GI Flashcards
1
Q
types of liver injury
A
acute
chronic
2
Q
acute liver injury consequences
A
recovery
liver failure
3
Q
acute liver injury causes
A
viral (A,B, EBV) drug alcohol vascular obstruction
4
Q
presentation of acute liver injury
A
malaise nausea anorexia jaundice (rarer=confusion, bleeding, hypoglycaemia)
5
Q
presentation of chronic liver injury
A
ascites oedema varices malaise anorexia easy bruising itching (rarer=jaundice, confusion)
6
Q
jaundice
A
raised serum bilirubin
unconjugated or conjugated
7
Q
unconjugated jaundice
A
pre-hepatic
e.g. gilberts, haemolysis
8
Q
conjugated jaundice
A
hepatic/post hepatic/cholestatic
e.g. liver disease (hepatic)
bile duct obstruction (post-hepatic)
9
Q
cholestatic (hepatic/post-hepatic) jaundice presentation
A
dark urine
pale stools
itching
abnormal liver tests
10
Q
pre hepatic jaundice presentation
A
normal urine, stools and liver tests
no itching
11
Q
liver disease causesand cholestatic jaundice
A
hepatitis- viral, drug, immune, alcohol
ischaemia
neoplasm
congestion
12
Q
obstruction causes and cholestatic jaundice
A
gallstone
stricture- malignant, ischaemic, inflammatory
blocked stent
13
Q
gallstones
A
70% cholesterol, 30% pigment, can have calcium
most form in gallbladder
1/3 of women over 60
14
Q
gallstone risk factors
A
female
fat
fertile
liver disease, ileal disease, TPN
15
Q
bile duct stone presentation
A
biliary pain, obstructive jaundice, cholangitis, pancreatitis
No cholecystitis
16
Q
gallbladder stones presentation
A
biliary pain, cholecystitis
maybe obstructive jaundice
No cholangitis and pancreatitis
17
Q
management of gallbladder stones
A
laparoscopic cholecystectomy
bile acid dissolution therapy, <1/3 success
18
Q
management of bile duct stones
A
ERCP w/ sphincterotomy and:
removal (basket/balloon)
crushing (mechanical/laser)
stent placement
19
Q
drug induced liver injury
A
1/10,000 patients/year
0.1-3% of hospital admissions
30% of acute hepatitis
>65% of acute liver failure
20
Q
types of drug induced liver injury
A
hepatocellular
cholestatic
mixed
21
Q
drugs commonly involved in liver injury
A
antibiotics- 32-45% (augmentin, ethryomycin)
CNS drugs- 15% (chlorpromazine, valproate)
immunosuppressants- 5%
analgesics-5-17% (diclofenac)
GI drugs- 10% (PPIs)
dietary supplements- 10%
multiple drugs- 20%
22
Q
drugs not commonly involved in liver injury
A
low dose aspirin NSAIDS (not diclofenac) beta blockers HRT ace inhibitors thiazides calcium channel blocker
23
Q
paracetamol induced liver failure: management
A
N acetyl cysteine
supportive treatment to correct: coagulation defects, renal failure, hypoglycaemia, fluid/electrolyte/acid-base balance
24
Q
paracetamol induced liver failure: severity indicators
A
late presentation, NAC is less effective >24 hours
acidosis pH<7.3
prothrombin time >70 sec
consider liver transplant otherwise mortality is 80%
25
signs of liver failure
leukonychia- white nails
spider naevus
ascites
26
alcoholic liver disease
main cause of liver death in UK
only 10-20% of heavy drinkers get ALD
25% of sufferers stop drinking, 25% reduce
poor outcome- 10 year survival= 25%
27
alcoholic liver disease: pathogenesis
hepatocytes balloon- mediated by neutrophils
injured liver cells accumulate cytoskeletal protein
changes in how the cells metabolise and produce fat- they accumulate fat (steatosis)
fibrosis occurs
28
portal hypertension
increased hepatic resistance
| increased splanchnic blood flow
29
portal hypertension causes
cirrhosis
fibrosis
portal vein thrombosis
30
portal hypertension: consequences
varices- oesophageal, gastric
| splenomegaly
31
liver transplants and alcoholic liver disease
100/760 liver transplants/year in uk (limited by liver supply)
4000 deaths from ALD in UK/year
32
treatment for alcohol withdrawal
lorazepam
33
why are liver patients vulnerable to infection
impaired reticulo-endothelial function
reduced opsonic activity
leukocyte activity
permeable gut wall
34
sites vulnerable to infection in those with liver disease
skin
lungs (pneumonia)
urinary tract
septicaemia
spontaneous bacterial peritonitis
35
spontaneous bacterial peritonitis and liver disease
most common infection in cirrhosis
| diagnosis based on neutrophils in ascitic fluid
36
causes of renal failure in liver disease
```
infection
GI bleeding
myoglobinuria
rental tract obstruction
drugs (NSAIDS, diuretics, ace inhibitors)
```
37
coma in patients with chronic liver disease
hepatic encephalopathy- caused by ammonia
hypoglycaemia
intracranial event
38
cirrhosis
represents end stage liver disease
residual nodules of hepatocytes
constant replication of hepatocytes in this condition puts them at risk of mutations and neoplasia
39
some consequences of liver dysfunction
malnutrition
coagulopathy- impaired coagulation factor synthesis, vitamin k deficiency
endocrine changes
hypoglycaemia
40
causes of chronic liver disease
```
alcohol
non-alcoholic steatohepatitis
viral hepatitis
immune
metabolic
vascular
```
41
types of hepatitis
viral- A, B, C, CMV, EBV
drug induced
auto immune
alcohol
42
main autoimmune diseases of the liver
autoimmune hepatitis
primary biliary cholangitis
primary sclerosing cholangitis
43
primary sclerosing cholangitis: raised globulins
variable
44
primary sclerosing cholangitis: autoantibodies
anti-neutrophil cytoplasmic
45
primary sclerosing cholangitis: other AI diseases
70% have one
| mainly colitis
46
primary biliary cholangitis: raised globulins
IgM
47
primary biliary cholangitis: autoantibodies
antimitochondrial
48
primary biliary cholangitis: other AI diseases
33%
| various
49
autoimmune hepatitis: raised globulins
IgG
50
autoimmune hepatitis: autoantibodies
antinuclear, smooth muscle, liver, kidney
51
autoimmune hepatitis and other AI diseases
40%
| various
52
autoimmune hepatitis: epidemiology
1-2/10,000 in UK
70-75% women
40% present with acute hepatitis
ANA, ASMA positive in 70%
53
autoimmune hepatitis: clinical variants
acute hepatitis
antibody negative
spontaneous remission
drug/virus/transplant related
54
primary biliary cholangitis: presentation
```
itching
fatigue
dry eyes
joint pain
variceal bleeding
liver failure
```
55
primary biliary cholangitis: treatment of the itch
cholestyramine helps 50%
rifampicin is effective but can damage liver
antihistamines dont really help
56
primary biliary cholangitis and fatigue
can be disabling
| correlated with autonomic neuropathy but not disease severity
57
ursodeoxycholic acid in PBC
improves liver enzymes and bilirubin
reduces inflammation but not fibrosis
70% have a good response and normal life expectancy
30% have poor response and impaired life expectancy
58
primary sclerosing cholangitis
disease of bile ducts
leads to strictures and gallstones
>50% have inflammatory bowel disease
59
primary sclerosing cholangitis: presentation
itching pain
jaundice
raised alkaline phosphatase and GGT
60
primary sclerosing cholangitis: treatment
ursodeoxycholic acid has questionable benefits
| good results from liver transplant
61
hepatocellular carcinoma
adenocarcinoma
mainly occurs in those with cirrhosis
may present with decompensation of liver disease, weight loss, ascites
62
hepatocellular carcinoma: risks
hep B,C and haemochromatosis = highest risk
| cirrhosis from alcohol or autoimmune= lower risk
63
hepatocellular carcinoma: treatment
transplant
| sorafenib prolongs life
64
non-alcoholic fatty liver
```
25% of population
usually no symptoms
most common cause of elevated LFTs
fat, inflammation, some fibrosis
no drug treatment- lose weight
```
65
non-alcoholic fatty liver: risk factors
obesity- 70%
diabetes- 35-75%
hyperlipidaemia- 20-80%
66
alpha 1-antitrypsin deficiency and liver disease
2% carry the allele for the gene- results in inability to export alpha 1- antitrypsin from liver to lungs
leads to liver disease from protein retention and emphysema from protein deficiency
67
alpha 1-antitripsin deficiency: treatment
no treatment
68
hepatic vein occlusion
terminal or central veins become occluded by fibrous tissue
| back pressure causes portal hypertension
69
hepatic vein occlusion: causes
thrombosis
membrane obstruction
veno-occlusive disease
70
hepatic vein occlusion: presentation
abnormal liver tests
ascites
acute liver failure
71
hepatic vein occlusion: treatment
anticoagulation
| transjugular intrahepatic portosystemic shunt
72
hepatitis definition
inflammation of the liver
73
acute vs. chronic hepatitis
```
acute= onset up to 6 months
chronic= persists after 6 months
```
74
acute hepatitis patient
```
can be asymptomatic
malaise
myalgia
GI upset
abdo pain
potential jaundice
raised AST, ALT
```
75
chronic hepatitis patient
```
can be asymptomatic
spider naevi, clubbing etc.
LFTs can be normal
compensated= liver function maintained
decompensated= jaundice, ascites, low albumin, coagulopathy
```
76
hepatitis A: transmission
faeco-oral
person-person
ingestion of contaminated food/water
77
hepatitis A: risk factors
travel
household or sexual contact
injecting drug use
78
hepatitis A: clinical
incubation period= 15-50 days
self limiting
100% immunity after infection
79
hepatitis A: management
supportive
monitor liver function
manage close contacts
vaccination
80
hepatitis E: presentation
95% are asymptomatic
self limiting however fulminant risk increased in pregnancy
extra-hepatic manifestations- neurological
81
hepatitis E: diagnosis
serology- anti HEV IgM+IgG
82
hepatitis E: managing acute infection
supportive
| liaise with hepatology and consider ribavirin if it becomes acute-on-chronic liver failure
83
hepatitis E: managing chronic infection
reverse immunosuppression if possible
| if REV RNA persists treat with ribavirin
84
hepatitis B: epidemiology
worldwide:
129 mill new infections/year
343 mill with chronic HBV
750,000 deaths/year
85
hepatitis B: transmission
blood-borne
highly infections
vertical, sexual, iatrogenic, IV drug use
86
hepatitis B: management
supportive
monitor liver function
consider transplant
manage their contacts
87
hepatitis B: treatment
nucleoside analogues
| pegylated interferon- alpha 2a
88
hepatitis B: pegylated interferon- alpha 2a
immunomodulatory- stimulates immune system
weekly sub cut injections
48 week long course
side effects= back pain, depression, hypothyroidism, anaemia
89
hepatitis B: nucleoside analogues
```
inhibit viral replication
one tablet a day
minimal side effects
renal monitoring required
may be needed life long
```
90
hepatitis D
defective RNA virus
transmitted via blood and body fluids
can be acquired simultaneously with HBV or after HBV
91
hepatitis D: test
hepatitis D antibody- if positive test HDV RNA
92
hepatitis D: treatment
pegylated interferon- alpha
93
hepatitis C: epidemiology
160,000 in England
50% undiagnosed
90% history of injecting drug use
94
hepatitis C: tests
```
HCV Ab- not detected= no recent exposure, detected= exposure)
HCV RNA- not dected= no current HCV, detected= current HCV
HCV genotype (1a,b,2,3,4,5,6)
```
95
hepatitis C: directly acting antivirals
combination of 2 or more of three drug classes- usually no symptoms but can have them with ribavirin (haemolytic anaemia, tiredness, dyspnoea, anxiety)
96
hepatitis C: prevention
no vaccine
can be re-infected (no immunity)
screening of blood products
lifestyle modification
97
diarrhoea definition
3 or more loose/liquid stools within 24 hours
98
infective diarrhoea
intraluminal infection
| systemic infections
99
non-infective diarrhoea
```
cancer
chemical
inflammatory bowel disease
IBS
malabsorption
endocrine
radiation
```
100
intraluminal infections: stool/ onset/duration
acute onset- viral/bacterial
chronic- parasites and non-infectious
floating stool- fat content, malabsorption
101
intraluminal infections: medication/immunocompromisation
recent antibiotics
| HIV/diabetes/chemo/transplant= higher risk
102
diarrhoea: investigating stool tests
if severe, bloody, dysenteric, persistent
| microscopy, culture, look for parasites and toxins (c. diff)
103
diarrhoea: investigating blood tests
blood culture
inflammatory markers
electrolytes and renal function
104
bloody/mucoid diarrhoea: mechanism
inflammatory
invasion
cytotoxin
105
bloody/mucoid diarrhoea: location
colon
106
bloody/mucoid diarrhoea: bacterial causes
shigella
e. coli
salmonella
C. diff
107
water diarrhoea: mechanism
non-inflammatory
108
watery diarrhoea: location
proximal small bowel
109
watery diarrhoea: bacterial causes
vibrio cholerae
e. coli
staph. aureus
110
watery diarrhoea: viral causes
rotavirus
| norovirus
111
watery diarrhoea: parasitic causes
giardia
112
diarrhoea in the UK
50-70% cases are caused by viruses e.g. rotavirus/norovirus
| since the rotavirus vaccine- 70% reduction in cases
113
immunosuppressed diarrhoea
increased risk, particularly to mycobacteria, microsporidia, CMV, HSV
114
traveller's diarrhoea
occurs w/i 2 weeks of arrival
115
traveller's diarrhoea: causes
```
e. coli= 30-70%
shigella=5-20%
campylobacter=5-20%
viral=10-20%
cholera
```
116
traveller's diarrhoea: presentation
```
2 or more unformed stool/day PLUS 1 of the following:
abdo pain
cramps
nausea
vomiting
dysentery
```
117
e coli
most strains are harmless
| some serotypes are pathogenic
118
enterotoxigenic e coli
non-invasive watery diarrhoea
most common cause of traveller's diarrhoea
leading bacterial cause in children of developing world
119
enterohaemorrhagic e coli
shiga-like toxin
intensive inflammatory response
can cause haemolytic uremic syndrome (bloody diarrhoea, abdo pain, no fever, haemolysis)
120
enterpathogenic e coli,
| enteroaggregative e coli and diffusely adherent E coli
watery diarrhoea due to adhesion to luminal wall
| non-invasive
121
cholera
contaminated food/ water
cholera toxin binds to intestinal wall, cAMP production activated cystic fibrosis transmembrane conductance regulator
this causes dramatic efflux of ions and water- huge volumes of diarrhoea
122
cholera symptoms
profuse water 'rice water' diarrhoea, up to 20L/day
vomiting
rapid dehydration
123
cholera treatment
doxycycline and fluids
124
asymptomatic c. diff
gram positive spore forming bacteria
| up to 5% have it as normal flora
125
symptomatic c. diff
can be symptomatic gut flora is altered:
- broad spectrum antibiotics (rule of C's)
- acid reducing drugs (PPIs)
- NG feeding
- immunocompromised
126
c. diff symptoms
fever
cramps
abdominal pain
bloody diarrhoea
127
c. diff treatment
metronidazole or oral vancomycin
128
diarrhoea: red flags
```
dehydration
electrolyte imbalance
renal failure
immunocompromised
severe abdo pain
cancer risk factors (over 50, chronic diarrhoea, weight loss, blood in stool)
```
129
diarrhoea: key management principles
barrier nursing: side room, gloves, apron
fluid and electrolytes
medications: antiemetics, anti-motility
130
peptic ulcer disease: causes
helicobacter pylori:
- gram negative rod
- synthesises urease forming ammonia which damages gastric mucosa and neutralises acid allowing it to survive
- almost 100% carriage in developing world
- >50% in uk over 50s
131
peptic ulcer disease: symptoms
acquisition of H.pylori usually asymptomatic
| can cause nausea, vomiting and fever
132
peptic ulcer disease: complications
```
duodenal ulcers (relieved by eating)
gastric ulcers (worsened by eating)
risk factor for cancer of stomach due to inflammation
```
133
peptic ulcer disease: diagnosis
stool antigen test
breath test
blood test for antibodies
endoscopy
134
peptic ulcer disease: treatment
clarithromycin
amoxicillin
PPI
135
biliary sepsis/ascending cholangitis: bacterial infection
obstruction of common bile duct causes stasis of bile and so an invasion of bacteria from duodenum
can be obstructed by stone, cancer, stricture or parasite
136
biliary sepsis/ascending cholangitis: gallstone risk factors
fair (northern european)
female
fat
fertile
137
biliary sepsis/ascending cholangitis: symptoms
clinical diagnosis based on charcot's triad- jaundice, RUQ pain, fever
5-10% mortality
138
biliary sepsis/ascending cholangitis: management
IV antibiotics
fluids
endoscopic retrograde cholangiopancreatography
139
peritonitis causes
medical: dialysis related, TB, pelvic inflammatory disease
| Surgical- perforation of GIT, trauma
140
enteric fever: causes
solmonella typhi:
- typhoid fever
- contaminated food/water
- faeco-oral spread
141
enteric fever: signs and symptoms
```
RLQ pain
high fever
headache
myalgia
rose spots
constipation
```
142
enteric fever: investigations
diagnosed through blood culture/bone marrow aspiration
143
enteric fever: complications
GI bleed
perforation
myocarditis
abscesses
144
enteric fever: treatment
emergency surgery
| antibiotics (mortality goes from 20%-1%)
145
units of alcohol
uk unit= 8 grams or 10ml pure alcohol
| men and women advised not to drink over 14 units a week
146
calculating the number of units
(strength % x amount in ml)/1000
147
common drink units
wine, 13.5%, small= 1.6, large=3.3, bottle= 10
| beer- regular 4% bottle= 1.8, pint=2.3
148
excessive drinking
drinking is excessive when:
it causes or elevates risk of alcohol related problems
OR
it complicates the management of other health problems
149
acute effects of excess alcohol intake
```
accidents/injury
coma from resp depression
aspiration pneumonia
gastritis
pancreatitis
hypoglycaemia
myopathy
arrhythmias
```
150
chronic effects of excess alcohol intake
```
pancreatitis
hypertension
gastritis
CHD
liver damage
CNS toxicity
```
151
alcohol withdrawal symptoms
tremulousness
activation syndrome
seizures
hallucinations
152
alcohol withdrawal: delirium tremes
can be severe or even fatal
| tremors, agitation, confusion, disorientation, hallucinations, seizures
153
alcohol specific and related deaths by condition
alcoholic liver disease- 82% of 5507 alcohol specific deaths (2016)
154
foetal alcohol syndrome
pre and post natal growth retardation
CNS abnormalities (mental retardation, irritability, hyperactivity)
craniofacial abnormalities
155
alcohol costs to the NHS
total cost in 2017 was £4.42 million
| decrease in cost from previous years due to reduction of disulfiram
156
psychosocial effects of excessive alcohol consumptions
```
interpersonal- violence, rape, depression
problems at work
criminality
poverty
driving incidents
```
157
NICE guidelines recommendations for policy (preventing harmful drinking)
price- make it less affordable
availability- licensing and import allowances
marketing- limit exposure, especially to children
158
NICE guidelines recommendations for practice (preventing harmful drinking)
```
licensing
resources for screening
supporting children
screening young people
screening adults
advice
referral
```
159
primary prevention to alcoholism
know your limits campaign
THINK driving campaign
restriction on alcohol advertising by Ofcom
minimum unit pricing
160
at risk drinking
a pattern of drinking which brings about the risk of physical or psychological harm
161
alcohol abuse
a pattern of drinking which is likely to cause physical or psychological harm
162
alcohol dependence
substance dependence is defined as a set of behavioural, cognitive and psychological responses that can develop after repeated substance use
163
alcohol dependence: pharmacological treatment
disulfiram
naltrexone
acamprosate calcium
164
alcohol dependence: psychosocial treatment
therapy
| social support
165
key policy for alcohol intervention
models of care for alcohol misusers (MoCAM)
| involves: screening and assessment, the four tier framework and care planning and co ordination
166
severity of dependence questionnaire
```
measure of dependence
20 questions:
-physical withdrawal symptoms
-affective withdrawal symptoms
-relief drinking
-frequency of alcohol consumption
-speed of onset of withdrawal symptoms
>30 is severe, 16-30 moderate, <16 mild
```
167
alcohol and the nervous system
alcohol potentiates gamma-amino butyric acid (major inhibitory neurotransmitter in CNS)
it also inhibits major excitatory neurotransmitter- glutamate and n-methyl-d-asparate
168
tolerance
a state in which an organism no longer responds to a drug
| a higher dose is required to achieve the same effect
169
alcohol withdrawal: Chlordiazepoxide absorption
```
absorbed in small intestine
highly lipophilic
it can be delayed in the elderly
half life is 6-30 hours
protein bound
```
170
alcohol withdrawal: Chlordiazepoxide distribution and metabolism
metabolised in liver
crosses blood brain barrier
active in CNS grey matter
171
alcohol withdrawal: Chlordiazepoxide elimination
excreted in urine in the form of its metabolites
| or as conjugates
172
alcohol withdrawal: Chlordiazepoxide contraindications
```
hypersensitivity to benzodiazepines
pulmonary insufficiency
pregnancy
chronic psychosis
myasthenia gravis
```
173
alcohol withdrawal: Chlordiazepoxide dependence
short term use= low chance of dependence
| risk of physical and psychological dependence increases with increased dose
174
alcohol withdrawal: Chlordiazepoxide drug interactions
alcohol- enhanced sedative effect
centrally acting drugs (antipsychotics, analgesics)
anti-epileptic drugs
175
alcohol withdrawal: Chlordiazepoxide side effects
```
drowsiness
ataxia
aggression
headache
resp depression
impaired liver function
```
176
wernicke's encephalopathy
```
deficiency of thiamine
common in dependent drinkers
poor diet
poor intake of vitamins
poor gastro-intestinal absorption
```
177
wernicke's encephalopathy treatment
pabrinex and ongoing with vit b/thiamine
178
alcohol relapse prevention: acamprosate
mechanism of action not fully understood but believed to act on neural pathways
safe no interaction with alcohol or diazepam
more effective when offered as combined therapy
179
alcohol relapse prevention: disulfiram
disrupts oxidative metabolism of alcohol
| results in a build up acetaldehyde
180
alcohol relapse prevention: disulfiram symptoms
```
long hangover
flushing of skin
tachycardia
SOB
nausea
vomiting
```
181
alcohol relapse prevention: nalmefine
opioid receptor antagonist
modifies activity at receptor sites linked to reward mechanisms
effects of alcohol present but reduces feeling of reward and pleasure
182
the four tier framework
non-substance misuse specific services
open access drug/alcohol services
specialist community based clinics
specialist in patient services
183
types of intestinal obstructions
intraluminal obstructions
intramural
extraluminal
184
extraluminal obstructions
outside the wall of the gut
185
intramural obstructions
within the wall of the gut
186
intraluminal obstructions
within the gut
187
intraluminal obstructions: tumours
carcinoma
lymphoma
tumours on the left side can obstruct more quickly than the right
188
intraluminal obstructions: diaphragm disease
caused by NSAIDS- cause submucosal fibrosis
this results in diaphragm like strictures in the GI tract
most common in small bowel
189
intraluminal obstructions: meconium ileus
meconium thicker and stickier
190
intraluminal obstructions: gallstone ileus
gallstones erode into the bowel causing the obstruction
191
intramural obstructions: inflammatory
crohn's
| diverticulutis
192
intramural obstructions: tumours
colorectal tumours
193
intramural obstructions: neural
hirschprung's disease:
| developmental where segment of bowel towards distal end hasnt got ganglion cells- no coordinated contraction
194
intramural obstructions: crohn's disease
main inflammatory cause of obstructions (granulomatous inflammation)
particularly ileum
deep fissuring ulcers and fibrosis
195
intramural obstructions: diverticular disease
mainly older people
small outpuching of mucosae which can become inflamed (stasis of faeces)
risk of rupture
196
diverticular disease pathogenesis
less fibre= more pressure in lumen of bowel to push faeces
holes in muscularis for blood vessels
pressure causes mucosa to be pushed through these holes
causes an outpouching
197
extra luminal obstructions: adhesions
previous surgery causes fibrosis
| adhesion can cause kinks in bowel resulting in obstruction
198
extra luminal obstructions: volvulus
sigmoid volvulus where sigmoid twists
| can twist and untwist resulting in abdomen pain coming and going
199
extra luminal obstructions: tumours
peritoneal deposits of tumour such as ovarian cancer
200
intestinal obstruction definition
arrest/blockage of onward propulsion or intestinal contents
201
small bowel obstructions
account for 60-75% of intestinal obstructions
202
small bowel obstructions: causes
crohn's disease (25%)
surgery/adhesions (60%)
hernia
malignancy
203
small bowel obstructions: clinical presentations
```
pain-colicky
vomiting- early and follows pain
tenderness
constipation
increased bowel sounds
```
204
small bowel obstructions: diagnosis
abdominal x-ray
examination
FBC
CT
205
small bowel obstructions: treatment
```
aggressive fluid resuscitation
bowel decompression
analgesia and antiemetic
antibiotics
surgery
```
206
large bowel obstructions
25% of obstructions
207
large bowel obstructions: causes
90% in US/europe due to colorectal malignancy
| in african countries more likely to be volvulus
208
large bowel obstructions: clinical presentations
```
abdominal pain
abdominal distention
bowel sounds normal, then increased lated
palpable mass
late vomiting
constipation
bloating
```
209
large bowel obstructions: diagnosis
digital rectal exam
FBC
abdominal x-ray
CT
210
large bowel obstructions: treatment
```
aggressive fluid resuscitation
bowel decompression
analgesia and antiemetic
antibiotics
surgery
```
211
pseudo-bowel obstructions
clinical picture mimics obstruction but with no mechanical cause
212
causes of pseudo-bowel obstructions
```
intra-abdo trauma
pelvic/spinal fractures
postoperative states
sepsis
pneumonia
drugs (opiates)
```
213
pseudo-bowel obstructions: clinical presentation
rapid and progressive abdominal distention and pain
214
pseudo-bowel obstructions: diagnosis
x-ray shows a gas-filled large bowel
215
pseudo-bowel obstructions: treatment
treat underlying problem
| IV neostigmine
216
lower GI tumours: epidemiology
higher prevalence in elderly
incidence rates higher in those with low fibre diet
incidence increasing due to screening
mortality decreasing
217
lower GI tumours: adenomas as a risk factor
the bigger the greater change of turning malignant
| normal epithelium -> dysplastic epithelium (adenoma) -> colorectal adenocarcinoma
218
lower GI tumours: familial adenomatous polyposis as a risk factor
born with normal colons but develop lots of polyps
Apc gene mutation causes beta catenin to build up resulting in increased epithelial proliferation causing more adenomas to form
219
lower GI tumours: hereditary nonpolyposis colorectal cancer as a risk factor
no DNA repair protein produced
| it has a risk of further cancers in index patients and relatives
220
lower GI tumours: resection margin coding
```
R0= tumour completely excised
R1= microscopic involvement of margin by tumour
R2= macroscopic involvement of margin by tumour
```
221
lower GI tumours: prognosis
circumferential resection margin (CRM) +ve= 20% 5 year survival with 85% risk of local recurrence
CRM -ve= 75% 5 year survival with 10% risk of local recurrence
222
lower GI tumours: staging
determine the spread of the tumour
greater the spread the worse the prognosis
lymph node and peritoneal involved included in staging
223
lower GI tumours: dukes' stages
A- inner lining of the bowel (95% 5 year survival)
B- grown through the muscle layer of the bowel (75% 5 year survival)
C- spread to at least 1 lymph node close to the bowel (35% 5 year survival)
D- spread to another part of the body (25% 5 year survival)
224
lower GI tumours: treatment
prevention (normal)
endoscopic resection (adenomas)
surgical resection
chemotherapy and palliative care
225
gastroduodenal ulceration and gastritis: causes
mucosal ischaemia
increased acid production
bile reflux
helicobacter infection
226
gastroduodenal ulceration and gastritis: mucosal ischaemia
reduces mucin production so no mucin barrier
| this causes cell death and acid enters between cells causing ulceration
227
gastroduodenal ulceration and gastritis: mucosal ischaemia treatment
reverse mucosal ischaemia
| PPIs- omeprazole, lansoprazole
228
gastroduodenal ulceration and gastritis: increased acid production
overwhelm defences, causing ulceration to occur
229
gastroduodenal ulceration and gastritis: increased acid production causes
stress
helicobacter pylori
drugs such as aspirin or ibruprofen
230
gastroduodenal ulceration and gastritis: increased acid production treatment
PPIs
| aspirin with enteric coats
231
gastroduodenal ulceration and gastritis: bile reflux
bile causes ulceration
232
gastroduodenal ulceration and gastritis: bile reflux causes
alcohol in high concentrations
233
peptic ulceration complications
ulcer can grow pass through the gastric wall into arteries causing a haemorrhage
if it continues to grow through the muscle wall into peritoneal cavity it causes peritonitis
234
malabsorption: main presentation
diarrhoea
anaemia
weight loss
fatty stools
235
malabsorption: causes
```
insufficient intake
defective intraluminal digestion
insufficient absorption area
lack of digestive enzymes
defective epithelial transport
lymphatic obstruction
```
236
malabsorption: defective intraluminal digestion
pancreatic insufficiency
defective bile secretion
bacterial overgrowth
237
defective intraluminal digestion: pancreatic insufficiency
pancreatitis - no enzymes
| cystic fibrosis -blocked pancreatic duct
238
defective intraluminal digestion: defective bile secretion
biliary obstruction - e.g. gallstone
| ileal resection - decreased bile salt uptake
239
malabsorption: insufficient absorption area
gluten sensitive enteropathy
crohn's disease
extensive surface parasitisation
small intestinal resection
240
insufficient absorption area: gluten sensitive enteropathy (coeliac)
villous atrophy
crypt hyperplasia
increased number of lymphocytes
241
insufficient absorption area: crohn's disease
inflammatory disease of the bowel
reduces surface area
cobblestone mucosa
242
insufficient absorption area: extensive surface parasitisation
```
giardia lamblia (malabsorption and weight loss)
parasites coat the surface of the vili (food cannot be absorbed)
```
243
insufficient absorption area: small intestine resection
done in:
morbid obesity
crohn's disease
infarcted small bowel
244
malabsorption: lack of digestive enzymes
```
disaccharidase deficiency (lactose intolerance)
bacterial overgrowth (brush border damage)
```
245
malabsorption: defective epithelial transport
abetaliapoproteinaemia
| primary bile acid malabsorption
246
malabsorption: lymphatic obstruction
lymphoma
| tuberculosis
247
coeliac disease pathology
```
allergic reaction to Giliadin protein
Giliadin peptide bind to antigen presenting cell
APC activated
cell injury
Giliadin antibodies, transglutaminase Ab
```
248
chronic idiopathic inflammatory bowel disease
crohn's disease
| ulcerative colitis
249
bowel inflammatory conditions
diverticulitis
ischaemic colitis
infective colitis
250
crohn's disease
inflammation of bowel anywhere from mouth to anus
| mainly terminal ilium
251
crohn's disease: features
skip lesions
passes all the way through mucosa, submucosa, muscularis propria and serosa
deep fissuring ulceration
fibrosis
252
crohn's disease: complications of the bowel
```
malabsorption
obstructions
perforation
fistula
neoplasia
anal fissures and skin tags
```
253
crohn's disease: systemic complications
amyloidosis
254
ulcerative colitis
inflammation with ulcer formation in the colon
| starts and rectum and moves proximally, stopping at caecum
255
ulcerative colitis: features
only in mucosa
distinct boundary between disease and normal bowel
diffuse pattern- not patchy
256
ulcerative colitis: complications of the colon
blood loss
toxic dilation
colorectal cancer
257
ulcerative colitis: complications of the joints
ankylosing spondylitis
| arthritis
258
ulcerative colitis: complications of the eyes
iritis
uveitis
episcleritis
259
ulcerative colitis: complications of the skin
erythema nososum
| pyoderma gangrenosum
260
ulcerative colitis: complications of the liver
fatty change
| chronic and/or sclerosing pericholangitis
261
oesophageal adenocarcinoma: epidemiology
increases with age
| more common in males
262
oesophageal adenocarcinoma
barret's oesophagus
| columnar lined lower oesophagus (CELLO)
263
oesophageal adenocarcinoma: metaplasia
change in differentiation of a cell from one fully differentiated type to another
264
oesophageal adenocarcinoma: pathogenesis
acid reflux causes metaplasia from stratified squamous to simple columnar
change in cell type increases risk of adenocarcinoma
265
oesophageal adenocarcinoma: pathway
normal squamous epithelium
gastro-oesophageal reflux causes metaplastic oesophageal glandular epithelium
reflux continues- dysplastic epithelium
finally neoplastic epithelium
266
oesophageal adenocarcinoma: causes
obesity is main cause of reflux
267
oesophageal squamous cancer- risk factors
smoking and drinking
268
oesophageal cancer: complications
difficulty swallowing early
can pass into blood vessels
a late presentation decreases survival rate
269
gastric cancer: epidemiology
incidence is decreasing
| more common in males
270
gastric cancer: causes
genetic- mutation in E cadherin transport proteins
environmental
helicobacter infection
pernicious anaemia- mucosal ischaemia
271
gastric cancer: pathogenesis
```
normal mucosa
intestinal metaplasia
dysplasia
intramucosal carcinoma
invasive carcinoma
```
272
gastric cancer: presentation
late presentation as tumour can grow quite large in the stomach before complications
273
gastric cancer: stages
early- no spread to muscular wall (can be in lymph nodes) 90% 5 year survival
late- spread to musclaris propria- 60% 5 year survival if fully resected
274
coeliac disease
inflammation of mucosa of upper small bowel that occurs when gluten is introduced into the diet
T cell mediated autoimmune disease where prolamin protein intolerance causes villous atrophy and malabsorption
275
coeliac disease: epidemiology
1% of population affected
occurs any age but peaks in infancy and 50-60 y/o
affects males and females equally
276
coeliac disease: risk factors
having other autoimmune disease
IgA deficiency
age of introduction to gluten
277
coeliac disease diagnosis
should maintain gluten for at least 6 weeks before testing to get true results
FBC, duodenal biopsy, serum antibody testing
278
coeliac disease diagnosis: FBC
low Hb
low B12
low ferritin
279
coeliac disease diagnosis: duodenal biopsy
gold standard
| see villous atrophy, crypt hyperplasia and increased intraepithelial white cell count
280
coeliac disease diagnosis: serum antibody testing
most sensitive tests (95%) are EMA, tTG (both are IgAs and correlate with severity of mucosal damage)
not sensitive if IgA deficient
281
coeliac disease: treatment
live long gluten free diet
correction of vitamin and mineral deficiencies
DEXA scan to monitor osteoporotic risk
282
coeliac disease: complications
not improving on the strict diet- non responsive coeliac disease
anaemia
secondary lactose intolerance
T cell lymphoma
283
coeliac disease: prolamins
gliadin- wheat
hordeins- barley
secalins- rye
prolamin is a component of gluten
284
coeliac disease: prolamins
gliadin- wheat
hordeins- barley
secalins- rye
prolamin is a component of gluten
285
peritonitis definition
inflammation of peritoneum
286
peritonism definition
tensing of the muscles to prevent movement of peritoneum
287
visceral peritoneum
on the organs
autonomic innervation
sensation poorly localised
288
parietal peritoneum
covers abdo wall
somatic innervation
sensation well localised
289
foregut sensation
lower oesophagus to D2, liver, spleen, gallbladder
autonomic pain= epigastric region
greater splanchnic T5-9
290
midgut sensation
D2- 2/3 of transverse colon
site of autonomic pain= umbilical region
less splanchnic T10-11
291
hindgut sensation
2/3 transverse colon to upper rectum
autonomic pain= hypogastric region
least splanchnic nerve T12/L1
292
peritonitis: causes
```
inflamed organ
air (ulcer, trauma)
pus (bacterial)
faeces/luminal contents (perforation)
blood (trauma)
```
293
primary peritonitis
```
inflammation on its own
spontaneous bacterial peritonitis
ascites
diagnose with ascitic tap and blood cultures
treat with broad spectum antibiotics
```
294
secondary peritonitis
caused by something else e.g. chemicals or bile
| treat the cause
295
peritonitis: common causes of abdo pain
```
gastritis (epigastric)
cholecystits (RUQ, midclavicular)
pancreatitis (epigastric)
appendicitis (umbilical then McBurney's point)
diverticulitis (LLQ)
```
296
peritonitis: epidemiology
370,000 admissions /year in uk
| mortality 15%
297
peritonitis: symptoms
kidney failure symptoms
abdominal pain:
-sudden onset= perforation
-slow onset= secondary to inflammatory disease
-poorly localised= irritation of visceral
-localised= irritation of parietal
298
peritonitis: signs
```
rebound tenderness
percussion pain
guarding
no bowel sounds
shock
lying still
```
299
peritonitis: complications
```
sepsis
multi-organ failure
kidney failure
paralytic ileus
abscess formation
CVS events
```
300
peritonitis: investigations
CT scan
blood test
CXR
abdo XR
301
peritonitis: treatment
```
treat cause
fluid resuscitation
antibiotics
surgery
after care (kidneys, phsyio, nutrition)
```
302
ascites definition
abnormal accumulation of fluid within peritoneal cavity
303
ascites: epidemiology
(healthy men/women= no fluid/20ml)
10-20% 5 year survival from onset
signifies serious illness such as cirrhosis
304
ascites causes
impaired blood flow
local inflammation
decreased oncotic pressure
305
ascites cause by impaired blood flow
cirrhosis- portal hypertension
cardiac failure
constrictive pericarditis
306
ascites cause by local inflammation
(leaky membrane)
peritonitis
abdo cancers (Esp. ovarian)
infection e.g. TB
307
ascites cause by decreased oncotic pressure
hypoalbuminaemia
nephrotic syndrome
malnutrition
308
ascites: exudate fluid
high protein fluid
309
ascites: exudate fluid pathology
low serum to ascites/albumin ratio
outflow is fine
altered oncotic pressure
membrane more porous
310
ascites: exudate fluid treatment
treat underlying cause
311
ascites: exudate fluid causes
malignancy
sepsis
TB
nephrotic syndrome
312
ascites: transudate fluid
low protein fluid
313
ascites: transudate fluid pathology
high serum to ascites/albumin ration
outflow increased
decreased oncotic pressure
membrane okay
314
ascites: transudate fluid causes
cirrhosis
| cardiac failure
315
ascites: transudate fluid management
treat cause
diet
diuretic
drainage
316
ascites: history
how long has swelling been there?
drugs?
weight loss?
any obvious underlying cause?
317
ascites: complications
stasis results in bacterial overgrowth- spontaneous bacterial peritonitis
318
ascites: examination
presences is confirmed by demonstrating shifting dullness with percussion
ultrasound/xray/ct
319
ascitic tap: diagnostic aspiration
```
10-20ml of fluid to see:
raised white cell count (bacterial peritonitis)
gram stain and culture
cytology for malignancy
amylase to exclude pancreatic ascites
```
320
ascitic tap: protein measurement (transudate)
less bad
| transparent due to little protein (<30g/L)
321
ascitic tap: protein measurement (exudate)
```
extremely bad
high protein (>30g/L)
```
322
ascites: treatment
```
treat cause
reduce sodium intake
increase sodium excretion
diuretic
drain fluid
```
323
ascites: risk factors
high sodium diet
hepatocellular carcinoma
splanchnic vein thrombosis- portal hypertension
