GI Flashcards
What is Grey-turners sign?
Bruising of the flanks and indicates intra-abdominal bleeding, consequently it is predictive of severe and acute pancreatitis
What is Cullen’s sign?
Bruising around the umbilicus, it is also indicative of intra-abdominal bleeding and predictive of acute pancreatitis
What does coffee ground haematemesis mean?
Upper GI bleeding, for example due to a peptic ulcer, or use of NSAIDs/SSRIs
What are some possible causes of epigastric pain?
Pancreatitis, peptic ulcer disease, aortic aneurysm, perforated oesophagus, MI
What are some possible causes of RUQ (hypochondrial) pain?
Biliary colic, cholecystitis, renal, hepatitis, peptic ulcer, carcinoma, subphrenic abscess, duodenal ulcer
What are some possible causes of LUQ (hypochondrial) pain?
Peptic ulcer, suphrenic abscess, renal, carcinoma, ruptured spleen, pneumonia
What are some possible causes of loin pain?
Renal colic, pyelonephritis, perforated bowel, referred pain, pancreatitis, ruptured spleen
What are some possible causes of LLQ (iliac fossa) pain?
Diverticulitis, volvolus, colon cancer, pelvic abscess, IBD, UTI
What are some possible causes of RLQ (iliac fossa) pain?
Appendicitis, UTI, volvolus, colon cancer, pelvic abscess, IBD, crohns ileitis
What are some possible causes of pelvic pain?
Pregnancy, UTI, carcinoma, mnestruation
What are some causes of generalised pelvic pain?
Gastroenteritis, IBS, constipation, peritonitis
What is an ileus?
Lack of movement in the intestines leading to build up and blockage
What is Gilbert’s syndrome?
A harmless inherited condition in which the liver doesn’t produce the enzyme to break down bilirubin, so it builds up causing jaundice
What is tenesmus and when is it common?
The sensation of incomplete emptying after defecation, commonly experienced in IBS
What is rebound tenderness and what usually causes it?
Pain upon removal of pressure from the abdomen, commonly caused by peritonitis
What is Rovings sign?
Palpation of the left lower quadrant produces pain in the right lower quadrant - this is indicative of appendicitis
What is Murphy’s sign?
Pain on taking a deep breath, when the examiner is pressing down on the right upper quadrant - this is indicative of cholecystitis
What is McBurneys point?
A point that lies one-third of distance laterally on a line drawn from the umbilicus to the right anterior superior iliac spine - this is where the appendix lies
In a GI exam, which organs should descend on inspiration?
Liver, spleen, kidneys
What are the two layers of the peritoneum?
Parietal (lines the abdominal wall)
Visceral (covers organs)
At what level does the oesphogus pass through the diaphragm?
T10
Where does the stomach receive its blood supply from?
Coeliac trunk of common hepatic artery
Gastric arteries
What causes dysphagia?
Mechanical block (malignancy, GORD, extrinsic pressures) Motility disorders (achalasia - failure of LOS to relax due to degeneration of myenteric plexus, stroke, MS, MND, parkinsons)
What cancers occur in the oesophagus?
Adenocarcinoma (from Barret’s)
Squamous cell carcinoma
What is the role of the duodenum?
- Takes in secretions from the pancreas and gallbladder, by producing CCK and secretin
- Slows gastric emptying
- Increases pancreatic activity
What is the role of the jejunum?
Lots of villi to increase surface area, involved in nutritional absorption and regular peristalsis
What is the role of the ileum?
Absorption of vitamin B12 and bile salts and whatever products of digestion were not absorbed by the jejunum
What are taeniae coli?
Three separate longitudinal ribbons of smooth muscle on the outside of the ascending, transverse, descending and sigmoid colons. They contract lengthways to produce haustra
What is the role of the large intestine?
- Absorption of water and minerals
- Mass movement (peristalsis twice an hour)
- Defaecation
What is peritonitis?
Perforation of a peptic/duodenal ulcer, diverticulum, appendix, bowel or gallbladder
What are the signs of peritonitis?
Prostration (lying flat), lying very still, shock, rebound tenderness, guarding, rigidity, absent bowel sounds
How is peritonitis managed (tests and treatment)?
Tests - FBC, CRP, U&E, amylase, LFT, ABG, urinalysis, erect CXR (gas), AXR, USS
Treatment - Laparoscopy
What are the symptoms of acute appendicitis?
Periumbilical pain that moves to the RIF
Anorexia
Vomiting (often from the pain)
Constipation/diarrhoea
What are the special tests to diagnose appendicitis?
Rosving’s sign - pain > in RIF when you press on LIF
Psoas sign - pain on extending hip if retrocaecal appendix
Cope sign - pain on flexion and internal rotation of right hip
Which is the gold standard imaging for acute appendicitis?
CT - only downfall is it takes time
How is acute appendicitis treated?
- Metronidazole + cefuroxime
2. Laparoscopic appendicectomy
A girl has acute abdominal pain radiating to the shoulder tip. What are your two main differentials and how do you differentiate between the two?
Acute cholecystitis - vomiting, jaundice, fever, rigors
Ectopic pregnancy - vaginal bleeding following weeks of amenorrhoea
What are the symptoms of intestinal obstruction?
Vomiting (faeculant = severe)
Colicky pain
Constipation (ask about flatulence)
Distenstion
What are the main causes of obstruction of the small bowel?
Adhesions
Hernias
What are the main causes of obstruction of the large bowel?
Colon cancer
Constipation
Diverticular structure
Volvolus
What is an ileus?
A functional obstruction of the bowel from reduced motility - painless, bowel sounds will be absent
What would you hear on auscultation of a mechanical obstruction?
Tinkling bowel sounds
How is an obstruction managed?
NGT and IV fluids to replenish electrolytes
Surgery
What is leukoplakia and what causes it?
Oral mucosal white patch - premalignant, HIV
What are aphthous ulcers and what causes them?
Shallow painful ulcers on the tongue/oral mucosa - trauma, crohn’s, coeliac, behect’s, erythema multiform, lichen plans, infections
What is candidiasis and what causes it?
White patches on buccal mucosa - fungal, antibiotics, immunusuppresion
What is angular stomatitis and what causes it?
Fissuring of the mouth corners - denture problems, candidiasis, iron deficiency
What is gingivitis and what causes it?
Gum inflammation and hypertrophy - poor oral hygiene, drugs, pregnancy, vitamin c deficiency, leukemia
What is oral pigmentation and what causes it?
Perioral brown spots - Peutz-Jehjers disease, Addison’s
What are the symptoms of peptic ulcer disease?
ALARMS Anaemia Loss of weight Anorexia Recent symptoms Malaena/haematemesis Swallowing difficulties
How can you differentiate duodenal and gastric ulcer by their symptoms?
DUODENAL - Gnawing epigastric pain BEFORE meals or at night, which is relieved by eating
GASTRIC - Gnawing epigastric pain AFTER meals
How are H.pylori peptic ulcers treated?
Triple therapy:
- Amoxicillin
- Clarithromycin
- Omeprazole/lansoprazole
How can you test for presence of H.pylori?
Non-invasive - 13C breath test
Invasive - CLO test (rapid urease test)
What are the risk factors for peptic ulcer?
H.pylori, smoking, NSAIDS, reflux, delayed gastric emptying, stress
What is GORD?
Reflux of stomach contents, causing over 2 episodes of heartburn a week (aka. waterbrash)
Prolonged reflux can lead to what?
Benign oesophageal stricture
Oesophagitis
Barret’s oesophagus (sqaumous –> columnar)
What are the risk factors for GORD?
Hiatus hernia Loss of peristaltic function Abdominal obesity Gastric acid hyper secretion Slow gastric emptying Smoking/alcohol Pregnancy Drugs
What are the symptoms of GORD?
Heartburn Belching Acid/waterbrash Odynophagia Nocturnal asthma/cough
How can GORD be managed?
Antacids/alginates/PPIs for symptomatic relief
What is the Rockall score?
A scoring system for upper GI bleeds, based on:
- Age
- BP
- Pulse
- Comorbidity
- Diagnosis
- Signs of recent haemorrhage on endoscopy (NB full resuscitation must be done before attempting this)
What is the main cause of upper GI bleeds?
Peptic ulcer, mallory-weiss
How should an acute GI bleed be managed?
Acute - ABC, 500ml fluid challenge over 5 minutes, surgery
Long-term - PPI (heal ulcer), antibiotics (h.pylori) to prevent rebleed
What are the main causes of lower GI bleeds (and the risk factors)?
Small bowel mucosal damage (NSAID/aspirin)
Diverticular bleeding (NSAID/aspirin)
Colorectal cancer (weight loss)
Ischaemic colitis (preceding hypovolaemia)
Aorto-colic fistulae (previous vascular surgery)
Radiation proctitis (previous malignancy)
Haemorrhoids (bright red blood)
What are the indications for surgery for an GI bleed?
- Severe bleeding, despite transfusion
- Active/uncontrollable bleeding at endoscopy
- Rockal score (>3 at start, or >6 after endoscopy)
What are oesophageal varices?
Dilated sub-mucosal veins, due to portal hypertension and cirrhosis (often related to alcohol abuse)
How are varices managed?
- Propanolol to reduce portal hypertension
2. Endoscopic banding ligation (tie off varices to prevent bleeding)
What are the diagnostic indications for upper GI endoscopy?
Haematemesis, new dyspepsia, suspected cancer, persistent vomiting
What are the diagnostic indications for colonoscopy?
Rectal bleeding, persistent diarrhoea, biopsy of lesion seen on barium enema, assessment of IBD, suspected cancer
What are the diagnostic indications for duodenal biopsy?
Coeliac disease, malabsorption
What is IBS?
A group of non-specific abdominal symptoms for which no organic cause has been found (likely due to a disorder of intestinal motility)
What are the symptoms of IBS?
Abdo pain relieved by defecation, altered stool form or bowel frequency and 2 of:
- Urgency
- Tenesmus
- Bloating
- Mucous PR
- Symptoms worse after eating
What exacerbates IBS?
Stress, menstruation, gastroenteritis
How is IBS managed?
Conservative - healthy diet, limit stress
Medical - stool softeners if constipated (isphagula, lactulose), bulking agents if diarrhoea, bloating (mebeverine)
What is IBD?
An immune-mediated chronic intestinal condition, made up of Crohn’s and UC
What is UC?
Relapsing and remitting inflammation of the colonic mucosa
Where does UC affect?
Anywhere proximal to the ileocaecal valve (often anal sparing)
Describe the inflammation in UC
Uniform and continous, confined to the mucosa, crypt abscesses
What are the symptoms of UC?
Crampy abdo pain, bloody diarrhoea, fatigue, systemically unwell during attacks, mouth ulcers (secondary to malabsorption)
What are the complications of UC?
- Perforation
- Toxic megacolon
- Venous thrombosis
- Colon cancer
How is UC treated?
Mild - sulfasalazine (DMARD) PO
Moderate - prednisolone PO
Severe - IV hydrocortisone
What are the indications for a stoma in UC?
Perforation
Massive haemorrhage
Toxic megacolon
Failed medical therapy
Needed in about 20% of patients
Where does Crohn’s affect?
Mainly terminal ileum and proximal colon, but can affect anywhere in the gut (often rectal sparing)
Describe the inflammation in Crohn’s disease?
Transmural, skip lesions (unaffected bowel between areas of active disease)
What are the symptoms of Crohn’s disease?
Abdominal pain, diarrhoea, fatigue, mouth ulcers (primary) systemically unwell
What are the complications of Crohn’s?
- Small bowel obstruction (due to narrowing and thickening)
- Abscess formation
- Fistulae
- Perforation and rectal haemorrhage
- Anal strictures
- Colon cancer
How is Crohn’s treated?
Mild: prednisolone PO
Severe: hydrocortisone IV
How can you tell if a stoma bag is an ileostomy or colostomy?
Ileostomy - protect skin due to enzymes, right sided
Colostomy - ok to touch skin, left sided
What causes bloody diarrhoea?
UC, gastroenteritis (campylobacter, shigella), colorectal cancer, polyps, ischaemic colitis
What causes mucus diarrhoea?
IBS, colorectal cancer, polyps
What causes steatorrhoea?
Pancreatic dysfunction
What is loperamide used for?
Diarrhoea - bulking agent
If colorectal malignancy is suspected, what imaging should be done?
Barium enema
Colonoscopy
What are the different types of laxatives used to treat constipation?
Stimulant - senna, glycerol Bulking agents (increased faecal mass to stimulate peristalsis) - loperamide Isphagula husk Stool softeners - docusate sodium Osmotic laxatives - lactulose, macrogol
What are the different types of laxatives used to treat constipation?
Stimulant - senna, glycerol Bulking agents (increased faecal mass to stimulate peristalsis) - loperamide Ispaghula husk Stool softeners - docusate sodium Osmotic laxatives - lactulose, macrogol
What is the classical triad of mesenteric ischaemia?
- Acute severe abdominal pain
- No other abdominal signs
- Shock
What are some causes of mesenteric ischaemia?
ASK ABOUT CARDIOVASCULAR HISTORY
- Thrombus/emboliv (usually in superior mesenteric artery)
- Venous
- Trauma
- Vasculitis
- Strangulation (volvolus/hernia)
How is staging investigated for GI cancers?
CT
PET (radioactive)
Laparoscopy
Endoscopic ultransound
What causes oesophageal cancer?
Smoking, alcohol, diet, Barret’s, achalasia
What causes gastric cancer?
Diet, H.pylori, smoking, alcohol, FAP, Barret’s, pernicious anaemia
What is the main type of:
a) oesophageal cancer?
b) gastric cancer?
BOTH adenocarcinoma
What are the 2WW criteria for upper GI?
- Dysphagia, obstructive jaundice, upper abdo mass
- Dyspepsia with weight loss, anaemia or vomiting, at any age
- All dyspepsia > 55 years for 6 weeks
- Dyspepsia with over 2 first degree relatives with upper GI cancer, Barrett’s, pernicious anaemia
- Previous peptic ulcer surgery
Describe the epidemiology of colorectal cancer
3rd most common cancer, and 2nd most common cancer deaths
What causes colorectal cancer?
IBD, poor diet, smoking, alcohol, genetic predisposition (FAP, HNPCC)
What are the specific symptoms of left sided colorectal cancer?
Looser stools, tenesmus, bleeding
What are the specific symptoms of right sided colorectal cancer?
Iron deficiency anaemia, weight loss, abdo pain, palpable mass
What are the specific symptoms of rectal cancer?
Rectal bleeding, tenesmus
What is FAP?
An inherited disorder causing numerous polyps to form in the epithelium of the large intestine
What is HNPCC/Lynch syndrome?
Lynch syndrome (HNPCC or hereditary nonpolyposis colorectal cancer) is an autosomal dominant genetic condition that has a high risk of colon cancer
What is the 2WW criteria for lower GI cancer?
- > 40yo rectal bleeding and looser/frequent stools for >6weeks
- > 60yo rectal bleeding >6weeks alone
- > 60yo looser/frequent stools >6weeks alone
- Any age with right lower abdo or rectal mass
- Any age unexplained iron deficiency anaemia
What is CEA?
Carcinoembryonic antigen - this is raised in many patients with CRC and indicates a worse prognosis
How are GI cancers staged (what criteria)?
Upper GI - TNM
Lower GI - TNM, Dukes
What screening tests are available for colon cancer?
Between 50-75 yrs:
- Faecal occult blood testing (check for hidden blood in stools)
- Flexible sigmoidoscopy
- Colonoscopy
Looks for adenomatous polyps (80% of cause)
What is the difference between diverticulum, diverticulosis, diverticular disease and diverticulitis?
Diverticulum - outpouching of gut wall
Diverticulosis - outpouchings are present
Diverticular disease - outpouchings are symptomatic
Diverticulitis - outpouchings are inflamed, causing colicky pain in the LLQ
Where do most diverticuli occur?
Sigmoid colon
What are the complications of diverticulitis?
Perforation - peritonitis and shock
Haemorrhage - sudden and painless
Fistulae - need surgery
Abscess - pus in rectum (if not could be subdiaphragmatic)
What is a hiatus hernia, and what are the two types?
When part of the stomach moves up through the chest through a hole in the diaphragm:
- Sliding (80%) - gastro-oesophageal junction slides up into the chest, causes reflux
- Rolling (20%) - junction remains in abdomen but a bulge of stomach herniates up into the chest, no reflux
What is a hernia?
The protrusion of a viscous through the wall of the cavity into an abnormal position
What is an incarcerated hernia?
It means that the contents of the hernial sac are stuck inside by adhesions
What is a strangulated hernia?
This means the hernia has become ischaemic, bowel sounds will be absent, and the patient becomes toxic –> URGENT SURGERY
What is an indirect inguinal hernia?
Passes through the internal inguinal ring and out through the external ring (75%)
What is a direct inguinal hernia?
Pushes directly forward through the posterior wall of the inguinal canal into a defect in the abdominal wall
These are more likely to strangulate than direct hernias
Where are the deep and superficial inguinal rings located?
Deep - midpoint of the inguinal ligament
Superficial - superior and medial to the the pubic tubercle
What is a femoral hernia and where is it felt?
Bowel enters the femoral canal and points down the leg - common in middle aged woman, likely to be irreducible and strangulate
The neck of the hernia is likely to be felt inferior and lateral to the pubertal tubercle
Name 6 different types of hernia
Inguinal Femoral Hiatus Paraumbilical Epigastric Incisional (through previously made incision) Lumbar Spigelan (rectus sheath) Richter (part of the bowel protrudes through abdo wall, can cause gangrene)
What values are measured using the MUST tool?
Height, weight (now and 6 months ago), BMI, acute disease effect
0 = low risk 1 = medium 2 = high
If conventional values can’t be used, what can you measure in a MUST tool?
- Mid upper arm circumference (muscle mass)
- Triceps skinfold thickness (fat stores)
- Grip strength (functional status)
- Waist cicrumference (fat stores)
When is parenteral nutrition used?
If gut is inaccessible or non-functioning, or if oral/enteral feeding is inadequate or unsafe
What does parenteral nutrition contain?
Glucose
Amnio acids
Fat emulsion
Vitamins and trace elemtents
What are the complications of parenteral nutrition?
- Line sepsis
- Vomiting and diarrhoea
- Glucose intolerance
- Thiamine depletion
- Refeeding syndrome
What is refeeding syndrome?
Fluid and electrolyte shifts with consequent metabolic implications in malnourished patients undergoing re-feeding
What systemic features are associated with IBD?
Clubbing
Apthous ulcers
Erythema nodosum (nodular red rash on shins)
Pyoderma gangrenosum (necrotic leg tissue)
Conjunvitivits/iritis
Large joint arthritis
Ankylosing spondylitis (HLA-b27 connection)