hypertrophy of the oesophagus.
Barium swallow shows a dilated tapering oesophagus
What is Zollinger-Ellison syndrome
Peptic ulceration secondary to gastric secreting adenoma (gastrinoma) in pancreas, stomach or small bowel.
What is glossitis + what causes it
Smooth, red, swollen, painful tongue
Iron deficiency
Folate deficiency
B12 deficiency
What is a meckels diverticulum
Embryological remnant
Variable length
Usually ~5cm from the ileo-caecal valve
Symptoms of a meckels diverticulum
Asymptomatic Haemorrhage Intestinal obstruction Diverticulitis Perforation
What is diverticulosis
Presence of diverticulae
Without symptoms
What is Diverticular disease
diverticula with symptoms
E.g. Haemorrhage / infection / fistulae
What is Diverticulitis
Evidence of diverticular inflammation
Lower quadrant pain h
- fever, tachycardia
Management of rectal prolapse
If partial - excise redundant prolapsed mucosa If complete (involves muscle) - surgical lifting of prolapse. E.g. De lormes procedure
What is goodsalls rule?
Anterior anal fistulae track directly into the anal track - straight line.
Posterior anal fistulae track around and open in the posterior midline = curved line
Managment of an anal fistula
If not through the puborectalis muscle - lay open the fistula track.
If it goes through the puborectalis muscle you shouldn’t lay it open as this damages the muscle + causes incontinence - insert a seton (non absorbable) and tie - gradually cuts through the muscle and allows it to heal by scarring
What is chaga’s disease + it’s symptoms
Parasitic disease from S America.
Skin nodule @ site of inoculation
Fever, anorexia, lymphadenopathy
Long time later - dysphagia + cardiomyopathy
Where and what age are diverticula most common
Descending and sigmoid colon
Elderly.
Rare before 40
Long term complications post gastrectomy
Gastrectomy syndrome - rapid gastric emptying
B12 deficiency
Iron deficiency
Osteoporosis (reduced calcium absorption)
Investigation of blood in stool
digital rectal examination Proctoscopy / sigmoidoscopy FBC Clotting studies LFTs if liver disease is suspected Colonoscopy
When to refer suspected bowel cancer
2 week wait for:
- Rectal bleeding plus change of bowel habit for six weeks and are aged 40 years or older.
- Palpable rectal or right-sided lower abdominal mass.
- Iron-deficiency anaemia without any obvious cause
Refer patients aged over 60 under 2 week rule if:
- Rectal bleeding without anal symptoms for six weeks.
- Change in bowel habit for six weeks without rectal bleeding.
