GI Flashcards

1
Q

Define peritonitis

A

Inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein

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2
Q

Describe causes of peritonitis

A

Usually sterile, reacts to chemical and mechanical stimuli. Abdominal infection can be peritonitis (generalised infection) or intra-abdominal abscess (localised).
Infection usually after perforation of an organ, but can be due to foreign bodies, bile acids or stomach acid entering the space.

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3
Q

Define classifications of peritoneal infection

A
  • Primary: from haematogenous dissemination/bacteria across gut wall, usually in the setting of an immunocompromised state. Most often spontaneous bacterial peritonitis, seen mostly in patients with chronic liver disease
  • Secondary: related to a pathologic process in a visceral organ, such as perforation or trauma, including iatrogenic trauma. The most common form of peritonitis encountered in clinical practice
  • Tertiary: persistent or recurrent infection after adequate initial therapy. Often develops in the absence of the original visceral organ pathology. Usually immunocompromised individuals. TB peritonitis is a problem among HIV+ve individuals.
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4
Q

How is peritonitis diagnosed?

A

Usually clinical
Peritoneal lavage if non-conclusive signs/history not available
Need to find cause it secondary peritonitis (erect CXR for free gas, CT scan, amylase, lipase, bilirubin, ALP, lactate, ß-HCG, urinalysis, stool culture, toxin assays)

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5
Q

Describe pathophysiology of secondary peritonitis

A
  • Secondary peritonitis results from direct spillage of luminal contents into the peritoneum (eg, perforated peptic ulcer, diverticulitis, appendicitis, iatrogenic perforation)
  • With the spillage of the contents, gram-negative and anaerobic bacteria, including common gut flora, such as E. coli and Klebsiella pneumoniae, enter the peritoneal cavity
  • Endotoxins produced by gram-negative bacteria lead to the release of cytokines that induce cellular and humoral cascades, resulting in cellular damage, septic shock, and multiple organ dysfunction.
  • Usually polymicrobial if colonic rupture
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6
Q

Signs and symptoms of peritonitis

A
  • Fever and chills (80%) (>38º, <36º)
  • Abdominal pain or discomfort (70%) (dull and poorly localized-> more severe and more localized. Worse with movement and local pressure. Patients on steroids, with diabetic neuropathy and extremes of age may present with less pain)
  • Worsening or unexplained encephalopathy
  • Diarrhea
  • Ascites that does not improve following administration of diuretic medication
  • Worsening or new-onset renal failure
  • Ileus
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7
Q

What Qs need to be asked with a pt presenting with ?peritonitis

A
  • Recent abdominal surgery
  • Previous episodes of peritonitis
  • Travel history
  • Use of immunosuppressive agents
  • Presence of diseases (eg, inflammatory bowel disease, diverticulitis, peptic ulcer disease) that may predispose to intra-abdominal infections
  • Anorexia and nausea
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8
Q

Differentials to peritonitis

A
  • Chemical irritation
  • Thoracic processes with diaphragmatic irritation (eg, empyema)
  • Extraperitoneal processes (eg, pyelonephritis, cystitis, acute urinary retention)
  • Abdominal wall processes (eg, infection, rectus hematoma)
  • External hernias (rule out intestinal incarceration)
  • Gynae conditions (chlamydia peritonitis, teratoma, salpingitis)
  • Parasitic infections
  • Vascular conditions (mesenteric embolus, ischaemic colitis)
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9
Q

Treatment of peritonitis

A
  • Find cause (if primary, parecentesis, drain and irrigate)
  • MC&S with pH (see if faecal contents or bile)
  • Broad spectrum abx
  • Drain abscess
  • Laparotomy?
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10
Q

What are the causes of pancreatitis?

A
GET SMASHED
Gall stones (38%)
Ethanol (35%)
Trauma (1.5%)
Steroids
Mumps
Autoimmune
Scorpion bites (Trinidad)
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP and emboli
Drugs
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11
Q

How many people have unexplained pancreatitis?

A

10-30%

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12
Q

Mortality of pancreatitis

A

12%

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13
Q

How does pancreatitis cause mortality?

A

Oedema and fluid shifts-> hypovolaemia
Fluid trapped in gut, peritoneum, retroperitoneum
Enzyme mediated autodigestion -> necrosis and infection
Protease induced coagulation cascade, complement activation, kinin, fibrinolytic cascade, oxidative stress

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14
Q

Signs and symptoms of pancreatitis

A
Symptoms:
•	Severe epigastric pain/central abdo pain
•	Pain radiates to back, relieved by sitting forward
•	Vomiting
Signs:
•	Tachycardia
•	Fever
•	Jaundice
•	Shock
•	Ileus
•	Rigid abdomen
•	Periumbilical bruising (Cullen’s) and flank bruising (Grey Turner’s) due to blood vessel autodigestion and retroperitoneal haemorrhage
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15
Q

Differential diagnoses to pancreatitis

A
  • Perforated duodenal ulcer
  • Mesenteric infarction
  • MI
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16
Q

What is the modified glasgow score?

A

Assesses severity and predicts mortality

Valid for alcohol and gallstones

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17
Q

What are the sections of the modified glasgow score?

A
PANCREAS
PaO2: <8
Age: >55
Neutrophils: >15
Ca2+: <2
Renal function: Urea>16
Enzymes: LDH>600, AST>200
Albumin: <32
Sugar: >10
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18
Q

What investigations need to be carried out in pancreatitis?

A

FBC: WCC raised
Raised amylase (>1000) and raised lipase
U&E: dehydration and renal failure
LFT: cholestatic picture (raised AST and LDH)
Low calcium, raised glucose
CRP: raised if severe (>150)
ABG: hypoxia if respiratory distress
Urine: glucose, conjugated bilirubin, decreased urobilinogen
CXR: exclude perforated duodenal ulcer, ARDS?
AXR: pancreatic calcification?
USS: Gallstones, dilated pancreatic ducts, inflammation
Contrast CT (look for pancreatic necrosis)

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19
Q

Management of pancreatitis

A
  • Hourly obs and urine output
  • IV fluids! Until UO>30ml/hr
  • Pancreatic rest (nil by mouth, NG tube if vomiting, TPN to prevent catabolism)
  • Analgesia (PETHIDINE/MORPHINE)
  • Laparotomy and debridement
  • ERCP and gall stone removal if progressive jaundice
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20
Q

Complications of pancreatitis

A
  • Shock, ARDS, renal failure, DIC, sepsis, hyperglycaemia, hypocalcaemia
  • Pancreatic necrosis and pseudocyst
  • Abscess, bleeding, thrombosis, fistulae
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21
Q

Main causes of chronic pancreatitis

A

Chronic pancreatitis:
70% alcohol
Genetic (CF, HH), Immune, Raised triglycerides, Structural (obstruction by tumour/pancreatic divism)

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22
Q

Signs & symptoms of chronic pancreatitis

A
Pain exacerbated by alcohol/fatty food
Relieved by sitting back or hot water bottle
Steatorrhoea and weight loss
Diabetic signs (olyuria, polydipsia)
Epigastric mass (pseudocyst)
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23
Q

Management of chronic pancreatitis

A
  • Diet: no alcohol, reduce fat, increase carbs
  • Analgesia, Creon supplementation of enzymes, ADEK vitamins, diabetes treatment
  • Surgery if unremitting pain, weight loss, duct blockage (Whipple’s or stenting)
24
Q

10 causes of bowel obstruction

A
  • Adhesions
  • Hernia
  • Colorectal neoplasm
  • Diverticular stricture (IBD, surgery, ischaemic colitis, diverticulitis, radiotherapy)
  • Volvulus
  • Paralytic ileus-> Post –op/pancreatitis/drugs/metabolic/mesenteric ischemia
  • Impacted faces/bezoar/worms
  • Intussusception
  • Gallstones
  • Congenital atresia
25
Q

Signs and symptoms of bowel obstruction

A
  • Abdominal distention
  • Nausea and vomiting
  • Abdominal pain (colicky, central, if localised ?strangulation)
  • Absolute constipation (no flatus or faeces)
  • Abrupt onset of symptoms (acute obstructive event)
  • Chronic constipation, straining at stools (diverticulitis/carcinoma)
  • Changes to stool caliber (carcinoma)
  • Recurrent left lower quadrant abdo pain over several years (diverticulitis/diverticular stricture)
26
Q

What examinations need to be done in ?bowel obstruction?

A
  • Bowel sounds? (increased in mechanical obstruction, decreased in ileus)
  • Inspect, auscultate, percuss abdo (distention)
  • Check for incarcerated hernia
  • Surgical scars
  • Anal patency in neonate? Content of anal vault, faecal occult blood test
27
Q

Diagnosis of bowel obstruction needs what investigations?

A
  • FBC (raised WCC)
  • U&E: dehydration, electrolyte abnormalities
  • Amylase (very high if strangulation/perforation)
  • Group and save + clotting (for poss surgery)
  • Erect CXR for perforation
  • AXR (>3cm with valvulae coniventes=small bowel, >6cm with haustra=large bowel, >9cm caecum)
  • CT can show transition point
  • Gastrograffin studies (shows mechanical obstruction)
  • Colonoscopy (may be used therapeutically to stent in volvulus, can perforate)
28
Q

Treatment of bowel obstruction

A
  • Resuscitate (drip and suck-> NMB, IV fluids, NG tube to prevent aspiration and stop vomiting, monitor urine output)
  • Analgesia
  • Abx cef + met if strangulation/perforation
  • Gastrograffin study (oral/NG tube)
  • Monitor
  • Surgery if closed loop obstruction/neoplasm/strangulation/perforation/failure of conservative management
  • Resection of obstructing lesion/bypass if unresectable
  • Endoscopic metal stents in palliation
29
Q

4 classifications of UTIs

A
  • Uncomplicated (normal GU tract and function)
  • Complicated (abnormal GU tract/outflow obstruction/reduced renal function/impaired host defence/virulent organism
  • Recurrent with different organism
  • Relapse with same organism
30
Q

Risk factors for UTI

A
  • Female
  • Sex
  • Pregnancy
  • Menopause
  • Diabetes mellitus
  • Abnormal tract (stone/obstruction/catheter/malformation)
31
Q

Signs and symptoms of UTI

A
  • Pyelonephritis: fevers, rigors, loin pain, vomiting, oliguria
  • Cystitis: frequency and urgency, polyuria, haematuria, dysuria, suprapubic tenderness, foul smelling urine
  • Prostatitis: flu-like, low backache, dysuria, tender swollen prostate on PR
  • Sterile pyuria-> TB? Appendicitis? Calculi? Papillary necrosis? Polycystic kidney? Chemical cystitis?
32
Q

List 4 common organisms causing UTIs

A

E. coli
Staph. Saprophyticus
Proteus (alkaline urine)
Klebsiella

33
Q

What investigations are done in UTI diagnosis

A
  • Dipstick
  • MSU for MCS
  • FBC, U&E and blood cultures if systemic signs
  • USS (in men, children, recurrence or pyelonephritis)
34
Q

Treatment of UTIs

A
  • Drink plenty, urinate often

* Abx (trimethoprim/nitrofurantoin for cystitis) (cefotaxime for pyelonephritis)

35
Q

3 categories of causes of urinary tract obstruction

A

Luminal
Mural
Extramural

36
Q

3 luminal causes of urinary tract obstruction

A

Stones
Blood clots
Sloughed papilla

37
Q

3 mural causes of urinary tract obstruction

A
  • Congenital/acquired stricture (trauma/Gonorrhoea/chemo)
  • Tumour (renal/ureteric/bladder)
  • Neuromuscular dysfunction
38
Q

3 extramural causes of urinary tract obstruction

A
  • Prostatic enlargement
  • Abdo/pelvic mass or tumour
  • Retroperitoneal fibrosis
39
Q

Acute versus chronic presentation of a urinary tract obstruction

A

Acute:
• Loin to groin pain (upper)
• Severe suprapubic pain and palpable distended bladder (lower)
Chronic:
• Renal failure and flank pain
• Frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence
• Distended, palpable bladder +- large prostate

40
Q

What investigations are undergone in urinary tract obstruction?

A
FBC, U&amp;E, Creatinine/urea ratio
Urine dipstick
USS (hydronephrosis? Hydroureter?)
Uterograms (allow therapeutic drainage)
CT/MRI
Urodynamics
41
Q

Management of urinary tract obstruction

A

Nephrostomy
Ureteric stent
Urethral/suprapubic catheter

42
Q

Name 7 complications of ureteric stents

A
Infection
Haematuria
Trigonal irritation
Encrustation
Obstruction
Ureteric rupture
Stent migration
43
Q

Name 12 causes of liver failure

A
  • Viral (Hep B, C, CMV)
  • Yellow fever
  • Leptospirosis (bacteria from animals)
  • Drugs (paracetamol OD, halothane, isoniazid)
  • Toxins (Amanita phalloides mushroom, carbon tetrachloride)
  • Veno-occlusive disease
  • Alcohol
  • Primary biliary cirrhosis
  • Haematochromatosis
  • Wilson’s disease
  • α-1 antitrypsin deficiency
  • Malignancy
  • HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) in PET
44
Q

Why does ascites occur in liver failure?

A

Hypersplenism so less blood in circulation-> RAAS-> fluid imbalance
+ Low albumin due to liver failure-> lower oncotic pressure, fluid not pulled back into capillaries

45
Q

What causes hepatic encephalopathy

A

Raised ammonia as liver fails, brain converts it to glutamine, causes osmotic imbalance and cerebral oedema.
Confusion, drowsiness, coma

46
Q

Signs of liver failure

A
  • Jaundice
  • Ascites
  • Hepatic encephalopathy
  • Fetor hepaticus (breath smells like pear drops)
  • Liver flap (asterexisis)
  • Constructional apraxia (can you draw a star?)
  • Signs of chronic liver disease
  • Signs of portal hypertension
47
Q

Liver failure causes what type of jaundice?

A

Hepatic jaundice

Unconjugated bilirubin in blood

48
Q

Give 6 signs of portal hypertension

A
Caput medusa
Oesophageal varices &amp; haematemesis
Melaena
Ascites
Haemorrhoids
49
Q

What tests are done in a pt with liver failure

A
  • CRP, WCC (infection)
  • FBC (anaemia, GI bleed)
  • Clotting & LFTS (extent of liver failure)
  • Paracetamol levels
  • Ferritin
  • α-1 antitrypsin
  • Autoantibodies
  • Blood, urine and ascitic fluid MC&S
50
Q

Treatment of ascites from hepatic failure

A

Fluid restriction, low salt, osmotic diuretic (MANNITOL)

51
Q

Treatment of cerebral oedema due to hepatic failure

A

MANNITOL IV, hyperventilate, LACTULOSE & laxatives to alter gut bacteria

52
Q

Which abx should be used for liver failure-> infection

A

Ceftriaxone (avoid Gent)

53
Q

How do you treat bleeding associated with hepatic failure?

A

Vit K, platelets, FFP, blood

54
Q

What should be avoided when treating hepatic failure

A

Avoid sedatives and hepatically metabolised drugs

Avoid gentamycin

55
Q

Management of someone in liver failure

A
  • Be aware of hypoglycaemia, GI bleed, sepsis, encephalopathy
  • Treat at 20º tilt in ITU
  • Intubate & NG insertion
  • Urinary and venous catheters (fluid balance)
  • 10% dextrose IV to avoid hypoglycaemia
  • Treat cause if known (sepsis/GI bleed, paracetamol OD ACETYL-CYSTEINE)
  • Thiamine & folate supplements
  • Monitor renal function (haemodialysis?)
  • PPI (LANSOPRAZOLE)
  • Transplant?
56
Q

Name 5 poor prognostic indicators in liver failure

A
  • Coma/stupor
  • Age>40
  • Albumin<30g/L
  • Raised INR
  • Drug induced
57
Q

Define liver cirrhosis

Common pathophysiology?

A

Irreversible liver damage with bridging fibrosis and nodular regeneration
Due to:
1) Chronic alcohol abuse, obesity & genes-> steatohepatitis-> fibrosis-> cirrhosis
2) Hepatitis virus -> fibrosis-> cirrhosis