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G.I. Flashcards

1
Q

Main types of hernia

A

Inguinal, femoral, incisional

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2
Q

Hernia definition

A

Protrusion of a viscus through a defect in the wall through its containing cavity

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3
Q

Hernia complications

A

Bowel obstruction, Incarceration (contests of hernial sac stuck), Strangulation (Ischaemia + Obstruction)

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4
Q

Inguinal ring Anatomy

A

Roof = Internal oblique and Transversus abdo

Floor = Inguinal ligament

Anterior = Apneurosis of external oblique

Posterior wall = Transversals fascia

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5
Q

Contents of inguinal canal

A

Men: Spermatic cord

Women: Round ligament

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6
Q

Why are hernias important

A

7% of ALL surgery

25% of men will get an INGUINAL hernia

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7
Q

Inguinal hernia

  • Who / RF
  • Types
A

Men (testes descend), obese, heavy lift, chronic cough

direct (directly through posterior wall - lateral to pubic tubercle)

indirect (through deep inguinal, medial to pubis, more likely to strangulate)

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8
Q

Inguinal hernia

  • Pres
  • Investigate
  • Treat
A

Groin lump
Pain
Cough impulse (palpate when coughing)

USS if any doubt

Lifestyle: stop smoking, weight loss
Surgical reduction and mesh closure

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9
Q

More likely hernia will strangulate if

A

Small defect
Indirect hernia
Femoral hernia

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10
Q

Contents of Femoral canal

A

NAVYVAN

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11
Q

Femoral hernia

  • Epidemiology
  • Pres
  • Complication
  • Tx
A

More in women

Lump (inferior and lateral to pubic tubercle)
cough impulse
Pain if incarceration

High (20%) strangulation rat - surgical emergency)

Surgical repair all due to high risk

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12
Q

Strangulated hernia presentation

A

Red, tender, tense, irreducible ± colicky abdo pain + vomit + distension (obstruction - a surgical emergency)

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13
Q

Umbilical hernias assoc

A

Congenital

Assoc with ascites

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14
Q

Dyspepsia definition

A

Epigastric pain/discomfort due to acid reflux

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15
Q

Red flags in dyspepsia (ALARMS)

A 
Anaemia
Loss of weight
Anorexia
Recent onset
Melaena
Swallow difficulty
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16
Q

Stomach is battleground.

  • Attack factors
  • Defence factors

The balance prevents ulcer

A

Acid, pepsin, H.pylori, bile salts, smoking (impairs mucosal repair)

Mucin secretion, cellular mucus, bicarbonate secretion, mucosal blood flow

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17
Q

ROME criteria for dyspepsia

1 of the 4 = diagnostic

A

1) Bothersome postprandial fullness
2) Early satiety
3) Epigastric pain
4) Epigastric burning

Also: No evidence of other disease to explain symptoms

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18
Q

Early post prandial pain

A

Gastritis, Gastric ulcer, GORD, Gastric Ca

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19
Q

Late postprandial pain

A

Duodenal ulcer

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20
Q

Drugs that can cause dyspepsia

A 
Nitrates
Bisphosphonates
Corticosteroids
NSAIDs
(Decrease mucus and bicarbonate secretion)
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21
Q

How do PPI work

A

Decreases expression of h=/K+ anti porter on luminal membrane of parietal cells

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22
Q

Dyspepsia investigations

A

FBC (Iron def anaemia = alarm -> chronic bleed)

H.pylori test

Endoscopy if WL, Dysphagia, chronic bleed (anaemia) etc or over 55

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23
Q

Dyspepsia Tx

A

Lifestyle: stop offending drugs, smoking, lose weight, aggravating foods
OTC antacids

PPI if ranitidine (H2 antagonist doesnt work)

Triple therapy H.Pylori if indicated: PAC: Amoxicillin, clarithromycin, PPI

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24
Q

Cell types in Stomach

A

CPL PIGEH GotGood DancingSkills

Chief - Pepsiongen

G-cells - Gastrin (antrum)

Parietal cells - IF & HCL (funds and body)

D-cells - Somatostatin (antrum)

Goblet cells (gastroprotective)- mucus and bicarbonate

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25
Q

Factors stimulating Acid production

A

Gastrin from G-cells (think, they are high up - astral)

Histamine (on H2)

ACh (M3)

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26
Q

Stop acid production

A

Somatostatin (also antrum)

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27
Q

Acid production

A

H20 + CO2 = H+ H2CO3-

H2CO3- swapped for Cl- form blood

cAMP related movement of Proton pump to luminal membrane to pump out H+

cAMP inc by gastrin, histamine, ACh

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28
Q

Cephalic phase
Gastric phase
Intestinal phase

what mediates and what is effect

A

Cephalic: Via Parasymp ANS - Vagus. Stimulates Gastric phase

Gastric: due to Gastrin, histamin secretions. From cephalic stem, proteins in stomach (G-cell) Stimulatory

Intetinal phase: nervous (intestinal stretch feedback) and hormonal (Somatostatin, incretins) inhibit Gastric phase

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29
Q

Chef brings you meat.

PARI et al

A

Chief cells make pepsinogen (pepsin) to digest proteins

Produce Acid, Release Intrinsic Factor

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30
Q

H.Pylori

  • what is it
  • What can it cause
  • symptoms
A

Gram negative curved bacillus

Peptic ulcer disease, Gastric adenocarcinoma (X6 risk)

Epigastric pain/bloating, early satiety

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31
Q

H.Pylori mechanism

A

2 Mechanisms

Urease secretor, form ammonia to neutralise acid in stomach, alkaline damages stomach lining

If antral:
Damage to d-cells = low somatostatin = high HCL

Both mech can cause ulcer

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32
Q

H.Pylori Investigations

A

C13 urea breath test (if urea is split after 10-30 min then +ve)

Stool antigen test

CLO test (pink with H.Pylori) on endoscopy looking for urease

Note: no PPI or ABx 2 weeks prior to test

FBC: iron def anaemia?

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33
Q

H.Pylori Treatment

A

PPI + amoxicillin + clarithromycin/metronidazole (1 week)

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34
Q

Types of peptic ulcer

A

80% Duodenal

20% gastric

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35
Q

Causes / RF peptic ulcers

A

H.pylori (95% DU, 80% GU),

NSAIDs, smoking, alcohol, stress, bile acids, pepsin

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36
Q

Defence mechanisms against stomach acid

A

Mucus, bicarbonate, prostaglandins

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37
Q

Pathophysiology

A

Increase in attack (acid) or decrease in defence mechanisms (mucus - Prostaglandin stimulation, bicarbonate)

Acid erosion of super facial epithelial cells = ulcer

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38
Q

Artery at risk

  • Gastric Ulcer
  • Duodenal Ulcer
A

Left Gastric artery

Gastroduodenal artery

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39
Q

Presentation of Gastric/Duoden ulcer

A

Epigastric pain (DU 1-3 hrs post prandially - when food moves down to there, Gastric on eating)

Posteriorduodenal ulcer radiate to back

Nausea, oral flatulence, bloating, distension, early satiety

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40
Q

Peptic ulcer Ddx

A

AAA, GORD, GaCa, gallstones, Cx panc, IBS, drug-induced

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41
Q

Investigating Peptic ulcer disease

A

FBC (iron def anaemia
H.Pylori test (CLO, C13 Urea)

Endoscopy if: over 55, ALARMS

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42
Q

ALARMS = Red Flag symptoms Stomach

A 
Anaemia
Loss of weight
Anorexia
Recent onset
Melaena
Swallow difficulty
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43
Q

Peptic ulcer management

A

Stop offending drug (NSAIDs) & smoking

Triple therapy (Amoxacillin, Clarithromycin, PPI)

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44
Q

Peptic ulcer complications

A

Haematemisis/Melena if large blood vessel erosion (L Gastric, Gastroduodenal)

Acute abdo & Peritonism if perforated

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45
Q

Gastritis:

  • What is
  • Symptoms
  • RF
  • Tx
A

Inflammation of Stomach lining

Post-Prandial fullness, satiety, epigastric pain, nausea, vomiting

ALCOHOL, NSAIDs, H.Pylori, Reflux disease/Dyspepsia

Same as dyspepsia
Lifestyle (smoke, alc, wtlss), OTC/Ranitidine If not work - PPI
Triple therapy (C+A+P)

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46
Q

GORD

  • Def
  • chronic comp
A

Reflux of acid contents (bile - particularly caustic/acid) into oesophagus

oesophagitis/ulceration/stricture, Barrett’s Oesophagus (metaplasia of squamous to glandular epithelium, 1% progress to cancer)

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47
Q

GORD Causes

A

Inc abdo pressure: obesity, preg

Inc Gastric pressure: large meal

Deficient LOS: hiatus hernia (cardia above diaphragm hiatus), CCB, Trycylic antidepressants

Dec oesophageal peristalsis: SSc

Lifestyle: fat (delay gastric empty), coffee, smoke, alc.

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48
Q

H.Pylori and GORD

A

No relation

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49
Q

Presentation GORD

A

Heart burn: postural and related to meals

Waterbrash: inc salivation

Odynophagia: painful swallowing

Belching

Atyp: Chronic cough, aspiration pneumonia, chronic hoarseness

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50
Q

GORD investigations

A

Endoscopy = Gold standard

FBC (exclude anaemia)

Barium swallow (hiatus hernia)

±CXR (Hiatus hern, Cardiac Ddx)

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51
Q

Hiatus hernia

  • def
  • RF
  • types
A

Abdo viscera herniation through diaphragmatic hiatus. Mainly Gastric Cardia

Anything increasing abdo pressure (obese, preg, ascites, age)

Sliding (90% - Gast-oes junc slide into thoracic cavity) -> more common GORD as sphincter involved

Rolling (10% - Gast-oes junc remains in place but stomach herniates next to oesoph)

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52
Q

Hiatus hernia Investigations

A

CXR

Barium swallow

Endoscopy

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53
Q

Hiatus hernia Ttx

A

Lifestlye as GORD
+ PPI longterm
+ surgery e.g. gastropexy if refractory

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54
Q

Oesophageal muscle and epithelium:
Upper
Middle
Lower

A

Striated (voluntary) & stratified squamous

Mixed & strat squamous

Smooth muscle & squamo/cloumnar junc

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55
Q

Causes of oesophagitis

A

Same as GORD (LOS weakness, inc abdo pressure) but ALSO drugs taken without water (direct burning)

Can cause mucosal breaks

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56
Q

Barretts

  • Def
  • Cause
  • Investigations
A

Any portion of distal squamous epithelium replaced by metaplastic columnar epithelium (occurs following mucosal inflammation and erosion)

Chronic GORD ± HH

Observed on Endoscopy
Confried on Biopsy (histology)

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57
Q

Baretts

  • Treatment
  • Complications
A

Tx as for GORD (lifestyle & PPI) ± ablation

High grade: oesophagectomy

5% progress to adenocarcinoma in 10-20yrs

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58
Q

Oesophageal cancer

  • Types
  • RF
  • Typical patient
A

Upper 2/3 = Squam
Lower 1/3 = adeno

Smoking, alcohol, Barretts, GORD, chronic stasis (achalasia)

Older man from middle east

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59
Q

RED FLAGS in Oesophagus

A 
Anaemia
Loss of weight
Anorexia/vomiting
Recent onset
Melena 
Swallowing difficulty (progressive, solids more than liquids)

Other: persistent retrosternal pain, intractable hiccups (infiltrations)

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60
Q

Investigating Oesophageal Ca

A

FBC (anaemia)

Endoscopy with biopsy

CXR - mets

CT/MRI staging (if emts seen more local stafgin not needed)

Barium swallow (dysphagia)

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61
Q

Oesophageal

  • Sites of spread
  • Tis, T1, T4
A

Liver, lung, stomach, LNs (coeliac LNs)

Tis - In situ

T1 - lamina propria/sub-mucosa invasion

T4 - Adjacent structure invasion

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62
Q

Oesophageal cancer Tx

A

Surgery ( with adjacent lymphadenectomy) - Ivor Lewis ± chemo

Mucosal resection (endocscopically) for early stage cancers

Palliation - Stenting/Radiotherapy

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63
Q

Oesophageal cancer prognosis

A

5 year survival 20%

64
Q

Ddx for Dysphagia

A

Oesophageal: GORD, Pesophagitis, Ca (oesophageal, pharyngeal)

Neurological: CVA, Achalasia, MS, MND

Other: pouch, CREST

65
Q

Achalasia

  • def
  • pres
A

Loss of Aubarches plexus

Impaired smooth muscle peristalsis and LOS fails to relax

Dysphagia to solids and liquids, Regurgitation

66
Q

Achalasia Investigations

A

CXR - dilated oesophagus

Barium swallow - Birds beak (dilated with distal narrowing)

Manometry (Gold Standard) - high resting pressure on swallow

67
Q

Achalasia treatment

A

CCB/nitrates (reduce LOS pressure may = GORD)

Endoscopic dilatation surgery (risk perforation)

68
Q

Systemic sclerosis GI

  • Paphys
  • Pres
  • Tx
A

Dysmotility due to collagen deposition

Reflux, delayed emptying

High dose PPI, Promotility agents (Domperidone)
dilatation of structure

69
Q

Upper GI bleeding

  • Ddx
  • Pres
  • Investigation
A

Peptic ulcer (most common - L gast/gastroduoden artery), Varices, oesophagitis, Mallory-Weiss, malignancy

Haematemisis (fresh = red, stomach or below = ground coffee)
Melaena - black tarry stools (Upper GI bleed, occasionally small bowel iron sups also give this)

Signs of anaemia/shock –> extent of blood loss
(postural hypotension = over 20%)

ENDOSCOPY urgently

Acute bleed = emergency,

70
Q

Mallory-Weiss

  • def
  • cause
  • pres
  • Investigations
A

Mucosal tear in OG junction

Persistent vomit/wretching
(Excess alc, bulimia, gastroenteritis)

Haematemisis, melena, dizzyness

Endoscopy, FBC & Haemocrit (assess severity), Renal function/U&E for fluid replace, cross match

71
Q

Boerhaave

  • def + site
  • complications
A

Oesophageal tear due to vom or trauma (e.g. endoscopy)

Pneumomediastinum, surgical emphysema (air in skin of chest/neck)

72
Q

Oesophageal varices

A

Dilated veins in distal oesophagus/proximal stomach. Due to portal HTN caused by congested/diseased liver/

Chronic Liver disease (cirrhosis)

Haematemisis, Melena, Liver disease features

Endoscopy, FBC (Hb), LFT, Clotting, renal function

73
Q

Investigation upper GI bleed

A

Assess for shock (pallor, anaemia, Cap refill, pulse, BP, cool extremities)

Liver disease stigmata (LFTs)

Endoscopy - post resuscitation or within 24 hours

Cross match (2-6 units)

74
Q

Upper GI bleed correcting hypovolaemia

What is done after

A

If shock = O2 + fluid resus (500ml over 15 mins)

Transfuse: Crossmatched blood, FFP (if INR over 1.5)

Endoscopy

75
Q

Upper GI bleed management

A

Ulcer as cause: Endoscopic

  • thermal coag active bleeds
  • Fibrin/Thrombin with adrenaline
  • Mechanical clips

Variceal bleed:

  • Terlipressin at presentation
  • Prophylactic Abx
  • Oseoph: band ligation
  • Gastric: N-butyl-2-cyanoacrylate ± TIPS
76
Q

Define

  • Ileus
  • Paralytic ileus
A

Ileus - non-mechanical obstruction, paralytic ileus - bowel inactivity

77
Q

Small bowel obstruction cause

A

Adhesions (75% - from prior operations), Strangulated hernia, Malignancy (caecum as small bowel malignancy rare) or volvulus

78
Q

Large bowel obstruction causes

A

Colorectal malignancy, Volvulus (Sigmoid = 5% all obstructions, caecal)
Ogilvie’s - loss of peristalsis
Pos-op ileus

Congenital: Neonatal e.g. CF, Hirschprungs (aganglionic section of bowel)

79
Q

Presentation of intestinal obstruction

A

Nausea and vomit (early in high level, faecal in low level) - May give hypotension

Abdo pain (severe) and increasing distension

Failure to pass bowel movements (constipation (early on in low level, late in high level)

If ischaemic/perforation: Pyrexia (acute abdo, peritonism)

80
Q

Intestinal obstruction investigations

A

Abdo Xray: distended bowel loops proximal to OBs, fluid levels
Gas under diaphragm - perforation

81
Q

Intestinal obstruction management

A

Fluid resus + correct electrolytes

Colon insulation used in volvulus, Endoscopic decompression may be used for proximal.

No clear diagnosis: Laparotomy + stoma consent (early if peritonitis/perforation

82
Q

Sigmoid volvulus

  • Def
  • RF
  • Pres
A

Faeces and gas filled sigmoid loop twists on mesentery to cause obstruction

Elderly, constipation, previous occur

Sudden onset colicky lower abdo pain with distension and fail to pass flatus/stool. may have palpable mass

83
Q

Sigmoid volvulus

  • Investigations
  • Treatment
A

Empty rectum,
Abdo XR: dilted, coffee bean sign
CT to assess bowel wall ischaemia

Decompress with sigmoidoscope with insulation

elective surgery for recurrence

84
Q

Paralytic ileus

  • def
  • who
  • causes
  • pres
  • investigation
A

No peristalsis causing pseudo-obstruction

elderly

Olgives (opioids, Parkinsons, post-op)

Large bowel obstruction with absent bowel sounds

ABX

85
Q

GO obstruction & triad

A

Gastric outlet obstruction

Obstruction at level of pylorus

Seen in children (projectile vomit, Tx with pyloromyotomy)

86
Q

Ddx for Acute abdomen

A 
Appendicitis
Peritonitis
Pancreatitis
Ectopic preg
Diverticulitis
Cholecystitis
Renal colic/pyelonephritis
PID
AAA
87
Q

Primary and secondary causes of Peritonitis

A

Primary = spontaneous bacterial peritonitis from ascites

Sec = pathology adjacent e.g. perforation

May be localised (e.g. appendix) or generalised

88
Q

omentum function

A

Attempts to confine infection by wrapping around it (e.g. appendicitis)

89
Q

Peritonitis presentation (e.g. appendicitis)

A

High fever, tachycardia, tenderness on palpation, guarding, rebound tenderness

90
Q

Causes of intra-abdominal sepsis

A

Peritonitis (.g. from SBP or perforation)

Abscess

91
Q

Investigating intra-abdo sepsis

A

FBC: leukocytosis
U&E: dehydration
Blood/Peritoneal fluid cultures

AXR, CXR (air under diaphragm)

92
Q

Treatment of intra-ado sepsis

A

Abscess&Peritonitis:

  • Fluids
  • Broad spec Abx (metronidazole, 3rd gen cephalosporin)
  • Surgical drain with open/laparoscopic surgery
93
Q

Anal fistula

  • Def
  • Cause
  • Investigations
  • Tx
A

Communication between skin and anorectal canal

Abscess, Crohn, Carcinoma

MRI

Surgical

94
Q

Pilonidal sinus

  • def
  • complication
  • Tx
A

Small hole at skin caused by obstruction of hair follicles

Abscess formation and sinus

Surgical excision of sinus tract and closure

95
Q

Haemorrhoids:

  • What
  • Tx
A

Dilated vascular plexuses in anal canal. May prolapse out

Painful,
Bleeding on defecation (on paper, not mixed with stool)

Prevent consitipation, 2 week wait if suspect anal cancer, lubber band ligation

96
Q

Appendicitis

  • Def
  • Complications
  • Epi
A

Invasion of appendix by gut flora with inflammation

Rupture - life threatening peritonitis (20% perforate)

Most common cause acute abdo, males 10-20

97
Q

Appendicitis

- Pres

A

Periumbilical pain (T10 - referred) moves to RIF (McBurney’s 1/3 way from ASIS - umbilicus) once peritoneum involved

Nausea, vomiting (a little), anorexia
Low grade fever, Tenderness/gaurding, rebound tenderness (inflammatory mediators moving back)

Shallow breathing - movement aggrivates

98
Q

Appendicitis management

A

Admit all
Laparoscopic/Open appendicectomy
IV fluids + opiates
IV metronidazole + Ceftriaxone

99
Q

Appendicitis

  • Ddx
  • Investigate
A

GI: obstruction, Meckel’s, Crohn’s
GU: Torsion, Calculi, UTI
Gyn: Ectopic, ovary cyst, PID

DKA

Clinical diagnosis so rule out other things.
Urinalysis (UTI), preg test, FBC (Raised WCC), USS (rule out gynae issues)

100
Q

Diverticular disease

  • definition/location
  • -losis Vs -litis
  • RF
A

Herniation of mucosa through colonic muscle. Typically descending colon/sigmoid

asymptotic diverticula Vs inflammation (fever, tachycardia)

Age, Obese, low fibre diet

101
Q

Diverticulitis

  • Pres
  • Complications (POFAS)
A

LLQ pain, bleeding, fever, tachycardia
Anorexia, vomiting, nausea

Perforation
Obstruction
Fistula
Abscess
Stricture
102
Q

Diverticular disease

  • Invetigation
  • Management
A

Colonoscopy/flexisig
FBC (raised WCC = -litis, Bleeding - anaemia)
Barium enema

High fibre
para for pain

-litis: admit, fluid/blood resus. 7d Co-amoxiclav. 30% need surgery (resection+colostomy for Perforation)

103
Q

Meckel’s diverticulum

  • what is it
  • complications
A

Remnant of viteline duct

Haemorrhage or intestinal obstruction (can cause intussusception)

104
Q

Types of bowel ischaemia

A

Acute mesenteric
(Embolus)

Chronic mesenteric
(intestinal angina)
Ischaemic colitis
(Shock, trauma, cocaine, dec CO = lower blood flow to SMA)
105
Q

Acute mesenteric ischaemia

  • Def
  • RF
  • Pres
  • Investigate
  • Tx
  • Prog
A

Sudden ischaemia can be arterial/venous thrombus.
Impaired blood and bacterial translocation = sepsis

hypercoag, Protein C+S deficiency, tumour, infection

Severe poorly localised colicky pain

AXR for obstruction, Angiography (gold standard)

Fluid resus, O2, Heparin for thrombus, surgical angioplasty

90% mortality

106
Q

Chronic mesenteric ischaemia

  • Cause
  • RF
  • Pres
  • Investigate
  • Treat
A

Atherosclerotic disease (intestinal angina)

Smoking, HTN, DM, hyperlipidaemia

Postprandial pain, weight loss

Arteriography is gold standard

Nitrate therapy, anticoagulant, bypass surgery

107
Q

Treating bowel ischaemic colitis:

A

Releive hypoperfusion
Bowel rest
supportive care

108
Q

Malabsorption

  • sympt
  • signs
  • important causes
A

Change in weight/growth, Chronic diarrhoea, Steatorrhoea

Iron/Float/B12 anaemia
Bleeding (Vit K),
Oedema (protein def)

Coeliac, CD, Chronic pancreatitis

109
Q

Malabsorption causes

1) Mucosal
2) Intraluminal
3) Structural
4) Extra-GI

A

1) coeliac, cow’s milk protein intol
2) Pancreatic insufficiency (CF), bile acid malprod/secrete
3) intestinal hurry, CD (fistulae, short bowel syndrome)
4) hypo/hyper thyroid, DM , carcinoid syndrome

110
Q

Malabsorption investigations

A 
FBC, LFT
Iron/Folate/B12 (pallor glossitis)
Anti-Transglutaminase (IgA) - coeliac
Faecal elastase 
AUSS gallbladder
Stool - foul smelling, floating, pale (steatorrhoea)
111
Q

Coeliac:

  • def
  • pres
  • assoc diseases
A

heightened immune response to gluten (gliadin protein) leading to malabsorption

Diarrhoea, weight loss, steatorrhoea, abdo pain, anaemia (80% iron, B12, folate def - mouth ulcers, angular stomatitis)
Skin: dermatitis
Neuro: peripheral neuropathy

T1DM, Thyroid dis, Down’s, Turner’s, primary biliary sclerosis/ primary sclerosis cholangitis

112
Q

Coeliac autoantibodies What is important before testing for these

A

Must have been eating wheat for 6 WEEKS pre-testing

Tissue transglutaminase (IgA)
Endomysial antibodies (IgA)
113
Q

Coeliac

  • Investigations
  • Definitive diagnosis
A

Autoantibodies (IgA)
Bloods: anaemia
Low B12/Ferritin/Floate
LFT: PBC, PSC AI dis

Distal ileum biopsy showing villous atrophy and crypt hyperplasia

114
Q

Coeliac management & complications

A

Lifelong gluten free diet
Calcium/Vit D supps

Delayed diagnosis = Osteoporosis, anxiety/depression, infertility

115
Q

Gastric Cancer

- Epidemiology/RF

A 
Japan, China
Over 55yrs
Male
H.Pylori (X2)
Salt/pickeld foods
Smoking
Pernicious anaemia 
Nutrosamine exposure
116
Q

Gastric Ca

  • Pres (problem)
  • RF symptoms
A

Vague: weight loss, vomit, dysphagia, most present late
Troisier’s sign: Virchow’s node

ALARMS

117
Q

Gastric Ca investigations

A

FBC (anaemia - GI bleed)
LFT (spread to liver)
Endoscopy + Biopsy (multiple ulcer edge biopsies) - Signet ring cells

118
Q

Gastric Ca spread

Staging

  • How?
  • T1?
  • T4?
A

Local, lymphatic, haematogenous
To lung and liver

CT abdo/thorax for mets
CXR, Transabdo USS, MRI

TNM
T1= Lamina propria/submucosa
T4 = to adjacent spleen/colon

119
Q

Gastric Ca

  • Manage
  • Palliation
  • Prognosis
A

Nutritional support

Surgery (distal = subtotal gastrectomy, proximal = total gastrectomy) 
Perioperative chemo (5-FU)

Palliation: Epirubucin + Cisplatin + 5-FU

15% 5 year survival

120
Q

MALT lymphoma

  • Type of lymphoma
  • Cause
  • Pres
  • Investigate
  • Treat
A

Non-Hodgkin

Autoimmune or infection (H.Pylori)

Dyspepsie ± fever, nausea, constipation, weight loss, pain, ulcer

Endoscopy and biopsy

H.Pylori eradication (triple therapy: C.A.P) = remission in 70%
Advanced disease: Rituximab (anti-B-cell)

121
Q

Gastric carcinoid

  • What
  • Assoc gene
  • Mets
  • Secrete + action
  • Investigate
  • Management
  • Tx carcinoid crisis
A

Neuro-endocrine tumour

MEN1

Liver

Serotonin + Bradykinin

Carcinoid syndrome: Flushing, diarrhoea, abdo pain, palpitations, hypotension, wheeze

24hr urinary 5-HIAA
Endoscopy, CT/MRI (staging - liver)

Surgical resection

Ocreotide (somatostatin analogue prevents 5-HT release)

122
Q

Colorectal cancer:

  • Location of tumour
  • Type of tumour
  • Mets
  • RF
A

2/3 colon, 1/3 rectum. 40% in rectum and sigmoid

Mainly adenocarcinoma

Liver

Fam Hx (FAP, HNPCC, Obesity, smoking, alcohol, DM

123
Q

Colorectal cancer

- Presentation

A 
Change in bowel habit
Rectal bleeding/anaemia
Mass
weight loss
occult bleed (Right)/Rectal bleed(let)
Obstruction 
Tenesmus
124
Q

Colorectal cancer genetics

A

FAP: APC gene mutation with 100% penetrance

HNPCC: AD, 80% risk (3+ relatives with colorectal Ca, 2+ successive generations, 1 before 50 = Amsterdam criteria)

125
Q

Colorectal cancer

Investigations

A

PR exam + Colonoscopy + biopsy of lesion

FBC and LFT (anaemia and liver mets)

Flexible sigmoidoscopy (detects 60%)

CEA: carcinoembryonic antigen

FOB - faecal occult blood (also in screening)

126
Q

Colorectal cancer Staging

A 
Dukes
A = mucosa (90% survival)
B = through serosa (70%)
C = regional LN (30%)
D = Distant mets/Liver (5%)
127
Q

Colorectal cancer screening?

Who
How

A

60-75, 2 yearly

Feacal occult blood test

If +ve then colonoscopy

128
Q

Treatment of Colorectal cancer

A

Surg: Hemicolectomy/colectomy + LN clearance

Chemo: FOLFOX (Folinic acid + Fluorouracil + Oxaliplatin

129
Q

Colorectal cancer mutation pathway

A 
*Normal cell*
APC mutation
K-ras 
SMAD 2-4 
P53 
*Adenocarcinoma*
130
Q

Polyp type and Colorectal cancer

A

Tubulovillous adenoma = highest risk

131
Q

IBS

  • def
  • cause
  • Types
A

Abdo pain relieved by defecation and a change in bowel habit. impact on QoL

Psychological distress assoc with abnormal smooth muscle activity

IBS-C (constipation main)
IBS-D (diarrhoea main)
IBS-M (mix)

132
Q

IBS

- diagnostic criteria

A

6 month of ABC

  • Abdo pain
  • Bloating
  • Change in bowel habit

AND

Relieved by defecation,
worse on eating,

133
Q

Management

A

De-stress, less caffeine, fluids, fibre

Meds
Diarrhoea: loperimide
Constipation: laxatives: Lactulose
Pain: busman (antispasmodic)

134
Q

IBS Ddx investigations

A 
FBC (Ca - iron def anaemia)
Coeliac screen (TTG/EMA)
Faecal calprotectin (IBD)
Faecal occult
TFT
135
Q

CD Vs UC

Macro
Micro
Barium

A

CD - rectal sparing, skip lesions, mucus cobblestoning
UC - non-rectal sparing, continuous disease, ulcers, polyps

CD - transmural inflammatory cell infiltrate, granuloma, focal crypt abscess, increased goblet cells
UC - inflammatory cell infiltrate confined to mucosa and submucosa, focal crypt abscess, goblet cell depletion

CD - rose thorn ulcers, kantors string sign (stricture)
UC - loss of haustrations, narrow short colon (lead pipe)

136
Q

Crohn’s disease

  • desc
  • location
  • RF
A

chronic relapsing IBD
Mouth to anus (ileum/colon classic)

Genetics (FH 20%), Smoking, NSAIDs, URTI infection

137
Q

Crohn’s disease presentation

+

Complications

A

Diarrhoea (chronic - over 6w) ± blood
Weight loss
Periods of exacerbation

Systemis symp: malaise, anorexia, fever, joints (large jet, sacroilitis), eyes (iritis, episcleritis)

POMFAN: perforation, oralulcer/obstruction, malabsorption (B12, Folate), fissure/fistula, anal skin tags/abscess, neoplasia,

138
Q

Investigation

A

FBC (pancytopenia)
LFT (fatty liver disease = complication)

Faecal calprotectin
Stool culture
Ileocolonoscopy + biopsy

Barium enema

139
Q

What does faecal calprotectin indicate?

A

Neutrophil migration into the intestinal mucosa as seen in inflammatory bowel (UC&CD)

140
Q

CD management

A

Oral prednisolone.IV hydrocortisone to induce remission. If another exacerbation in 12M add Azothiaprine (Or MTX + folic acid)

Surgery if limited to distal ileum

Maintain remission:

  • stop smoking
  • monotherapy (MTX, azathioprine)
  • monitor osteopenia.osteoporosis
141
Q

Ulcerative colitis

  • def
  • smoking?
A

relapsing remitting chronic inflammatory disease ONLY colon. Distal to proximal pattern.

Smoking protective

142
Q

Ulcerative colitis presentation + complications

A

Bloody diarrhoea
Tenesmus, colicky pain (LIF), urgency, mucus

Systemic: fever, malaise, weight loss, anaemia, Arthritis (large joints, Ank spondylitis), Eyes( episcleritis, anterior uveitis), Liver (primary sclerosis chlangitis)

Toxic Megacolon - admit!

2X risk cancer, risk toxic megacolon by opiates and osteoporos with steroids

143
Q

Ulcerative colitis

- investigations

A

FBC (pancytopenia), LFT (PSC), faecal calprotectin

1st line = colonoscopy and multiple biopsies

Toxic megacolon - AXR

144
Q

Ulcerative colitis

- Treatment

A

Avoid antispasmodic - megacolon

for mild disease and to maintain remission = topical/oral Mesalazine (salycilate ani-inflam)

IV hydrocortisone added for more severe

Toxic megacolon if non-responsive then surgery is curative

145
Q

Constipation:

  • def
  • common cause
  • Investigate
  • Tx
A

infrequent stools or hard stools

Low fibre, dehydration, immobility, IBS
metabol (hypothyroid), opioids, spinal nerve injury

investigate if over 40, recent change, weight loss, bleeding, tenesmus
FBC, UE, Calcium, TFT, sigmoidoscopy+biopsy

Treat Cause, fluids, anticonstipation

146
Q

Anti-constipation drug types

Bulk, osmotic, stimulant

A

Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk

Stimulant - increase motility e.g. senna, docusate

Osmotic - retain fluid in bowel - e.g. lactulose

147
Q

Acute diarrhoea causes

A

Infection (with fever, sudden)

Drugs: Abx, cytotoxic, NSAID, metformin, SSRI

Constipation with overflow

Anxiety

Food allergy

148
Q

Things to ask regarding diarrhoea

A

Foreign travel, fever, food poisoning, stress

149
Q

Diarrhoea Red Flags

A

Blood (CMV, shigella, salmonella, c.jej, e.histolytica)

recent ABX (c.diff), vomiting, wt loss,

watery + high volume (dehydration) (Vibrio Cholerae)

150
Q

Diarrhoea investigate

A

dehydration (mod/severe: confused, muscle cramps, hypotensive less than 90 systolic)

Stool sample culture and sensitivity

151
Q

Diarrhoea Tx

A

supportive: fluids and food

Only give drugs if cause clear. giving loperamide in obstruction is not good

admit if cant stop vomiting, bloody diarrhoea, dehydration/shock

152
Q

Causes and time to improv

Usually
Rotavirus
C.jej/Salmonella
Giardia

A

2-4 days

3-8 days

2-7 days

Persists to chronic

153
Q

Cause of diarrhoea:

Traveler
ABx
Small child
Vom Within 6h food 
Bloody
Bloody and Haemolytic uraemia syndrome
A

E.coli

C.diff

Rotavirus

S.aureus

Shigella, Salmonella

Enterohaemorhagic E.coli (O157:H7)

154
Q

Chronic diarrhoea causes

A

Malabsorption -> osmotic (coeliac)

Inflammatory (CD&UC)

IBS

Neoplasia

Hyperthyroid

Carcinoid tumour

ABx & C.diff

Alcohol

155
Q

Chronic diarrhoea Tx

A

TFT, Coeliac (EMA, TTG), B12/Folate if malabsorp,

Treat cause - may be call for antimotility drugs e.g. codeine/loperamide

156
Q

Chronic diarrhoea Red flags

A

Blood (CMV, shigella, salmonella, c.jej, e.histolytica), recent ABX (c.diff), vomiting, wt loss

Final (26 decks)

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