GI Flashcards
1
Q
Causes of small bowel obstruction
A
Adhesions
Hernias
2
Q
Causes of large bowel obstruction
A
Colon ca
Constipation
Diverticular stricture
Volvulus
3
Q
Features of small intestines on X-ray
A
Around 2.5cm (vertebrae height)
Central
Multiple loops
Valvuli coniventers (across the lumen)
4
Q
Large intestine features on X-ray
A
Larger calibrate around 6cm
Peripheral
Semi- lunar folds (haustra)
5
Q
Upper GI bleeding causes
A
Peptic ulcers
Mallory-Weiss tear
oesophageal varices
drugs (NSAIDs, aspirin, steroids, thrombolytics, anticoagulation)
6
Q
Rockall risk score pre endoscopy
A
Age 0pt: <60yrs, 1pt: 60-79 2pts: 80+
Shock (systolic&pulse) 0pts: >100&<100 1pt: >100 both, 2pts: <100 systolic
Co-morbidity 0pts: nil, 1pt: heart failure, IHD, 2pts: renal/liver failure, 3pts: mets
7
Q
Rockall score post-endoscopy
A
Diagnosis 0pts: Mallory-Weiss tear/ no lesion/ no recent bleed, 1pt: all other, 2pts: GI malignancy
Recent haemorrhage signs: 0pts: none/dark red spots, 2pts: blood/ adherent clot/ visible vessel
8
Q
Varices: high risk of re-bleeds features
A
- active arterial bleed
- visible vessel
- adherent clot/black clots
9
Q
Child- Pugh score, what is it for?
A
Progression of liver cirrhosis
10
Q
Child- Pugh score
A
1pt. 2pts. 3pts. Bilirubin <34. 34-51. >51 Albumin. >35 28-35. <28 Prothrombin time inc (s) 1-3. 4-6. >6 Ascites. -- Slight. Moderate Encephalopathy (Grade) -- 1-2. 3-4
11
Q
Haemorrhaging shock classification
A
Blood loss (%loss)
Class I <15%
Class II 15-30%
Class III 30-40%
Class IV >40%
12
Q
Murphy’s sign
A
Acute cholecystitis
RUQ Compression on inspiration
Positive if painful
13
Q
Boas’ sign
A
Acute cholecystitis
Pain in the tip of r. scapula
Hyperaesthesia
14
Q
Grey-Turner’s sign
A
Acute pancreatitis
Bruising/discolouration
Flanks
15
Q
Cullen’s sign
A
Acute pancreatitis
Bruising/discolouration
Around the umbilicus
16
Q
Rosvig’s sign
A
Acute appendicitis
LIF palpating -> RIF pain
17
Q
Signs of peritonitis
A
Rebound tenderness Rigidity Guarding Positive cough test Pain worse with any movement
18
Q
Antibiotics for suspected peritonitis
A
Metronidazole + cefuroxime
19
Q
Abdo trauma: investigation of choice
A
CT abdomen
20
Q
Abdo trauma: focused abdominal sonography for trauma (FAST), where does it look?
A
4Ps Morison's pouch Pouch of Douglas Perisplenic Pericardium
21
Q
Trousseau’s sign of latent tetany
A
Sign of hypocalcaemia (e.g. In malignancy)
BP cuff inflated to above pt’s systolic BP
Held for 3 mins
Brachial artery occluded
Hypocalcaemia induces neuromuscular irratibility causing muscle spasm
Wrist and MCP flexes
PIP and DIP joints extend
22
Q
GORD causes (4)
A
- lower sphincter dysfunction/ loss of peristalsis/ slow emptying
- hiatus hernia/ obesity/ overeating
- alcohol/ drugs (tricyclics, nitrates, anticholinergics)
- pregnancy
23
Q
GORD management
A
OTC: antacids, alginates, H2 antagonists
PPI
Metoclopramide (decreases muscle tone and helps with gastric emptying)
Surgery to increase resting muscle tone
24
Q
Barrett’s oesophagus cell change
A
Stratified squamous cell to simple columnar metaplasia
25
Barrett's oesophagus: what criteria is used
Barrett's oesophagus: what criteria is used
26
Prague criteria: what is it for?
Barrett's oesophagous
27
Prague criteria outline
Locate gastro-oesophageal junction
Circumfermental metaplasia distance
Maximal extend metaplasia distance
28
Barrett's oesophagous management
```
PPI
Metoclopramide
Annual surveillace (low grade changes)
Resection of high grade changes
Others: ablation
```
29
Achalasia: define
- oesophageal motility disorder
- failure of the lower sphincter relaxation
- leads to oesophageal dilatation and uncoordinated peristalsis
30
Achalasia: what does it involve?
degeneration of myenteric plexus
31
Achalasia treatment
balloon dilatation
surgical myotomy
botulin toxin injection
32
Diffuse oesophageal spasm features
intermittent motility disorder
| symptoms with hot or cold food
33
Los Angeles classification: what is it for?
GORD
34
What classification is used for GORD?
Los Angeles classification
35
Los Angeles classification outline
1. Max 1 mucosal break <5mm long not exceeding over <2 mucosal fold tops
2. Mucosal break > 5mm, <2mucosal fold tops
3. Mucosal break over 2 mucosal tops
3. Break over >75% of the circumference
36
Sliding hiatus hernia define
Hernia through the diaphragmatic hiatus with the gastro-oesophageal junction in the chest cavity
37
Rolling hiatus hernia
Stomach herniation anteriorly
Cardiac in normal position
Sphincter intact- no GORD symptoms
Can strangulate
38
Hiatus hernia management
Surgery if pts get obstructive symptoms or have reduced lung capacity
NG tube for emergency decompression
39
Oesophageal perforation cause
Iatrogenic (50%)
| Spontaneous from vomiting
40
Oesophageal perforation consequences
```
Shock, cyanosis, sepsis
Pneumothorax
Pleural effusion
Medinastitis
Peritonitis
```
41
Suspected oesophageal perforation investigations
erect CXR
| CT +/- contrast swallow
42
Oesophageal perforation management
```
oesophagogastric centre transfer
cervical: NBM + IV fluids + Abx
Thoracic: as above + stent or surgical repair
- drainage
- anti-fungals
- jejunostomy feeding
```
43
Peptic ulcer: define
ulcers to columnar mucosa in the lower oeasophagus, stomach, duodenum or small bowel.
Usually die to action of acid
Include gastric and duodeneal ulcers
44
Duodenal ulcer: the usual location
1st part of duodenum
| 50% on the anterior wall
45
Duodenal ulcer: endangered artery
gastroduodenal artery
46
Gastric ulcer: usual location
lesser curvature (distal half)
47
Gastric ulcer: endangered arteries
splenic
| Right and left gastric
48
Duodenal ulcer: malignant potential?
Rarely
49
Gastric ulcer: malignant potential?
Yes
50
Duodenal ulcers: course
Acute or chrnoic
51
Gastric ulcer: course
Always chronic
52
Peptic ulcer: causes
```
H. pylori
NSAIDs
Smoking
Hyperparathyrodism
Blood group O
```
53
How does H.pylori cause ulcers?
H.pylori sits in gastric mucosa
- > gastritis
- > G cell stimulaition
- > increased acid secretion
- > gastric metaplasia
54
How do NSAIDs cause ulcers?
NSAIDs inhibit prostaglandin secretion
by inhibiting cyclo-oxygenase
Prostaglandins are involved in mucus and bicarbonate production
-> protective mechanisms are reduced
55
How does hyperparathyrodism cause ulcers?
increased Calcium levels
| -> acid secretion stimulated
56
Clinical features of gastric ulcers
pain when eating
| reduced by vomiting
57
Clinical features of duodenal ulcers
pain when hungry
| reduced by food, antacids, milk and vomiting
58
Suspecteed peptic ulcer investigations
Endoscopy + biopsy (to exclude malignancy)
H.pylori testing
- CLO test
59
Explain H.pylori testing
Biopsy sample placed urea
Ammonia released by H.pylori
-> colour change
60
Peptic ulcer medical management
Diet (alcohol, smoking, avoid NSAIDs)
PPI- omeprazole 20mg
H2 blockers- renitidine
H.pylori eradication if positive
61
H. pylori eradication
PPI
Metronidazole
Clarithromycin
62
Peptic ulcer surgical management
endoscopic dilatation
| pyloroplasty +/- vagotomy
63
Zollinger-Ellison syndrome cause
gastin-secreating tumour (gastroma)
| - usually intra-pancreatic or stomach/duodenum
64
Zollinger- Ellison syndrome has association to what other syndrome ?
MEN syndrome (multiple endocrine neoplasia)
65
Zollinger-Ellison syndrome symptoms
Diarrhoea- caused by increased levels of acid in intestine
Steatorrhoea- inactivation of lipase by acid
Ulcer symptoms
66
Zollinger-Ellison diagnosis and investigation
problematic diagnosis
- unusal ulcer sites at young age
- persistent ulcers
Serum gastrin levels
CT/MRI to localise tumour
67
Zollinger- Ellison syndrome manaement
Tumour excision
| PPI
68
Peptic ulcer: perforation normally associated with which ulcer?
Duodenal
| Perforations are rare with peptic ulcers
69
Ulcer perforation: clinical features
```
Epigastric and shoulder tip pain
Peritonitis (pale, shocked, peripheral shut down)
Appendicitis features (stomach contents in the r. paracolic gutter)
```
70
Ulcer perforation investigations and diagnosis
Erect CXR -> pneumoperitoneum
Amylase -> moderate hyperamylasaemia
Contrast meal/CT if diagnosis uncertain
71
Ulcer perforation initial management
Peritonitis: ABCDE, oxygen, IV fluids, Abx, NG tube
Opiate analgesia
IV PPI
72
Duodenal ulcer perforation: surgical management
sutured close with omental patch
| consider gastrotomy
73
Gastric ulcer perforation: surgical management
sutured close with omental patch (prepyloric)
local excision (body)
15% will be malignant
-> gastric resection if biopsy positive
74
Gallstones: pathophysiology
result of imbalance of the constituents of bile
| e.g. inability to keep cholesterol in the micellar form in GB
75
Gallstones complications in the GB and cystic duct (6)
```
Biliary colic
Cholecystitis
Mucocoele
Empyema
Carcinoma
Mizzi's syndrome (GS impacted in the cystic duct -> compression of th CBD -> obstructive jaundice)
```
76
Mizzi's syndrome
GS impacted in the cystic duct
- > compression of th CBD
- > obstructive jaundice
77
Gallstones complications in the bile duct (3)
obstructive jaundice
cholangitis
pancreatitis
78
Gallstones complications in the gut (1)
Gallstone ileus
- > GS errodes through the GB into duodenum
- > terminal ileum obstruction
- > duodenal obstruction (Bouveret's syndrome)
79
Bouveret's syndrome
Duodenal obstruction caused by GS eroding though thr GB and into duodenum
80
Acute cystitis definition
inflammation of the gallbladder caused by a stone impaction in the neck of GB
81
Acute cystitis features
pain (r. hypochondrial) and fever
Murphy's sign
phlegmon (RUQ mass of inflammed omentum)
82
Acute cystitis natural progression
Resolves within 4-5d normally
| can progress to gangrene/ empyema
83
Acute cystitis management
cholecystectomy
| percutaneous drainage if unfit for surgery
84
Biliary colic definition
Intermittent pain caused by transient obstruction of GB from an impacted stone
without inflammation
85
Biliary colic complication
Acute cholecystitis
86
Bile production
Bile-acid dependent component (bile acids and pigments)
- hepatocytes
- kupffer cells (Hb breakdown to heme and globin. Heme broken into bilirubin, conjugated to glucoronic acid and secreted into bile)
Bile acid independent component
- alkaine juice from duct cells
87
What do micelles contain
anaphilatic bile salts
| Anaphobic: cholesterol, phospholipids, bile pigments
88
Flow of bile
```
bile secreted into canicli
reach terminal duct
leave the liver via the transverse fissure
left and right hepatic ducts merge
common hepatic duct
->GB
```
89
Obstructive jaundice cause
stone blocking CBD
| cholangiocarcinoma
90
Courvoisier's law
palpable GB + jaundice
- > cause is unlikely to be a stone
- > suggestive of malignancy
91
Ascending cholangitis definition
Bile duct infection
Caused by obstructed bile flow
-> increased pressure
allows for bacterial contamination and bacteraemia
92
Ascending cholangitis features
Charcot's triad
| RUQ pain, fever and jaundice
93
Charcot's triad: what does it suggest and what features are present?
Ascending cholangitis
RUQ pain, fever and jaundice
94
Acute pancreatitis causes
```
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Sphincter Oddi dysfunction/scorpion bites
Hypercalcaemia/lipidaemia
ERCP
Drugs
```
95
Drugs which can cause acute pancreatitis
```
Azathioprine/mercaptopurine
Corticosteroids
Erythromycin/ trimethoprim / tetracycline
Frusemide
Isonizid
Metformin
Opoids
Sitagliptin
```
96
Acute pancreatitis: clinical features
```
epigastric pain -> back
relieved by sitting forward
guarding & tenderness
Grey-turner's sign (l. flank ecchynosis)
Cullen's sign (periumbilical ecchynosis)
```
97
Grey-turner's sign
Acute pancreatitis sign
| L. flant ecchynosis
98
Cullen's sing
Acute pancreatitis sign
| Periumbilical ecchynosis
99
Acute pancreatitis investigations
Amylase (>1000 U or 3x upper limit of normal)- not always raised
Lipase
Alk. phos- raised suggests gallstone
CT (contrast- enhanced) -> oedema (necrosis)
AXB: absent psoas sign, colon cut-off sign, gallsotne or pancreatic calcification
USS (within 48h)- to identify a stone
100
Acute pancreatitis management
```
Morphine
Fluids (large amounts)
NBM
Nutritional support (enternal not TPN)
ERCP
```
101
Acute pancreatitis complications
```
Pancreatic necrosis
pseudocyst
abscess
progressive jaundice
GI bleeding
GI ischaemia/fistula
```
102
Chronic pancreatitis definition
chronic inflammatory condition of the pancreas characterized by fibrosis and exocrine pancreatic dysfunction
103
Chronic pancreatitis causes
Alcohol
smoking
rarely hereditary
104
Chronic pancreatitis pathophysiology
viscid pancreatic juice causes protein plugs in ducts
- > calcification -> stones
- > impaired pancreatic juice flow
- > inflammation and stricture formation
- > replacement of normal tissue by fibrous tissue
- > loss of acinar tissue -> steatorrhoea
- > loss of islet tissue -> DM
105
Chronic pancreatitis clinical features
```
epigastric pain -> back (relieved by leaning forward)
avoidance of fatty foods
heat brings pain relief
steatorrhoea
DM
```
106
Chronic pancreatitis diagnosis and investigations
CT: speckled calcification +/- inflammatory changes +/- pseudocyst
MRCP: pancreatic duct stricture
Random blood glucose for monitoring
Fecal fat excretion measurement
107
Chronic pancreatitis management
```
abstinence from alcohol
non-opiate analgesia
creon (pancreatic exocrine supplement)
endoscopic: stent
surgery to relieve pain and compression
- drainage and roux limb of jejunum
```
108
Appendix location
posterio-medial wall of cecum
2cm below ileocaecal valve
at McBurney's point (1/3 along a line drawn between the right anterior superior iliac spine and the umbilicus)
109
McBurney's point location
1/3 along a line drawn between the right anterior superior iliac spine and the umbilicus
110
What's inside the appendix?
Lymphoid follicles in the submucosa
abundant in children
atrophy with age
111
Appendicitis: clinical features
Generalised pain -> localises to McBurney's point
Rovsing's sign
Psoas stretch sign
112
What causes pain in acute appendicitis to localise to McBurney's point?
Inflammation of the parietal peritoneum
113
Rovsing's sign
Acute Appendicitis
| LIF palpation causes pain in the RIF
114
Psoas stretch sign
Acute Appendicitis
| painful hip flexion
115
Acute appendicitis managemen
appendicectomy
IV fluids
Abx (metronidazole)
116
Meckel's diverticulum
```
2% of the population
2 inches (5cm) long
2 feet (60cm) from ileocecal valve
2/3 have ectopic tissue
- 2 types of ectopic tissue: gastric or pancreatic
2% become symptomatic
```
117
Colovesicular fistula: define
fistula between the colon and the bladder
118
Colovesicular fistula: common cause
diverticular disease complication
119
Colovesicular fistula: symptoms
dysuria
cloudy urine
bubbling on mictuition
120
Colovesicular fistula: diagnosis
barium enema
| cystoscopy
121
Colovesicular fistula: management
resection of the affected colon region and bladder repair
122
Bowel ischaemia: cause
atheroma at the origin of the inferior mesenteric artery
| leads to gangrene and perforation
123
Bowel ischaemia: clinical features
General: abdo pain, nausea, vomitting
| red currant jelly bloody diarrhoea
124
Angiodysplasia in the colon: define
anteriovenous malformations
| lead to bleeding
125
Angiodysplasia: diagnosis
Colonoscopy by visualising a bleeding point
| Angiography
126
Angiodysplasia: management
angiographic embolisation
injection sclerotherapy
emergency laparotomy
127
Diverculosis: define
presence of divericula in the colon
128
Diverticular disease: define
symptomatic diverticula
129
Diverculitis: define
inflammation of a diverticulum
130
Diverticular disease: common location and reason
sigmoid
high intramural pressure
rectum normally spared
131
Diverticular disease: reason for rectal sparing
different arrangement of blood vessels
| outer longitudinal smooth muscle encompasses the full circumference of the rectum
132
Diverticular disease: clinical features
```
general: abdo pain, nausea
fever, loose stools -> acute diverticulisis
bleeding pr (dark red clotted blood)
```
133
Diverticular disease complications
- diverticulitis
- pericolic/paracolic abscess
- perforation/peritonitis
- fistula
- strictures
134
Diverticular disease management
diet high in fibre
antispasmodics
laxatives
resection if persistent symptoms
135
Volvulus common location
sigmoid (around sigmoid mesentery)
136
Caecum volvulus
around the SMA in anticlockwise direction
| rare
137
Volvulus management
decompression with sigmoidoscopy
138
Familial Adematous Polyposis (FAP) mutation and consequences
APC gene mutation (chromosome 5)
Wnt signalling pathway
-> 90% chance of developing adenocarcinoma by the 3rd-4th decade
139
FAP management
surgical prophylaxis- colon excision
140
FAP extra-colonic features
- gastric fundus polyps
| - antral and duodenal adenomas
141
Adenomatous polyps, what conditions are they found in?
usually sporadic
FAP
HNPCC (hereditary non polyposis colorectal cancer) AKA Lynch syndrome
142
Adenomatous polyps: features
caused by XS growth of colorectal epithelium
| precursor for colonic cancer
143
Juvenile polyposis syndrome: type of polyps and description
hamartomatous polyps
| excesive amounts of the normal architectural components
144
Juvenile polyposis syndrome: inheritance pattern
autosomal dominant
145
Juvenile polyposis syndrome: consequences
50% lifetime risk of colorectal ca
146
Juvenile polyposis syndrome: management
surveillance
| prophylactic surgery
147
Peutz-Jaghers syndrome: mutation and inheritence pattern
```
autosomal dominant
LKB1 gene (chromosome 19)
```
148
Peutz-Jaghers syndrome: manifestations
GI polyps
- commonly in jejunum
- hamartomas (XS growth of normal architectual components)
Melanin pigmentation at mucocutaneous junctions (eyes and mouth)
149
Peutz-Jaghers syndrome: consequences
increased risk of cancer of:
- colorectal
- gastric
- pancreatic
- breast
- ovarian
150
Peutz-Jaghers syndrome: symptoms
```
dark brown/blue spots on the lips/ inside of the mouth
abdo pain
obstruction (interssusception)
rectal bleeding
iron deficiency anaemia
```
151
Important to consider what, in AF patients with abdo pain?
mesenteric ischaemia
152
Mesenteric ischaemia: vessel commonly affected?
superior mesenteric artery -> small bowel
153
Mesenteric ischaemia: causes
thrombotic
embolic
non-occlusive in low flow states
other: trauma, strangulation (volvulus or hernia)
154
Mesenteric ischaemia: classical triad
acute severe abdo pain
no abdo signs
rapid hypovolaemia -> shock
155
Mesenteric ischaemia: tests
increased Hb (due to plasma loss)
increased WCC
modestly increased amylase
156
Haemorrhoids define
excessive amounts of the normal endoanal cushions
| comprise anorectal mucosa, submucosal tissue and submucosal blood vessels
157
Haemorrhoids pathophysiology
degeneration of fibro-elastic tissue and smooth muscle
158
Haemorrhoids: predisposing features
constipation
chronic straining
obesity
pregnancy (increased connective tissue laxity)
159
Internal haemorrhoids definition
confined to the tissue of the upper anal canal
160
Haemorrhoids clinical features
- bleeding pr- bright red on wiping
- prolapse
- irritation features (pruritis, mucus, discharge, perianal discomfort)
161
Haemorrhoids investigations
DRE to exclude other conditions
Rigid sigmoidoscopy/proctoscopy -> diagnosis
Flexible sigmoidoscopy/colonoscopy (atypical features, >55y.o ?cause)
162
Haemorrhoids: management based on degree
1st/ thrombosed piles: medical: consitipation aoidance, bulking laxitives, high fibre diet or
2nd: banding, dilute penthol injections
3rd/4th: haemorrhoidectomy
163
Haemorrhoids stages (degrees)
1st: bleeding, visible on proctoscopy but don't prolapse
2nd: prolapse, spontaneous reduction
3rd: prolapse: manual reduction
4th: irreducibly prolapsed
164
Anorectal internal sphincter: muscle type , innervation and relaxants
```
smooth muscle (involuntary)
circular
pelvic autonomic supply
relaxants: nitic oxide donours (GTN) and calcium antagonists (diltazem)
```
165
Anorectal external sphincter: muscle type, innervation and relaxants
```
skeletal muscle (volountary)
-> blends with puborectalis
- surrounds the lower 2/3 anal canal
pudendal nerve supply (S2, 3, 4)
relaxants: botulin toxin
```
166
Anorectal canal: arterial supply
above pectinate line: superior rectal a. (IMA branch)
below pectinate line: inferior rectal a. (internal pudental branch)
both anastimose with middle rectal a.
167
Anorectal canal: venous drainage
above pectinate line: superior rectal v. -> inferior mesenteric v.
below pectinate line: inferior rectal v. -> inferior pudental v.
168
Anorectal canal: nerve supply
above pectinate line: inferior hypogastric plexus (visceral inn.)
below pectinate line: anferior anal n (pudental nerve branch- somatic)
169
Anorectal canal: lymphatics
above pectinate line: internal iliac l.n.
| below pectinate line: superficial inguinal l.n.
170
Fistula-in-ano: define
an abnormal connection between two epithelial surfaces
| to perianal or vaginal skin
171
Fistula-in-ano: pathophysiology
sepsis in an anal gland abscess pushes through
172
Fistula-in-ano: clinical features
perianal 'pressure' sensation
| chronic perianal discharge (seropurulent via punctum)
173
Fistula-in-ano: investigations
perineum and rectum investigation under anaesthesia
endoanal USS
MRI (most sensitive)
174
Fistula-in-ano: management
abx (symptomatic)
abscess drainage
seton suture -> allows drainage
fistulotomy to remove granulation tissue
175
Fissure-in-ano: define, location within canal and features
```
lineal anal ulcer
in the canal below the dentate line
usually the posterior wall
(anterior after childbirth)
little granulation tissue
-> fistula
```
176
Fissure-in-ano: clinical features
skin tags (sentinel pile) frequently present
outlet pr bleeding
DRE too painful when active
defecation avoidance -> overflow incontinence (children)
177
Fissure-in-ano: management
acute: self resolving
only treat chronic (>6wks)
stool softeners
diltiazem/nitrates for sphincter relaxation
botulin toxin
sphincterectomy (int. sphincter division)
-> anal incontinece risk
anal advancement flap or rotational flap to cover the fissue with well vascularised skin
178
Crohn's disease: pathological features
```
cobble stone appearance
- skip lesions
- oedematous islands
deep fissure ulcers
transmural inflammation
granulomas
mucosal thinckening -> fibrosis
```
179
Crohn's disease: definition
Inflammatory bowel disease
| chrnoic inflammatory non-caseating granulomatous disease affecting any part of the GI tract
180
Crohn's disease: peak incidence
teens
| early 20s
181
Crohn's disease: risk factors
smoking
| family history
182
Crohn's disease: clinical features
```
chronic disease with exacerbations
diarrhoea +/- mucus or blood
abdo pain
tenderness
tenesmus
malabsorption (vit B12)
```
children: failure to thrive
183
Crohn's disease: extra-interstitial manifestations
erythema nedosum
primary biliary cirrhosis
polyarthritis/ ankylosing spondylitis
chronic active hepatitis
184
Crohn's disease: investigations
```
anaemia
increased acute-phase proteins (inc. CRP, WCC)
barrium follow through
MRI w oral osmotcally active agents
sigmoidoscopy/colonoscopy
video capsule endoscopy
CT colonography
```
185
Crohn's disease: findings on barrium follow through
rose thown ulcers
terminal ileal strictures
mucosal thickening/ luminal narrowing
186
Crohn's disease: medical management
glucocorticosteroids or 5-ASA (induce remission)
azathioprine or mercaptopurine (adjunct to induce remission/ maintenance)
consider methotrexate/ infliximab
187
Crohn's disease: surgical management indications (4)
```
Acute/ emergency:
-> fulminant colitis, haemorrhage, obstruction
Subacute:
-> symptomatic reflief if medication fails
Chronic
-> ca prophylaxis, steroid dependency
Perianal disease
->abscess, fistula, anorectal stricture
```
188
UC: pathological features
```
columnar mucosal and submucosal inflammation
crypt abscess
-> architectural distortion
-> ulceration
goblet cell depletion
```
189
UC: definition
inflammatory bowel disease
chronic inflammatory condition affecting the columnal mucosa and submucosa of the rectum and extends proximally in continuity
occasional rectal sparing
190
UC: peak incidence
any age
| peaks in early adulthood and 60s
191
UC: association to smoking
smoking is protective
| first presentation around 6m after quitting is common
192
UC: clinical features
chronic condition with exacerbations
diarrhoea with blood and mucus
intermittent pyrexia
incapacitating fecal urgency and frequency
193
UC: rectal complications
thick mucosa
contact bleeding
loss of rectal mucosal vessels (sigmondoscopy)
194
UC: investigations
```
sigmoidoscopy/colonoscopy + biopsy for diagnosis
-> loss of haustra
anaemia
acute protein proteins (WCC, CRP)
AXR -> thumb-printing, rigler's sign
Barium enema -> lead pipe appearance
```
195
Thumbprinting on AXR suggests what?
mucosal thickening
| eg UC
196
Lead pipe appearance (barium enema) suggests what?
loss of haustra in UC
197
UC proctitis/colitis management
topical steroids/ 5- ASA
suppositories or enema
prednisolone PO if required
198
Pancolitis (severe UC) management
topical steroids/ 5- ASA (suppositories or enema)
systemic steroids/5-ASA
azathioprine/ mercaptropurine
cyclosporin (red. lymphocyte function) or infliximab
199
Acute severe colitis management
IV hydrocortisone 100mg QDS
IV cyclosporin
IC/PO metronidazole (if infective)
200
What is Rigler's sign (AXR) and what does it suggest?
perforation
| air on inside and outside of the wall
201
UC: surgery indications
- acute/chronic- not responsive to medical therapy
- recurrent exacerbations
- high-grade dysplasia or ca
202
Trousseau sign of malignancy
Thrombophelbitis migrans
| cancers associated with hypercoagulopathy (unknown mechanism)
203
Haematoma of rectus sheath: pathophysiology
spontaneous or traumatic
rupture of an inferior epigastric artery branch
(eldery on anticoags.)
204
Desmond tumour definition
arises from fibrous intramuscular septa in the lower rectus abdomnis
malignant potential (fibro sarcoma)
205
Desmont tumour management
wide excision
206
Hernia: define
abnormal protrusion of a viscous or its part though a weaknes in its containing wall
207
Reducible hernia: define
contents can be restored
208
Incarcerated hernia: define
part or all of the contents can't be reduced
| due to a narrow neck or adhesions
209
Strangulated hernia: define
blood supply affected
| usually caused by a tight neck of the peritoneal sac
210
Hernia perforation sequence
venous and lymphatic occlusion
- > oedema and increased venous pressure
- > impeding arterial flow
- > bowel necrosis and perforation
211
Inguinal hernia presentation
lump above inguinal ligmament
| +/- ache
212
Inguinal hernia investigations
USS
| +/- CT, MRI
213
```
Inguinal canal boarders:
anterior
posterior
roof
floor
```
anterior: aponeurosis of the external oblique
posterior: transversialis fascia (deep ring)
roof: tranverscialis fascia, transverscialis abdominis and internal oblique
floor: inguinal ligament and lacunar ligament (medially)
214
Hasselbach's triangle boarders
medial to inferior epigastric a
rectus sheath
inguinal ligament
215
What runs through the superficial ring?
Spermatic duct or round ligmant
216
Which hernias occur through the Hasselbach's triangle?
Direct inguinal hernia
217
Aetiology of indirect inguinal hernia
Congenital
| Patent processus vaginalis
218
Which of the inguinal hernias is more likely to strangulate and why?
Indirect hernia
| Narrow neck
219
Inguinal hernia management
Open/laparoscopic mesh repair
| herniotomy (infants)
220
What makes up rectus sheath?
appeneuroses of:
- external oblique
- internal oblique
- transversus abdominis
221
Arcuate line
arch of fibres in the abdominal wall
half way between the umbilicus and pubic symphysis
place where rectus sheath no longer contains rectus abdominis (above) and now lies superficial to it (below)
222
Pyramidalis: location
```
2nd vertical muscle in the abdominal wall
triangular muscle
anterior to rectus abdominis
at the base of the pubis
attached to linea alba
```
223
Abdominal wall nerve supply above the umbilicus
T7-9
224
Abdominal wall nerve supply around the umbilicus
T10
225
Abdominal wall nerve supply below the umbilicus
T11-12 & L1
226
Scrotum/ Labia majora nerve supply
L1 (illio-inguinal nerve)
227
Femoral hernia location
below inguinal ligmaent
lump inferior and lateral to pubic tubercle
via femoral canal (which is in the femoral triangle)
228
```
Femoral canal: location, contents and boarders
medial
lateral
anterior
posterior
```
```
Located within the femoral triangle
Contains deep inguinal lymph node
medial- lacunar lig
lateral- femoral v
anterior- inguinal lig
posterior- pectineal lig and pectineus muscle
```
229
```
Femoral triangle: contents and boarders
superior
lateral
medial
roof
base
```
Contains NAVEL (femoral nerve, artery, vein, empty space, lymph canal)
superior- inguinal lig
lateral- sartorius
medial: adductor longus (med. boarder)
roof: fascia lata
base: pectineus, illiopsoas and adductor longus
230
Femoral hernia management
all require repairing
-> hernia reduction and narrowing of the femoral cnal
approach above the inguinal lig (McEcedy approach)
Interrupted sutures
suture plication
mesh plug
231
True umbilical hernias: define and natural progression
congenital in infants
95% close by age of 3
if not excise sac and close the defect in the abdo fascia
232
Paraumbilical hernia: aetiology and natural progression
acquired weakness
obese multiparous women
enlarge in size -> thinning the skin as they do
233
Paraumbilical hernia: management
risk of strangulation
| -> laparoscopic mesh repair
234
Epigastric hernia: definition
defects in the linea alba between the xiphisternum and the umbilicus
235
Epigastric hernia: risk of hstrangulation and management
moderate risk of strangulation
| laparoscopic intraperitoneal mesh or non0absorbable sutures
236
Oesophageal carcinoma types and locations
squamous cell- upper 2/3
| adenocarcinoma- lower 1/2
237
Risk factors for oesophageal SCC
smoking
alcohol
diet (preserved food with nitrates and low in oxidants)
238
Risk factors for oesophageal adenocarcinoma
GORD
Barrett's
obesity
achalasia
239
clinical features of oesophageal carcinoma
progressive dysphagia
hoarseness (recurrent laryngeal nerve)
neck swelling (SVC obstruction)
Horner's syndrome (sympathetic chain)
240
Investigations for suspected oesophageal cancer
endoscopy + biopsy
USS for local invasion
CT/PET for mets
laparoscopy for peritoneal mets
cytology of enlarged lymph nodes (if positive surgical excision contraindicated)
barrium swallow if failed intubation or suspected post-cricoid ca
241
Indications for barrium swallow in oesophageal cancer
failed intubation
| suspected post-cricoid cancer
242
Oesophageal cancer: resection contraindications
positive cytology of lymph nodes
243
Potentially curative management of oesophageal cancer
neoadjuvant chemo
| resection or ablation
244
Palliative management of oesophageal cancer
```
for dysphagia:
-endoluminal self exdanding stenting
-external beam radiotheraphy
symptomatic mets:
-chemo
```
245
Oesophageal cancer prognosis
poor
<10% 5 year survival
due to late presentation
246
Dysphagia: red flags
progressive
weight loss
painful
neurological (acute to both fluids and solids or associated neurological symptoms)
247
Gastric adeocarcinoma risk factors
h. pylori
diet: pickled or salt preserved food
chronic gastritis
248
Gastric adenocarcinoma clinical features
dyspepsia (new onset in over 55yo)
trosier's sign/ enlarged Virchow's node
sister Joseph's nodule (periumbilical mass)
249
Gastric adenocarcinoma investigations
endoscopy + multiple (>6) biopsies of ulcer edge
CT for mets
EUS for invasion depth
Laparoscopy for peritoneal mets assessment
250
Gastric adenocarcinoma TNM (P/H) staging
T: 0- mucosa, 1- submucosa, 2- muscle, 3- serosal surface, 4- other organs
N: 0- no l.n., 1- <3cm from primary, 2- >3 cm
P: peritoneal mets
H: hepatic pets
251
Gastric adenocarcinoma management
neoadjuvant chemo
radical gastrectomy
post-op chemo
palliative chemo for disseminated diease in advanced ca
252
Gastric adenocarcinoma early disease definition and prognosis
no mets
| >90% 5-year survival
253
Gastric adenocarcinoma advanced disease definition and prognosis
T3 +, N2 +, P1+, H1+
| <25% 5-year survival
254
Gastric ca: Gastrointerstitial stromal tumours (GIST) aetiology
arise from pacemaker cells
usually submucosal
variable natural history
255
What type of gastric ca arises from pacemaker cells?
Gastrointerstitial stomal tumours (GIST)
256
Gastrointerstitial stromal tumours (GIST): management
small (2-5cm)- survaillence
| big (>5cm) or symptomatic - resect
257
Gastric ca: carcinoid tumour aetiology
nauroendocrine orginin
| malignant potential
258
What is carcinoid syndrome caused by?
serotonin overproduction
259
Gastric lymphoma: aetiology
many arise from MALT
commonest site of GI lymphomas
H.pylori association (eradication can cure it)
260
Gastric lymphoma: management
H.pylori eradication
| High grade -> chemo
261
Hepatocellular carcinoma risk factors
cirrhosis (2/3)
chronic viral hepatitis
alcohol
alfatoxin, contraceptives & androgens
262
Hepatocellular carcinoma origin
liver parenchymal cells
263
Hepatocellular carcinoma presentation
rapid deterioration of pre-exisiting cirrhosis
264
Hepatocellular carcinoma investigations
```
LFTs
alpha-fetoprotein (early detection in susceptible individuals)
USS
CT/MRI
needle aspiration (if not for resection)
```
265
Hepatocellular carcinoma management
curative (if no mets and technically possible)
- partial hepatectomy
- transplant
Palliative: embolisation
266
Hepatocellular carcinoma prognosis
45% 5-year survival if resectable
267
Cholangiocarcinoma origin
intra- or extra- hepatic billiary tree ducts
268
Cholangiocarcinoma risk factors
chronic parasitic infection
| cysts
269
Cholangiocarcinoma typical sites
distal CBD
common heptic duct
confluence of hepatic ducts (Klatskin tumour)
270
Cholangiocarcinoma clinical features
```
painless progressive jaundice
advanced:
-pruritis
-pain/cholangitis
-weight loss
-ascities
```
271
Cholangiocarcinoma investigations
USS
| CT/MRI
272
USS findings suggestive of Cholagiocarcinoma
intrahepatic duct dilatation
| collapsed gallbladder
273
Cholangiocarcinoma management
whipple operation
hepatic resection+roux limb of jejunum
palliation: stents
274
Metastatic liver disease: origin
```
colorectal
pancreas
stomach
breast
oesophagus
```
275
Metastatic liver disease: chances of mets elsewhere
90%
276
Metastatic liver disease: clinical features
```
hepatomegaly + tenderness
ascites
jaundice
cachexia
pyrexia (10%)
alk phos increased
```
277
Metastatic liver disease: investigations
```
alk phos increased
needle biopsy/ aspiration cytology
-> diagnostic confirmation
USS/CT
-> extend of disease
```
278
Metastatic liver disease: management
```
limited for advanced disease
liver resection
- must exclude extrahepatic involvement (CT chest/abdo/pelvis + colonoscopy)
chemotherapy
pre op portal embolisation
```
279
Pancreatic cancer types
ductal adenocarcinoma
| pancreatic neuroendocrine tumours (PET)
280
Pancreatic ductal adenocarcinoma: risk factors
```
smoking
age
high fat diet
DM
alcohol
chronic pancreatitis
family history
```
281
Pancreatic ductal adenocarcinoma: clinical features
```
obstructive jaundice (CBD obstruction)
pain (epigastric, LUQ -> back, vague)
hepatomegaly (mets)
acute pancreatitis
thrombophlebitis migrans (10%)
```
282
Thrombophlebitis migrans
vessel inflammation due to blood clot (thrombophlebitis)
recurrent or appearing in different locations over time
sign of malignancy
Trousseau sign of malignancy
283
Pancreatic ductal adenocarcinoma: investigations
serum CA19-9 (level correlates with ca volume)
abdo USS
doppler USS of portal vein and superior mesenteric vein
CT +/- FNB
ERCP +/- cytology
284
Pancreatic ductal adenocarcinoma: management
currative (5%)
- whipple's operation
- total/distal pancreatectomy
- adjuvant chemo
palliative
- jaundice (ERCP, stenting, percutaneous billiary drainage)
-duodenal obstruction (surgical gastric bypass)
-pain (oromorph, chemical ablation of the coeliac ganglioma)
285
Pancreatic ductal adenocarcinoma: palliative pain management
oromorph
| chemical ablation of the coeliac ganglioma
286
Pancreatic neuroendocrine tumours (PET): facts
rare
| usually malignant
287
Pancreatic neuroendocrine tumours (PET): cause
sporadic or autosomal dominant
MEN type 1 (multiple endocrine neoplasia)
von Hippel Lindau
neurofibromatosis type 1
288
Pancreatic neuroendocrine tumours (PET): clinical features
non-functional tumours: late diagnosis
| functional tumours: depending on the hormone produced
289
Small bowel tumours: types
adenocarcinoma
GIST (gastrointerstitial stromal tumours)
Lymphomas
Carcinoid tumours
rarely malignant
290
Small bowel adenocarcinoma: origin
mucosa
| pre-ampillary duodenum
291
Small bowel adenocarcinoma: associations
FAP
Peutz-Jegher's syndrome
Crohn's
untreated Coeliac disease
292
Small bowel adenocarcinoma: clinical features
present late often with mets
obstruction
recurrent abdo pain
GI bleeding
293
Small bowel adenocarcinoma: management
surgical resection
| palliative bypass
294
Small bowel cancer: what is GIST?
Gastro-interstitial stromal tumours
arise from the connective tissue of GI wall
-> mesenchymal tissue, mesentery (smooth muscle, fibroblasts, lipocytes)
295
GIST: tumour location
```
smooth muscle of gut
50% gut
20-30% small bowel
10% rectum
5% oesophagus
```
296
GIST: maligancy association
c-kit mutation
| tyrosine kinase inhibitos
297
Small bowel lymphoma: usual type
non Hodgkins B-lymphomas
298
Small bowel lymphoma: origin
MALT
| mucose associated lymphoid tissue
299
Small bowel lymphoma: associations
immune dysfunction conditions
300
Small bowel lymphoma: clinical features
colicky pain
obstruction signs
GI bleed
systemic symptoms
301
Small bowel lymphoma: management
```
depends on subtype and stage
H.pylori eradication (can be helpful)
resection
bone marrow transplant
chemo
```
302
Carcinoid tumours: origin
neuroendocrine tissue
| submucosal enterochromaffin cells
303
Carcinoid tumour: common locations (3)
appendix
Meckel's diverticulum
duodenum (rare)
304
Carcinoid tumour: associations
MEN type 1 syndrome
305
What is carcinoid syndrome?
present in 10% carcinoid tumours
paraneoplastic syndrome
symptoms and signs due to carcinoid tumours
- flushing, diarrhoea, bronchal constriction, restrictive cardiomyophathy and right sided valvular heart disease (-> HF)
Caused by serotonin and kallikrein secretion
306
Carcinoid syndrome diagnosis
24 hour urine lovels of 5-HIAA
307
Carcinoid tumour: clinical features
vague symptoms of pain and weight loss
| accidental finding
308
Carcinoid tumour: management (inc. carcinoid crisis and syndrome)
```
resect w/ wide margin excision if possible
IV octeotide - for crisis
somatostatin analogues- for synd.
inteferon alpha
chemo
biological agents
```
309
Small bowel tumours: investigations
CT chest/abdo -> primary identification, involvement assessment
CT angiography- vascular tumours, GISTS or tumouts located near major blood vessels
310
Colorectal cancer: commonest type
adenocarcinoma
311
Colorectal adenocarcinoma: histological features
mucinous
signet ring cell
anaplastic
312
Colorectal adenocarcinoma: predisposing factors
ingerited polyposis syndromes
family history
chronic Crohn's & UC
poor fruit and veg intake
313
Colorectal adenocarcinoma: common location
left side
| rectum
314
Colorectal adenocarcinoma: clinical features
```
rectal & sigmoid location
- bright PR blood
- bowel habit change
- tenesmus
right- sided
- iron deficiency anaemia
```
315
Colorectal adenocarcinoma: investigations
PR examination
rigid sigmoidoscopy/colonoscopy
CT +/- colonography
316
Colorectal adenocarcinoma: management
```
potentially curative
-surgical resection
- neoadjuvant chemo
- adjuvant chemo (LN involvement)
palliative Rx
- chemo (inc. life expectancy)
- endoluminal stenting (obstructions)
```
317
Colorectal adenocarcinoma: what is meant by potentially curative?
no ments
or mets curative by liver/lung resenction
technically resectable
318
Colorectal adenocarcinoma right or left sided: surgical management
hemicolectomy
319
Colorectal adenocarcinoma sigoid/rectum: surgical management
anterior resection
320
Colorectal adenocarcinoma lower rectum: surgical management
low anterior resection or
| adnomino-peritoneal resection
321
Colorectal adenocarcinoma: staging
```
Duke's
A- spread into muscularis propria
B- spread through full thickness bowel wall
C- lymph node involvement
D- distant mets
```
322
Oglive's syndrome
acute pseudo-obstruction (like mechanical obs. w/o cause)- > acute megacolon
seen in severely ill
323
Varices prophylaxis in liver cirrhosis
B-blockers (propanolol)
endoscopic banding ligation
tranjugular intrahepatic porto systemic shunt (TIPS)
324
Spontaneous bacterial peritonitis: associated conditions
commonly seen in patients with portal HTN and nephrotic syndrome
325
Ileocecal valve: what is it and what is it's function
sphincter muscle between small and large intestine
prevents reflux into small intestine
absorption site of B12 and bile acids
