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GI Flashcards

1
Q

What are 3 emergency causes of haematemesis in order of frequency?

A

Duodenal ulcer
Gastric ulcer
Oesophageal varices

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2
Q

What are 5 non-emergency causes of haematemesis?

A

Oesophagitis - reflux, bisphosphonates, toxins, Crohn’s, candida
Mallory-Weiss tear
Gastric carcinoma

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3
Q

5 important questions in haematemesis history

A 
Timing, frequency, volume
Smoking, alcohol
Medical history
Dyspepsia, dysphagia, odynophagia
Steroids, NSAIDs, bisphosphonates, anticoagulants
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4
Q

Signs on haematemesis exam

A

Telangiectasia
Liver stigmata - jaundice, hepatosplenomegaly, spider naevi, ascites, palmar erythema
Epigastric tenderness (PUD, gastritis)

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5
Q

Investigations haematemesis

A

FBC - anaemia, low platelets if hypersplenism from portal hypertension (varices)
High urea:creatinine ratio = upper GI bleed
LFT - liver damage
Group and save and 4u crossmatched
OGD - immediately after resus if emergency, in 24h if not
CT abdo with IV contrast if endoscopy unremarkable or too unwell
Erect CXR for perforated ulcer - pneumoperitoneum
H pylori - PUD
ABG - hypoperfusion

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6
Q

What are the 2 scoring systems for upper GI bleed and what is it for?

A

Glasgow-Blatchford Bleeding score:
1. FBC - urea, Hb
2. Obs - pulse, systolic bp
3. Sx - melaena, syncope
4. Hx - known hepatic or cardiac failure
Associated with >risk of intervention need

Rockfall score - severity for GI bleed post-endoscopy

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7
Q

Resus for haematemesis

A

Transfuse blood, platelets, clotting factors according to local massive bleed protocol
Platelet transfusion if <50 and active bleeding
FFP if active and APTT>1.5
Prothrombin complex if activebleeding and warfarin
Recombinant factor VIIa if all else failed

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8
Q

Manage non-variceal upper GI bleed

A 
Endoscopic:
- Clips +- adrenaline
- Or thermal coagulation with adrenaline
- Or fibrin/thrombin with adrenaline
PPI if stigmata of recent haemorrhage seen on endoscopy
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9
Q

Manage variceal upper GI bleed

A

Terlipressin until haemostats is achieved or 5d
Abx prophylaxis if suspected
Band ligation for oesophageal, and TIPS if not successful
Endoscopic injection if gastric, then TIPS if not successful
Long term B blockers

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10
Q

GI bleeding control and prevention if on anticoagulants

A

Continue low dose aspirin once haemostasis achieved
Stop NSAIDs during acute phase
Consider stopping clopidogrel - seek specialist advice

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11
Q

Likely causes of diarrhoea with blood and mucus

A

Inflammation - UC, radiation, bacterial, pseudomembranous colitis
Acute gastroenteritis - campylobacter, shigella, E. coli

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12
Q

Likely cause of pale and greasy stools

A

Malabsorption - SI disease, pancreatic insufficiency

  • coeliac disease fhx
  • alcohol
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13
Q

Likely cause of diarrhoea with nausea and vomiting

A

Enteritis, chronic pancreatitis

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14
Q

Likely cause of diarrhoea with joint pain, skin damage, uveitis

A

IBD

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15
Q

Hypomotility and malabsorption in bowels

A

Scleroderma

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16
Q

Jaundice and steatthoroea

A

Pancreatitis or pancreatic carcinoma

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17
Q

Important drug history in diarrhoea

A

Colchicine, metformin, digoxin = GI ADR
Purgatives
Broad spectrum abx (penicillin, cephalosporins) = C diff - pseudomembranous colitis

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18
Q

Important medical history in diarrhoea

A

Vagotomy in GI surgery = diarrhoea
GI resection = reduced motility and absorption
Radiotherapy on abdo/pelvis = GI ADR for years
Systemic conditions: DM - neuropathy, collagen, vascular disease
HIV = atypical infections ie cryptosporidium and CMV

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19
Q

Diarrhoea and dehydration on exam

A

Acute onset
IBD
VIP-oma - lose electrolyte-rich fluid in large quantities

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20
Q

Diarrhoea and pallor on exam

A

IBD/malignancy = blood loss
Anaemia of chronic disease
Iron and vit B/folate deficiency in malabsorption

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21
Q

Weight loss and diarrhoea

A

Malignancy or malabsorption

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22
Q

3 IBD findings on exam

A

Aphthous ulcers, pyoderma gangrenosum, uveitis

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23
Q

1 thyrotoxicosis finding on exam

A

Proptosis or exophthalmos

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24
Q

1 adrenal insufficiency finding on exam

A

Pigmentation

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25
Q

1 diabetes finding on exam

A

Peripheral neuropathy

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26
Q

Skin colour changes on GI exam for diarrhoea

A

Radiation enteritis

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27
Q

RIF mass on exam for diarrhoea

A

Crohn’s or caecel carcinoma

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28
Q

Diarrhoea and low urea

A

Malabsorption or malnutrition

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29
Q

Diarrhoea and high urea

A

Dehydrated or melaena

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30
Q

Urine dipstick for diarrhoea

A

5-hydroxyindoleacetic acid (5-HIAA) = metabolite of serotonin = carcinoid syndrome

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31
Q

LFT for diarrhoea

A

Pancreatic insufficiency or alcohol excess

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32
Q

Primary care investigations for diarrhoea

A

FBC (deficiencies - calcium, B12, folate, ferritin), coeliac screen (IgA tissue transglutaminase antibody (t-TGA) or IgA endomysial antibody (EMA)), U&E, LFT, thyroid, ESR, CRP, urine dipstick, stool culture

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33
Q

3 possible stool culture findings in diarrhoea

A

Ova and cysts in giardia - 3 specimens 2-3 days apart due to intermittent shedding
C diff if recent abx or nursing home resident
Viruses if immunosuppressed

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34
Q

Imaging for diarrhoea

A

Flexible sigmoidoscopy if <45y/o or colonoscopy if >45y/o, +- biopsy: mucosal inflammation, rectosigmoid carcinoma or polyps, melanosis coli in purgative abuse
Others:
Abdo x-ray for faecal impaction or megacolon (UC and very unwell)
Small bowel barium study/enema/colonoscopy if blood or anaemia - IBD
Duodenal biopsy if steatthorea and folate deficiency - coeliac
Breath test for bacterial overgrowth (H pylori) if steatthoea, low B12, normal folate

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35
Q

Red flag symptoms for diarrhoea

A 
Unintentional or unexplained weight loss
Rectal bleeding
>6 weeks in >60y/o
Abdominal or rectal mass
Anaemia
Raised inflammatory markers
Family history or bowel or ovarian cancer
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36
Q

Diverticular disease - what is it and symptoms

A

Mucosal outpouchings in descending and sigmoid colon

Painless heavy self limiting bleeds

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37
Q

Haemorrhoids - what is it and symptoms

A

Enlarged vascular cushions in the anal canal
Cause mass and priorities
Fresh blood separate from stool
Painful when thrombosed

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38
Q

Malignancy symptoms with rectal bleeding

A

Other GI symptoms, weight loss
Family history
No focal anal symptoms
dark red blood mixed with stool

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39
Q

6 questions in rectal bleeding history

A

Pain - wake at night, increase or decrease with defecation
Mucus
Previous episodes
Haematemesis
Family history of cancer or IBD
Nature - colour, duration, frequency, relation to stool

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40
Q

Rectal bleeding examination findings and suggestions

A

General - anaemia, cachexia, lymphadenopathy
Mass = constipation from haemorrhoid with fissure
LIF tenderness +- guarding = inflammed diverticulae
Perianal lesions or skin tags = thrombosed haemorrhoids
Discharge = IBD or anorectal carcinoma
Increased tone and pain on DRE = fissure
Mass on DRE = rectal polyp or carcinoma

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41
Q

Investigations for rectal bleeding and indications

A

Proctoscopy for position of haemorrhoids or anal fissure
Rigid sigmoidoscopy for suspicious lesions 15-20cm from anal margin - carcinoma, IBD
Flexible sigmoidoscopy for left colon malignancy
Full colonoscopy and angiogram to identify bleeeding vessel +- arterial embolisation
Emergency OGD and CT angiogram if haemodynamically unstable
Others: FBC, U&E, LFT, coag, g&s, stool culture

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42
Q

Where is the cause of rectal bleeding likely to be depending where blood is in relation to stool?

A

Mixed and dark red = higher up - polyps, cancer, angiodysplasia, inflammatory
Separate from stool = low rectal +- mucus - anorectal carcinoma, diverticular disease, haemorrhoids, IBD
Spotting = haemorrhoids, anal tear

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43
Q

8 symptoms of IBS

A 
LIF pain, relieved by passing wind and defecation
Rectal dissatisfaction
Distension and sensation of bloating with no obstruction
Strain/urgency
Symptoms worse after meals
Mucus
Pain
Change in bowel habit
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44
Q

4 non-GI symptoms of IBS

A

Dysparaunia
Urinary symptoms
Fatigue
Anxiety and depression

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45
Q

Things to check in IBS history

A

No: weight loss, night symptoms, not acute onset, rectal bleeding, not >50y/o

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46
Q

3 IBS theories

A

Abnormal GI sensation or motility
Abnormal bowel flora
Altered GI serotonin signalling

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47
Q

Treat IBS: 4 advice and 4 medication

A
  1. Reassure and explain
  2. Try excluding certain foods
  3. Increase fibre and fluids if constipated
  4. Hypnotherapy, exercise and relaxation
  5. Anti-spasmodic - mebeverine
  6. Anti-motility - loperamide
  7. Laxative - bisacodyl
  8. Treat depression - TCA for pain
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48
Q

Blood supply to colon, 3 on each side

A

Right - ileocaecal, right colic, middle colic

Left - marginal, left colic, sigmoid arteries

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49
Q

What are the brought categories of causes of jaundice and what form is the bilirubin in for each?

A 
Pre-hepatic = unconjugated
Intra-hepatic = mixed
Post-hepatic = conjugated
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50
Q

What is the process of heme breakdown and where is it done?

A

Spleen/macrophages: heme + heme oxygenase = biliverdin
+ biliverdin reductase = bilirubin (unconjugated and insoluble, bound to albumin)
Through sinusoids to hepatocytes in liver
Unconjugated bilirubin + glucuronic acid = conjugated bilirubin (water soluble)
Through biliary system into SI, + bacterial proteases = urobilinogen
90% = reduced to sterocobilinogen/oxidised to stercobilin = pigment in faeces
10% through portal vein to liver, then to kidney = urobilin (pigment) and to urine

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51
Q

What is the enterohepatic urobilinogen cycle?

A

Conjugated bilirubin is metabolised by bacterial proteasese to 90% urobilinogen reduced to stercobilin, oxidised to stercobilinogen which is the pigment in faeces

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52
Q

What happens to urobilinogen as a result of biliary obstruction?

A

Less conjugated bilirubin enters SI so lower levels of urobilin and stercobilin. Conjugated bilirubin enters blood stream and secreted by kidneys, so dark urine and pale stools

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53
Q

What are 2 main causes of dark urine and pale stools?

A

Cholestasis - less conjugated bilirubin enters SI

Reduced intestinal flora by broad spectrum abx - less conjugated bilirubin metabolised

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54
Q

What are 3 causes of reduced urobilinogen in urine?

A

Obstruction - reduce bilirubin in SI
Abx - reduced bacterial flora to metabolise bilirubin
Drugs that acidify urine ie ascorbic acid (vit c)

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55
Q

How are post-hepatic and hepatic causes of jaundice differentiated?

A

USS - dilated bile ducts = obstruction ie gall stones

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56
Q

What sign is seen on examination for haemolytic anaemia?

A

Haemosiderin deposits on lower legs

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57
Q

What localised conditions are associated with haemosiderin deposits? Name 4

A

Venous eczema
Venous ulcers
Dermatitis
DVT

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58
Q

Where is pre-hepatic jaundice caused?

A

Spleen and blood vessels

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59
Q

Name 4 causes of pre-hepatic jaundice and 2 causes of the main 2 categories

A

Immune
Burns
Infection
Mechanical
Transfusion
Haemolytic anaemia: thalassaemia, RBC membrane defects (spherocytosis)
Congenital hyperbilirubinaemia: Crigler-Najjar syndrome, Gilbert’s syndrome

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60
Q

Name 6 causes of intra-hepatic jaundice

A 
Alcoholic liver disease
Hepatobiliary carcinoma
Hereditary haemochromatosis
Hepatitis - viral, EBV, CMV, AI
Intrahepatic cholestasis of pregnancy
Drugs - paracetamol, amoxicillin, flucloxacilin, valproate, TB drugs, allopurinol
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61
Q

Where is post-hepatic jaundice caused? Name 4 locations

A

Biliary tree: L and R and common hepatic arteries, cystic duct, common bile duct, ampulla of vater

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62
Q

Name 2 intra-hepatic causes of post-hepatic jaundice

A

Cholangiocarcinoma

AI - PSC, PBC

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63
Q

Name 4 extra-hepatic causes of post-hepatic jaundice

A

Gall stones
Biliary stricture after lap chole
Chronic pancreatitis
Drugs causing cholestasis - Flucloxacillin, co-amoxicillin, steroids, nitrofurantoin

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64
Q

Relevant hepatitis hx (5)

A 
Contact/area with A-E or EBV
Risky behaviours - sharing needles, sex
Seafood abroad
Alcohol
Farm/sewers = leptospirosis
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65
Q

Relevant jaundice PMH (2)

A 
UC = PSC
Cholecystectomy = stricture or bile duct stone
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66
Q

Relevant jaundice fx (3)

A

Congenital hyperbilirubinaemia
Wilson’s disease
A1 antitrypsin deficiency

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67
Q

What law is looked for on jaundice exam?

A

Courvoisier’s law: palpable gall bladder, non tender is not gall stones

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68
Q

Jaundice with acute distension (2)

A

Acute hepatitis

Hepatic vein thrombosis causing ascites

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69
Q

Jaundice with raised JVP and peripheral oedema

A

Heart failure = congested

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70
Q

Causes of generalised lymphadenopathy and jaundice (3)

A

EBV
CMV
Toxoplasmosis

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71
Q

5 signs of chronic liver disease

A 
Palmar erythema
Spider naevi
Gynaecomastia
Ascites
Hepatosplenomegaly
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72
Q

Kaiser-Fleicher rings and jaundice

A

Wilson’s disease

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73
Q

Resp disease and jaundice

A

CF or a1 antitrypsin deficiency

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74
Q

Neuro signs and jaundice

A

Hepatolenticular degeneration in Wilson’s disease

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75
Q

AST:ALT raised

A

Viral hepatitis

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76
Q

AST:ALT >2

A

Alcoholic liver disease

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77
Q

Alkaline phosphatase raised

A

Biliary obstruction (or bone injury)

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78
Q

Gamma-GT raised

A

Biliary obstruction

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79
Q

What clotting study is abnormal in liver disease and why?

A

PT: vit K absorption reduced as it is fat soluble and there are fewer bile salts. Less factor 2, 7, 9, 10 (vit K dependent) so increased PT

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80
Q

FBC in alcoholic liver disease

A

MCV raised due to RBC damage (increased deposition of lipids and cholesterol on membrane surface, increasing size of RBC) - marrow toxicity, and B12/folate deficiency

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81
Q

Acute viral serology in liver screen

A

EBV, CMV, hepatitis A, B, C, E

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82
Q

Chronic viral serology in liver screen

A

Hep B, C

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83
Q

Acute non-infective markers in liver screen (4)

A

Anti-nuclear antibody - Sjogren’s, SLE, scleroderma
Paracetamol level
IgG subtypes increased in chronic active and alcoholic hepatitis and cirrhosis
Caeruloplasmin - carries copper, oxidises iron so it can be carried by transferrin, synthesised in liver - low in Wilson’s disease

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84
Q

Chronic non-infective markers in liver screen (5)

A

ANA (SLE, sjogren’s, scleroderma), AMA (PBC), Anti-SM (AI hepatitis)
Caerulosplasmin - low in Wilson’s disease
T-TGA - coeliac disease
Ferritin (increase) and transferrin (decrease) saturation - acute phase protein
A1 antitrypsin

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85
Q

Signs of Wilson’s disease (5)

A 
Keyser-Fletcher rings
Renal tubular acidosis
Hyperparathyroid
Infertility
Cardiomyopathy
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86
Q

Imaging for jaundice

A

USS
MRCP if USS inconclusive or limited, or obstructive (dilated ducts)
Biopsy

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87
Q

Urine test for jaundice (3)

A

Low urobilinogen and raised bilirubin = obstruction
Low bilirubin = unconjugated (pre-hepatic cause)
Haemosiderin = haemolysis

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88
Q

Manage complications of liver failure (3)

A

Vit K, treat hypoglycaemia, FFP

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89
Q

Manage encephalopathy (decompensated liver failure)

A

Laxative

Neomycin/rifaximin - decrease ammonia producing bacteria in bowel

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90
Q

Obstructive jaundice management (surgery, med and symptoms)

A

ERCP, open surgery, cholecystectomy, bile duct stenting
Cholestyramine increases biliary drainage
Antihistamines for pruritis

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91
Q

Role of IgG

A

Secondary immune response - activates complement pathway: macrophages and neutrophils to phagocytosis, eosinophils and NK cells to extracellular targets
Internal body fluids, crosses placenta (Gestation)
Inhibited by staph a

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92
Q

Role of IgA

A

Most prevalent, produced in mucosae
Neutralises microorganisms in GI and resp tract
In breast milk

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93
Q

Role of IgM

A

Primary response (Meets), stays in circulation

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94
Q

Role of IgD

A

On B cells - antigen receptor

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95
Q

Role of IgE

A

Extracellular organisms - activates mast cells and basophils to release inflammatory mediators which attack parasitic worms

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96
Q

What is acute liver failure?

A

Massive hepatocyte necrosis

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97
Q

3 main causes of acute liver failure and survival rates

A

1) paracetemol toxicity 65%
2) idiosyncratic drug use 25%
3) acute hepatitis B 25%

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98
Q

Normal paracetamol metabolism

A

Mostly glucuronidation or sulfation, some with p450 to NAPQI, binds to glutathione to conjugate and makes cysteine and mercaptopuric acid conjugates

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99
Q

Paracetamol toxicity metabolism

A

Glutathione depleted (also in malnutrition) so more NAPQI which causes hepatocyte injury

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100
Q

Classification of acute liver failure?

A

From onset of jaundice to hepatic encephalopathy:

1) hyperacute <7d
2) acute 8-28d
3) subacute 29d-12w

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101
Q

Outcome of hyperacute liver failure

A

Cerebral oedema and RICP more likely

Spontaneous resolution more likely

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102
Q

Definition of acute liver failure (3)

A

Hepatic encephalopathy
Jaundice
Coagulopathy INR>1.5

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103
Q

Hepatic encephalopathy grading and purpose

A

Grade at presentation is prognostic
On consciousness and physical signs
1) sleep reversible, reduced awareness, short attention span
2) personality changes, lethargy, poor memory; asterexis
3) somnolence, disorientated, confusion; rigidity, clonus, hyper-reflexia, nystagmus
4) stupor and coma

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104
Q

Risk factors for acute liver failure (7)

A 
>40y/o, female
Pregnant
Poor nutrition
Paracetamol for chronic pain
Drug/alcohol/substance abuse
Chronic hep b
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105
Q

4 symptoms acute liver failure

A

Nausea and vomiting
Abdo pain
Malaise
Depression and suicidal ideation

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106
Q

4 signs of acute liver failure

A

Hepatomegaly (acute viral hepatitis, Budd-Chiari syndrome, CHF with congestion)
RUQ tenderness
Signs of cerebral oedema: abnormal pupillary reflexes, rigidity, decerebrate posturing
No signs of chronic liver disease - spider naevi, splenomegaly, ascites, palmar erythema

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107
Q

LFTs in Wilson’s disease

A

AST:ALT >2.2, alk phos:bilirubin <4

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108
Q

Role of U&E in acute liver failure

A

Renal failure predicts mortality - hepatomegaly syndrome, ATN, hypovolaemia
Correct K, phosphate and Mg

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109
Q

FBC in Wilson’s disease

A

Anaemia with Coombs test negative haemolysis

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110
Q

Role of ABG in acute liver failure

A

Paracetamol = metabolic acidosis, lactate increased = prognostic

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111
Q

Hepatitis viral serologies in acute liver failure - which ones?

A

Anti-A and E IgM
Anti-B core and surface IgM
Anti-C IgG

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112
Q

Imaging in acute liver failure

A

USS and Doppler for:
Hepatic vein thrombosis in Budd-Chiari
Nodularity in cirrhosis, or regeneration

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113
Q

Monitoring in acute liver failure (3)

A

Neuro status
Culture surveillance
Central venous pressure and pulmonary artery

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114
Q

Management of acute liver failure (6 points)

A

ICU as risk of rapid deterioration, sepsis, cerebral oedema, haemodynamic instability and renal failure
RICP: raise head, +- mannitol (requires good renal function or RRT)
RRT for optimal fluid management and electrolyte correction
Caution in IVi for fluid overload
Propofol and fentanyl as short half lives
Enteral nutrition

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115
Q

Manage acute liver failure due to paracetamol toxicity

A

NAC

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116
Q

Manage acute liver failure due to Budd-Chiari syndrome

A

Anticoagulation, hepatic vein stent or TIPS

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117
Q

Manage acute liver failure due to pregnancy

A

Caessarian

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118
Q

Manage acute liver failure due to AI hepatitis

A

If AST>10x or >5x with raised GGT = prednisolone

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119
Q

Manage acute liver failure due to Wilson’s disease

A

Plasmapheresis, continuous veno-venous haemofiltration

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120
Q

Contraindications to liver transplant (3)

A

Severe infection or septic shock
Extrahepatic malignancy
ARDS, severe cardiopulmonary disease or multi organ failure

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121
Q

Acute indications for liver transplant (3)

A

Post-operative
Trauma
Fulminant hepatic failure - paracetamol and others ie congenital biliary atresia in children

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122
Q

Chronic indications for liver transplant (5)

A 
Cirrhosis due to alcoholism >6m abstinence
Chronic hepatitis
Hepatocellular carcinoma
PSC
PBC
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123
Q

Assessment for liver transplant score (2)

A 
Child-Pugh score - determines severity and required treatment:
Bilirubin
Refractory ascites
Albumin
INR
eNcephalopathy

MELD score - stratifies severity of end stage liver disease for transplant planning:
Creatinine
Sodium
Bilirubin
INR
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124
Q

Post-op treatment for liver transplant (4)

A

Cefuroxime
Metronidazole
PPI
Immunosuppression - methylprednisolone, ciclosporin, azathioprine, tacrolimus, monoclonal antibodies

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125
Q

Early complications of liver transplant

A

Bleeding, hypothermia
CVS - haemorrhage, vasodilation
Resp - TRALI, hypoxia, atelectasis, pleural effusion
Neuro - encephalopathy, cerebral oedema
Small for size - raised bilirubin, ascites, portal hypertension
Biliary leak
Biliary duct stricture
Hepatic artery thrombosis = fever and raised LFT
Portal vein thrombosis = ascites and renal failure

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126
Q

Late complications of liver transplant

A 
Chronic rejection
Renal failure
Sepsis from immunosuppression
Diabetes
Post-transplant lymphoproliferative disease - EBV
Disease recurrence
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127
Q

What is chronic liver disease?

A

Progressive destruction of liver parenchyma over >6m leading to fibrosis and cirrhosis

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128
Q

What are the 2 categories of hepatic encephalopathy?

A

Overt - defines decompensated liver failure
Covert -
- subtle neuropsychological signs, psychomotor slowness and difficulty with ADLs
- minimal and subclinical
- diagnose with psychometric testing

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129
Q

Sx of chronic liver disease for each region of body

A 
Asterexis, Dupeytron’s contracture, palmar erythema, leuconychia
Fatigue and encephalopathy
Jaundice and fetor hepaticus
Spider naevi and gynaecomastia
Ascites, hepatomegaly and caput medusae
Polyneuropathy
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130
Q

What is non-alcoholic fatty liver disease and what causes it?

A

Microvesicular steatosis, AST

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131
Q

Which hepatitis can cause chronic liver disease?

A

B, C, D

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132
Q

What is the most common cause of chronic liver disease?

A

Alcohol - 25% of cirrhosis

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133
Q

What questionnaire assesses drinking?

A

CAGE:
Do you ever think you should Cut down?
Do people Annoy you criticising your drinking?
Do you ever feel Guilty about how much you drink?
Do you ever need a drink as an Eye opener in the morning? To calm nerves or a hangover

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134
Q

Sx of alcoholic liver disease (3)

A

Nausea and vomiting
Abdo pain
Diarrhoea

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135
Q

Extrahepatic sx of alcoholic liver disease

A 
Porphyria cutanea tarda
Psychosocial - Wernicke-Korsakoff
Malnutrition
Cardiomyopathy, arrhythmia, HF
Gastritis and erosions
Proximal myopathy
Peripheral neuropathy
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136
Q

What is Wernicke’s encephalopathy? (4)

A

Confusion
Nystagmus
Ataxia
Opthalmoplegia

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137
Q

What is Korsakoff’s psychosis?

A

Short term memory loss

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138
Q

How is alcohol broken down?

A

Oxidised by cytochrome p450 or by alcohol dehydrogenase to acetaldehyde
By acetaldehyde dehydrogenase to acetate

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139
Q

How is the liver damaged by alcohol breakdown?

A

NADPH becomes NADP and NADH becomes NAD, releasing free radicals which cause hepatocellular damage

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140
Q

What are the 3 features of alcoholic liver disease?

A

Fatty change
Hepatitis
Fibrosis with nodular regeneration

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141
Q

Describe the fatty change seen in alcoholic liver disease

A

Ethanol is metabolised to fatty acids, which accumulate and cause cell destruction

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142
Q

When is fatty change seen except alcoholism? (4)

A

Diabetes, obesity
Starvation
Pregnancy

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143
Q

Describe hepatitis in alcoholic liver disease

A

Polymorphonuclear leukocytes and Mallory bodies (hyaline) infiltrate (also in chronic active hepatitis)

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144
Q

What is Zieve syndrome?

A

Triad of alcoholic hepatitis/cirrhosis, hyperlipidaemia and haemolytic anaemia, with unconjugated bilirubin (jaundice) and abdo pain. Caused by alcohol withdrawal. Treat with abstinence

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145
Q

FBC in alcoholic liver disease (3)

A

Macrocytosis
Thrombocytopoenia - toxic to megakaryocytes
Leukocytosis

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146
Q

Further investigations for alcoholic liver disease

A

USS - macronodular, irregular margin, fatty change

Biopsy (trans jugular to minimise bleeding) - fatty change and cirrhosis

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147
Q

Manage alcoholic liver disease (4)

A

Abstinence increases 5y survival from 60-90%
Thiamine
Protein and calorie supplements
Withdrawal with benzodiazepines

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148
Q

What is haemochromatosis? Name 6 things it causes and investigation results

A

Excess iron absorption causing deposition in liver and organs

Cirrhosis
Diabetes
Heart failure
Arrhythmia
Hypogonadism
Skin discolouration

Iron, ferritin and transferrin saturation increased, seen on biospy

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149
Q

What is the treatment for haemochromatosis? (2)

A

Regular venesection or desferrioxamine

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150
Q

What is Wilson’s Disease? Name 6 things it causes and investigation results

A

Autosomal recessive accumulation of copper

Neuropsychiatric - Parkinsonism
Keyser-Fleicher rings
Arrhythmia
Cardiomyopathy
Cirrhosis
Renal tubular damage

Caeruloplasmin reduced, urinary copper increased

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151
Q

What is the treatment for Wilson’s disease?

A

Copper chelators - penicillamine

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152
Q

What is a1 antitrypsin deficiency and name 2 things it causes

A

A1-AT is a protease inhibitor which mediates inflammatory process. Deficiency causes excess breakdown of proteins in lungs and liver
Causes early onset basal lung emphysema and late onset cirrhosis

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153
Q

What are 5 genetic causes of chronic liver disease?

A 
A1 antitrypsin deficiency
CF
Haemochromatosis
Wilson’s disease
Hereditary glycogen storage diseases
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154
Q

Who gets AI hepatitis and what is it associated with?

A

F>M, peaks in early 20s and perimenopausal

Associated with thyroiditis, psoriatic arthritis, AI haemolytic anaemia

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155
Q

What are 3 causes of AI hepatitis?

A

Primary sclerosing cholangitis
Primary biliary cirrhosis
AI hepatitis

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156
Q

Sx of primary biliary cirrhosis (6)

A 
Pruritis
Fatigue and lethargy
Dark urine and pale stools
Xanthelasma/xanthoma
Bone disease from reduced vit D absorption
Signs of chronic liver disease
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157
Q

Investigations for PBC (6)

A 
LFT:  alk phos +
Cholesterol +
AMA ++, ANA/antiSM +
IgM +
MRCP
USS for focal lesion, thrombosis, external compression
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158
Q

Complications of PBC (4)

A

Renal tubular acidosis
Cirrhosis
Osteoporosis
Osteomalacia and coagulopathies

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159
Q

Treat PBC (4)

A

Cholestyramine for pruritis
Ursodeoxycholic acid
Vit A, D, E, K and calcium
Bisphosphonates

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160
Q

What is primary sclerosing cholangitis?

A

Inflammation and fibrosis of intra/extra hepatic biliary ducts

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161
Q

6 sx of PSC

A 
IBD symptoms (linked to UC)
Abdo pain, jaundice, pruritis
Fatigue and weight loss
Recurrent biliary infections
Features of CLD
Cirrhosis
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162
Q

Investigate PSC (4)

A

ANCA, AntiSM, ANA
LFT - high or normal
MRCP - bead like multiple strictures
Biopsy - progressive fibrous cholangitis

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163
Q

Complication of PSC

A

Cholangiocarcinoma

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164
Q

Treat PSC (6)

A 
Ursodeoxycholic acid
Cholestyramine
Vitamins
Antibiotics if bacterial cholangitis
Stent/drain - balloon dilatation, sphincterotomy
Liver transplant
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165
Q

Presentations of AI hepatitis (3)

A

CLD +- jaundice
Acute hepatitis with jaundice
AI - fever, rash, arthritis, malaise

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166
Q

Investigations for AI hepatitis (3)

A

LFT - raised bilirubin, ALT, IgG
FBC - normocytic normochromic anaemia, thrombocytopoenia, leucopoenia
Anti-SM antibodies

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167
Q

Treatment for AI hepatitis (2)

A

Corticosteroids induce remission

Azathioprine - antiproliferative immunosuppressant

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168
Q

Drugs which cause chronic liver disease and why (5)

A

Isoniazide - acute hepatitis
Methotrexate and amiodarone - cholestasis
Phenytoin and valproate - necrosis

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169
Q

Sarcoidosis and chronic liver disease, and treatment

A

Non-caseating granulomas, normally in lung, lymph nodes and skin
Treat with steroids and azathioprine

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170
Q

3 main areas of cirrhosis features

A

CLD stigmata
Endocrine
Neuro

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171
Q

Endocrine features of cirrhosis (5)

A

Loss of libido
Testicular atrophy, amenorrhoea
Parotid enlargement
Gynaecomastia

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172
Q

Cirrhosis investigations

A

LFT normal or all abnormal
Glucose high from pancreatic insufficiency
Dilutional hyponatraemia and albuminaemia
Raised PT
Macrocytic anaemia, B12/folate deficiency

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173
Q

Cirrhosis biomarker

A

A-fetoprotein for hepatocellular carcinoma

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174
Q

Secondary investigations for cirrhosis

A

USS - size, fatty change, fibrosis, carcinoma
Biopsy - macronodular = hepatitis B/C, micronodular = alcohol
Endoscopy for varicose - band or B blocker

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175
Q

4 complications of cirrhosis

A

Portal vein hypertension
Ascites
Encephalopathy
Hepatorenal syndrome

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176
Q

What causes hepatorenal syndrome?

A

Reduced intravascular volume activates RAAS, causing vasoconstriction of afferent arterioles, lowering GFR
Renal failure also from sepsis, diuretics or paracentesis reducing volume

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177
Q

What causes hepatic encephalopathy?

A

Toxic metabolites and ammonia from protein breakdown

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178
Q

What causes portal hypertension?

A

Collagen and fibrosis causes sinusoidal portal vascular resistance
Vasoactive substances from toxic metabolites ie nitric oxide cause vasodilation
Sodium retention causes increased plasma volume

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179
Q

How to treat vasodilation, increased plasma volume and varices in cirrhosis

A

Vasodilation - crystalloids and blood to replace intravascular volume; vasopressin analogue terlipressin to cause splachnic vasoconstriction and decrease portal flow
Plasma volume - spironolactone, loop diuretics, shunt (IJV, TIPS)
Varices - endoscopy and sclerotherapy, balloon tamponade, banding, TIPS, and B blockers

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180
Q

Cause of ascites in cirrhosis (2)

A

Vasoactive substances cause arterial vasodilatation - active RAAS - increase hydrostatic pressure - transudate
Hypoalbuminaemia decreases oncotic pressure

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181
Q

Sx and treatment of peritonitis

A

Nausea, abdo pain, fever, neutrophilia, clinical deterioration
Treat with fluroquinolone (ciprofloxacin)

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182
Q

How is iron absorbed?

A

Kept soluble by gastric acid, as ferrous and bound to gastroferrin. Binds to transferrin and undergoes endocytosis then is split, releasing iron into the blood where it is once again bound to transferrin

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183
Q

How are carbohydrates broken down in the intestine?

A

By a-amylase and bb enzymes to glucose

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184
Q

How is glucose absorbed?

A

Uses sodium gradient for active absorption using the SGLT1 cotransporter, into mucosal cells. Then diffuses through GLUT2 into ECF

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185
Q

How are fructose and lactose absorbed?

A

Through facilitated diffusion

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186
Q

What is in oral rehydration therapy and why?

A

Sodium and glucose - stimulates 2 osmotic gradients to increase water absorption

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187
Q

How is calcium absorbed?

A

Stimulated by PTH, uses vitamin D, to use Ca-ATPase pump for facilitated diffusion

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188
Q

How much calcium is absorbed compared to intake?

A

700mg absorbed of 6g consumed

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189
Q

How is B12 absorbed?

A

Binds to intrinsic factor to be absorbed in terminal ileum

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190
Q

What is absorbed in duodenum?

A

Water, HCO3- and iron

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191
Q

What is absorbed in jejunum?

A

Amino acids, fatty acids, carbs, vitamins, minerals, electrolytes and water

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192
Q

What is absorbed in large intestine?

A

Final water and salt

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193
Q

How much fluid is absorbed in SI?

A

14l to 1.5l

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194
Q

What happens when carbs are not absorbed?

A

Fermented by colonic bacteria to carbon dioxide, methane and hydrogen which causes bloating and distension
And fatty acids (acetate, lactate) which cause diarrhoea

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195
Q

What happens if fats are not absorbed? (2)

A

Trap fat soluble vitamins A, D, E, K - deficiency

Unabsorbed bile salts causes water secretion into colon which causes diarrhoea

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196
Q

How does bacteria cause malabsorbtion?

A

Overgrowth causes deconjugation and dehydroxylation of bile salts, decreasing fat absorption

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197
Q

What is the mechanism of coeliac disease?

A

Gluten-sensitive T cells cause inflammatory response causing mucosal villus atrophy in SI

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198
Q

Diagnosis of coeliac disease (4)

A 
T-TGA
Anti-EMA (endomysial antibody)
Iron deficiency (microcytic anaemia)
SI biopsy (D2) = villus atrophy, crypt hyperplasia, increased Intraepithelial cells
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199
Q

4 symptoms of coeliac disease

A

Failure to thrive
Anorexia
Apathy
Soft bulky clay-coloured offensive-smelling stools

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200
Q

8 signs of coeliac disease

A 
Hypotonia
Muscle wasting
Pallor and sx of anaemia
Abdo distension
Glossitis
Angular stomatitis
Apthous ulcers
Dermatitis herpatiformis
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201
Q

Skin condition associated with coeliac disease

A

Dermatitis herpatiformis - intense pruritic papulo-vesicular rash. Symmetrical on elbows, knees, shoulders, buttocks, scalp - extensors

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202
Q

Complications of coeliac disease

A

Intestinal lymphoma and other GI malignancies
Reduced fertility and amenorrhoea
Vit D and calcium deficiency causing osteomalacia/poenia/porosis

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203
Q

What 3 conditions are linked with exocrine pancreatic insufficiency?

A

CF (90% of CF patients will have it)
Chronic pancreatitis
Diabetes (T1)

204
Q

6 sx of exocrine pancreatic insufficiency

A 
Weight loss
Anorexia
Diarrhoea
Abdo pain
Steatthoroea
Flatulence
205
Q

Diagnosis of exocrine pancreatic insufficiency

A

Elastase in stool
Direct pancreatic output test (invasive)
ERCP (invasive), MRCP, USS, CT

206
Q

Investigation for macrocytic anaemia and what is it caused by

A

B12 deficiency from damaged terminal ileum - Schilling test for pernicious anaemia

207
Q

What is Zollinger-Ellison syndrome

A

Gastrinoma - islet cells or gastric producing duodenal cells

208
Q

Laxative for soft faeces and route

A

Stimulant/irritant - Senna (bisocodyl) - excites nerve endings increasing intestinal motility
PO or suppository, or glycerol as rectal stimulant
Pre-op or impaction
Rapid (6-8h)

209
Q

Initial ADR of bisacodyl (senna) (2)

A

Cramps

Hypokalaemia

210
Q

Long term ADR of bisacodyl (2)

A 
Colonic atony
Melanosis coli (abuse)
211
Q

CI to bisacodyl (2)

A

Obstruction

Acute colitis

212
Q

Bulking laxative?

A

Isphagula husk or fybogel
Add water in GI = increased peristalsis
Takes a few days

213
Q

ADR of bulking laxatives (3)

A

Obstruction
Distension
Flatulence

214
Q

CI to bulking laxatives (4)

A

Dysphagia
Atony
Obstruction
Impaction

215
Q

Softener laxative and what for

A

Arachis oil enema - lubricates

For fissure/adhesion/haemorrhoids and <3y/o

216
Q

Osmotic laxatives (4)

A 
Laculose
Movicol - 2-3D
Mg and Na salts - pre-op as rapid
Phosphate enema - pre-op as rapid
Retain fluid in bowel
217
Q

How does laculose work and what is this useful for

A

Ferments with fructose and colonic bacteria to make acetic acid and lactic acid = osmotic diarrhoea
Causes low pH that discourages growth of ammonia-producing organisms
For hepatic encephalopahy

218
Q

ADR of laculose (4)

A

Bloating
Cramps
Abdo discomfort
Flatulence

219
Q

4 types of laxatives and an example of each

A

Stimulant - bisacodyl//senna
Bulking - isphagula husk or fybogel
Softener - arachis oil enema
Osmotic - laculose, movicol, Mg/Na salts, phosphate enema

220
Q

IBS treatment - diet and medication

A
  1. Reduce insoluble fibre if diarrhoea predominant
    Fibre supplements if constipation predominant
    +- probiotics for 4w
  2. Anti-motility loperamide for diarrhoea
    Anti-spasmodic mebeverine for pain
  3. TCA
221
Q

4 classes of anti-diarrhoeals

A
  1. Codeine/loperamide - antimotilility to increase absorption anal tone and decrease defamation reflex
  2. Bulker isphagula, or kaolin increases water absorption
  3. Bile salt sequestrant cholestyramine - for Crohn’s, post-vagotomy when increased bile salts causes diarrhoea
  4. Pancreatic enzymes Creon if malabsorption
222
Q

ADR of anti-motility loperamide (3)

A

NV, constipation, drowsy

223
Q

CI of anti-motility loperamide

A

Toxic megacolon

224
Q

Treatment of GORD/oesophagitis - 3

A

Lifestyle
Antacid - ST buffer gaviscon or alginate - layers GI surfaces sucralfate
PPI omeprazole/lansoprazole if oesophagitis (to aid healing and maintenance) or proven GORD (initial healing)

225
Q

Lifestyle changes for GORD - 7

A 
Weight loss
Avoid trigger foods - coffee, tomatoes
Small meals, last 3-4h before bed
Stop smoking
Reduce alcohol
Raise head of the bed
Treat anxiety/stress
226
Q

Causes of dyspepsia - 5

A 
GU/DU
GORD/oesophagitis
Duodenitis/gastritis
Non-ulcer dyspepsia
Gastric malignancy
227
Q

H Pylori treatment (3)

A

PAC triple therapy for 1-2w, 90% effective:
PPI lansoprazole
Amoxicillin - B lactate, strep, gram neg
Clarithromycin - macrolide, protein synthesis

Surgical lower oesophageal sphincter reinforcement
Vagus resection

228
Q

How does H2 antagonist work

A

Stops amplification of ACH and gastric by histamine for 80% acid reduction

229
Q

ADR of cimetidine - 4

A

Dizzy, rash, fatigue, gynaecomastia

230
Q

What stimulates gastrin release (2)

A

Proteins/peptides

ACh

231
Q

What stimulates ACh release (3)

A

Post-ganglionic PSNS - cephalic phase
Distension - gastric phase
Amines on food buffer H+, decreasing acid (gastric phase)

232
Q

What inhibits gastrin release (2)

A

Less food causing more acid (intestinal phase)

Chyme leaves stomach, causing release of CCK and GIP (intestinal phase)

233
Q

Where are chief cells in the stomach and what do they release?

A

Upper 2/3 = enzymes

234
Q

Where are parietal cells in the stomach and what do they release?

A

Upper 2/3 = acid and intrinsic factor

235
Q

Where are G cells in the stomach and what do they release?

A

Lower 1/3 = gastrin

236
Q

Where are neck cells in the stomach and what do they release?

A

Lower 1/3 = mucous and HCO3- unstirred layer

237
Q

What do PPIs do and when should they be taken?

A

Irreversibly inhibit ATPase so no acid is pumped

30m before breakfast

238
Q

ADR of PPI (3)

A

NV, headache, gastric atrophy

239
Q

Mechanism of vomiting - 4

A

Pyloric sphincter closes
Cardia and oesophagus relax
Diaphragm and abdo wall contract
Glottis closes

240
Q

Where is chemoreceptor trigger zone?

A

Chemoreceptor trigger zone on floor of 4th ventricle in postrema area - part of medulla oblongata

241
Q

What area activates vomiting?

A

Medullary centre in CTZ

242
Q

How does 4th ventricle communicate with medullary centre?

A

Dopamine to D2

243
Q

Where do domperidone and metaclopramide act and what other mechanism do they use?

A

Inhibit D2 in CTZ, and ACh for M1 receptors

Pro kinetic - increase frequency and power of contractions to increase rate of emptying

244
Q

7 uses for domperidone?

A 
L-Dopa
Uraemia
Radiation
GI
Opioids
Migraine and post-op = metaclopramide
245
Q

2 ADRs of domperidone and metaclopramide?

A

Extrapyramidal ADRs - dystopia, oculogyric crisis (young people)
Increased prolactin = galactorrhoea

246
Q

How do ondansetron and granisetron work and what for?

A

Block serotonin from medullary centre - for CNS and GI stimulates ie cytotoxic drugs and post-op

247
Q

What can enhance ondansetron?

A

Steroids increase effect

248
Q

ADRs of ondansetron and granisetron - 3

A

Flushing
Headache
Constipation
- reduced vagal afferent nerve

249
Q

What is cyclizine for?

A

Inhibits H1 in medullary centre - crosses BBB so sedative as well - good for acute NV, motion and morning sickness

250
Q

ADR of cyclizine

A

Prolongs QT interval - CI = MI

251
Q

What do hyoscine and scopolamine do?

A

Inhibit ACh between vestibular apparatus and medullary centre for motion sickness and post-op
Also antispasmodic and antisecretory

252
Q

Why is hyoscine good for motion sickness?

A

Inhibits ACh from vestibular apparatus and short half-life

253
Q

ADR of hyoscine and scopolamine - 4

A

Dry mouth
Blurred vision
Palpitations
Brady/tachycardia

254
Q

DDI for hyoscine and scopolamine and why?

A

Prokinetic D2 antagonist metaclopramide and domperidone as anti-spasmodic

255
Q

What 2 neurotransmitters communicate vestibular apparatus and medullary centre?

A

ACh and histamine

256
Q

Initial treatment for severe vomiting

A

IV fluids
K replacement
Monitor electrolytes and fluid balance

257
Q

What kinds of cancer are in the oesophagus and where are they?

A

SCC in upper 2/3, adenocarcinoma in lower 1/3

258
Q

What blood vessels supply the oesophagus?

A

Inferior thyroid artery, thoracic aorta with oesophageal branches
Azygous vein

259
Q

SCC of the oesophagus associated factors (5)

A

Developed countries
Smoking and alcohol
Vit A/riboflavin deficiency
Chronic alcoholism HPV

260
Q

Adenocarcionoma of the oesophagus associated factors

A

Developed world
Barrett’s oesophagus = metaplastic epithelium = dysplasia = malignant
- long standing GORD, obesity, high density fat

261
Q

Red flags for oesophageal carcinoma

A

Dyspepsia, dysphagia, weight loss and upper abdo pain

>55y/o

262
Q

Early sx of oesophageal carcinoma - 2

A

Restrosternal dyscomfort and dyspepsia

263
Q

Late sx of oesophageal carcinoma - 5

A

Dysphagia - solids then liquids
Significant weight loss - dysphagia and anorexia
Odynophagia
Hoarse
Productive cough - aspirating pharyngeal secretions or oesopho-tracheal fistula

264
Q

Exam for oesophageal carcinoma - 4

A

Weight loss/cachexia
Lymphadenopathy
Dehydration
Metastatic - jaundice, ascites, hepatomegaly

265
Q

5 advanced investigations for oesophageal carcioma

A

OGD - biopsy and histology
CT neck thorax
Endoscopic USS and spiral CT for staging - penetration into wall
Staging laparoscopy for intraperitoneal masses
FNA for palpable cervical lymph nodes

266
Q

Curative management of SCC in the oesophagus

A 
Upper = chemoradiotherapy
Mid/lower = neoadjuvant CRT +- surgery
267
Q

Curative management of oesophageal adenocarcinoma

A

Neoadjuvant chemo or CRT followed by resection

If less fit, surgery only

268
Q

How much of oesophageal cancer is palliative and what is the management - 5?

A

70% of patients
Oesophageal stent
RT/chemo to reduce size and bleeding
Photodynamic therapy - oxygen produced by light waves kills tumour
Nutrition - thickened fluid and supplements
Radiologically inserted gastrectomy

269
Q

Complications of surgery for oesophageal carcinoma - 3

A

Pneumonia
Anastamosis leak
Death

270
Q

Management of anastamotic leak following oesophageal surgery

A

CT CAP with PO contrast
NBM
Resuscitate

271
Q

Post-op nutrition for oesophageal surgery

A

Feeding jejunostomy and small meals 5x/d as some of stomach is lost

272
Q

Mechanism of surgery for oesophageal cancer

A

Ivor-Lewis resection: remove tumour, nodes and top of stomach and make stomach into tube to replace oesophagus
Very early cancer = endoscopic mucosal resection +- radiofrequency ablation

273
Q

6 causes for malabsorption/digestion

A
  1. Inadequate mixing/rapid emptying ie gastroenterostomy or gastrocolic fistula
  2. Impaired transport ie pernicious anaemia or Addison’s
  3. Acutely abnormal epithelium ie infection, alcohol or neomycin; Chronically abnormal epithelium ie Crohn’s, coeliac, ischaemia
  4. Insufficient digestive agents ie cirrhosis, chronic pancreatitis, CF
  5. Abnormal milieu ie bacterial overgrowth, Zollinger-Ellison, motility problem ie diabetes, scleroderma, high/low thyroid
  6. Short bowel from resection or jejunoileal bypass for obesity
274
Q

Investigate gastrinoma in pancreas/duodenal wall - 2

A

Gastrin serum level, CT/scintigraphy/PET scan

275
Q

Treat gastrinoma - 3

A

PPI, surgery, chemo

276
Q

FBC and sx of iron deficiency

A

Hypochromic microcytic anaemia

Glossitis

277
Q

FBC vit B12/folate deficiency

A

Macrocytic anaemia

278
Q

Vit C/k deficiency 3 sx

A

Bleeding
Petechiae
Bruising

279
Q

What vit deficiency causes peripheral neuropathy?

280
Q

What vit/min deficiency causes glossitis? (5)

A

B12, B2, folate, niacin, iron

281
Q

What does calcium and magnesium deficiency cause?

A

Carbopedal spasm

282
Q

What deficiencies can cause bone pain and fracture?

A

K, Mg, Ca, vit D

283
Q

What sign does protein deficiency cause?

284
Q

8 risk factors for gastric cancer

A 
H Pylori
Age
Smoking
IBD
Alcohol
Salt
Family history 
Pernicious anaemia
285
Q

What is H Pylori and how does it cause damage?

A

Gram neg helicobacter, releases urease which breaks urea down to carbon dioxide and ammonia. Ammonia neutralises acid producing an alkaline microenvironment for a cycle of damage to epithelial cell, causing inflammation, ulceration and neoplasia

286
Q

Presentation of gastric cancer

A

Non specific and vague
Dyspepsia, dysphagia, NV, melaena, haematemesis
Cancer symptoms at late stage

287
Q

Signs in advanced gastric cancer (6)

A 
Anaemia 
Epigastric mass
Jaundice
Hepatomegaly
Acanthosis nigricans
Troisier’s sign (supraclavicular/Virchow’s node)
288
Q

3 initial investigations for gastric cancer

A

CEA (in 50%) - monitor progress and treatment
Endoscopy for polyps and biopsy
CLO breath test for H Pylori

289
Q

What is found on biopsy of gastric cancer?

A

Ulcerating, fungating, linitis plastica (=infiltration)

290
Q

2 investigations for treatment plan of gastric cancer?

A

Her2/neu protein expression for targeted monoclonal therapies
CT CAP and laparoscopy for staging and peritoneal masses

291
Q

Where does gastric cancer spread to?

A

Through wall to duodenum, transverse colon, pancreas

Transcoelomic to ovaries, peritoneum, liver, nodes

292
Q

4 complications of gastric cancer?

A

Gastric outlet obstruction
Perforation
Iron deficiency
Malnutrition

293
Q

Curative treatment options for gastric cancer? (3)

A

Endoscopic mucosal resection if confined to mucosa
Subtotal gastrectomy if distal (antrum or pyloris)
Total gastrectomy if proximal
And connect small bowel to oesophagus
+ neo/adjuvant chemo

294
Q

Complications of total gastrectomy - 5

A 
Anastamotic leak
Reoperation
B12 deficiency
Dumping syndrome
Death
295
Q

What is dumping syndrome?

A

Early (10-30m) - sudden hypertonic contents in small intestine causes intraluminal fluid shift, causing distension, causing NV, diarrhoea, hypovolaemia which activate the SNS = tachycardia and sweating
Late (1-3h) - insulin surge = hypoglycaemia - avoid with small frequent meals

296
Q

Nutrition for gastric cancer?

A

Nasogastric or radiologically inserted gastrotomy tube

297
Q

Palliative management of gastric cancer (4)

A

Supportive
Chemo
Stent obstruction
Surgery - distal gastrectomy or bypass if no stent or bleeding

298
Q

What are the 4 main types of gastric cancer?

A

Glandular adenocarcinoma - well differentiated glandular formation or mucous-secreting acini
Diffuse spreading fibrous adenocarcinoma = linitis plastica
Lymphoma from MALT (B cell non-Hodgkin’s)
Stromal - Interstitial cells of Cajun - uncommon and unpredictable, necrosis, mitosis and pleomorphism

299
Q

What is the targeted therapy for stromal gastric cancer?

A

Imatinim to CD117 or CKit

300
Q

What are 2 sx of gastric lymphoma and what’s the prognosis?

A

Night sweats
Raised LDH
Marrow involvement
80-90% survival with curative incision

301
Q

What gastric cancer is associated with H Pylori?

A

Lymphoma - treat with abx first

302
Q

How common is colorectal cancer?

A

Commonest GI cancer and 3rd most common cancer in the UK

303
Q

What are 6 risk factors for colorectal cancer? How many cases are sporadic?

A 
>60y/o
Family history
IBD
Low fibre
High processed meat
Smoking and alcohol
75% sporadic
304
Q

What genetic mutations are related to colorectal cancer? (4)

A

Adenomatous polyposis coli (TSG) on chr5 - Familial Adenomatous Polyposis = increased adenomatous tissue growth
Kras, KBraf
Hereditary non-polyposis colorectal cancer - DNA mismatch repair

305
Q

What is the timeline of progression from normal epithelium to colonic carcinoma?

A

Normal - abnormal - small adenomatous - large adenoma - colonic carcinoma
10-15y

306
Q

What is found on microscopy of colorectal cancer?

A

Abnormal glands - signet cells, mucous cells - growing into muscle wall

307
Q

What is found on macroscopy of colorectal cancer and what are the key symptoms with each side?

A

Right = fungating = abdo pain, occult bleeding, RIF mass
Left = stenosis = bleeding, change in bowel habit, tenesmus, LIF mass
Weight loss only if mets or obstruction

308
Q

Where are most colorectal cancers?

A

60-70% rectosigmoidal

309
Q

Primary investigation for colorectal cancer and when to do it?

A

Occult faecal blood test
>40 and unexplained weight loss or abdo pain
>50 and rectal bleeding
>60 and iron def anaemia or change in bowel habit

310
Q

Imaging for colorectal cancer?

A

Colonoscopy and biopsy, unless comorbidities
Significant comorbidities = flexible sigmoidoscopy
CTCAP for staging
MRI for resection margin, tumour and node staging to predict recurrence
Endoanal USS to assess suitability for trans-anal resection

311
Q

What is the staging system for colorectal cancer?

A 
Duke’s staging:
A = confined to muscularis mucosa
B = extension through muscularis
C = regional nodes - 1 = close, 2 = apical
D = distant mets
312
Q

What are survival rates for different stages of colorectal cancer?

A 
A = 90%
B = 65%
C = 30%
D = <10%
313
Q

Management for colorectal cancer?

A

Regional colectomy with margin and lymph node drainage, creating primary anastamosis or stoma
Neo/adjuvant CRT if rectum (15cm) or anus (8cm)

314
Q

Blood supply to right side of colon?

A

Middle colic, right colic and ileocolic - off SMA

315
Q

Blood supply to left side of colon?

A

Middle colic off SMA

Left colic with superior and inferior branches - off IMA

316
Q

Blood supply to sigmoid?

A

Superior rectal and sigmoidal off IMA

317
Q

Difference between anterior resection and abdominal perineal resection?

A 
Anterior = >5cm from anus, sphincter intact and anastamosis
APR = <5cm from anus, permanent colostomy
318
Q

What is Hartmann’s procedure?

A

Emergency for obstruction/perforation - end colostomy and close stump

319
Q

Palliative surgery for colorectal surgery?

A

Endoluminal stent if left sided and not rectal as = tenesmus

Stoma if acute obstruction

320
Q

Where are carcinoid tumours found? (3)

A

Appendix, terminal ileum, rectum

321
Q

Presentation of carcinoid tumours (5)

A 
Diarrhoea (secretory)
Flushing
Abdo pain
Obstruction
Liver mets
322
Q

How is serotonin metabolised? (3)

A

Reduced by first pass metabolism
With bradykinin and histamine
In urine

323
Q

Cardiac complications of carcinoid syndrome?

A

Right cardiac lesions - tricuspid regurgitation, pulmonary artery stenosis

324
Q

Treat carcinoid tumour?

A

Resect or somatostatin analogue to reduce gut hormone release

325
Q

3 types of anal cancer?

A

Squamous from below dentate line = 80%
Adenocarcinoma from upper canal epithelium and crypt glands = 10%
Melanomas and anal skin cancers = 10%

326
Q

What is a precursor to anal cancer and how is it graded?

A

Anal Intraepithelial Neoplasia - in canal or perianal skin
Strongly linked with HPV
Graded by cytological atypia degree and depth
2-3 = premalignant and becomes invasive cancer

327
Q

Risk factors for anal cancer? (6)

A

HPV 16/18, HIV, Crohn’s, age, smoking, immunosuppression

328
Q

6 symptoms of anal cancer

A

Bleeding and pain (50%)
Discharge
Pruritis
Tenesmus and incontinence from sphincter involvement

329
Q

Exam findings for anal cancer (4)

A

Lymphadenopathy
Wart like lesions on perineum, perianal and vulval/vaginal
Palpable mass on DRE - establish distance from anal verge and fraction of circumference
Fistula-in-ano and infection if locally invasive

330
Q

7 areas of investigation for anal cancer

A 
Examine - DRE, perianal area, nodes
Proctoscopy
Under anaesthetic for size and invasion
Biopsy
HIV
Smear test for CIN or VIN
Staging imaging:  USS FNA palpable inguinal nodes, CT CAP, MRI pelvis for extent of local invasion (T of TNM)
331
Q

What nodes do different parts of anus drain to?

A

Below dentate line = superficial inguinal nodes

Above dentate line = para-aortic, mesorectal, paravertebral

332
Q

Management of T1N0 anal cancer?

A

Local excision

333
Q

Management of anal cancer? (2 lines)

A

CRT - external beam RT to anal canal and inguinal nodes
+ dual chemotherapy
Abdominoperineal resection if advanced or chemo failure

334
Q

Short term complications of CRT for anal cancer? (4)

A

Dermatitis
Proctitis and cystitis
Diarrhoea
Leucopoenia and thrombocytopoenia

335
Q

Long term complications of CRT for anal cancer? (4)

A

Fertility
Erecitile dysfunction and vaginal dryness
Faecal incontinence
Rectovaginal fistula

336
Q

4 benign liver primaries

A

Hepatic adenoma
Bile duct adenoma/haematoma
Haemangioma
Focal nodular hyperplasia

337
Q

Manage hepatic adenoma? What’s associated with it?

A

Resect due to risk of malignancy or rupture
Associated with OCP
Can cause intrahepatic bleeding

338
Q

Diagnose haemangioma?

A

USS or angiography

339
Q

Manage focal nodular hyperplasia?

A

No risk of malignancy, normal function, asymptomatic or RUQ pain
Mistaken for cirrhosis on radio/FNA

340
Q

Who is most likely to get hepatocellular carcinoma? 6

A 
>70 and male
Hepatitis - B and C
Aflatoxin
Alcohol
Smoking
Family history
341
Q

What conditions cause hepatocellular carcinoma? (3)

A

Viral hepatitis - B
Chronic alcoholism
Hereditary haemochromatosis, PBC
- causing cirrhosis

342
Q

Features of cirrhosis - groups of symptoms, 3 of signs

A

Fatigue, fever, weight loss, lethargy
RUQ dull ache - indicative of cancer in cirrhosis

Irregular enlarged craggy tender liver
Liver failure - jaundice, ascites (exudate +- blood)
Mets - lung and bone = pleural effusion and pathological fracture

343
Q

Initial investigations for liver cancer (3)

A

LFT - normal or raised as necrosis, alk phos raised from bony mets
FBC - low platelets, abnormal clotting
a-Fetoprotein raised in 70%

344
Q

Imaging for liver cancer - 4

A

USS: >2cm and raised afp = diagnostic
Staging CT
MRI and contrast CT angiography shows arterial hypervascularity
Biopsy and percutaneous FNA

345
Q

Barriers to liver cancer biopsy - 3

A

Ascites
Deranged clotting
Risk of seeding

346
Q

Liver cancer staging?

A

Barcelona Clinic Liver Cancer Staging System to determine which treatment: stage, liver function, physical status, cancer symptoms

347
Q

Score for cirrhosis?

A 
Child-Pugh:  risk of mortality and effectiveness of treatment options
Bilirubin
Refractory ascites
Albumin
INR
ENcephalopathy
348
Q

Score for end stage liver disease/transplant

A 
MELD:
Bilirubin
Dialysis number
INR
Creatinine
Sodium
for likelihood of tolerating transplant
349
Q

Management of liver cancer (4) and prognosis

A

<5% 6m survival
Surgery - if no cirrhosis and good baseline health, but 60% 5y recurrence
Transplant - if <5cm or 3x3cm and no vascular infiltration, and fulfil Milan criteria
Image guided USS or alcohol ablation causing necrosis - for small tumours and functioning liver
Trans-arterial Chemo embolisation if stage B multinodular - into hepatic artery causing ischaemia, preserves the majority of the liver

350
Q

How common is secondary liver malignancy?

A

Most common cause of death in cancer patients

351
Q

Where do liver mets come from? (5)

A 
Bowel (portal circulation)
Breast
Pancreas
Stomach
Lung
352
Q

What is there more of in secondary liver cancer than primary?

A

Ascites and hepatomegaly
Jaundice and RUQ pain
Non-specific cancer symptoms

353
Q

ALP in secondary liver cancer?

A

Raised ALP from biliary obstruction

354
Q

Management of secondary liver cancer?

A

Surgery if confined to liver and primary is controlled - TACE or internal radiotherapy
Palliative likely - most have other mets

355
Q

What is hep B associated with? - sx and conditions

A

Arthralgia and urticaria

Arthritis, glomerulonephritis, HCC

356
Q

What sx from hep A?

A

Jaundice, abdo pain
Fever, headache
Vomiting, diarrhoea

357
Q

What is Hep E associated with?

A

Pregnancy causing acute liver failure

358
Q

Treatment for hep A and B?

A 
A = self limiting
B = antivirals
359
Q

Age group for pancreatic carcinoma

360
Q

Types of pancreatic carcinoma? (3)

A

90% ductal carcinoma with poor prognosis
Exocrine = pancreatic cystic carcinoma
Endocrine = islet cell

361
Q

4 risk factors for pancreatic carcinoma

A

Smoking
Chronic pancreatitis
Recent or late onset diabetes (>50y/o)
Family history

362
Q

Presentation of pancreatic cancer - 6

A

Vague and late presentation - jaundice, cachexia/malnourished
Rare = pancreatitis, thrombophlebitis migrans (hypercoagulable)
Epigastric mass
Courvoisier’s law - enlarged painless gall bladder (distal to cystic duct)

363
Q

Where is the tumour likely to be in the pancreas if there is abdo pain and why?

A

Outer 2/3 - coeliac plexus invasion

364
Q

Where is the tumour likely to be in the pancreas if there is back pain?

A

Middle 1/3

365
Q

Where is the tumour likely to be in the pancreas if diabetic?

366
Q

Biomarker for pancreatic cancer

A

Ca19-9 for treatment response

367
Q

Investigations for pancreatic cancer (5)

A

Ca19-9
FBC = anaemia, thrombocytopoenia
LFT = raised alk phos, bilirubin and gamma GT = obstructive jaundice
USS = mass or dilated biliary tree, hepatic mass, ascites
CT for diagnosis and staging - assess respectability = arterial, pancreatic and portal vein phases

368
Q

Management for pancreatic cancer - 4

A

Surgery - distal pancreatectomy if body/tail, pancreaticoduodenectomy/Whipple’s procedure if head
Adjuvant chemotherapy
Creon - with meals if exocrine insufficiency causing malabsorption and steatthoroea
Palliative = stent if obstructive jaundice, pruritis (ERCP or percutaneous)

369
Q

What is Whipple’s procedure?

A

Pancreaticoduodenectomy for tumour at head of pancreas - also D1, D2, gall bladder, bile duct, stomach antrum
Tail and hepatic duct attached to jejunum and anastamosis to stomach

370
Q

Complications of surgery for pancreatic cancer - 3

A

Fistula
Delayed gastric emptying
Pancreatic insufficiency

371
Q

Endocrine tumours of pancreas?

A

MEN1/Wermer’s syndrome:

1) Hyperparathyroid
2) Endocrine tumour of pancreas
3) Pituitary tumour

372
Q

What does endocrine G cell tumour make and cause?

A

Gastrin = gastric acid = Zollinger-Ellison = PUD refractory to treatment, diarrhoea, steatthoroea

373
Q

What endocrine tumour can cause diabetes? What else does it cause?

A

A cells = glucagon = increase BM = diabetes, hyperglycaemia, necrolytic migratory erythema
Triad = weight loss, recent onset diabetes, unusual dermatitis

374
Q

What endocrine tumour can cause hypoglycaemia? What else does it cause?

A

B cells = insulin = decrease BM = hypoglycaemia, neuroglycopoenia symptoms (dysphoria, irritability, emotional, unconscious)

375
Q

What does d cell tumour cause (4)?

A

Somatostatin = reduce GH, TSH, prolactin and gastrin = mild diabetes, steatthoroea, gall stones (CCK), achlorhydria (reduced HCl in stomach

376
Q

What does a non-islet cell pancreatic tumour do?

A 
VIP = water and electrolytes into GI, relax enteric SM
Profuse watery diarrhoea
Hypokalaemia
Dehydration
= VIPoma = Verner-Morrison syndrome
377
Q

What 2 conditions can cause an isolated increase in bilirubin?

A

Gilbert’s syndrome = unconjugated hyperbilirubinaemia

Haemolysis = splenomegaly, anaemia

378
Q

How is the cause of haemolysis with increased reticulocye count identified?

A

Direct Coombs test: positive = AI, negative = do a blood film = membrane abnormalities, G6PD etc

379
Q

What causes elevation in ALT?

A

Acute hepatitis - A, B, C, E, EBV/CMV/toxoplasmosis, drugs, immunoglobulins, AI
Chronic hepatitis - B, C, diabetes, thyroid, lipids, immunoglobulins, a1-antitrypsin

380
Q

What causes elevation in ALP?

A

Acute cholestatic illness: stones, tumours, pancreas,drugs

Chronic cholestatic illness: PBC, PSC, NASH, HIV, sarcoidosis, amyloidosis, a1-antitrypsin

381
Q

What drugs can cause acute cholestatic disease?

A

OCP, azathioprine, isoniazid, allopurinol

382
Q

What score assess alcoholic hepatitis?

A

Glasgow Acute Alcoholic Hepatitis score

383
Q

7 causes of acute liver failure

A 
Drugs (paracetamol, halothane, ecstasy)
AI hepatitis
Viral hepatitis
Ischaemic hepatitis
Budd-Chiari syndrome
Wilson’s disease
Acute fatty liver of pregnancy
384
Q

Treat acute liver failure - 9

A 
N-Ac
Abx
Central access
Ventilate
Monitor coagulopathy, hypoglycaemia, renal function and acidosis
Nutrition
385
Q

6 signs of chronic liver failure

A 
Asterexis
Oedema
Splenomegaly
Gynaecomastia
Testicular atrophy 
Relative hypotension
386
Q

What is the mechanism of ascites and what is its incidence in liver failure?

A

50% of chronic liver failure patients in 10y, 50% die in 2y
Dilated peripheral arteries, reduced blood pressure, RAAS/SNS/ADH activation, increased water and sodium, dilutional hyponatraemia/reduced urinary sodium

387
Q

Treat ascites - 3

A

Salt and water restriction
Diuretics - spironolactone, furosemide
Paracentesis - diagnostic and therapeutic

388
Q

2 products contributing to encephalopathy

A

Protein = ammonia

Urea

389
Q

How is protein linked to encephalopathy?

A

From intake, GI bleed and constipation - increased ammonia and nitrogen production and absorption

390
Q

How is urea linked to encephalopathy from liver failure?

A

Renal failure increases urea

391
Q

What 2 physical mechanisms cause encephalopathy?

A

Reduced hepatocellular function from disease, anaemia, sepsis, hypotension
Portocaval shunting

392
Q

What causes portocaval shunting? (4)

A

Surgical
Spontaneous
TIPS
Portal vein thrombosis

393
Q

What drugs cause encephalopathy? (4)

A

Psychoactive - benzodiazepines, antiemetics, antihistamines, ethanol

394
Q

Treat encephalopathy - 4

A

Decrease disease effects: prevent sepsis, bleeding, stop drug
Avoid sedatives, hypnotics and opiates
Laculose BD
Metronidazole/neomycin

395
Q

5 causes of encephalopathy

A 
Increased protein = ammonia from intake/GI bleed/constipation 
Urea from renal failure
Portocaval shunting
Hepatocellular dysfunction
Psychoactive drugs
396
Q

2 ADRs of terlipressin for variceal haemorrhage

A

Ischaemia

Arrhythmia

397
Q

2 treatments for hyponatraemia

A

Fluid restriction

NaCl - hypertonic saline

398
Q

When to admit someone with hyponatriaemia -4

A

Severe or acute onset
Symptomatic
Hypovolaemia
?Addison’s?

399
Q

What kinds of things causes SIADH? (4)

A

Pulmonary disease
CNS disease
Drugs
Neoplasm

400
Q

What is the mechanism of SIADH?

A 
Continued AVP (arginine vasopressin) despite normal or increased plasma volume
Causes hyponatraemia, hypoosmolarity and sodium renal excretion
401
Q

3 ADRs of interferons for hepatitis B

A

Lethargy
Neuropsychiatric
Neutropoenia

402
Q

Ribavirin 3 ADRs for hepatitis C

A

Thrombocytopoenia, haemolytic anaemia

Anxiety

403
Q

Risk factors for HCV? (3)

A

PWID
Haemodialysis
Birth - vertical

404
Q

Results from HCV treatment?

A

20% cleared
80% chronic - of these, 1/3 will have no sx, 2/3 will have sx/cirrhosis
Eventual: 4% liver failure, 1.5% cancer

405
Q

How does terlipressin work in hepatorenal syndrome?

A

Stops splachnic dilatation so stops hypovolaemia - prevents renal bv constriction and lowering of GFR

406
Q

Outcome of hepatorenal syndrome and treatment?

A

80-95% 2w mortality

Decrease with transplant, vasopressin analogues and TIPS

407
Q

How does TIPS work in hepatorenal syndrome and what are 2 ADRs?

A

Lowers blood pressure, prevents vasodilation

Encephalopathy and haemolysis

408
Q

Risk factors for hepatorenal syndrome in hepatic failure - 2

A

Advanced diuretic resistant ascites

Large volume paracentesis

409
Q

Types of hepatorenal syndrome?

A

Type 1 = acute with 2w survival: creatinine rises or 24h CrCl decreases
Type 2 = chronic with 6m survival: refractory ascites

410
Q

Microscopic changes in non alcoholic fatty liver disease (4)

A

Mallory bodies
Lobular neutrophil inflammation
Perisinusoidal fibrosis
Ballooning degeneration

411
Q

Treat NASH?

A

Treat diabetes and hyperlipidaemia - statins, fibrates

412
Q

What 2 things contribute to NASH?

A

Insulin resistance and oxidative stress

413
Q

What 4 things cause oxidative stress?

A

Endotoxins
Cytokines
ROS
Toxins

414
Q

What 3 cellular things cause NASH?

A

Stellate cell activation
Cytokines
Peroxidation of hepatocyte membrane

415
Q

4 complications of non alcoholic fatty liver disease

A

Advanced liver fibrosis
Diabetes 2
Hypertension
CKD

416
Q

4 complications of non alcoholic fatty liver disease and diabetes 2?

A

AF
MI
Stroke
CVD

417
Q

5 drugs that cause non alcoholic fatty liver disease?

A 
MC-fAT
Methotrexate
Corticosteroids
tamoxiFen
Amiodarone
Tetracycline
418
Q

Diagnose NAFLD? -3

A

LFT
USS
Biopsy

419
Q

3 symptoms of NAFLD

A

Fatigue
Malaise
Abdo discomfort

420
Q

4 treatments of NAFLD?

A

Diet
Exercise
Antiglycaemics
Bariatric surgery

421
Q

What complicates diagnosis of cirrhosis?

A

Don’t diagnose if have diabetes or obese, unless NAFLD or ALF

422
Q

Diagnose cirrhosis

A

Transient elastography

Biopsy

423
Q

Management of cirrhosis and its complications - 8

A 
Varicael band ligation
IV abx if upper GI bleed
TIPS if refractory ascites
PO ciprofloxacin if refractory ascites
Albumin, vit K, blood products
Anticoagulation - prothrombotic, even if increased INR
424
Q

Liver transplant for hepatitis c?

A

50% recurrence

Follow with corticosteroid then calcineurin inhibitor ie tacrolimus

425
Q

When to refer for liver transplant? (3)

A

Irreversible progressive impairment (synthetic function) or portal hypertension problems
Significantly impaired QoL
Curable HCC

426
Q

Contraindications to liver transplant? (3)

A

Extrahepatic infection
Advanced malignancy
Poor cardiorespiratory status

427
Q

3 assessments of alcohol intake

A

CAGE
AlcoholUseDisorderID questionnaire
Severity of AlcoholDependenceQuestionnaire (psych, phys and cognitive)

428
Q

Sx of chronic alcoholism - 6

A 
Dupeytron’s contracture
Gynaecomastia
Spider angiomata
Enlarged spleen
Large/small liver
Testicular atrophy
429
Q

Sx of alcohol withdrawal - 8

A 
NV
Headache
Anxiety
Agitation
Diapheresis
Tremor
Seizures
Hallucinations
430
Q

How much is one unit and what is a binge?

A

250ml beer, 125ml wine

8 units for men, 6 units for women

431
Q

4 parts of brief alcohol intervention

A

Advice on dangers
Avoid triggers
Set objectives
Info on local organisations

432
Q

When inpatient for withdrawal alcohol?

A

Suicide risk, lack of social support of hx of withdrawal reactions

433
Q

Community management of alcohol withdrawal - 4

A

Daily supervision for vomiting/mental deterioration
Multivitamins for encephalopathy
BZD for symptoms
Support

434
Q

Acute management of alcohol withdrawal - 4

A

Diazepam for tremor/agitation (diazepam)
Lorazepam for seizures
+- b blockers
Vit B complex, thiamine, multivitamins

435
Q

3 drugs for alcohol abstinence and what for?

A

Acamprosate - maintain stabilisation
Naltrexone for binges
Nalmefene if no withdrawal Sx - give with psych support

436
Q

How does acamprosate work? - 2 mechanisms, 2 results

A

Inhibits NMDA receptors which are unregulated by alcohol, preventing delirium tremens
Positive allosteric modulator at GABA receptors which have been down regulated by alcohol (also a positive allosteric modulator), preventing physical withdrawal symptoms
- neuroprotective, reduces cravings

437
Q

How does naltrexone work?

A

Blocks competitive opioid receptor. Take 1h before alcohol, reduces positive effects of alcohol

438
Q

When should naltrexone not be used (3)?

A

Liver failure, acute hepatitis or recent opioid use

439
Q

5 causes of dysphagia

A

Inflammatory candidiasis/epiglottitis/retropharyngeal abscess
Obstructive - malignancy, structure, posterior cricoid web
Pharyngeal pouch
CT disorder
CNS disorder - MS, myasthenia gravies, bulbar palsy, CVA

440
Q

Signs of acute abdo (3)

A

Vomiting
Guarding
Reduced bowel sounds

441
Q

Vomiting and rectal bleeding?

A

GI inflammation

Malignancy

442
Q

Epigastric pain radiating to back (2)

A

Acute pancreatitis

Ruptured AAA

443
Q

Chronic epigastric pain (3)

A

IBS
GORD
CVS

444
Q

Epigastric pain relieved leaning forward

A

Pancreatitis

445
Q

Epigastric pain relieved by eating

446
Q

Epigastric pain relieved with defecation

447
Q

Signs of pancreatitis (3)

A

Rigid abdo
Epigastric pain relieved leaning forward
Flank discolouration

448
Q

Rigid abdo and epigastric pain (2)

A

Pancreatitis

Peritonitis

449
Q

2 faeces tests for diarrhoea

A 
Calprotectin = IBD
Elastase = pancreatic disease
450
Q

5 causes of diarrhoea with blood

A 
Haemorrhoids
Anal fissure
Gastroenteritis
Diverticular disease
IBD
451
Q

6 GI red flag symptoms

A 
Dyspepsia
Dysphagia
Vomiting
Epigastric pain
Diarrhoea
Constipation
452
Q

Leading causes of c dif (2)

A

2nd and 3rd gen cephalosporins

Clindamycin

453
Q

First and second line treatments for c dif

A

PO metronidazole for 10-14d

Then PO vancomycin and IV metronidazole if very unwell, or just PO vancomycin if relatively well

454
Q

What is Charcot’s triad?

A

For ascending cholangitis: fever/rigors, jaundice, RUQ pain

455
Q

What is Reynold’s pentad?

A

Severe ascending cholangitis = Charcot’s triad plus hypotension and confusion

456
Q

What is cyclic vomiting syndrome?

A

Episodes of vomiting precipitated by nausea and sweating, last hours to days
No symptoms in between
Associated with migraines

457
Q

Most common kind of oesophageal cancer

A

Adenocarcinoma

458
Q

1st line investigation for oesophageal cancer

A

Upper GI endoscopy

459
Q

What is Troussea’s sign and what cancer is it most commonly seen in?

A

Migratory thrombophlebitis in pancreatic cancer

460
Q

Microscopy of Crohn’s disease (3)

A

All layers inflamed
Granulomas
Goblet cells increased

461
Q

Microscopy of UC (3)

A

Not beyond submucosa
Crypt abscesses
Depletion of goblet cells

462
Q

2 complications/conditions from Crohn’s

A

Gall stones - reduced bile acid absorption

Renal stones - oxalate as reduced calcium absorption due to reduced bile acid absorption

463
Q

5 sx of pharyngeal pouch

A 
Dysphagia
Regurgitation
Aspiration 
Halitosis
Neck swelling which gurgles on palpation
464
Q

Management of ascending cholangitis

A

IV abx

ERCP to relieve obstruction 24-48h after

465
Q

Management of Barrett’s oesophagus metaplasia (2)

A

Endoscopic surveillance and biopsy (/3-5y)

PPI

466
Q

Management of oesophageal dysplasia (2)

A

Endoscopic mucosal resection

Radiofrequency ablation

467
Q

First and second line treatment of mild/moderate UC

A

Mesalazine

+ PO prednisolone if not improving in 4w

468
Q

When to do surgery in sigmoid volvulus?

A

Suspected peritonitis or perforation
Necrotic bowel on endoscopy
Repeated failed decompressions

469
Q

2 treatments initially for hepatic encephalopathy

A

PO/PR lactulose

PO rifaximin

470
Q

Why do coeliacs need vaccinations and which do they need?

A

Pneumococcal and yearly influenza

Due to functional hyposplenism

471
Q

4 features of Peutz-Jegher’s and key complication

A 
Hamartamous GI (small bowel) polyps
Pigmented lesions mouth, feet, palms
Intestinal obstruction ie intussusseption
GI bleed
50% die of colorectal cancer by 60y
472
Q

Causes of peritonitis - 5

A

Primary = rare, strep from bloodstream
Secondary =
- perforation of appendix/diverticuli/upper gi/tumour/ischaemic bowel
- acute pancreatitis - inflammatory
- peritoneal dialysis - atypical or cutaneous organisms
- post-op - anastomotic leak or enteric injury

473
Q

Symptoms of peritonitis - 3

A

Severe generalised abdo pain radiating to back and shoulders, worse with cough and movement
Anorexia
Fever

474
Q

Signs of peritonitis - 4

A

Fever, tachycardia
Generalised abdo pain with guarding and rigidity, may be maximal on source
Mass on gentle palpation

475
Q

Initial management and tests for peritonitis

A

Resuscitation with large bore cannula
Catheter and fluid balance chart
FBC, UE, CRP, G&S
Amylase for peritonitis
ABG for ischemic bowel, pancreatitis, shock
Abdo CT for source of pathology
Antibiotics - metronidazole and cefuroxime

476
Q

Appendicitis management

A

Open/laparoscopic resection

IV antibiotics

477
Q

Upper GI causing peritonitis management

A

Omental patch - prepyloric or DU
Excision - GU
Gastrectomy

478
Q

Diverticular disease causing peritonitis management

A

IV antibiotics

Resection

479
Q

Management for peritonitis from peritoneal dialysis

A

Lavage

Antibiotics - fluid culture

480
Q

2 causes of small bowel and large bowel obstruction

A

Small bowel - adhesions and hernias

Large bowel - malignancy, volvulus, diverticular disease

481
Q

Extramural, mural and intramural GI obstructions

A

Extramural - hernias, adhesions, volvulus, peritoneal masses
Mural - carcinoma, Meckel’s diverticum, inflammatory strictures, intususception, lymphoma
Intramural - foreign body, faecal impaction, gallstone ileus

482
Q

Pathology of GI obstruction causing perforation

A
  1. Dilatation of proximal limb
  2. Increase in peristalsis
  3. Secretion of large volume of electrolyte-rich fluid (third spacing)
  4. Ischaemia and perforation
483
Q

What is a closed loop obstruction?

A

When there is a proximal secondary obstruction such as volvulus or competent valve

484
Q

Symptoms of GI obstruction - 4

A

Pain
Vomit
Distension
Absolute constipation

485
Q

Signs of GI obstruction - 2

A

Tinkling bowel sounds

Focal tenderness/guarding/rebound = ischaemia

486
Q

Inv finding on GI obstruction

A

Low K, high urea
Lactate = ischaemia
Metabolic disturbance from dehydration/vomiting

487
Q

Differentials for GI obstruction - 3

A

Paralytic ileus
Pseudoobstruction
Toxic megacolon

488
Q

AXR findings for GI obstruction

A

SI >3cm, valvulae conniventes, central

LI >6cm, >9cm at caecum, peripheral, haustra

489
Q

CT findings for GI obstruction

A

True or pseudo
Location and cause
Mets

490
Q

Imaging for GI obstruction

A

AXR
CT - more sensitive than AXR
Contrast fluoroscopy for SI

491
Q

Initial management GI obstruction

A 
NBM
NGT decompression
IV fluids and electrolyte correction
Catheter and fluid balance
Analgesia
492
Q

When to operate on GI obstruction - 4

A

Ischaemia
Small intestine obstruction without previous surgery
Tumour or strangulation
Failure to improve >48h

493
Q

Manage adhesions in SI

A

Conservative unless ischaemia/strangulation

494
Q

Complications of GI obstruction - 3

A

Ischaemia
Perforation causing faecal peritonitis
Dehydration and renal impairment

495
Q

2 complications of gastric outlet obstruction

A

Intermittent - vomiting - weightloss, dehydration and electolyte disturbance
Gastric dilatation - reduced contractility - undigested food accumulates - aspiration pneumonia

496
Q

Benign causes of gastric outlet obstruction - 6

A 
Gastric polyps 
Pyloric stenosis
Congenital duodenal web
Gall stones
Pancreatic pseudocyst
Bezoar
497
Q

How does PUD cause gastric outlet obstruction?

A

Acute inflammation - oedema - fibrosis and scarring

498
Q

Manage PUD

A

H2 antagonist, PPI

H pylori eradication

499
Q

Tumours causing gastric outlet obstruction - 5

A 
Gastric
Duodenal
Pancreatic
Ampullary
Cholangiocarcinoma
500
Q

Symptoms of gastric outlet obstruction

A 
N&amp;V - undigested food within 1h
DU or incomplete obsturction causes
- early satiety, weight loss
- epigastric fullness
- indigestion
- pain
- metabolic insufficiency, malnourished
501
Q

Exam findings for gastric outlet obstruction

A

Chronic dehydration/malnutrition
Tympanic mass
Succession splash

502
Q

Investigations for gastric outlet obstructiotn - 4

A

Electrolyte abnormalities - urea, nitrogen, creatinine high
= Hypokalaemic hypochloraemic metabolic acidosis (low K and Cl)
NaCl test - 750ml through NGT, >400ml after 30 mins = GOO
Imaging - CT, endoscopy for intraluminal obstruction

503
Q

Manage gastric outlet obstruction

A 
Treat cause 
Pneumatic balloon dilatation
NG decompression
Vagotomy
Pyloroplasty
504
Q

Consideration before surgery for gastric outlet obstruction

A

Pre-op nutrition important, and electrolyte corrections

505
Q

Complications of treatment for gastric outlet obstruction - 3

A

Perforation
Stent migration
Anastamotic leak

Finals (13 decks)

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